Allegheny County Medical Society
BulletinDecember 2019
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Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate Allegheny County Medical Society
BulletinDecember 2019 / Vol. 109 No. 12
Opinion Departments Articles
Editorial ...... 406 Society News ...... 418 Materia Medica ...... 425 Winter nourishment • Greater Pittsburgh Diabetes Club Trikafta™ (ivacaftor/tezacaftor/ Deval (Reshma) Paranjpe, MD, FACS • Pennsylvania Geriatrics Society – elexacaftor): A breakthrough therapy Western Division for cystic fibrosis patients who carry Editorial ...... 410 • Pittsburgh Ophthalmology Society at least one F508del mutation Retirement • Pennsylvania Medical Society Adam Patrick, PharmD candidate Richard H. Daffner, MD, FACR announcements Legal Report ...... 428 Editorial ...... 413 Activities & Accolades...... 421 Regulatory sprint to coordinated care: Then and now New Stark and Anti-Kickback rules Andrea G. Witlin, DO, PhD Membership Benefits...... 422 Michael A. Cassidy, Esq. Perspective ...... 415 In Memoriam ...... 424 Special Report ...... 432 Choosing a Medicare plan • Robert Love Baker, MD Update on the prevalence of blindness Namita Ahuja, MD at the Western Pennsylvania School for Editorial Index...... 440 Blind Children Heidi Ondek, EdD Advertising Index...... 442 Albert Biglan, MD Beth Ramella, MEd
Special Report ...... 437 Reportable Diseases 2019: Q1-3
Special Report ...... 438 2019 PAMED House of Delegates report On the cover Light the Night Malcolm Berger, MD
Dr. Berger specializes in neurology. EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212; (412) Bulletin 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny Medical Editor County Medical Society at above Deval (Reshma) Paranjpe address. ([email protected]) The Bulletin of the Allegheny 2019 PAMED DISTRICT TRUSTEE Associate Editors County Medical Society welcomes Executive Committee Amelia A. Paré Richard Daffner contributions from readers, physicians, and Board of Directors ([email protected]) medical students, members of allied COMMITTEES Charles Horton professions, spouses, etc. Items may President Awards ([email protected]) be letters, informal clinical reports, Adele L. Towers Keith T. Kanel Anthony L. Kovatch editorials, or articles. Contributions President-elect Bylaws ([email protected]) are received with the understanding William K. Johnjulio Patricia L. Bononi Scott Miller that they are not under simultaneous consideration by another publication. Vice President Finance ([email protected]) Patricia L. Bononi David L. Blinn Amelia A. Paré Issued the third Saturday of each Secretary Gala ([email protected]) month. Deadline for submission Peter G. Ellis Patricia L. Bononi Joseph C. Paviglianiti of copy is the SECOND Monday Treasurer Membership ([email protected]) preceding publication date. Periodical Matthew B. Straka William K. Johnjulio Anna Evans Phillips postage paid at Pittsburgh, PA. Board Chair Nominating ([email protected]) Bulletin of the Allegheny County Robert C. Cicco Thomas P. Campbell Andrea G. Witlin Medical Society reserves the right to ([email protected]) edit all reader contributions for brevity, DIRECTORS ADMINISTRATIVE STAFF clarity and length as well as to reject Managing Editor 2019 any subject material submitted. Chief Executive Officer Meagan K. Sable Thomas P. Campbell Jeremy T. Bonfini ([email protected]) The opinions expressed in the Michael B. Gaffney ([email protected]) Editorials and other opinion pieces Keith T. Kanel are those of the writer and do not Senior Manager, Jason L. Lamb necessarily reflect the official Society Governance and Maria J. Sunseri policy of the Allegheny County Medical Community Engagement 2020 Medical Society, the institution with Dorothy S. Hostovich David L. Blinn which the author is affiliated, or ([email protected]) Lawrence R. John the opinion of the Editorial Board. Bruce A. MacLeod Manager, Medical Community Advertisements do not imply Amelia A. Paré Engagement and Society ACMS ALLIANCE sponsorship by or endorsement of Angela M. Stupi Governance Co-Presidents the ACMS, except where noted. Patty Barnett 2021 Michelle Besanceney Publisher reserves the right to exclude Barbara Wible William F. Coppula ([email protected]) any advertisement which in its opinion David J. Deitrick Recording Secretary Director of Operations, does not conform to the standards of Kevin O. Garrett Justina Purpura Finance and Compliance the publication. The acceptance of Marcy L. Jackovic Corresponding Secretary Amanda S. Kemp advertising in this publication in no Raymond E. Pontzer Doris Delserone ([email protected]) way constitutes approval or endorse- Treasurer ment of products or services by the Director of Publications Sandra Da Costa PEER REVIEW BOARD Allegheny County Medical Society of Meagan K. Sable Assistant Treasurers 2019 any company or its products. ([email protected]) Liz Blume Robert W. Bragdon Annual subscriptions: $60 Kate Fitting John A. Straka Vice President of Physician Advertising rates and information 2020 Engagement and Digital Strategy sent upon request by calling James W. Boyle James D. Ireland (412) 321-5030 or online at Matthew A. Vasil ([email protected]) www.acms.org. 2021 Director, Medical Community www.acms.org Thomas P. Campbell Engagement Keith T. Kanel Nadine M. Popovich COPYRIGHT 2019: ([email protected]) ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Improving Healthcare through Education, Service, Society, 713 Ridge Avenue, Pittsburgh, PA 15212. and Physician Well-Being. ISSN: 0098-3772
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801-770-1199 http://www.hipaaone.com/contact/ Editorial Winter nourishment
Deval (Reshma) Paranjpe, MD, FACS
appy Holidays! It’s that time of year Food Rescue as in the past, with a Christmas at the Frick is not to be Hagain – we all could use some goal of raising $50,000 in donations. missed: a lovely break from the hustle cheer, company and delicious food to and bustle of modern times. Round out Christmas Story pop-up bar warm our hearts and get us through to your visit with a visit to the Katherine the new year. • DoubleTree Hotel Bar, 500 Mans- Hepburn costume exhibit (through Jan. Here are some unique and delight- field Ave., Green Tree 12) and lunch at the Café at the Frick ful holiday suggestions that might take • Thursday, Dec. 19, and Friday, (members may make reservations; you off the beaten path for an unex- Dec. 20, 4:30 to 9 p.m. others, first come first serve) or neigh- pectedly fun outing: If you’re like me and can’t get boring Point Brugges for mussels and enough of this beloved holiday film, you other delights. Miracle Christmas pop-up bar may want to get a grown-up Christmas • Downtown: Miracle on Liberty, Story fix during the two-day run of this City of Pittsburgh Gingerbread 717 Liberty Ave., in The Clark Building new pop-up bar featuring 360 degree House Competition • South Side: Miracle on Carson, film décor (Red Ryder BB gun, bun- 2240 East Carson St., formerly the ny suit and all) as well as cardboard • City-County Building, Downtown Lava Lounge cutouts of the actors. You’ll be offered • Until Jan. 3; Mondays-Saturdays, • Both locations are open until cinema-themed cocktails including the 10 a.m. to 8 p.m.; Sundays, 10 a.m. to Tuesday, Dec. 31, from 5 p.m. to 2 “Oh Fudge,” “Major Award” and “Pink 5 p.m. a.m.; South Side location opens daily Nightmare” as the movie streams con- Come look at hundreds of com- at 4 p.m. tinuously in the background. And watch munity-made gingerbread houses on Nationally award-winning hometown out for that Leg Lamp – remember, it’s display for inspiration and wonder mixologist Spencer Warren is bring- “Fra-JEE-Lay. And please don’t shoot (look, but don’t eat, please!) your eye out – trust me, I’m an ophthal- ing back the wildly popular Miracle, Lumaze Interactive Light Show a Christmas-themed pop-up bar that mologist. • Strip District: 31st Street Studios celebrates all things Christmas with A Gilded Age Christmas: lavish decorations and fabulous liba- • Until Saturday, Jan. 4 tions – 22 unique specialty cocktails in Holiday Tours of Clayton • https://www.lumazelights.com/ all this year that will at once make you • The Frick Mansion, 7227 Reynolds pittsburgh-christmas/ feel hip … and forget about any other St., Point Breeze Tired of the cold? Here’s an indoor joint pains. This year, Pittsburgh is • Open until Sunday, Jan. 5 light festival with seasonal food and treated to two locations, which promis- • Tickets: www.thefrickpittsburgh.org beverages, light gardens, entertain- es to break up the congestion, and is Come see the opulence of a bygone ment and more than 30 vendors from important to remember should you tell era and step back in time as you walk the I Made It! Market at its vendor someone to meet you at Miracle. Both through the doors of the Frick Mansion. market. Season passes available; also Miracle bars will be partnering with 412 Beautifully decorated in period style, look for Groupon specials.
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Chanukah Festival at the award-winning ciders and mead made The Winter Edition of Pittsburgh Waterfront from local fruits and honey. (www. Restaurant week is the perfect excuse threadbarecider.com) to come out of post-holiday hibernation, • Monday, Dec. 23, 8 a.m. to 5 p.m. Guapo (Federal Galley, 200 Chil- join friends and try out new eateries and • https://jewishpgh.org/event/chanu- dren’s Way, North Side) revisit old favorites, all while enjoying kah-festival-at-the-waterfront-2/ Discover the Land of Enchantment fabulous deals and prix fixe menus. Celebrate the first night of Chanu- at Guapo. New Mexico native turned You can find the schedule, including kah with an all-day event featuring an Pittsburgher Frank Adelo is turning out restaurants and menus, here: http:// outdoor concert, menorah lighting, food traditional New Mexican cuisine red- pittsburghrestaurantweek.com/restau- vendors, and games and children’s olent of fragrant Hatch Chile. Nothing rants/winter-2020-restaurants/ activities. warms up your blood on a cold day like Fig & Ash (East Ohio Street, North Chinese food and movies on enchiladas slathered in red, green or Side) Christmas (some of each) chile sauce. Upscale wood-fired grill entrees Christmas Eve and Christmas Tacos and other delights also are on from a chef who has graced the finest Day the menu, with fillings that range from restaurants in Pittsburgh. Opening: • Row House Cinema, Lawrenceville carne adovada (Hatch chile braised winter 2019. • Tuesday, Dec. 24, and Wednes- pork stew), chicken, shrimp or vege- Oakmont Barbecue Company day, Dec. 25 tarian calabacitas (fire roasted squash, (Allegheny River Boulevard, Verona) If Chinese food and a day at the onions, corn, mushroom and more What to expect: The same delicious movies are a tradition for you, come Hatch chile with cheese). Libations barbecue that’s been served by the switch it up at Row House Cinema. range from beer to palomas, margari- popular Oakmont Barbecue Company Choose from a wide selection of mod- tas and a lovely cocktail program. food truck – pulled pork, beef brisket, ern holiday classics including Open for lunch and dinner seven ribs, nachos and mac and cheese Die Hard, Krampus, National Lam- days a week, plus weekend brunch – only in a brick-and-mortar setting. poon’s Christmas Vacation and The starting at 10 a.m. (https://www.federal- Opening: early 2020. Muppet Christmas Carol. Order Chi- galley.org/restaurants/guapo/) The Woods House (Monongahela nese take-out and sushi at the conces- KIIN Lao and Thai Eatery (5846 Avenue, Hazelwood) sion stand and have it delivered to your Forbes Ave., Pittsburgh Squirrel Hill, The John Woods House was built in seat mid-movie for a new experience. formerly Bangkok Balcony) 1792 and may be the oldest dwelling in KIIN Lao & Thai Eatery features Lao the City of Pittsburgh. It is being reno- New restaurants worth a try and Isan-style cuisine (Isan is a region vated into a Scottish pub featuring both Gordo’s Taco Diablo (297 Beverly of Thailand bordering both Laos and Scottish and Pittsburgh (think piero- Road, Mt. Lebanon) Cambodia). Bangkok balcony favor- gies) fare and, naturally, many kinds of From the people behind Café Io, ites also are included on the menu for beer. Step back into history and enjoy behold Mexico City inspired tacos, with those who miss the old restaurant. KIIN an overlooked but legendary homesite. a twist. Dinner weekdays; lunch and means “Eat together” in both regions Opening: 2020. dinner weekends. Closed Monday. and is a fitting name for this adventure. The Eagle Food and Beer Hall Threadbare Cider and Mead Tast- Open Monday through Friday, 11 (Penn Avenue, Downtown) ing Room (Ross Park Mall) a.m. to 10 p.m.; weekends 11 a.m. to What to expect: More excellent fried Threadbare Cider and Mead has 11 p.m. chicken in Pittsburgh. Brined, dredged opened a tasting room and bottle shop and deep-fried, the Eagle’s chicken next to that of its sister brand, Wigle Coming attractions will be served with hot honey, southern Whiskey, at the Ross Park Mall. If Pittsburgh Restaurant Week favorites, craft beer and, best of all, holiday shopping has you in need of Winter 2020 Edition: Friday, Jan. 10, blues music. Opening: 2020. some cheer, stop by and sample their through Sunday, Jan. 19 Continued on Page 408
ACMS Bulletin / December 2019 407 Editorial TIME From Page 407 for a The Coop Chicken and Waffles (401 East Ohio St., cor- ner of Cedar and East Ohio streets, formerly Rita’s Italian Ice, Physician Billing Audit? North Side) More great fried chicken, this time with a plethora of If you’re working harder, but your revenue waffles. The eponymous food truck will now have a brick-and isn’t keeping up, maybe it is time. mortar shop which will deliver to Allegheny General Hospital and Downtown. Opening: January 2020. To learn more, please contact John Fenner at Wishing you delicious holidays and a warm and wonderful 412-638-1846 or [email protected]. winter!
Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@ 3 Penn Center West hotmail.com. Pittsburgh, PA 15276 412-788-8007 The opinion expressed in this column is that of the fennercorp.com writer and does not necessarily reflect the opinion of the Editorial Board, a leader in physician billing the Bulletin, or the Allegheny County Medical Society. and consulting since 1991
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/ Z HC Editorial Retirement
Richard H. Daffner, MD, FACR
he email from the International Skeletal Society (ISS) the New York Times crossword puzzle, and could take a nap Tinvited me to be on the faculty for the Refresher Course whenever I felt like it. at their annual meeting. I responded that I was flattered to I still wasn’t ready. I enjoyed my work – the daily con- be asked and added that I had been retired (at that time) sultations with various clinicians, as well as teaching my for five years. The return email insisted that I participate residents and the medical students. But things were chang- and speak on the imaging of suspected spine trauma. After ing. Our group was one of the last independent practices all, the chairperson reminded me, I was still considered an in the then West Penn-Allegheny system that had recently expert in that area, having written what was considered the been taken over by Highmark. Pressure was being put on definitive textbook on the subject as well as the recommen- our chairman to have the group become Highmark employ- dations for imaging on that topic for the American College ees, like the other physicians in the system. At the time, of Radiology in their Appropriateness Criteria®. And so, as there were five members of the group who were over age Michael Corleone said in “Godfather III:” “Just when you 65, and I felt that subtle pressure was being placed on us to think you’re out, they pull you back in.” retire. For me, the fun stopped when I learned that my week- I have been asked by many colleagues and friends who end call was being increased by 25%. At the same time, I were nearing retirement age if I had any advice and words received a phone call from my tax advisor asking if I had of wisdom on the subject. In short, here are six areas for taken my minimum required deduction (MRD) from my IRA, potential retirees to consider: 1). Know when the time is since I had turned 70 and a half. Some quick mathematical right; 2). Understand that retirement is not just stopping calculations of my MRD from not only my IRA, but also from working; 3). Have a plan; 4). Fill your time; 5). Financial my TIAA/CREF accounts from my days working at Duke, considerations; and, perhaps most importantly 6). Be aware showed that I would be pushed into a higher tax bracket. of how your retirement will affect your spouse/partner. Let’s So, the prospect of working harder and paying more in taxes consider each of these areas. convinced me that the time was right to retire. Another, perhaps more common, scenario is the situation Knowing when the time is right where the physician loses his/her ability to continue practicing. Years before I thought of retiring, older colleagues, whom This may be the result of illness, including (early) dementia. In I met at professional meetings, often asked me when I was some instances, the physician recognizes his/her shortcom- going to retire. My answer was always the same, “Either ings and voluntarily retires. In others, his/her partners may when I have a serious health issue or if the job stops being notice a drop in clinical acumen, lower productivity, or an in- fun.” In 2007, I underwent a total hip replacement and creased error rate and recommend that their colleague retire. was off work for two months. As I sat rehabbing at home, I In these situations, the hospital Medical Staff Committee may thought that if retirement was going to be like this, I wasn’t recommend retirement and loss of privileges. ready for it. Two years later, I had the other hip replaced. This time, Understanding what retirement is however, I began thinking that this wasn’t so bad. I got up Many people think retirement is simply stopping work. later, had a leisurely breakfast, read the newspapers, did And, for many, that is exactly what they do. They stop work-
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ing, sit at home, watch television, eat snacks, gain weight I have been a Boy Scout leader for 43 years, devoting and often die at an early age. During their working lives, they one evening a week to troop meetings and two weeks for never developed outside interests or hobbies. For them, summer camp. I immediately signed up to be on the staff their occupations were their lives. For others, however, and of two additional weeks of an Advancement Camp, where I I include myself in that group, retirement meant leaving one taught several different merit badges. In addition, I signed up chapter of their lives, and moving on to one or more new to be on the medical staff for Mountainfest, a Council-wide chapters. That may involve an entirely new occupation, par- event at Heritage Reservation, our main scout camp. In ticularly for those who have the financial need (see below). addition, as a member of the Laurel Highlands Council Or, pursuing and/or developing other interests. Often, the Enterprise Risk Management Committee, I agreed to be the retiree becomes (more) involved in (additional) volunteer Council Medical Supervisor, overseeing the medical policies activities or seeks to broaden their knowledge bases by and procedures at our many resident and weekend camps. participating in one or more adult education programs, such Finally, I increased my vacation time. In addition to my as Osher at CMU or at the University of Pittsburgh. two weeks at scout camp, I increased my week at a summer When I announced that I was going to retire to my cabin owned by my cousin at lake Luzerne, in the Adiron- chairman, he asked me if I would consider continuing giving dacks. And my wife and I also extended our annual visit to lectures to our residents and students. He pointed out that Grand Cayman to an additional week. I gave more didactic conferences to our residents than any Filling your time other faculty member. Furthermore, he reminded me that many of my topics covered areas that the other staff either Filling your time once you retire is a must. Think about had no interest in or that they felt were not in their areas of other interests that you have and make your participation in expertise. As a musculoskeletal (MSK) radiologist, I concen- them a reality. Again, this may involve taking on additional trated on interpreting (old fashioned) X-ray images as well responsibilities in organizations to which you already belong. as CT applications to bone abnormalities. My younger MSK I have been a Trustee of the Albany College of Pharmacy colleagues preferred doing MRI and invasive procedures and Health Sciences (ACPHS), my alma mater, on and off (arthrograms, biopsies and CT-guided screw placements). for many years. The year I retired, the president of ACPHS And so, I agreed to continue lecturing for two years, but with announced his retirement after the current academic year. the stipulation that I now be paid the going rate for visiting The chairman of the Board asked me to chair the Search professors. The reason I set a time limit was because I felt Committee, since he knew “I had the time.” That job required that without exposure to current clinical cases, my material frequent trips to Albany from July through December, when would become outdated. Fortunately, my former partners we selected our new president. I didn’t realize how many were more than generous in providing me with new material trips I made until the Southwest Airlines gate agent in Albany whenever I requested it. started greeting me by name! I joined other organizations, volunteering at South Hills Having a plan Interfaith Movement (SHIM), building shelves and storage Most new retirees have some sort of plan for what they will areas for their food pantries; Rotary Club; Mt. Lebanon be doing with all their free time: getting up later in the morning; Reader’s Theater, where we read one-act plays at retire- spending more time with their children and/or grandchildren; ment and nursing homes; and Global Links, where I rebuild taking longer vacations, for example. For many, they will now wheelchairs that are sent to Central and South America.1 be able to spend more time on hobbies, projects, or in volun- One of my most rewarding activities is the participation teer activities to which they already belong. In many instanc- in the Osher Lifelong Learning Institute programs. Here one es, however, most of those activities already take place in can take a variety of courses covering a list of topics in arts evenings, after the normal working day. I already played in a and humanities, business and commerce, science, social community concert band and belonged to a flute choir. I joined sciences, as well as a diverse list of topics called “learning a second band that played primarily during summer months by doing.” We are fortunate here in Pittsburgh, in that we when most other community bands took time off. Continued on Page 412
ACMS Bulletin / December 2019 411 Editorial
From Page 411 Spousal/partner considerations have two Osher programs – one at CMU and the other at Don’t forget your spouse or domestic partner when the University of Pittsburgh. The CMU program has a fixed considering retirement. In most instances, while we are busy number of memberships due to space limitations; the Pitt tending to the ills of humanity, they also have developed a program is under the auspices of their Graduate Education lifestyle of their own. Retirement often is a cause of divorce Department and has open membership. In addition to taking among older couples. Physicians, because of their busy pro- courses, I am also a study leader for both programs. The fessional schedules, don’t often spend a lot of time at home. thing I appreciate most about the Osher program is that all Once they retire, they’re home much more, especially if they participants, both learners and study leaders, are mature don’t fill their time. adults, who are motivated to learn. This is in sharp contrast It’s often been said that retirement leads couples to either to my experience teaching medical students and residents. become much closer, or, get on each other’s nerves. Right And, of course, I have been able to contribute to the Bul- after I retired, my wife of 48 years explained the “rules of the letin first as an author of Perspective pieces, and now as an house” (for example, “Last one up makes the bed”). There assistant editor. Filling my time has led me to often observe are activities we do together as well as those we do individ- that I’m busier now than when I had gainful employment. ually. Financial considerations Summary Maintaining your lifestyle and determining what you do Retirement represents entering a new stage in one’s in retirement is, of course, dependent on how financially life. The retiree will have opportunities to participate more secure you are. Some people, unfortunately, can’t retire frequently in activities which they enjoy, or to try new ones. because they have not done the requisite financial planning Approaching retirement requires planning, not only to fill to assure a comfortable retirement. Sadly, Social Security your time fruitfully, but also to assure that you will have the is not enough to live on. Furthermore, serious or prolonged financial wherewithal to maintain your current lifestyle. illness can rapidly deplete one’s retirement “nest egg.” Financial planning for retirement should begin immediately Dr. Daffner, associate editor of the ACMS Bulletin, is a when one joins the workforce after residency or fellowship. retired radiologist who practiced at Allegheny General Hospi- Unfortunately, many young physicians don’t think of this tal for more than 30 years. He is emeritus clinical professor as they start practicing. An important but simple tool is to of Radiology at Temple University School of Medicine and is make a table of one’s yearly income and expenses from the author of nine textbooks. He can be reached at bulle- existing savings and checking accounts. This will change [email protected]. over time, as children enter college, graduate and move on with their lives. The result, under each set of family circum- The opinion expressed in this column is that of the writer stances, will give you a monetary number of what you need and does not necessarily reflect the opinion of the Editorial Board, to maintain your current lifestyle. There may be a need for the Bulletin, or the Allegheny County Medical Society. sacrifices – perhaps one less vacation, or eating out less frequently. Or, if you have planned properly, you can be as- Reference sured by your financial advisor that you have enough money 1. Daffner RH. The ‘R’s’ have it. ACMS Bulletin 2017; August, to maintain your lifestyle until age 110. 288-289.
For classified advertising information, including special member rates, email Bulletin Managing Editor Meagan Sable at [email protected], call (412) 321-5030, ext. 105, or visit www.acms.org.
412 www.acms.org Editorial Then and now
Andrea G. Witlin, DO, PhD
he good ole days in medicine were replaced the static B scan unit midway gender for the first time and share the Tunquestionably different for patients through my second year of residency. excitement with the gleeful parents! and doctors alike. Recently, I’ve been a This wonderful new technology was Radiology was light years behind! party to numerous discussions lament- the size of a volleyball that required “Plain films” and floro(s) predominat- ing “the loss” of those “better times.” two hands to grasp. Needless to say, ed and had to be reviewed with the Personally, I’m not convinced that the resolution was poor, but at least we radiologist in the hospital department. when I started school in the ’70s (my could finally view a beating fetal heart. Nuclear medicine scans were avail- reference point) was that idyllic. The The much-maligned vaginal probes able, albeit with poor resolution. Head abuse and harassment were pervasive. weren’t introduced until years later. We CT scans were introduced during my Complaining was not an option. could start “dating” pregnancies, but residency but lacked the current res- As students and house staff, we early scans were far from routine and olution. Abdominal CT scans followed both marveled and were appalled at rarely ordered. Worse, as residents, we later. High-resolution chest CTs for our autonomy. I could write a book were routinely chastised for ordering pulmonary embolisms (PEs) weren’t of my exploits that would make you GYN ultrasounds. The rationale – if you even in the vocabulary. MRIs didn’t shutter with horror and disbelief. That could feel a pelvic mass, why did you appear until I was in practice but were said, our independence afforded us need an ultrasound? If you couldn’t feel rarely ordered because of cost and irreplaceable experience. Fortunately, a mass (even in the obese patient), you reimbursement issues. today’s trainees are not subject to weren’t worth your salt as a resident. Pharmacology was rudimentary as that “baptism of fire” that had been Quantitative human chorionic gonad- well. One could actually recognize the pervasive when I trained. Attendings otropins (HCGs) were only available classes and function of most medi- were infrequently “in house” (especially to monitor trophoblastic disease and cations. Chemo options were limited. after 5 p.m.) and were seldom sited at were not used to determine viability or Rheumatologic treatments were limited a vaginal delivery unless the woman monitor ectopic pregnancies. The first to NSAIDs, prednisone, methotrexate was a VIP or “crowning.” We residents in-vitro baby was a case report. Assist- and gold. DMARDs and monoclonal “made the call” regarding Cesarean(s) ed reproductive technologies were in antibody therapies weren’t even a with attendings arriving with our patient their infancy. The rare amniocentesis figment of anyone’s imagination. We already on the OR table. Undeniably, was performed by marking a spot on entertained the drug reps and were we had our share of complications and the patient’s belly that corresponded to anxious for their samples (and gifts). were regularly reprimanded for either a pocket of amniotic fluid as observed Fortunately, the TV ads were absent. calling too early or too late. on our rudimentary ultrasound in radiol- Patients tended to present “sicker” Technology in obstetrics/gynecology ogy, followed by transport to the clinic and/or more advanced in their disease (OBG) was in its infancy then. We were where a needle was inserted blindly process. Diffuse early complaints were lucky if we had a bulky Doppler device (and hopefully without complication). usually ignored or dismissed. Retro- that could detect the fetal heart rate by Admittedly a positive – it was more spectively, my personal medical care 14 weeks. Our first real-time ultrasound fun to deliver a baby and discern the Continued on Page 414
ACMS Bulletin / December 2019 413 Editorial
From Page 413 call and schemed together to deal with nurses who routinely stayed overtime and those who did the minimum to get was a casualty of this practice and my our harassment from the nurses. There diagnoses were delayed. Conversely, were no iPhones, iPads, laptops, not by. Those who kept up and those who there was a lack of treatment heroics even TVs in the patient’s rooms. Just didn’t. for end-stage disease and its related old-fashioned communication. So, let’s be real … do you really complications. Advanced heart failure Malpractice insurance was less want to return to the good ole days? was a death sentence. Liver transplant expensive, malpractice suits less com- There are clearly vexing issues (insur- for end-stage disease secondary to mon and awards smaller. Defensive ance authorizations and administrative cancer or lung transplant for cystic fi- medicine was rarely discussed though quagmires) that present seemingly brosis would have been unfathomable. we did focus on adhering to current, insurmountable stressors for patients Death was considered inevitable for quality standards of care. I don’t recall and doctors alike. It is likely that my many conditions. any current or pending lawsuits for generation and those before didn’t Inpatient treatment was the norm. any of our attendings. It was almost object vehemently enough and that we Hospice didn’t exist. Critically ill and unheard of for a resident to be sued. allowed these problems to fester and dying patients “camped out” in their We routinely had patients transferred multiply. But we dealt with them, nev- hospital beds for days to months. The manifesting outrageous complications ertheless. Life’s a trade-off. I, for one, positive was that we witnessed the true secondary to egregious “malpractice” prefer to tackle the current obstacles extent of human suffering. We inter- and negligent care. Yet, it was almost and not ruminate about those elusive acted with family members and under- unheard of that our patients sued their halcyon times. stood their anguish. Correspondingly, local doc. progress notes were sparse and many Life was definitely less complicated Dr. Witlin, associate editor of the times illegible. Everyone knew what by today’s terms. We still had burnout ACMS Bulletin, is a retired maternal/ was going on, so why write about it? (although the term wasn’t used), drug fetal medicine physician and research- Camaraderie amongst physicians and alcohol abuse, and suicides. There er. She can be reached at agwmfm@ was common. It was not uncommon were the never-ending complaints gmail.com. to see the hospital cafeteria popu- about the administrators. Docs made The opinion expressed in this column is that lated with groups of house staff and decent incomes, some more than of the writer and does not necessarily reflect attendings following morning teaching others. Some chased money and some the opinion of the Editorial Board, rounds. Residents commiserated to- didn’t. There were good docs and the Bulletin, or the Allegheny County Medical Society. gether in the resident’s lounge while on bad, caring nurses and not. Docs and
Improving Healthcare through Education, Service, and Physician Well-Being.
414 www.acms.org PerspectivePerspective Choosing a Medicare plan Namita Ahuja, MD
efore you can choose the Medicare Advantage plan that Bis best for you, it’s important to understand the basics of Original Medicare. Mark Your Calendar Medicare is a federal health insurance program. In order to qualify, you must be a U.S. citizen or lawfully present in 28th Annual Clinical Update in the United States. You also must be age 65 or older; or be under age 65 with certain disabilities; or have permanent kidney failure requiring dialysis. GERIATRIC Medicare has four parts: Part A hospital coverage, Part B medical coverage, Part C Medicare Advantage plans and Part D prescription drug plans. MEDICINE March 5-7, 2020 Part A hospital coverage Marriott Pittsburgh City Center, Pittsburgh, PA Most people do not pay a monthly premium for Part A. If Course Directors: Shuja Hassan, MD ■ Neil M. Resnick, MD ■ Lyn Weinberg, MD you or your spouse worked for 10 years and paid Medicare M taxes, you will not have to pay a premium. Presented by The Pennsylvania Geriatrics Society* – Western Division Part A helps cover inpatient hospital care; skilled nursing UPMC / University of Pittsburgh Aging Institute facility care; home health care; and hospice care. and University of Pittsburgh School of Medicine Your costs under Part A include inpatient hospital deduct- Center for Continuing Education in the Health Sciences ible; inpatient hospital copays; skilled nursing copays; and *Join the Society Now and Save! Call Nadine Popovich at (412) 321-5030. your monthly plan premium, if applicable. M The fastest growing segment of the population comprises individuals above the age of 85 years. The purpose of our conference is to provide an evidence-based Part B medical coverage approach to help clinicians take exceptional care of these often frail individuals. Part B requires you to pay a monthly premium along with M This course is the recipient of the American Geriatrics Society State Achievement Award a yearly deductible before coverage begins. You also are for Innovative Educational Programming. responsible for paying part of the costs that Part B does not For more information on conference details, please visit our website: cover. Services that are NOT covered by Medicare include: http://www.dom.pitt.edu/UGM or email us: [email protected] This activity is approved for the following credit: AMA PRA Category 1 Credit™, ANCC, and ACPE. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this routine hearing, dental and vision exams; hearing aids or activity. glasses (except for glasses after cataract surgery); emer- gency assistance while traveling outside the United States; fitness club membership; long-term care (such as a nursing equipment like prosthetics, wheelchairs and hospital beds. home); and prescription drug coverage. What costs are you responsible for under Part B? Part B Part B helps cover doctor and other healthcare provider includes the following costs: your Medicare Part B monthly services; outpatient surgery; lab and X-ray services; ambu- premium, if applicable; yearly deductible (paid before Medi- lance services; preventive services; and durable medical Continued on Page 416
ACMS Bulletin / December 2019 415 PerspectivePerspective
From Page 415 plan. You will pay your Part A monthly covered by that plan. Your costs when care begins paying); and coinsurance premium (if applicable) and Part B enrolled in a Part D plan include: your (percentage of the cost that Medicare monthly premium, if applicable. You Part D plan monthly premium, if appli- also will pay your Medicare Advantage does not pay). cable, any out-of-pocket costs such as plan monthly premium, if applicable. copays, coinsurance and deductibles Part C Medicare Advantage You are responsible for any out-of- included with the prescription drug plan plans pocket costs such as copays, deduct- that you choose, and a late enrollment ibles and coinsurance that come with penalty (this only applies if you have Part C is referred to as Medicare the Medicare Advantage plan you a period of 63 days without Part D Advantage plans. Medicare Advantage chose. coverage). plans are Medicare-approved private Additionally, there are two types Some Medicare Advantage plans health plans. Medicare Advantage of Medicare Advantage plans: Health cover prescription drugs. If your plan plans work differently from supplement Maintenance Organization (HMO) and does not cover your prescriptions, or plans. They allow you to get all of your Preferred Provider Organization (PPO). you do not have a Medicare Advantage Part A Hospital, Part B Medical and, HMO plans use a network of participat- plan, you may want to consider adding sometimes, Part D Prescription Drug ing hospitals and doctors for your care. Part D coverage. coverage combined into one plan. With an HMO plan, you must receive You want to make sure you get They also can provide you with some services from participating hospitals the most out of your Medicare ben- additional benefits and services that and doctors, except for emergency efits. Keep these helpful thoughts Original Medicare does not cover. care, out-of-area urgent care and in mind as you weigh your Medicare Medicare Advantage plans can have out-of-area kidney dialysis. Make sure coverage options. lower out-of-pocket costs than Original your current doctors are included in the Look for a plan that helps you save Medicare. plan’s provider network before joining with low cost doctor visits. This cost When enrolled in a Part C Medicare a plan. is a called a copay. This will be very Advantage plan, you can get coverage PPO plans offer coverage for important if you think you will visit the for: Medicare Part A (hospital cover- services received both in and out doctor often. Many Medicare Advan- age) and Medicare Part B (medical of the plan’s provider network. With tage plans offer options with savings at coverage). a PPO plan, you may pay a higher the doctor’s office. To join a Medicare Advantage coinsurance, copayment, or deductible Ask yourself, does this plan offer plan, you must: be a U.S. citizen or for care received outside of the plan’s care from respected doctors and lawfully present in the United States; participating provider network. hospitals in my area? Many plans offer be enrolled in Medicare Parts A and Part D prescription drug cost savings by requiring you to get B; live for six months or more each your medical care from doctors and year in the plan’s service area; and not coverage hospitals in a set network of providers have permanent kidney failure (some Part D coverage is offered through that accept the plan. Ask about the exceptions may apply). Medicare-approved private insurance network of any plan you are consid- Medicare Advantage plans help cov- companies. You can receive Part D ering. Find out if it offers high quality er all services that Parts A and B cover, coverage through a prescription drug care from the most trusted doctors and except hospice care (which is covered plan (PDP) or by including it in a Medi- hospitals in your community. by Medicare). Additional benefits and care Advantage prescription drug plan Look for a plan that gives you the services that Medicare does not cover (MAPD). coverage you need AND fits your include hearing, dental, vision, travel Part D helps cover brand-name monthly budget. This is why it is and fitness. and generic medications. Prescription important to compare your options. You will have some costs when coverage varies by plan; each plan has While some options may have lower enrolled in a Medicare Advantage a formulary that lists the drugs that are costs for hospital stays or specialist
416 www.acms.org PerspectivePerspective
visits, they may come with a steep company you are considering works tions so you can start to review your monthly premium. Determine what with Medicare. Medicare Advantage choices. Requesting this information your actual health needs are and find plans are Medicare-approved plans ensures that you will be able to review the plan that is right for you and your offered by companies with a Medicare all your options and select a choice budget. contract. Unlike Medicare Supplement you can feel confident in without DO NOT assume the plan you have plans, Medicare Advantage plans al- feeling pressured to make a decision. now will remain the same. Check to low you to get all your Part A hospital, Always make sure the information you see what is changing about your cur- Part B medial, and sometimes, Part D request is FREE, and that there is no rent coverage. The benefits you have prescription drug coverage combined obligation to buy anything for respond- now may change. This means you may into one plan. They also can provide ing. be able to get more savings and value you with some extra benefits and by switching to a new option. Find out services that Original Medicare does Dr. Ahuja is the current president what about your current health plan is not cover. of the Pennsylvania Geriatric Society – going to change. Start learning about Find out if the coverage option you Western Division. She is board certified your options now so you have time to are considering would require you to in Geriatrics and Hospice & Palliative make a smart decision. buy extra coverage for other needed Medicine and is senior medical direc- Consider if it is important for you to services such as preventive dental, tor of Medicare at UPMC Health Plan have doctor, hospital and prescription routine vision, fitness and world travel. and a clinical assistant professor with coverage in one plan. Having pre- Medicare Advantage offers import- the Division of Geriatric Medicine at scriptions included with your medical ant extra benefits you don’t get from University of Pittsburgh. She can be coverage may help you from having to Original Medicare alone. You pay one reached at [email protected]. take more than one card to the doctor, premium and get all your coverage hospital and pharmacy. A Medicare Ad- under one plan. These extra benefits The opinion expressed in this column is that vantage plan allows you to get all three add more value to your healthcare of the writer and does not necessarily reflect types of coverage for one monthly coverage and can help you stay the opinion of the Editorial Board, the Bulletin, or the premium with one card to carry. healthy. Allegheny County Medical Society. Make sure you know how the Request information about your op-
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ACMS Bulletin / December 2019 417 SocietyPerspective News
Diabetes Club program Attendees attracts record number listen to the presentation The Greater Pittsburgh Diabetes at the Greater Club (GPDC) met Oct. 29 at the Rivers Pittsburgh Casino. Ralph A. DeFronzo, MD, Diabetes speaker, presented: “Treatment of Club dinner T2DM: A Sound Approach Based upon program Oct. its Pathophysiology.” 29 at Rivers The program broke a record with Casino. the highest attendance to date (107) and the most exhibitor sponsors (14). The next GPDC educational pro- Michelle gram offering CME credits is scheduled Besanceney / for April 30, 2020, and will feature An- ACMS drew F. Stewart, MD, who will present: “Beta Cell Regeneration for Diabetes: discipline, including nursing, advanced 28th Annual Clinical Update in Geri- Moving from Impossible to Possible.” practice, physical therapy, pharmacy, atric Medicine conference, scheduled For more information, call Michelle occupational therapy, dentistry, audiol- for March 5-7, 2020, at the Pittsburgh Besanceney, administrator, at (412) ogy, speech-language, pathology and Marriott City Center. The ceremony will 321-5030, ext. 100, or email mbesan- social work, who have made significant take place Thursday, March 5, 2020, [email protected]. contributions to the education and where recipients will be honored with training of learners in geriatrics and to a plaque and receive complimentary Geriatrics Teacher of the Year the progress of geriatrics education membership in the society for one year. Award: Call for nominations open across the health professions. Members POS hosts November meeting The Penn- and non-members of the Pennsylvania sylvania Geri- Geriatrics Society will be considered. The Pittsburgh atrics Society Eligible nominees will have demon- Ophthalmology – Western strated leadership and inspired learn- Society (POS), met Division (PAGS- ers to better the care of older adults Nov. 7 at the Allegh- WD) is seeking and will have contributed to the growth eny County Medical nominations for of geriatrics in their professions. Teach- Society. the Geriatrics ing expertise and/or education program The Society wel- Dr. Dhaliwal Teacher of the development are valued in the selec- comed local faculty Year Award. tion of the recipient for this honor. and POS members Ian The award will Award eligibility and criteria, along Conner, MD, PhD, assistant professor be presented to with the nomination form, is available on of Ophthalmology, Glaucoma and Cat- two outstanding the Society’s website at www.pagswd. aract Service, chief of Ophthalmology, teachers for org. Nominations must be received UPMC Shadyside, diplomate, American their dedication on or before Jan. 25, 2020. Questions Board of Ophthalmology and associate and commit- regarding the awards or nomination residency program director, University ment to geriatrics education. process can be directed to Nadine of Pittsburgh School of Medicine; and The annual award will recognize Popovich, administrator, at npopovich@ Deepinder Dhaliwal, MD, L.Ac, pro- and honor both a physician and a acms.org or (412) 321-5030. fessor of Ophthalmology, University of professional from another healthcare Awardees will be recognized at the Pittsburgh School of Medicine, director
418 www.acms.org SocietyPerspective News
Nadine Popovich / ACMS At left, at the Nov. 7 POS meeting, are, from left, Jamie Odden, MD (resident presenter); Ian Conner, MD, PhD (pre- senter and POS Board member); and David Buerger, MD, FACS (POS president). At right, at the Dec. 5 POS meeting are, from left, Collin McClelland, MD (guest faculty); Gabrielle Bonhomme, MD (POS member); and Marshall Stafford, MD, POS president-elect.
of Refractive Surgery and the Cornea Thank you to Aerie Pharmaceuticals for ogy and adult strabis- Service, UPMC Eye Center and found- sponsoring the meeting. mus. Special thanks to er and director, Center for Integrative Pamela Rath, MD, for Eye Care, University of Pittsburgh. POS hosts December meeting inviting Dr. McClelland More than 60 members attended to The Pittsburgh Ophthalmology Soci- to speak and to Atlas hear Drs. Conner and Dhaliwal present ety (POS), met Dec. 5 at the Allegheny Ocular and Carl Zeiss two exceptional lectures, followed by County Medical Society and welcomed Meditec for their sup- Dr. McClelland active question-and-answer sessions Collin M. McClelland, MD, associate port of the program. after each lecture. professor, Department of Ophthalmol- Dr. McClelland Following the first lecture, Jamie ogy and Visual Neurosciences, Univer- presented two interesting lectures on Odden, MD, resident at the University sity of Minnesota, and the Reinhardt L. Diplopia and Tips in the Evaluation for of Pittsburgh Eye Center, presented an and Ruth H. Schmidtke Endowed Chair Giant Cell Arteritis, with a lively ques- interesting case for review and dis- in Neuro-Ophthalmology. Dr. McClel- tion and answer session following the cussion by Dr. Conner and attendees. land specializes in neuro-ophthalmol- Continued on Page 420
ACMS Bulletin / December 2019 419 SocietyPerspective News
From Page 419 pghoph.org. Thank you to Thierry Verstraeten, MD, for presentations. Jared Weed, MD, resident at the University inviting Dr. Singh and to Dutch Ophthalmic USA for support of Pittsburgh Eye Center, presented an interesting case for of the program. commentary by Dr. McClelland. POS members also are reminded to renew their member- Mark your calendar for upcoming 2020 ship dues. If you are unsure of membership status, please monthly meetings. The next monthly meet- contact Nadine Popovich, administrator, at (412) 321-5030 ing will take place Thursday, Jan. 9, when or [email protected]. the POS welcomes Ho Sun Choi, MD, San- Pennsylvania Medical Society announcements ta Clara Ophthalmology, San Jose, Calif. Dr. Choi specializes in the diagnosis and • Nominate a physician member for one of Pennsylvania treatment of cataracts, glaucoma, diabetic Medical Society’s (PAMED’s) annual awards between now Dr. Choi retinopathy, age-related macular degen- and Jan. 13 – www.pamedsoc.org/Awards eration, dry eye syndrome and other eye • PAMED’s Year-Round Leadership Academy is a great conditions. He also created the Solo Eye way for physicians to get foundational leadership skills Physicians network, which has more than – combination of online learning and live courses; peer-to- 130 members throughout the entire country. peer, professional development, and performance coaching; Dr. Choi currently serves as a committee the opportunity to work on a Capstone project; and a lot of member on the OMIC board of directors. CME are just some of the many benefits. The cost is $2,500 Thank you to Horizon Therapeutics for for members. Scholarships are available – apply by Feb. 3 support of the program. Dr. Singh – www.pamedsoc.org/YRA Complete meeting details and registration can be found • Medical marijuana often leaves physicians with more on the POS website at www.pghoph.org. questions than answers. PAMED is hosting a hands-on The final monthly meeting of the educational series will workshop April 20, 2020, at Mount Nittany Medical Center in be held Thursday, Feb. 6, 2020, when POS members wel- State College, Pa. Learn more and register at www.pamed- come Rishi Singh, MD, staff physician, Cole Eye Institute, soc.org/Marijuana2020. The cost is $49 for members. and medical director, Clinical Systems Office, Cleveland • NORCAL will be doing a more in-depth presentation on Clinic. In addition, Dr. Singh is associate professor of Oph- the topic of dealing with difficult patients at PAMED’s spring thalmology, Case Western Reserve University, Cleveland, practice administrator meetings (April 14 - Harrisburg/Live Ohio. Webcast, April 21 – Doylestown, and April 29 - Cranberry Dr. Singh will present: “Influence of systemic control on Township).For more information, visit https://www.nor- anti-VEGF treatment outcomes in diabetic macular edema” cal-group.com/library/topic/physician-ratings and “Diagnosis and management of central serous chorio- • Our next Frontline call will be held at 11:30 a.m. retinopathy.” Online registration begins January 14 at www. on Thursday, Jan. 9. To sign up, visit https://bit.ly/38AJkry.
Retiring? ACMS Members: New Partner? Professional announcement advertisements are available to ACMS members Congratulatory New Address? at our lowest prices. message? Contact Meagan Sable, managing editor, at [email protected].
420 www.acms.org InPerspective Memoriam
Robert Love Baker, MD, 93, died Maxwell Air Force Base in Montgom- (Kathleen), Andrew Hoffman Baker after a stroke sustained in July 2019. ery, Ala. (Allison), James Henry Thomas III Dr. Baker graduated in medicine Board certified in neurological sur- (Samantha), David Kessler Thomas, from Northwestern University and the gery in 1958, he practiced at more than Barbara Diane Thomas, Jessica Leigh University of Pittsburgh. He completed 20 hospitals in Western Pennsylvania, Dement Connolly (Paul), Timothy Miller his internship at St. Francis Medical serving patients from 1955-2003. Dement (Emily) and Bennett Baker De- Center in 1948-49. His neurological His wife of 65 years, Barbara Jane ment (Elizabeth); great-grandchildren surgery residency was one of the first Kessler Baker, is deceased. Also de- Penelope Jeanne Baker, Elizabeth at the Western Pennsylvania Hospital, ceased is a daughter, Gwendolyn Ann where he trained from 1949-52; he also Baker Thomas. Grace Baker and Liam Robert Baker; trained at the University of Pittsburgh Surviving are son Robert Love sister-in-law Vicki Kessler Cole; and from 1954-55. Baker II, DO (Connie); daughter numerous nieces and nephews. A veteran of the U.S. Air Force, he Patricia Diane Baker Dement (Joseph); A memorial service was held Satur- served as a captain during the Korean son-in-law James Henry Thomas Jr.; day, Dec. 7, 2019, at Hebron Church, War, practicing neurological surgery at grandchildren Robert Love Baker III Pittsburgh.
ActivitiesPerspective & Accolades
ACMS member recognized for contributions to rheumatology ACMS member celebrates new practice ACMS mem- ACMS member ber Susan Manzi, Nicole Vélez, MD, MD, MPH, is the founder of recipient of the Pittsburgh Skin, American College of held a grand Rheumatology’s 2019 opening Sept. Distinguished Clinical 26 to celebrate Dr. Manzi Investigator Award. the new practice. She recently was presented with the The event was award at the American College of facilitated by the Rheumatology/Association of Rheu- North Pittsburgh matology Professionals (ACR/ARP) Chamber of Annual Meeting in Atlanta. Commerce, who The meeting is attended by an esti- led the festivities. mated 16,000 participants from around Dr. Vélez is a the world. At this year’s event, Dr. dermatologist Manzi also had the honor of presenting and Mohs the “ACR: Year in Review” along with surgeon. David S. Pisetsky, MD, PhD, Duke University Medical Center. Chair of the Allegheny Health Network (AHN) Medicine Institute and Photo provided Continued on Page 424 2020 ACMS Membership Benefits
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[email protected] | Phone: 412-321-5030 | Fax: 412-321-5323 | prosuranthealth.com ActivitiesPerspective & Accolades
From Page 421 colleagues at the Lupus Center of Ex- data safety monitoring boards. director of its Lupus Center of Excel- cellence helped design Avise-SLE™ – “In addition to being a compassion- a blood test to help clinicians diagnose ate physician, insightful leader and lence, Dr. Manzi is among an elite lupus with greater ease and accuracy. devoted patient advocate, Dr. Manzi group of honorees including leading Her research program has been gener- is a brilliant clinical scientist whose researchers, clinicians, mentors and ously supported by organizations such contributions have led to significant other professionals who exhibit superi- as the National Institutes of Health advancements in quality, innovation or commitment to the advancement of (NIH), Department of Defense, Lupus and best practices in the diagnosis and the field of rheumatology. Foundation of America and the Arthritis treatment of patients with autoimmune Dr. Manzi is internationally known Foundation. Dr. Manzi has served on diseases,” said Mary Chester Wasko, for her research and patient care in advisory boards for the FDA and more MD, MSc, division director, Rheuma- lupus, and has published more than than 20 pharmaceutical and biotech tology, AHN. “As a true asset to the 200 research reports on lupus and companies, and has chaired or served rheumatology community, she could related diseases. Notably, she and her on numerous NIH study sections and not be more deserving of this award.”
Help your patients talk to you about their BMI
Allegheny County Medical Society is offering free posters explaining body mass index (BMI) and showing a colorful, easy-to-read BMI chart. The posters can be used in your office to help you talk about weight loss and management with your patients. To order a quantity of posters, call the society office at 412-321-5030. You can view or download a smaller version online at www.acms.org. Allegheny County Medical Society
For digital or display advertising information, call Terri Dowd, vice president, Business Development, at (412) 491-6811 or email [email protected].
424 www.acms.org Materia Medica Trikafta™ (ivacaftor/tezacaftor/elexacaftor) A breakthrough therapy for cystic fibrosis patients who carry at least one F508del mutation
Adam Patrick, mutation-specific CF, as more studies How it works2,3,4,5 are coming out attesting to the clinical PharmD candidate Elexacaftor and tezacaftor are benefits they may provide. Ivacaftor, “corrector” compounds that bind to a CFTR potentiator, has proven to be ystic fibrosis (CF) is a genetic different sites on the CFTR protein and well-tolerated and produced signifi- condition that affects the cystic work synergistically to facilitate the C cant results in CF patients with certain fibrosis transmembrane conductance cellular processing and trafficking of types of gating mutations.2 Dosing of regulator (CFTR) gene. This gene F508del-CFTR and thus increase the ivacaftor is dependent on age but is to codes for production of the CFTR amount of CFTR protein delivered to be taken twice a day with fatty foods protein which is incorporated into any the cell surface.3,4,5 Ivacaftor is a “po- to increase absorption. In patients organ that produces mucus; these or- tentiator” that aids in opening the chan- with two copies of F508del, the most gans include but are not limited to the nel gate of the CFTR protein at the common mutation in CF patients, lungs, liver, pancreas, intestines and cell surface.2,5 The combined effects 1 the “corrector” drugs lumacaftor and sweat glands. The primary function of of elexacaftor, tezacaftor and ivacaftor mucus is to protect the linings of the tezacaftor have been used in combi- nation with ivacaftor to provide clinical increase the quantity and function airways, digestive tract and other or- benefits in patients with the identified of F508del-CFTR at the cell surface gans and tissues by forming a natural mutations.3,4 In patients older than 12 leading to greater CFTR activity and slick buffer. In individuals with CF, the years, lumacaftor 200mg/ivacaftor improved chloride transport across the mucus is thick and sticky and can build 5 125 mg (Orkambi™) is taken every membrane. up, leading to blockages, damage, or 12 hours daily with fat-containing 5 infections. The lungs are most often Indication foods, while tezacaftor 100 mg/iva- involved in the serious complications caftor 150mg (Symdeko™) is taken Trikafta™ is indicated for the related to disease progression, but once in the morning with a dose of treatment of CF in patients of at least patients also may have difficulty main- ivacaftor 150 mg taken 12 hours later 12 years of age who carry at least one 5 taining adequate nutritional status due in the evening.3,4 Lumacaftor/iva- F508del mutation in the CFTR gene. to impaired nutrient absorption. While caftor(Orkambi™) was approved for Dosage5 there is not yet a cure for CF, patients use in 2015, and tezacaftor/ivacaftor are leading longer, healthier lives Adults and pediatric patients aged (Symdeko™) was approved for use in 5 thanks to advancements in the treat- 2018.3,4 12 years and older: ment and support of the condition. • Morning dose: Two elexacaftor 5 CF patients are most often pre- What it is 100 mg/tezacaftor 50 mg/ivacaftor 75 scribed a variety of medications Trikafta™ is a combination of mg tablets by mouth including antibiotics, anti-inflammatory ivacaftor, tezacaftor and elexacaftor • Evening dose: One ivacaftor 150 medications, bronchodilators, mucus approved by the U.S. Food and Drug mg tablet by mouth thinners and CFTR modulators.1 Administration (FDA) for the treatment • Doses should be taken approxi- CFTR modulators are rapidly becom- CF in patients aged 12 years and older mately 12 hours apart with fat-contain- ing more popular in their use as a who have at least one F508del muta- ing food.5 mainstay therapy for the treatment of tion in the CFTR gene.5 Continued on Page 426
ACMS Bulletin / December 2019 425 Materia Medica
Table 1.6,7 Primary and Secondary Heterozygous F508del Homozygous F508del Endpoints mutation (vs placebo) mutation (vs tezacaftor/ ivacaftor) % improvement in absolute 13.8 (95% CI: 12.1, 15.4; 10.0 (95% CI: 7.4, 12.6; change in lung function at P<0.0001) P<0.0001) week 4 % improvement in absolute 14.3 (95% CI: 12.7, 15.8; -- change in lung function at P<0.0001) week 24 Mmol reduction sweat 41.8 (95% CI: -44.4, -39.3; 45.1 (95% CI: -50.1, -40.1; chloride through week 24 P<0.0001) P<0.0001) % reduction in pulmonary 63 (RR: 0.37 [95% CI: 0.25, -- exacerbations 0.55]; P<0.0001) Point improvement in CFQ-R 20.2 (95% CI: 17.5, 23.0; 17.4 (95% CI: 11.8, 23.0; respiratory domain score P<0.0001) P<0.0001)
From Page 425 reactions to Trikafta™ (occurring in drinks containing grapefruit should be 5 • Should not be used in patients ≥5% of patients and at a frequency avoided. higher than placebo by ≥1%) were with severe hepatic impairment (Child- Contraindications5 Pugh Class C). Patients with moderate headache, upper respiratory tract hepatic impairment (Child-Pugh Class infection, abdominal pain, diarrhea, Trikafta™ should not be used in pa- B) should be assessed to determine rash, alanine aminotransferase tients with severe hepatic impairment 5 if potential benefit exceeds the risk. If increased, nasal congestion, blood (Child-Pugh Class C). creatine phosphokinase increased, therapy is to be used in these pa- Use in pregnancy5 tients, they should only receive the aspartate aminotransferase increased, two Trikafta™ tablets in the morning rhinorrhea, rhinitis, influenza, sinusitis There is limited human data from 5,6,7 without taking the ivacaftor dose in the and blood bilirubin increased. Nota- clinical trials on the use of Trikafta™ or evening. Liver function tests should be bly, the incidence of rash events was its individual components, elexacaftor, closely monitored.5 higher in female Trikafta™-treated tezacaftor and ivacaftor, in pregnant • Reduce dose when co-adminis- patients (16%) than in male Trikaf- women to inform a drug-associated 5 tered with drugs that are moderate or ta™-treated patients (5%).5,6,7 Hor- risk. 5 strong CYP3A inhibitors. monal contraceptives may play a role Clinical efficacy5,6,7 in the occurrence of rash.5,6,7 How supplied5 The efficacy of Trikafta™ in patients Drug interactions5 Trikafta™ is only supplied as a fixed with CF aged 12 years and older was dose combination containing elex- Trikafta™ should be appropriately evaluated in two Phase 3, double-blind, acaftor 100 mg, tezacaftor 50 mg and dose reduced when co-administered controlled trials. Patients discontinued ivacaftor 75 mg. It is co-packaged with with strong (e.g., ketoconazole, itracon- any previous CFTR modulator thera- ivacaftor 150 mg tablets.5 azole, posaconazole, voriconazole, pies, but continued on their other stan- telithromycin and clarithromycin) or dard-of-care CF therapies. Patients 5,6,7 Adverse events moderate (e.g., fluconazole, erythro- had a ppFEV1 at screening between The most common adverse drug mycin) CYP3A inhibitors. Foods and 40-90%. Patients with a history of
426 www.acms.org Materia Medica colonization with organisms associated baseline at week 4 and through week Conclusion1-8 with a more rapid decline in pulmonary 24 all reported statistically significant Trikafta™ is a triple combination of status, including but not limited to Bur- treatment difference indicating the elexacaftor, tazocaftor and ivacaftor kholderia cenocepacia, Burkholderia superiority of Trikafta™ over placebo that is available as an oral tablet and dolosa, or Mycobacterium abscessus, (Table 1, page 426).6 is FDA-approved for CF patients that or who had an abnormal liver function The second trial was a four-week, are 12 years or older and who have test at screening, were excluded from randomized, double-blind, active-con- at least one F508del mutation of the the trials.6,7 trolled study in patients who are CFTR gene. Where previously ap- The first trial was a 24-week, ran- homozygous for the F508del muta- proved therapies required patients domized, double-blind, placebo-con- tion.7 Patients received tezacaftor 100 to be homozygous for the F508del trolled study in patients who had an mg qd/ivacaftor 150 mg q12hr during mutation, Trikafta™ can cover patients F508del mutation on one allele and a four-week open-label run-in period even if they are only heterozygous for a mutation on the second allele that and were then randomized and dosed the mutation. This represents a broad- results in either no CFTR protein or a to receive Trikafta™ or tezacaftor 100 ening spectrum of coverage that can CFTR protein that is not responsive mg qd/ivacaftor 150 mg q12hr during now affect 90% of CF patients.1 In two to ivacaftor and tezacaftor/ivacaftor.6 a four-week double-blind treatment clinical trials, one comparing against This trial evaluated 200 Trikafta™ and period.7 There were 107 patients with placebo and the other comparing 203 placebo patients with CF aged CF aged 12 years and older with a against tezacaftor/ivacaftor, Trikafta™ 12 years and older with the mean age mean age of 28.4 years evaluated in was shown to lead to statistically being 26.2 years. The primary end- this trial.7 The primary endpoint was significant improvements in absolute point assessed at the time of interim mean absolute change in ppFEV1 change in lung function and CFQ-R analysis was mean absolute change from baseline at week four of the dou- respiratory domain score as well as in ppFEV1 from baseline (mean at ble-blind treatment period. Following baseline: 61.4%) at week four.6 Of the the four-week open-label run-in period reductions in pulmonary exacerbations 403 patients included in the interim with tezacaftor/ivacaftor, mean base- and sweat chloride levels. Its wide analysis, there was a 13.8% (95% CI: line ppFEV1 was assessed at 60.9%.7 applicability across heterozygous and 12.1, 15.4; P<0.0001) treatment differ- Treatment with Trikafta™ compared homozygous F508del mutated patients ence between Trikafta™ and placebo to tezacaftor/ivacaftor resulted in a paired with its early and significant for the mean absolute change from statistically significant improvement clinical response lead many to believe baseline in ppFEV1 at week four.6 in ppFEV1 of 10.0% (95% CI: 7.4, that Trikafta™ is a huge step forward in The treatment difference for the mean 12.6; P<0.0001).7 The key secondary the treatment of CF but further compar- absolute change in ppFEV1 from efficacy endpoints were absolute ative studies are needed to definitively baseline through week 24 was similar change in sweat chloride and CFQ-R determine its place in therapy. to week four at 14.3% (95% CI: 12.7, Respiratory Domain Score from base- 15.8; P<0.0001).6 Improvements in line at week four and both reported At the time of this writing, Mr. Patrick ppFEV1 were observed regardless of back statistically significant treatment was on a clinical rotation in the Center age, sex, baseline ppFEV1 and geo- difference in patients treated in the for Pharmaceutical Care at Allegheny graphic region. Secondary endpoints Trikafta™ arm vs the tezacaftor/iva- General Hospital. For any questions of absolute change in sweat chloride caftor arm (Table 1).7 concerning this article, please contact Tucker Freedy, PharmD, at the Allegh- from baseline at week 4 and through 8 week 24, number of pulmonary exac- Cost information eny Health Network, Allegheny General erbations through week 24, absolute Trikafta™ will cost $311,503 annual- Hospital, Center for Pharmaceutical change in BMI from baseline at week ly, or $23,896 per 28-day pack, accord- Care, Pittsburgh, Pa., (412) 359-3192, 24, and absolute change in CFQ-R ing to the Securities and Exchange or email [email protected]. Respiratory Domain Score from Commission.8 Continued on Page 428
ACMS Bulletin / December 2019 427 Materia Medica
From Page 427 2017;101(1):130–141. 7. Heijerman HGM, McKone EF, 4. Taylor-Cousar JL, Munck A, McKone Downey DG, et al. Efficacy and safety of References EF, van der Ent CK, Moeller A, Simard C, the elexacaftor plus tezacaftor plus ivacaftor 1. U.S. Department of Health and et al. Tezacaftor–ivacaftor in patients with combination regimen in people with cystic Human Services, National Heart, Lung, cystic fibrosis homozygous for Phe508del. N fibrosis homozygous for the F508del mu- and Blood Institute. (2019). Cystic Fibrosis. Engl J Med 2017;377:2013-23. tation: a double-blind, randomised, phase Bethesda, MD: U.S. Government Printing (TM) Office. 5. TRIKAFTA oral tablets, elexacaftor, 3 trial. Lancet (Published Online October 2. Condren M.E., Bradshaw M.D. tezacaftor, ivacaftor oral tablets; ivacaftor 31, 2019 https://doi.org/10.1016/ S0140- Ivacaftor: A novel gene-based therapeutic oral tablets. Vertex Pharmaceuticals Incor- 6736(19)32597-8). approach for cystic fibrosis. J Pediatr Phar- porated (per manufacturer), Boston, MA, 8. FDA approves drug to treat cystic macol Ther 2013;18:8–13. 2019. fibrosis in patients 12 and older-and it 3. Schneider E.K., Reyes-Ortega F., 6. Middleton PG, Mall MA, Dřevínek P, et will cost $311,503. Advisory Board. 2019; Li J., Velkov T. Can Cystic Fibrosis Pa- al. Elexacaftor–Tezacaftor–Ivacaftor for Cys- published online Oct 28. https://www.advi- tients Finally Catch a Breath With Luma- tic Fibrosis with a Single Phe508del Allele. N sory.com/daily-briefing/2019/10/28/cf-drug caftor/Ivacaftor? Clin Pharmacol Ther Engl J Med 2019; 381(19):1809-1819. (accessed Nov 5, 2019).
Legal Report
Regulatory sprint to coordinated care: New Stark and Anti-Kickback rules
Michael A. Cassidy, Esq. n Oct. 22, 2019, the Centers for are confusingly similar with respect to The regulators have provided “Stark OMedicare & Medicaid Services their intended purpose, they serve the Law Exceptions” and “Anti-Kickback (CMS) and OIG (Office of Inspector following different functions: Safe Harbors” which are remarkably General) released new proposed 1. The Stark Act prohibits physicians similar but apply in the different context rules regarding Stark Law Exceptions from referring only the Stark “desig- described above. and Anti-Kickback Safe Harbors in nated health services” to healthcare In general, the new Safe Harbors response to what has universally been entities with which they have financial and Exceptions cover three major christened as the “Regulatory Sprint relationships. areas: to Coordinated Care,” first announced 2. The Anti-Kickback statute pro- 1. Coordinated Care and Val- by the U.S. Department of Health and hibits anyone from paying, receiving, ue-Based Enterprises. Human Services (HHS) in June 2018. soliciting, or offering any kind of remu- 2. Extension of the EHR Safe Har- As background, please remember neration in exchange for the referral of bor sunset. that, although the Anti-Kickback Safe any Medicare or governmental health 3. Revising the definition of fair mar- Harbors and the Stark Law Exceptions covered service. ket value that applies to both the Stark
428 www.acms.org Legal Report
Law Exceptions and the Anti-Kickback on pages 430 and 431. competing for a bigger share of the Safe Harbors (AKS). In order to provide a sense of the health care dollar without regard to This article is intended to cover vagueness of the intended scope of the inefficiencies that resulted for the the “new kid on the block,” i.e., the these arrangements, I have inserted system as a whole – in other words, value-based enterprises (VBE). The the two following quotes from the regu- a volume-based system. According new definitions for the Stark Act and latory announcements: to several commenters, the current the AKS are each attached as Exhibit physician self-referral regulations – Evolution of healthcare A and Exhibit B, respectively. A VBE is intended to combat overutilization in a essentially defined as two or more VBE landscape volume-based world – are outmoded participants collaborating to achieve “The health care landscape when because, by their nature, integrated at least one value-based purpose as the physician self-referral law was care models protect against overutiliza- parties to a value-based arrangement, enacted bears little resemblance to the tion by aligning clinical and economic which has an accountable body or landscape of today. As some CMS RFI performance as the benchmarks for person responsible for management commenters highlighted, the physi- value. And, in general, the greater the and a governing document describing cian self-referral law was enacted at economic risk that providers assume, its purpose. That is a rather circular a time when the goals of the various the greater the economic disincentive to definition, and the specific definitions components of the health care system overutilize services. According to more for both the Anti-Kickback Safe Harbor were not merely unaligned but often than one of these commenters, the and the Stark Exceptions can be found in conflict, which each component Continued on Page 430
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ACMS Bulletin / December 2019 429 Legal Report
From Page 429 New Definitions: Stark Act (Exhibit A) current prohibitions are even antithetical Value-Based Activity: to the stated goals of policy makers (1) Means any of the following activities, provided that the activity is reasonably both in the Congress and within HHS designed to achieve at least one value-based purpose of the value-based enterprise: (i) The provision of an item or service; for health care delivery and payment (ii) The taking of an action; or reform. Although we agree in concept, (iii) The refraining from taking an action. (2) The making of a referral is not a value-based activity. we continue to operate substantially in a volume-based payment system. Thus, Value-Based Arrangement: means an arrangement for the provision of at least one value-based activity for a target patient population between or among— we must proceed with caution, even (1) The value-based enterprise and one or more of its VBE participants; or as we propose the significant changes (2) VBE participants in the same value-based enterprise. outlined in this proposed rule.” Value-Based Enterprise (VBE): means two or more VBE participants— The government regulators are late (1) Collaborating to achieve at least one value-based purpose; (2) Each of which is a party to a value-based arrangement with the other or at least to the game in recognizing the ambigu- one other VBE participant in the value-based enterprise; ity and the absence of reality regarding (3) That have an accountable body or person responsible for financial and operational oversight of the value-based enterprise; and the existing regulations. The regulatory (4) That have a governing document that describes the value-based enterprise philosophy has long been to make ev- and how the VBE participants intend to achieve its value-based purpose(s). erything illegal and then work their way Value-Based Purpose: means— backwards, granting Exceptions and (1) Coordinating and managing the care of a target patient population; (2) Improving the quality of care for a target patient population; Safe Harbors, precisely because actu- (3) Appropriately reducing the costs to, or growth in expenditures of, payors without reducing the quality of care for a target patient population; or ally “describing” an acceptable arrange- (4) Transitioning from health care delivery and payment mechanisms based on the ment is extremely difficult, especially volume of items and services provided to mechanisms based on the quality of care and control of costs of care for a target patient population. when the violation could be based upon the intent of the individuals. That lack of VBE Participant: means an individual or entity that engages in at least one value-based activity as part of a value-based enterprise. clarity has always created a great deal of potential risk for participants. Target Patient Population: would mean an identified patient population selected by a value- based enterprise or its VBE participants based on legitimate and verifiable criteria that are set out in writing in advance of the commencement of the value-based arrangement and further the VBE description value-based enterprise’s value-based purpose(s). “We intend the definition of ‘val- ue-based enterprise’ to include only and how the parties intend to achieve organized groups of health care provid- qualifying as a value-based enterprise.” ers, suppliers, and other components its value-based purpose(s). Whatever Accountable care organizations of the health care system collaborating its size and structure, a value-based (ACOs) were the first attempt to pro- to achieve the goals of a value-based enterprise is essentially a network of vide exceptions for organized health- health care system. An ‘enterprise’ may participants (such as clinicians, pro- care enterprises. ACOs were created be distinct legal entity – such as an viders and suppliers) that have agreed by the Accountable Care Act of 2010. ACO – with a formal governing body, to collaborate with regard to a target A standing joke for legal presenters operating agreement or bylaws, and patient population to put the patient at discussing ACOs was to ask the audi- the ability to receive payment on behalf the center of care through care coor- ence what an ACO was called before of its affiliated health care providers. dination, increase efficiencies in the it was called an ACO. The answer is: An ‘enterprise’ may also consist only delivery of care, and improve outcomes a felony! of the two parties to a value-based for patients. We have proposed our These ideas are new, and the arrangement with the written docu- definition of ‘value-based enterprise’ in general intent is to protect legitimate mentation recording the arrangement terms of the functions of the enterprise value-based enterprises from the serving as the required governing as it is not our intention to dictate or Anti-Kickback or the self-referral pro- document that describes the enterprise limit the appropriate legal structure for hibitions. However, at this stage, they
430 www.acms.org Legal Report Moving? New Definitions: Anti-Kickback Safe Harbors (Exhibit B)
Value-based activity Be sure to let (A) Means any of the following activities, provided that the activity is reasonably designed to achieve at least one value-based purpose of the value-based enterprise: (1) The provision of an item or service; us know .... (2) The taking of an action; or (3) The refraining from taking an action. (B) Does not include the making of a referral. We can update our Value-based arrangement means an arrangement for the provision of at least one value-based activity for a target patient population between or among: system to better serve (A) The value-based enterprise and one or more of its VBE participants; or (B) VBE participants in the same value-based enterprise. you! When your
Value-based enterprise or VBE means two or more VBE participants: patients call, (A) Collaborating to achieve at least one value-based purpose; (B) Each of which is a party to a value-based arrangement with the other or at least one other VBE participant in the value-based enterprise; we will know where (C) That have an accountable body or person responsible for financial and operational oversight of the value-based enterprise; and to send them. (D) That have a governing document that describes the value-based enterprise and how the VBE participants intend to achieve its value-based purpose(s). Call (412) 321-5030
Value-based enterprise participant or VBE participant means an individual or entity that to update your engages in at least one value-based activity as part of a value-based enterprise. VBE participant does not include a pharmaceutical manufacturer; a manufacturer, distributor, or information. supplier of durable medical equipment, prosthetics, orthotics, or supplies; or a laboratory.
Value-based purpose means: (A) Coordinating and managing the care of a target patient population; (B) Improving the quality of care for a target patient population; (C) Appropriately reducing the costs to, or growth in expenditures of, payors without reducing the quality of care for a target patient population; or Where to turn… (D) Transitioning from healthcare delivery and payment mechanisms based on the volume of items and services provided to mechanisms based on the quality of care and control of costs Domestic Abuse of care for a target patient population. Palm Cards Target Patient Population means an identified population selected by the VBE or its VBE participants using legitimate and verifiable criteria that: (A) Are set out in writing in advance of the commencement of the value-based Available at ACMS arrangement; and (B) Further the value-based enterprise’s value based purpose(s). Where-to-Turn cards
give important information are obviously quite vague. This calls of explanation, fairly broad in the terms and phone numbers for to mind Justice Potter Stewart’s quote of coverage and without any actual ex- victims of domestic violence. regarding pornography: amples of what does and doesn’t work, The cards are the size of a “I shall not today attempt further you should be very cautious when you to define the kinds of material I un- first participate in any VBE design to business card and are derstand to be embraced within that take advantage of these situations. discreet enough to carry in a shorthand description, and perhaps wallet or purse. I could never succeed in intelligibly Mr. Cassidy is a shareholder at doing so. But I know it when I see it Tucker Arensberg and is chair of the Call ACMS at …” – Jacobellis v. Ohio (U.S. Supreme firm’s Healthcare Practice Group; he (412) 321-5030 for more Ct. 1964). also serves as legal counsel to ACMS. information. Since these proposed regulations He can be reached at (412) 594-5515 are brand new, fairly short in the way or [email protected].
ACMS Bulletin / December 2019 431 Special Report Update on the prevalence of blindness at the Western Pennsylvania School for Blind Children
Background n 2005, we reported the causes of childhood blindness at Iour school between years – 1887 through 2000. Over the past four decades, we have observed an evident change in the causes for blindness in our school population. The most common causes for blindness are no longer related to defects in the eyes, but rather due to changes within the brain and visual pathways: cortical visual impairment (CVI). Today, more than 70% of the children at the Western Heidi Ondek, Albert Biglan, Beth Ramella, Pennsylvania School for Blind Children (WPSBC) have a di- EdD MD MEd agnosis of CVI. The education of this population of children has been greatly reduced by improved instrumentation and is a challenge and requires many specialized adaptations newer surgical techniques. Blindness due to glaucoma and in the educational process to provide the children with an children’s cataracts has been greatly reduced. education and to foster their autonomy. Herein, we provide The epidemic of blindness caused by retinopathy of information on CVI and we relate how to best educate these prematurity (ROP) has been reduced by early treatment. children. However, even with improved neonatal care, the premature Progress: Many causes for blindness in infant remains at risk for ROP and is highly susceptible to intraventricular hemorrhages (IVH). These hemorrhages can children have been reduced or eliminated damage the optic radiations and can add a cortical compo- In the early part of the 20th Century, blindness was nent to the infant’s blindness. mainly caused by conditions that are now, for the most part, With effective treatments reducing causes for blindness, treatable. Corneal opacification due to infection was elimi- cortical defects have arisen as the most common cause of nated with the introduction of the Crede’ prophylaxis (1900) blindness in children attending our school. Table 1 (below, and the introduction of penicillin in the 1940s. page 433) lists the five most prevalent causes of blindness Blindness related to retinal detachments in childhood in children attending our school over the past 18 years.
Table 1. Causes for blindness at the WPSBC: Top 5 vision conditions for each year
Year 2000: 183 students Vision Diagnosis Number of Children Cortical Visual Impairment (CVI) 84 Optic Nerve Disorders 27 Retinopathy of Prematurity (ROP) 11 Septo-Optic Dysplasia (SOD) 10 Retinal Disorders 9
432 www.acms.org Special Report
Year 2005: 185 students Vision Diagnosis Number of Children Cortical Visual Impairment (CVI) 97 Optic Nerve Disorders 20 Retinopathy of Prematurity (ROP) 17 Septo-Optic Dysplasia (SOD) 8 Retinal Disorders 7 Year 2010: 182 students Vision Diagnosis Number of Children Cortical Visual Impairment (CVI) 91 Optic Nerve Disorders 17 Retinal Disorders 14 Retinopathy of Prematurity (ROP) 14 Septo-Optic Dysplasia (SOD) 12 Year 2015: 187 students Vision Diagnosis Number of Children Cortical Visual Impairment (CVI) 119 Optic Nerve Disorders 20 Retinal Disorders 10 Retinopathy of Prematurity (ROP) 9 Cataracts 5 Year 2019: 188 students Vision Diagnosis Number of Children Cortical Visual Impairment (CVI) 130 Optic Nerve Disorders 16 Retinal Disorders 12 Septo-Optic Dysplasia (SOD) 9 Retinopathy of Prematurity (ROP) 6
What is cortical visual impairment (CVI)? The term cortical visual impairment, sometimes referred Although vision or sight is primarily associated with to as “cortical blindness,” is blindness that occurs as a result the eyes, the eyes are only a part of the complex system of injury to, or lack of proper development of, the brain. needed for processing visual information. It has been esti- Causes include asphyxia, prematurity with intraventricular mated that about 40% of the brain is involved with the visual hemorrhage extending into the brain causing peri ventricular system. Unlike children with defects in the eyes or anterior leukomalacia (PVL), hydrocephalus, stroke, head trauma, visual pathways, children with CVI usually have normal “shaken baby” and infections such as meningitis or enceph- appearing eyes but they will have difficulty processing or alitis. understanding what their eyes see. Continued on Page 434
ACMS Bulletin / December 2019 433 Special Report
From Page 433 dren. The cause, extent and timing individuals with blindness and visual Symptoms and signs observed in of the cortical damage will determine impairment. an infant or very young child with CVI the extent of recovery of vision and We at the WPSBC recognize our include poor eye contact after 3-6 function. Following the insult, a child’s responsibility to continuously pursue months of age. The child may prefer brain may slowly recover lost function. improved methods of identification and viewing objects with high contrast or With intervention, brain plasticity may educational interventions for children bright colors, use head movement reorient pathways to recover some believed to have CVI. For this to hap- to sustain visual attention, demon- function. pen, medical research in partnership with special educators of the visually strate visual latency, field preference, Is this important? non-purposeful gaze, absent blink impaired is essential. reflex, variable vision, and objects may The high prevalence of cortical blindness that we see at the WPS- Programs for CVI at the be held close to the eyes. WPSBC The diagnosis of CVI requires a BC is a problem of most developed thorough examination of the visual countries. With the reduction of the WPSBC is a leader in CVI instruc- system. A complete history to include eye-related causes of blindness, the tional strategies. On campus, and with birth and the neonatal period is a great remaining population may have CVI our outreach programs, our school has place to start. Questions about infec- and have complex medical issues. established a separate CVI program tions, strokes, hemorrhages and head Working to educate these children with for enrolled and non-enrolled students. trauma should follow. physical and intellectual challenges, This program draws families of children On examination, the eyes are and to provide them with some degree with CVI, or suspected CVI, from all usually found to be normal but may of autonomy, is a challenge to the child, over the United States. The goal of exhibit some degree of secondary family, therapists, the educators and to our educational program is to maxi- optic nerve atrophy. Additional testing society. mize potential in undamaged areas of should include assessment of the level Western Pennsylvania School the brain and to facilitate functioning of visual acuity using high contrast areas of the brain to develop plasticity objects, and assessment of the field of for Blind Children (WPSBC) and reorganized pathways to provide vision. The anterior visual pathways, Established in 1887, the Western better visual function. Programs at the pupil reflexes, are usually normal. The Pennsylvania School for Blind Children’s school are linked with many of our local clinical evaluation should be followed (WPSBC) educational program was universities. by an MRI scan of the head. Spe- initially geared toward serving students Beginning education cialized ophthalmic testing may be with the single disability of blindness. considered: visually evoked response With a change in the population served, and habilitation/rehabilitation (VER), pattern, visual evoked potential school programs have evolved and have Early contact of the family with (VEP) and possibly an electroretino- been restructured to provide services available services and intervention are gram (ERG) to exclude retinal causes for children with medical complexity and critical to success. Research on critical for blindness. blindness. periods of development prove that op- CVI may cause only mild reduction The mission of the Western Penn- portunities are lost when interventions of central vision or reduction of the sylvania School for Blind Children is to are delayed. field of vision. CVI may be tempo- nurture the unique abilities of individ- We recommend that the family or rary or permanent. Research shows uals with blindness and visual impair- caregivers visit our school as soon as that children with proper educational ment through educational excellence the diagnosis has been established. interventions and who are neurolog- and a lifetime of learning. The vision Families with children with suspected ically stable make marked progress of the Western Pennsylvania School CVI can be self-referred to our school over time. Recovery of some visual for Blind Children is to be a global for evaluation at any age. When they function may be seen in some chil- leader in education and advocacy for can be scheduled on our campus, our
434 www.acms.org Special Report assessments are provided at no cost instruction recommendations, con- be driven by the child’s vision. These to the family. The child should have sultation on the current Individualized assessments are reviewed and updat- a medical evaluation and diagnosis Education Plan (IEP) and adaptations ed annually and modified to respond to established by a medical professional. are given for presenting material, not progress made and maturation of the Eye care professionals, physicians, only in school, but also for daily life child. school districts, early intervention activities. agencies and Intermediate Units are Ongoing services the source of many of our regional Recommendations and Education is a lifelong process. referrals. implementation Our staff remains dedicated to the success of each individual. Our goal Assessment of the child’s Immediately following the as- sessment, an informal verbal report is to ensure that each child receive an capability is shared with the parents including optimal education and is committed to The first part of the process is some basic recommendations. This is providing skills which are needed for a comprehensive evaluation and followed by a comprehensive narrative daily life. To provide this, our school’s functional assessment of the child’s report including recommendations. professional team of teachers, ther- capabilities with a goal of determining This report is provided to the parents apists, instructional aides and resi- the best way to reach and stimulate with extra copies which can be dis- dential aides receive ongoing training the child. This assessment includes the tributed to educators, physicians and specific to CVI. The needs of each child with family members and uses an specialists such as physical therapists, child are continually evaluated and interview format. occupational therapists, speech ther- updated to better help the child and For enrolled students or students apists and mobility specialists. This family adapt to the daily environments participating through an outreach clinic, report includes a design for instruction and make learning accessible for we partner with parents, medical pro- and intervention that matches the students. viders and school districts to conduct child’s visual function and medical Providing a proper education and appropriate functional vision evalua- needs. safe care for our students is labor tions specific to the child with CVI. Some learning strategies may intensive. At our Oakland location, The assessment is a three-part include modifying materials (i.e., use we have a staff to child ratio of 4:1 process which includes interviewing of a particular color and light; adding and a 24-hour, on-site nursing staff to the parents, observing the child and Mylar to the surface of a target to oversee and respond to the complex direct assessment. The assessment is “grab” visual attention; presenting medical needs that often accompany made over a period of approximately material on a black background; high- children with CVI. two hours. lighting around print letters in a color; Support for our school comes in part During the interview, the history of occluding parts of a page for print to from students’ home school districts, birth and development and any medical decrease complexity) in all forms of which pay 40% of tuition; the Com- issues are reviewed. The child is ob- learning instruction. These modifi- monwealth of Pennsylvania pays 60%. served to determine how they play and cations make the learning materials Private donations and grants, and the interact with a variety of visual stimuli. accessible to the educator and student WPSBC Foundation, fund an array The assessment is used to determine and are individualized based on the of supports and services that would the child’s current level of functional results of assessment. These recom- not otherwise be made available for vision, to determine the child’s level of mendations also should be integrated students. functional vision and to make recom- into the student’s daily routine. Vision Graduation and beyond mendation on building upon the vision strategies are written and included they have developed using accessible in the Specially Designed Instruction Following graduation, it is import- materials, environments and learning section of each student’s Individual- ant that the school provide continuing strategies. From the assessment, ized Education Plan (IEP). The IEP will Continued on Page 436
ACMS Bulletin / December 2019 435 Special Report
From Page 435 Children, 201 North Bellefield Ave., Dr. Biglan is a retired pediatric guidance and support for the grad- Oakland, Pittsburgh, Pa., 15213-1499; ophthalmologist who has served on the (412) 621-0100; or Albert Biglan, MD, Board of the WPSBC since 2000. uated young adult and the family. at [email protected] or (412) 794- Services for continuing support are 8581. Ms. Ramella has been working at sporadic. The school advocates for the Western Pennsylvania School for state, federal and private funding for Dr. Ondek joined the Western Blind Children for more than 20 years. programs that will continue this edu- Pennsylvania School for Blind Chil- Currently, she is the outreach director cation and support process throughout dren as superintendent and executive and CVI project leader. In her outreach life. director in July 2018. She began her position, she creates and implements For more information or to schedule career in public education more than programming for blind and visually a CVI evaluation, contact Beth Ramella 30 years ago as a special education impaired students across the state of at (412) 621-6028. teacher, later becoming director of Pennsylvania and evaluates children If you or one of your staff would pupil services, elementary princi- at both the Outreach Program and CVI like a tour of our unique educational pal, high school principal, assistant Clinic. Ms. Ramella is Perkins-Roman facility, you can contact Heidi On- superintendent and superintendent in CVI Endorsed and a mentor for Cor- deck, EdD, at https://www.wpsbc.org; various school districts in Texas and tical Visual Impairment in the state of Western Pennsylvania School for Blind Pennsylvania. Pennsylvania.
940M20260-011 Medtronic HCP Product Half Page Ad OUTLINED.indd 1 1/24/19 2:09 PM 436 www.acms.org Special Report
REPORTABLE DISEASES 2019: Q1-Q3
Allegheny County Health Department Selected Reportable Diseases/Conditions
January to September Selected Reportable Disease/Condition* 2017 2018 2019** AMEBIASIS 1 1 1 CAMPYLOBACTERIOSIS 89 110 95 CREUTZFELDT-JAKOB DISEASE 4 3 1 CRYPTOSPORIDIOSIS 19 22 27 DENGUE FEVER 0 0 1 GIARDIASIS 26 45 67 GUILLAIN-BARRE SYNDROME 4 0 1 HEPATITIS A 5 4 7 HEPATITIS B ACUTE 10 3 3 HEPATITIS B CHRONIC 52 50 58 LEGIONELLOSIS 84 75 74 LISTERIOSIS 3 3 3 MALARIA 4 4 3 MEASLES 0 1 7 MUMPS 1 2 2 NEISSERIA MENINGITIDIS 0 1 1 PERTUSSIS 53 15 29 SALMONELLOSIS 122 102 105 SHIGELLOSIS 11 15 12 SHIGATOXIN-PRODUCING E COLI 5 19 14 STREPTOCOCCUS PNEUMONIAE INVASIVE 45 32 35 TOXOPLASMOSIS 6 1 3 TYPHOID FEVER 1 1 1 VARICELLA 38 18 23 WEST NILE VIRUS 2 1 0 ZIKA VIRUS 1 0 0
* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report.
** These counts do not reflect official case counts, as current year numbers are not yet finalized. Inaccuracies in working case counts may be due to reporting/investigation lag.
NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state.pa.us/NEDSS. To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243.
For more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/Health- Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.
ACMS Bulletin / December 2019 437 Special Report
ALLEGHENY COUNTY MEDICAL SOCIETY 713 RIDGE AVENUE • PITTSBURGH, PA 15212-6098 P: 412-321-5030 • f: 412-321-5323 • www.acms.org
2019 PAMED House of Delegates October 25-27, 2019 - Hershey, PA Report
The PAMED House of Delegates met the weekend of October 25-27, 2019 in Hershey, PA. It was a busy weekend of business and activities. The ACMS had a full delegation in attendance. Chairing the delegation was Kevin O. Garrett, MD; and Vice Chair David J. Deitrick, DO.
ACMS DELEGATES / ALTERNATES David L. Blinn, MD Todd M. Hertzberg, MD Patricia L. Bononi, MD Scott Heyl, MD Gil Citro, MD Keith T. Kanel, MD Robert C. Cicco, MD Bruce A. MacLeod, MD Douglas F. Clough, MD Barbara S. Nightingale, MD Patricia L. Dalby, MD Joseph C. Paviglianiti, MD David J. Deitrick, DO Matthew B. Straka, MD Peter G. Ellis, MD Maria J. Sunseri, MD Amber L. Elway, MD Adele L. Towers, MD Trent Emerich, MD Rajiv R. Varma, MD Stephen N. Fisher, MD Matthew A. Vasil, DO H. Jordan Garber, MD David Webster, MD Kevin O. Garrett, MD John P. Williams, MD Mark A. Goodman, MD G. Alan. Yeasted, MD
ACMS was pleased to include the participation and interest of the following Residents and Medical Students:
Residents Medical Students Shea Ford, MD Jordan Hay Michael Hu, MD, MPH, MS Victoria Humphrey Shreyus Kulkarni, MD Deirdre Martinez-Meehan Michael McDowell, MD Samyuktha Melachuri Nallammai Muthiah Arnab Ray Lauren Strelec
It was an exciting House of Delegates for the ACMS delegation. Lawrence R. John, MD became the 170th President of the Pennsylvania Medical Society at his inaugural Saturday evening. Over 400 colleagueswww.acms.org 438joined family and friends in recognition of this event.
Trent Emerich, MD and Scott Heyl, MD were recipients of the Top 40 Physicians under 40 Award. The Early Career Physicians Section presented the award at their business meeting. ALLEGHENY COUNTY MEDICAL SOCIETY 713 RIDGE AVENUE • PITTSBURGH, PA 15212-6098 P: 412-321-5030 • f: 412-321-5323 • www.acms.org
2019 PAMED House of Delegates October 25-27, 2019 - Hershey, PA Report
The PAMED House of Delegates met the weekend of October 25-27, 2019 in Hershey, PA. It was a busy weekend of business and activities. The ACMS had a full delegation in attendance. Chairing the delegation was Kevin O. Garrett, MD; and Vice Chair David J. Deitrick, DO.
ACMS DELEGATES / ALTERNATES David L. Blinn, MD Todd M. Hertzberg, MD Patricia L. Bononi, MD Scott Heyl, MD Gil Citro, MD Keith T. Kanel, MD Robert C. Cicco, MD Bruce A. MacLeod, MD Douglas F. Clough, MD Barbara S. Nightingale, MD Patricia L. Dalby, MD Joseph C. Paviglianiti, MD David J. Deitrick, DO Matthew B. Straka, MD Peter G. Ellis, MD Maria J. Sunseri, MD Amber L. Elway, MD Adele L. Towers, MD Trent Emerich, MD Rajiv R. Varma, MD Stephen N. Fisher, MD Matthew A. Vasil, DO H. Jordan Garber, MD David Webster, MD Kevin O. Garrett, MD John P. Williams, MD Mark A. Goodman, MD G. Alan. Yeasted, MD
ACMS was pleased to include the participation and interest of the following Residents and Medical Students:
Residents Medical Students Shea Ford, MD Jordan Hay Michael Hu, MD, MPH, MS Victoria Humphrey Shreyus Kulkarni, MD Deirdre Martinez-Meehan Michael McDowell, MD Samyuktha Melachuri Nallammai Muthiah Special Report Arnab Ray Lauren Strelec
It was an exciting House of Delegates for the ACMS delegation. Lawrence R. John, MD became the 170th President of the Pennsylvania Medical Society at his inaugural Saturday evening. Over 400 colleagues joined family and friends in recognition of this event.
Trent Emerich, MD and Scott Heyl, MD were recipients of the Top 40 Physicians under 40 Award. The Early Career Physicians Section presented the award at their business meeting.
ACMS is pleased to announce the following election results for ACMS delegates: Todd R. Hertzberg, MD was voted as Vice Speaker of the House. John P. Williams, MD was voted as Hospital-based Trustee to the PAMED Board.
For business at hand, ACMS presented two resolutions to the House. The results were: Restrictive Covenants in Physician Contracts – Approved to develop a coalition to continue efforts at the federal level.
Review of Disparity between Dues Paying vs. Non-Dues Paying Members To Allocate Seats at the House of Delegates – Referred for study
These will be reviewed by the PAMED Board of Trustees and reported back to the Delegation.
ACMS presented a memorial resolution for George F. Buerger, Jr., M.D. It is with regret that we note for our senior members a memorial resolution for Roger Mecum, who served as executive director for PAMED for many years and passed away October 23, 2019. Also recognized was the tragedy at the Tree of Life on its one-year anniversary. The House of Delegates held a moment of silence for all.
ACMS congratulates the Top 40 Physician winners, our elected delegates to PAMED office and special congratulations and best wishes to Dr. John as he begins his term as President, PAMED.
A special thanks to all the delegates for their time, interest, lively discussion and participation in the ACMS caucus and the PAMED committees. The goal is better physicians and a better medical community - and we are grateful for your efforts.
Additional information on the House of Delegates, election results, Reference Committees and Resolutions can be found at www.pamedsoc.org/Delegation.
Improving Healthcare through Education, Service, and Physician Well-Being. PerspectiveEditorial Index
Volume 109 No. 7 July 2019 Pages 193-232 Volume 109 No. 8 August 2019 Pages 233-276 Volume 109 No. 9 September 2019 Pages 277-316 Volume 109 No. 10 October 2019 Pages 317-356 Volume 109 No. 11 November 2019 Pages 357-400 Volume 109 No. 12 December 2019 Pages 401-444
A Deval (Reshma) Paranjpe, MD, FACS G ACMS Alliance News...... 259, 305, Personalized medicine: Evolution, not H 333 revolution...... 284 I Activities & Accolades ...... 218, 260, Anna Evans Phillips, MD, MS In Memoriam: Medical malpractice 101: A primer – 306, 340, 384, 421 George F. Buerger Jr., MD ...... 219 B Part IV: The expert witness...... 286 Eugene W. Delserone, MD...... 307 C Richard H. Daffner, MD, FACR Classifieds ...... 216, 314 Is it really self-inflicted?...... 292 Robert Love Baker, MD...... 424 Community Notes...... 260, 307, 333 Andrea G. Witlin, DO, PhD J D Physician life hacks...... 322 K E Deval (Reshma) Paranjpe, MD, FACS L Editorial: Taking the tide...... 324 Legal Report: Summer nourishment ...... 198 Richard H. Daffner, MD, FACR Feds utilize 1960s-era organized crime Deval (Reshma) Paranjpe, MD, FACS The Jekyll and Hyde of EMRs...... 326 law to attack private insurance We believe in the getting physicians Andrea G. Witlin, DO, PhD fraud...... 223 Pocket MBA...... 362 back to the art of medicine...... 200 William M. Maruca, Esq. Amelia A. Paré, MD Deval (Reshma) Paranjpe, MD, FACS Physician non-compete Medical malpractice 101: A primer – A voice of one...... 364 Part II: The road to the courtroom...204 Richard H. Daffner, MD, FACR restrictions...... 226 Richard H. Daffner, MD, FACR When the music stops...... 366 Karen E. Davidson, Esq. Beneath the veil of the white coat....207 Andrea G. Witlin, DO, PhD Medicare physician fee schedule Andrea G. Witlin, DO, PhD ‘Generation A’ comes of age...... 368 changes: 2020...... 310 If the spirit moves you...... 238 Anthony L. Kovatch, MD Michael A. Cassidy, Esq. Deval (Reshma) Paranjpe, MD, FACS Winter nourishment...... 406 Private equity deals – back to the Moving, on...... 240 Deval (Reshma) Paranjpe, MD, FACS future?...... 346 Charles Horton, MD Retirement...... 410 William H. Maruca, Esq. Medical malpractice 101: A primer – Richard H. Daffner, MD, FACR Regulatory sprint to coordinated care: Part III: Elements of a malpractice Then and now...... 413 New Stark and Anti-Kickback suit...... 242 Andrea G. Witlin, DO, PhD rules...... 428 Richard H. Daffner, MD, FACR F It’s complicated...... 246 Feature: Michael A. Cassidy, Esq. Andrea G. Witlin, DO, PhD Moving physicians from burnout to Legal Summary: I rather like you, and I don’t want you to wellness a priority for new PAMED Beth Anne Jackson, Esq...... 144, 264, die...... 282 president...... 386 390
440 www.acms.org PerspectiveEditorial Index
M N R Materia Medica: O Reportable Diseases...... 274, 437 Brexanolone: An advancement in the P S treatment of postpartum Perspective: Society News ...... 212, 256, 302, depression...... 220 PCPs can provide valuable care during 334, 383, 418 Erlynn B. Frankson, PharmD hospice...... 209 Special Report: Sean W. Clark, PharmD Robert H. Potter Jr., MD, CMD, FAAFP RCM services allow for profitablity Estradiol vaginal inserts (Imvexxy®) I am who I am, and not what I do: and more focus on patient care...... 229 for the treatment of dyspareunia in Redefining self-identity to combat Jacqueline Meriweather post-menopausal women...... 262 physician burnout...... 210 Direct primary care: A win-win for Archana Raghavan, PharmD Wendy Palastro, MD doctoros and patients...... 265 Sara Weinstein, PharmD, BCPS Tired of saying goodbye...... 248 Kirsten Lin, MD Bezlotoxumab (Zinplava™): For the Jorge Lindenbaum, MD Highlights of the ADA 2019 revisions prevention of recurrence of clostridium To be, or not to be...... 249 difficile infection...... 308 Maria J. Sunseri, MD, FAASM to the standards of care in Anna Zuschnitt, PharmD candidate Platelet-rich plasma: New uses in diabetes...... 267 Switching between P2Y12 inhibitors: dermatology...... 251 Lori Bednarz, RN, MSN, CDE, CPT Considerations in dosing and Jorge Lindenbaum, MD NASH: A patient’s perspective...... 271 timing...... 342 Management of uveitis: A partnership Tony Villiotti Aubrey Dusch between rheumatology and Review of child deaths in Allegheny Kylie Horvath ophthalmology...... 294 County, 2008-2017: Data and Maleia Ruane Jared Knickelbein, MD, PhD insights...... 392 Suzann Sebastiani The fine line between functionality and Michael Freedman, MD, MPhil Courtney A. Montepara, PharmD cosmesis...... 300 Harm reduction saves lives: The role of Bictegravir/emtricitabine/tenofovir Suzan Obagi, MD naloxone in reducing overdose deaths alafenamide (Bitkarvy)...... 386 Knowledge of nutrition is power: What in Allegheny County...... 396 Kevin Wissman, PharmD will you do with yours?...... 329 Alice Bell, LCSW Erica Wilson, PharmD, BCPS Kristen Ann Ehrenberger, MD, PhD Update on the prevalence of blindness Trikafta™ (ivacaftor/tezacaftor/ How to advise your patients when at the Western Pennsylvania School for elexacaftor): A breakthrough therapy they ask about stem cell treatment for Blind Children...... 432 for cystic fibrosis patients who carry osteoarthritis...... 331 Heidi Ondek, EdD at least one F508del mutation...... 425 Paul S. Lieber, MD Albert Biglan, MD Adam Patrick, PharmD candidate An ode to Planet Nine Pluto: A human Beth Ramella, MEd Medical Student Musings: hospice physician sharing a pet 2019 PAMED House of Delegates A medical education should be a liberal hospice experience...... 374 education...... 254 Keith R. Lagnese, MD, FAAHPM, report...... 438 Arthi Narayanan HMDC T Membership Benefits: 296, 336, 378, A case for diversity in the Pittsburgh U 422 workorce...... 380 V Miller Time: William Simmons, MD W High-dose opiates and benzodiazepines Choosing a Medicare plan...... 415 X in end-of-life care...... 372 Namita Ahuja, MD Y Scott Miller, MD, MA, FAAHPM Q Z
ACMS Bulletin / December 2019 441 AdvertisingPerspective Index 2019 Bulletin Advertising Index: July-December Accounting Tucker Arensberg PC...... (412) 566-1212 Kline Keppel & Koryak PC...... (412) 281-1901 Quatrini Rafferty...... (888) 288-9748 Medical Supplies Billing/Claims/Collections Medtronic...... (877) 691-8185 Fenner Consulting ...... (412) 788-8007 Miscellaneous Clinical ACMS Foundation...... (412) 321-5030 Allegheny Health Network ...... (724) 933-1445 AAMRO...... (800) 489-1839 Encompass Health...... (877) 937-7342 Hand & UpperEx Center...... (724) 933-3850 Jewish Healthcare Foundation...... (412) 594-2550 Vujevich Dermatology Associates, PC...... (412) 429-2570 Pennsylvania Medical Society...... (717) 558-7750 Southwest PA Environmental Health Project.... (724) 260-5504 Compliance HIPAA One...... (801) 770-1199 Real Estate/Development Insurance Berkshire Hathaway: The Preferred Realty.....(800) 860-SOLD Berkshire Hathaway: Julie Wolff Rost ...... (412) 521-5500 NORCAL Mutual...... (800) 445-1212 Ophthalmic Mutual Insurance Company...... (800) 562-6642 Beynon & Co...... (412) 261-3460 Legal Wealth Management Fox Rothschild LLP...... (412) 391-1334 Charles Schwab...... (412) 347-5959 Houston Harbaugh PC...... (412) 281-5060 The Bulletin depends on its advertisers. Be sure to tell them you saw their ad here.
ACMS members: ACMS Bulletin 2020 Copy Deadlines Issue Deadline We want to hear your February 2020 Monday, Jan. 13 March 2020 Monday, Feb. 10 opinions on important April 2020 Monday, March 16 May 2020 Monday, April 13 topics affecting healthcare. June 2020 Monday, May 11 Email [email protected] July 2020 Monday, June 15 August 2020 Monday, July 13 to learn more about September 2020 Monday, Aug. 10 October 2020 Monday, Sept. 14 submitting a Perspective November 2020 Monday, Oct. 12 column to the Bulletin. December 2020 Monday, Nov. 16 January 2021 Monday, Dec. 14
442 www.acms.org Happy Holidays from all of us at ACMS!
Thank you for your membership in the Alleghenyfiller County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.
Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email [email protected]. Our Their $ >$
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