INSIDE Reflecting Back and Looking Forward

Summer 2013
www.pasg.org
PSG
Pennsylvania Society of Gastroenterology Newsletter
I NSIDE
President’s Message
Reflecting Back and Looking Forward
By Louis La Luna, MD
Intro to Risk
Management Series
FIT Corner
Hot Topics
Louis La Luna, MD
Annual Meeting
It seems like just yesterday I began my two-year term as president
of the PSG, and following our September Annual Scientific Meeting
in Hershey in September, Dr. David Sass will take over as your new
PSG president. I have worked with him for a number of years and I
am confident he will do a great job. I also want to acknowledge the
administrative staff and Board Members that have worked with me
and thank them for all of their help. Like all aspects of medicine, the
PSG has changed with the times and will continue to do so. We have
expanded our board to include fellows, we are currently updating
our website, we continue to pursue value-added services, and we
moved to include a hands-on portion to our Scientific Meeting.
The field of gastroenterology is also rapidly evolving, making it difficult to stay upto-date. Add in information technology (report writers and EMR’s) as well as billing
and practice regulations (ICD-10, HIPPA, etc.), and things become more complex. The
pressures of data collection, quality improvement and pay for performance are everincreasing. Even our national societies seem to want increasing amounts of data from us.
If you have not been approached by your local hospital to join a clinical integration network, odds are you will be asked to in the next few years. Gone are the days of practicing
medicine without paying attention to the business of medicine. Now more than ever,
physicians need to engage. We need to be part of the process. We need to take control
rather than be controlled. I appreciate and encourage progress and I am willing to change
with the times, but sometimes I feel like saying “enough is enough.” Sometimes I just
want to be a doctor without all the distracting hassles.
Over the next couple of years we will see significant changes in healthcare and I strongly
encourage you to pay close attention. We need to voice our opinions and stick together
to maintain the integrity of the field of medicine. Healthcare changes are inevitable; the
question is whether we will be a part of the process or victims of apathy. I encourage any
feedback or ideas you would like to share.
I will end by saying it was my humble pleasure to serve as President these past two years
and thank you for the opportunity. I have learned a lot along the way and met some
fantastic people. I look forward to seeing you this September at the Annual Scientific
Meeting in Hershey.
Legislative Update
SLC Update
PRESIDENT
Louis LaLuna, MD
1101 Reed Road
Wyomissing, PA 19610
(610) 374-4401, ext. 220 (Phone)
(610) 374-7140 (Fax)
llaluna@dda-bcdh.com
PRESIDENT-ELECT
David A. Sass, MD
Jefferson Digestive Disease Institute
132 S. 10th Street
Main Building, Suite 480
Philadelphia, PA 19107
(215) 955-8900 (Phone)
(215) 503-2146 (Fax)
david.sass@jefferson.edu
SECRETARY
Ralph D. McKibbin, MD
Blair Gastroenterology Associates
810 Valley View Blvd.
Altoona, PA 16602-6342
(814) 946-5469 (Phone)
(814) 946-4970 (Fax)
ralphmckibbin@hotmail.com
TREASURER
James W. Srour, MD
Gastroenterology Assoc. of York
2690 Southfield Dr.
York, PA 17403
(717) 741-1414 (Phone)
(717) 741-4774 (Fax)
jushla2@gmail.com
AdmINISTRATIVE OFFICE
EXECUTIVE DIRECTOR
Maria B. Elias
777 East Park Drive, P.O. Box 8820
Harrisburg, PA 17105-8820
(717) 558-7750 ext. 1584
gastro@pamedsoc.org
2
Risk Management
Major Areas of Physician Risk Exposure: Quality, Malpractice, and Compliance
By Richard E. Moses, DO, JD
The Pennsylvania Society of Gastroenterology (PSG) introduced a Risk
Management section in the last issue
of Rumblings (Spring 2013) to discuss
various issues. Feedback from PSG membership was positive. Going forward,
we will identify relevant and timely
topics to discuss as they relate locally
and nationally to medical practice and
Gastroenterology.
Despite the belief and allegations by
Pennsylvania government and the
plaintiff’s bar that the Medical Care
Availability and Error Reduction (Mcare) Act
has made a positive difference in reducing
medical malpractice cases throughout Pennsylvania, I have yet to meet and/or work with
a medical malpractice defense attorney, or a
malpractice insurance company, that has a
paucity of work or agrees. Frivolous lawsuits
are still common, as are awards in the millions of dollars to plaintiffs.
I will briefly call your attention to five major
areas of medical malpractice risk for health
care providers:
Inadequate Informed Consent
Failure to provide adequate informed consent
and patient education is one of the top ten
medical malpractice allegations in all medical
specialties nationwide. This is a particularly
relevant area of risk for Gastroenterologists.
Issues to consider include:
• Who provides the actual informed
consent discussion?
• What are the roles of the schedulers as to
the role of the physician?
• Where is the informed consent obtained
– in the office during consultation, in
the holding area before endoscopy, in
the procedure room minutes before the
procedure begins?
• How is informed consent documented?
Is it witnessed? Does it include adequate
patient education using a variety of
modalities such as printed material, video
materials and personal discussion?
Missed Abnormal Lab Tests
• Who is responsible for identifying abnormal lab tests and pathology results,
physicians or support staff?
• How are physicians notified? How are
patients notified? If a phone call is made,
do doctors or staff properly document the
transaction?
• Are messages left on answering machines
(potential HIPAA violation)? Are results
mailed to the patient? Is the mailing
documented?
• If no direct contact is made or if the
results show a serious problem that needs
expedient follow-up, is a certified letter
sent? If the certified letter is mailed and
returned, what follow-up steps are taken
to document and preserve that effort of
communication?
Incomplete History and Physical
Electronic medical records (EMR/EHR)
create a false sense of security on the part of
providers in obtaining and documenting the
patient’s history and physical exam among
other portions of the medical record. This is
an extensive topic in and of itself on a number
of risk management and healthcare fraud
levels. But for the sake of this discussion,
be advised that failures to obtain complete
medical information are common and are
frequently identified allegations in medical
malpractice actions. Particular attention needs
to be paid to missing a comorbid medical
problem, inadequate documentation, errors in
medication documentation, and the tendency
to “cut and paste” and rely on dropdown
menus.
3
PSG’s 2013
Annual Scientific
Meeting
September 27-29, 2013
The Hotel Hershey
Hershey, PA
Risk Management
continued from page 2
Medication Management Errors
Patient medical problems and management
have become more complex over the years
with more co-morbidities and the use of more
medications. The frequent use of anti-platelet
and anti-coagulation therapies, with their
associated limited reversibility, are just one
set of examples in this regard. Errors in
medication management may occur on the
medicine floor, in endoscopy and surgical
suites, during outpatient procedures, and in
the office. Physicians must ask:
• What systems are in place to obtain information on, and reconcile all medications?
• When did the patient allegedly stop medicines as instructed prior to a procedure?
• How is this documented?
• Are the nurses and other medical staff
adequately assessing the various medication orders they are managing?
• Are medications being given in the proper
dose and as scheduled?
Patient Handoff
Over the years, the communication between
physicians and other health care providers
has become increasingly important. This is
readily apparent in the hospital setting as
primary management of patients has come
under the purview of Hospitalists, Intensivists, and other admitting physicians. The same
principles hold true for the outpatient setting,
and will become increasingly important.
Patients are at increasing risk for suffering
actual harm due to delays in communication,
or because physicians are focused on too
many “transactions” at one time. The patient
handoff process must be timed, documented
with regard to the specific information
shared between providers, and must involve
immediate and active follow up care by the
receiving physician and support staff.
4
FIT Corner
Fellows: Don’t Miss New Opportunities at the PSG Annual Meeting
By Eva Alsheik, MD and Dustin Wallace, MD, Fellows-in-Training Representatives
The PSG Annual Scientific Meeting at The
Hotel Hershey will prove to be an exciting
one for fellows and residents alike. Similar to
previous years, the PSG will offer the Gastroenterology/Hepatology Poster Competition to
all GI and Hepatology fellows in PA, as well
as Internal Medicine residents. The PSG is
currently accepting abstracts online at www.
pasg.org and the deadline for submission
is July 26, 2013. Research topics as well as
clinical vignettes on interesting cases can be
submitted at no cost for a chance to win a first
prize of $750. All accepted presenters are offered a generous stipend by the PSG to attend
the meeting.
Welcome
NEW
Members
Lia Kaufman, MD
Raman Khehra, MD
Benjamin Raile, MD
Alexander
Schlachterman, MD
If you would like to
submit a question or
story idea, contact
Dr. Ravi Ghanta,
newsletter editor, at
rghanta@hotmail.com.
As a new opportunity for trainees, in addition
to the high-yield general sessions ranging
from talks about celiac sprue to refractory
IBD, C. Diff and fecal transplant, and even
updates on the Affordable Care Act, the PSG
is piloting the first-ever Fellow-in-Training
breakout session. This session will take place
immediately following the general session
on Saturday, September 28th and has been
designed specifically with fellows in mind.
Fellows will have the unique opportunity to
participate in an informal session with members of the PSG board to discuss absolutely
anything they would like, including searching
for a job, interviewing, contract negotiations,
and general questions about both private and
academic practice. A range of board members
from both private and university settings will
be present to answer questions and provide
insight into the world beyond training.
Although we are taught a plethora of didactic
and clinical knowledge during our three years
as GI fellows, we are grossly underprepared
on how to approach life after fellowship. By
virtue of training in university settings, we are
seldom exposed to the world of GI beyond
our training center. The PSG affords us with
the unique opportunity to engage in discussions with experienced attendings in a very
informal, relaxed setting. Speaking with those
who have been through the process before
and are now in positions to hire for their
practice will undoubtedly be useful. Richard
Moses, DO, JD, will be there as well to provide his unique legal perspective on contracts
and negotiations. This will be particularly
helpful for the third year fellows who will be
in the midst of contract negotiations this fall.
A number of internal medicine residents
who are interested in GI frequently come
to the annual PSG meeting to present their
research. Residents are also invited to the FIT
breakout session, where they will not only be
able to meet fellows from across the state, but
attendings from some of the premier training programs. Fellows will be able to share
their application experiences and give their
insight as to what they consider important in
a training program. The fellows will also be
available to answer questions about the common application form, personal statements,
interviews, and the match process.
We are very excited about the FIT breakout
session at the annual PSG meeting this year
and look forward to meeting you there!
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Hot Topics
The Current Trend: Practice Mergers and
Consolidations
By Richard E. Moses, DO, JD
Medical practice across all specialties, and
health care in general, is undergoing a major
change from solo private practice physicians
or small groups toward an employment model
of non-physician owned or controlled organizations, such as hospitals and health systems.
More than fifty percent of physicians currently
in practice are employed by larger practices
or health systems, with estimates that this
number will increase to almost eighty percent
within the next three to five years.
The Government’s and third party payers’
efforts over the past few years to change the
health system from a fee-for-service model to
a quality improvement-based global reimbursement model have fueled these changes.
Most recently, the Patient Protection and
Affordable Care Act (PPACA) has escalated
system changes through its requirements
to report data beyond Meaningful Use and
Electronic Health/Medical Records (EHR/
EMR) requirements in order to avoid the reimbursement penalties that will begin in 2014.
Quality data on physicians already exists and
will become the norm. The administrative
burden and cost to a medical practice will be
enormous.
Practice-merging and physician employment
is felt by some to be the answer to handling
these practice challenges. The theory is that
a larger practice or institution is in a better administrative and financial position
to absorb the associated costs involved in
the system-wide change. These maneuvers
continued on page 8
The PSG would like to thank the following
corporate sponsor for their support:
Janssen Pharmaceutical Companies
7
PSG Hosts 2013 Annual Scientific Meeting in
Hershey September 27-29
Physician Breakout Sessions
• Refractory IBD
By Gary R. Lichtenstein, MD
• GI Aspects of Neuroendocrine Tumors
By David C. Metz, MD
• Minimally Invasive Surgery for Achalasia
By Abbas Abbas, MD
Physician Hands-On Track
• Station 1: Spirus and Balloon Enteroscopy
By Mitchell I. Conn, MD
• Station 2: Solesta Injection
By Evangelos Messaris, MD, PhD
• Station 3: Radio Frequency Ablation for Barrett’s
Esophagus
By Robert M. Coben, MD
• Station 4: HET/CRH Therapy for Hemorrhoids
By Ravi K. Ghanta, MD
Nurse Breakout Sessions
• A Review of Pre-Endoscopy Imaging and Testing
By Dustin Wallace, MD
• Scope Processing
By Eileen C. Young, RN, BSN, CNOR
• Infection Control in the Endoscopy Lab
By James Davis, BSN, RN, CCRN, CIC
Nurse Hands-On Track
• Station 1: Spirus and Balloon Enteroscopy
By Mitchell I. Conn, MD
• Station 2: Solesta Injection
By Evangelos Messaris, MD, PhD
• Station 3: Radio Frequency Ablation for
Barrett’s Esophagus
By Robert M. Coben, MD
• Station 4: HET/CRH Therapy for Hemorrhoids
By Ravi K. Ghanta, MD
Sunday’s General Session Lectures include such
topics as:
• Understanding the Affordable Care Act: What is it and
How Does it Apply to Gastroenterology?
C. Richard Schott, MD
• Measurements of Quality: Are They Useful or Just a
Waste of Time?
Lawrence B. Cohen, MD
• New Guidelines for Colon Cancer Surveillance and
Surveillance for IBD Patients
Neilanjan Nandi, MD
• HCV: Non Interferon Therapy
Santiago Munoz, MD
• Endoscopy, Outside the Lumen: Perforations and
Other Topics
Abraham Mathew, MD
• Mind-Gut Connection
Paul J. Lebovitz, MD
• C. Difficile: Fecal Transplant and Fidaxomicin
David G. Binion, MD
During breaks between sessions, physicians and nurses
can peruse exhibits and poster displays. Attendees and
their families will also have the opportunity to sample
some of Hershey’s famous attractions. On Saturday
evening, guests are invited to enjoy cocktails and food
stations with wine and chocolate pairings; this is also a
kid-friendly event. Hersheypark will be open throughout
the weekend as well.
We hope to see you at Hershey in September! Please
spread the word to your colleagues, nurses, and FITs to
register! Watch your mail for a registration brochure, visit
http://www.pasg.org/NewsEvents/AnnualMeeting.aspx
for online registration.
8
LEGISLATIVE UPDATE
By Richard E. Moses, DO, JD
Chair, PSG Legislative Committee
The PSG, in cooperation with the Pennsylvania Medical Society and other State Societies,
continues to track health care bill legislation
introduced into the Pennsylvania Congress.
The PSG has made access to select bills available to members through a portal on the PSG
website: www.pasg.org. This list of bills is
periodically updated.
The 2013 Pennsylvania Congress has introduced a number of health care-related bills,
with a few pertaining to physicians. Some
recently introduced bills that may be of interest include:
• HB 540: An act providing for the collection and disposal of leftover and expired
medicines and for penalties for violations.
• HB 564: An act amending the act of July
19, 1979 (P.L. 130, No. 48), known as
the Health Care Facilities Act, reenacting and amending provisions relating
to definitions, powers and duties of
the Department of Health and State
health services plan; reenacting provisions relating to regulations; reenacting
and amending provisions relating to
certificate of need and issuance of license; prohibiting certain referrals and
claims of payment; and repealing sunset
provisions.
Hot Topic
continued from page 6
can strengthen the physicians’ negotiating
position with third-party payers, employers,
hospitals, and suppliers.
However, there is a downside to merging
practices or entering a health system employment model: physicians give up control and
autonomy. There is also a lot to be said about
being an “employee.” These decisions should
not be rushed into, and there needs to be a lot
of open discussion and forethought. It is wiser
not to merge a practice or take a job than to
• SB 482: An act requiring health insurers
to disclose fee schedules and all rules and
algorithms relating thereto; requiring
health insurers to provide full payment to
physicians when more than one surgical
procedure is performed on the patient by
the same physician during one continuous operating procedure; and providing
for causes of action and for penalties for
violations.
• SB 568: An act amending the act of March
20, 2002 (P.L. 154, No. 13), known as the
Medical Care Availability and Reduction
of Error (Mcare) Act, establishing the
Mcare Commission.
• HR 1427 (NATIONAL LEVEL): This bill
intends to eliminate consumer confusion over who is considered a “medical
doctor.” Rep. Larry Bucshon, M.D. (R-In.)
and Rep. David Scott (D-Ga.) cosponsored the bill. HR 1427 is being named
the “Truth in Healthcare Marketing
Act of 2013.” The bill would essentially
make it illegal for any healthcare professional to make false or deceptive claims in
marketing materials and advertisements
regarding their credentials or clinical
expertise. Marketers of health provider’s
services must also clearly state the type of
license the provider holds.
rush into a situation and later realize there
are major incompatibility issues. As a general
rule, the larger the organization, the greater
the potential is for disagreements and incompatibility. The influence ideas of the physician
lessen. For the physician who historically has
been the “captain of the ship,” this can be a
major problem and a recipe for disaster.
Deciding what to do professionally as a
physician has never been more challenging.
Consulting with an experienced health care
attorney is a must prior to entering into any
agreement or arrangement, no matter what is
decided.
9
10
SLC Update
By Ralph D. McKibbin, MD, FACP, SLC Representative
The Pennsylvania Medical Society
(PAMED) Specialty Leadership Cabinet
(SLC) met on May 21, 2013. The SLC discussed legislative and regulatory items of
interest to physician specialists. The PSG
actively represents the specific interests
of gastroenterologists in Pennsylvania.
Recommendations are made to the Board
of Trustees to the Pennsylvania Medical
Society. Discussed below are May agenda
items of particular interest.
Governance restructuring was again
reviewed for input. Further progress in
the form of workgroup proposals was detailed. PAMED is actively working to redesign
its governance structures and processes. It
is anticipated that the SLC will continue to
represent specialty interests.
All specialty societies have been asked by
the Pennsylvania Academy of Dermatology
and Dermatologic Surgery to write a letter
of support for House Bill 1259, The Tanning
Regulation Bill. This bill would require registration with the state of all tanning salons,
payment of a reasonable annual fee, inspections and safety standards, as well as limits of
teen access to tanning beds.
The PAMPAC “Got Names Campaign” was
reviewed. In these times of rapid change, it is
imperative that our voices be heard. The “Got
Names” campaign is an opportunity to detail
relationships with Pennsylvania legislative
representatives. By detailing any relationships
that exist between physicians and legislators, a network will be constructed that can
effectively reach decision makers. This will
11
enhance our ability to be heard on key issues.
Look for information in the near future from
PAMPAC. We encourage gastroenterologists
to participate.
Thirty five specialty societies have joined
the campaign entitled “Choosing Wisely.”
It encourages health care stakeholders to
talk about the necessity of medical tests and
procedures. The societies have created list
of “Things Physicians and Patients should
Question.” These are evidence-based recommendations to help make wise decisions
about the appropriate care for a particular
patient’s individual situation. Members of the
Cabinet are asked to increase awareness of the
program.
The American Gastroenterological Association has compiled five recommendations for
“Choosing Wisely.” In summary they are:
1. Limit long term use of anti-reflux therapy
to the lowest effective dosage.
2. Do not repeat colorectal cancer screening
for ten years in average-risk individuals
after a normal high quality colonoscopy.
3. Do not repeat colonoscopy for five years
if only one or two small adenomas are
found.
4. Barrett’s esophagus surveillance intervals
are three years if there is no dysplasia.
5. Individuals with functional abdominal
pain should not have CT examinations
repeated without significant change.
Specific details can be found at www.
choosingwisely.org. Look for national media
coverage on this campaign. Promoting the
high-quality procedures performed by trained
endoscopists couple with appropriate use of
healthcare resources is important in presenting our case to the public.
The PA Department of Health is investigating
accreditation from the Public Health Accreditation Board. A Pennsylvania State Health
Assessment (PA SHA) project is required and
under construction. The project will provide
state-specific information on a variety of
health issues, including health status, risks,
and healthcare services in Pennsylvania.
The document will be a ready source of
information for answering public and legislative questions and a source of scientifically
accurate information for grant writers and
policy-makers involved in decision making
and planning. Academic-based practitioners
should keep watch on this key document.
The PSG is committed to representing the
interests of Pennsylvania gastroenterologists.
Your feedback, comments, and concerns are
needed. Please contact your PSG representative or email me directly at ralphmckibbin@
hotmail.com. Please include PSG/SLC in the
subject line.
PSG
PRSRT STD
U.S. POSTAGE
PAID
HARRISBURG PA
PERMIT NO. 922
777 East Park Drive
PO Box 8820
Harrisburg, PA 17105-8820
2013 PSG
Annual
Scientific Meeting
The Hotel Hershey
Sept. 27–29
Plan a family weekend getaway in Hershey while
joining us for education, fellowship, food, and fun!
Watch your mail in July for the registration brochure.
www.pasg.org