‘‘

By CINDy SANDERS

There’s no question healthcare delivery is in the middle of a transformational period highlighted by unprecedented consolidation. While there are a number of factors impacting alignment decisions, Paul Keckley, PhD, boiled the equation down to its simplest terms, “Economics drives behavior.”

Keckley, managing director for Navigant’s Center for Healthcare Re-search & Policy Analysis, said physicians are having to assess their practices in light of a new reality that requires effi ciency, effectiveness and con-tracting clout to survive.

“If you’re of a view that the economics favors you being in-dependent for the rest of your practice, you go that route,”

he stated. However, the noted healthcare expert who has published three books and more than 250 articles on the

industry and health reform, said that practice model is becoming increasingly rare.

For many, Keckley said practice decisions take a step-wise progression. Option A fi nds two small practices within a specialty band-

ing together. Option B brings multiple special-ties together to form a large group. Option C has

physicians or practices joining forces with a hospital or payer under some type of employment, joint venture, or

managed services organization (MSO) agreement.

Partnering in a New Paradigm

(CONTINUED ON PAGE 8)

By LyNNE JETER

TAMPA – Fewer trips to local emergency rooms for asthma may have helped the metro area earn a slightly bet-ter ranking in the Asthma & Allergy Foundation of America’s (AAFA) list of “2014 Asthma Capitals” than other cities in the subtropical south.

Tampa ranks No. 50, with better-than-average scores on estimated asthma prevalence, annual pollen score, and school inhaler access law. The metro area proved average in self-re-ported asthma prevalence, crude death rate, air quality, public smoke-free laws, and ER visits for asthma. Work is needed in worse-than-average categories: poverty rate, uninsured rate, use of quick relief meds, use of control meds, and number of specialists.

To better understand the local asthma landscape, Medical News spoke with Thomas B. Casale, MD, a nationally known expert in asthma, and a professor of internal medicine at the University of South Florida’s Morsani College of Medicine in Tampa.

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Understanding the Rise in Asthma Prevalence Tampa struggles with asthma triggers and lack of medication adherence

Taking Your Breath Away How cities in the Southeast ranked in the new annual asthma report

A thriving city rich in history, perched on the brow of the picturesque James River, has once again captured the uncoveted title as the most challenging place to live with asthma ... 3

NASS Takes a Proactive Approach to Evidence-Based Coverage DecisionsIn an effort to improve patient access to appropriate, evidence-based care, the North American Spine Society (NASS) recently released recommendations ... 7

We’re always looking for children and adults with asthma for research studies as we strive to fi nd better medications and treatments for the disease.”

’’

– Thomas B. Casale, MD, Allergist-Immunologist, Professor, Internal Medicine, Morsani College of Medicine, University of South Florida.

(CONTINUED ON PAGE 4)

2 > AUGUST 2014 t a m p a b a y m e d i c a l n e w s . c o m

By JEFF WEBB

SARASOTA - Ask Jeffrey Lyons about his reaction to being named 2014 Physician of the Year at Doctors Hospi-tal of Sarasota earlier this year, and he doesn’t have much to say about himself. Instead, he talks about the people around him.

“I think this community has some in-credible doctors and I don’t claim to be the best doctor in town by any means. There are so many more who are more intelligent than me. But it’s a nice award and I appreciate it,” said the soft-spoken 54-year-old. “I get along well with the staff there. … It’s a fun place to work and I have a lot of respect for the nurses and staff. I feel like I have a lot of support,” said Lyons, who is one of four EmCare Inpatient Services hospitalists at Doctors.

But Lyons’ hesitation to speak about himself is compensated by what others have to say about him. The physician of the year is voted on anonymously by the staff -- nurses, therapists, technicians, etc., at Doctor’s Hospital, not physicians. Here are some excerpts of what the staff had to say about Lyons:

“Dr. Lyons goes above and beyond in helping out his patients and the clini-cal staff.”

“Dr. Lyons is very knowledgeable. ... He is also very caring and respectful to

the nurses. Most of all, he is great with the patients and truly cares about them and their families.”

“Dr. Lyons puts in tireless hours and is always cheerful and polite. … He is ap-proachable, patient and humble.”

Lyons seemed pleased by that last assessment. “I think everyone should be approachable and somewhat humble,” he said.

Lyons has had that reputation at least

since he was an undergraduate biology student at Indiana University Southeast in New Albany. It was there that one of his mentors recognized that Lyons was special. “We had three or four professors on him all the time. We really cared about him and wanted him to do well. We knew he was s smart guy,” said Claude Baker, PhD, who was the pre-professional advisor and a biology professor at the school. “At that time Jeff had no plans of becoming a doctor. He was interested in research,” said Baker, who now is the senior pre-professional advisor at Southern Arkansas University.

Lyons said Baker advised him to excel in academics. “He pushed me harder than I could ever imagine and impressed upon me that we should have high expectations and standards,” he said. “He’s a stellar individual. He’s changed a lot of people’s lives.”

After graduation, Lyons headed to Marshall University to earn his masters degree in biological science, and with every intention of becoming a college pro-fessor and researcher. “But I got involved in research at the local medical school and switched my career interest,” he said. “I got accepted into a combined MD/PhD program and had a full ride with tuition and a stipend because I was assisting with teaching in one of the labs. Then the Rea-gan budget cuts hit and they told me they

could no longer do the stipend,” Lyons explained. “At that point, I made another career decision. Dr. Baker was down in Florida doing research on inshore reef fishes. I took a vacation there while trying to decide what to do. At the time there was a huge influx of people into south Florida. The schools were overwhelmed and they didn’t have enough science teachers. So, I decided to take a break from academics and teach,” which he did for four years at Boca Raton High School. “The teaching experience was OK, but it made me real-ize I needed to go back into what I was training to do as an undergraduate, which was go into the medical field.”

Lyons enrolled at NOVA/Southeast-ern College of Osteopathic Medicine in Ft. Lauderdale and after receiving his DO in 1994, he headed north to Erie, Pa., for an internal medicine internship. But he was very pleased when he landed a three-year family medicine residency at Sun Coast Hospital in Largo (now known as Largo Medical Center). “It’s a well-known and well-respected program.I sought it out,” he said. “I decided on family practice because I enjoy talking with people and helping people and getting to know them personally.”

Lyons spent the next nine years in pri-vate practice, most of it in Sarasota, before moving to east Tennessee. He returned to Sarasota in 2010 and went to work for EmCare. He said he’s very happy to be a hospitalist. “We’re involved in everything that comes in the hospital in one way or another,” said Lyons, who also sees pa-tients in nursing homes.

Lyons’ college mentor, Dr. Baker, said he is not surprised his former student feels at home in that environment. “He connects with everyone. What he’s doing right now is perfect for his personality be-cause he really has the empathy needed to be a diagnostician,” said Baker. “I still get a call from him every month or two. He’s a tremendous individual … and the best, or close to the best, student we ever had at ISU when it comes to a medical career. … I’m not surprised he got this doctor of the year award.”

Lyons said his schedule doesn’t allow for much leisure time, but when he can he likes to fish and hunt. That might mean joining a friend who goes trolling for grou-per in the Gulf of Mexico, or taking an occasional trip to north Florida to stalk wild boars.

But most of his personal time is oc-cupied with his two sons, ages 16 and 18, and his wife Mary Lou, who is studying to become a nurse.

Do his children have any interest in becoming a physician like dad? “They have NO interest in medicine. After see-ing my lifestyle, they wouldn’t think about it,” he chuckled.

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Jeffrey Lyons, DOEmCare Inpatient Services, Doctors Hospital

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Providing High-Quality, Patient-Centered Asthma Care

U.S. Asthma Guidelines list six key steps for physicians with asthma patients:

• Assess asthma severity.

• Provide a written asthma action plan.

• Direct patients how to properly use inhaled corticosteroids (ICS).

• Show patients and their families how to control environmental triggers at home, work or school.

• Schedule follow-up visits.

• Assess and monitor asthma control care.

SOURCE: AAFA.

By LyNNE JETER

A thriving city rich in history, perched on the brow of the picturesque James River, has once again captured the uncov-eted title as the most challenging place to live with asthma.

For the second consecutive year, and four of the last fi ve years, Richmond, Va., took the title perch, with worse than aver-age ratings for prevalence factors (crude death rate for asthma), risk factors (an-nual pollen score, poverty rate, the un-insured, and public smoking laws), and medical factors (emergency room visits for asthma).

Medical News markets located across the South and Midwest were represented in “Asthma Capitals 2014,” the 11th an-nual research project released by the Asthma & Allergy Foundation of America (AAFA). Boston Scientifi c Corporation (NYSE: BSX) sponsored this year’s report.

Medical News market rankings, with 2013 rankings in parentheses:

No. 2: Memphis, Tenn. (3)No. 6: Chattanooga, Tenn. (2)No. 22: New Orleans, La. (24)No. 26: St. Louis, Mo. (55)No. 27: Little Rock, Ark. (31)No. 38: Nashville, Tenn. (32)No. 41: Knoxville, Tenn. (10)No. 42: Jackson, Miss. (47)No. 48: Birmingham, Ala. (23)No. 49: Orlando, Fla. (62)No. 50: Tampa, Fla. (57)No. 55: Lakeland, Fla. (60)No. 64: Daytona Beach, Fla. (76)No. 65: Baton Rouge, La. (79)No. 75: Sarasota, Fla. (87)No. 81: Raleigh, NC (91)No. 87: Charlotte, NC (86)Most Metropolitan Statistical Areas

(MSAs) in Medical News markets im-proved over 2013, collectively dropping 45 spots. The St. Louis market showed the least improvement, moving up 29 spots among the most challenging places to live with asthma. The most improved MSAs for easier asthma living: Knoxville, Tenn., sliding down 31 spots, followed closely by Birmingham, Ala., which dropped 25 spots.

MethodologyAnalytical data from the 100 most-

populated MSAs in the United States de-termined the ranking system. Researchers and medical specialists focused on three primary areas – prevalence, risk, and medical factors – that include 13 unique factors, with non-equal weights applied to each data set in individual factor groups. Total scores were calculated as a compos-ite of all factors, refl ecting each factor’s relative impact on exposure to asthma triggers, quality of life, costs and access to care.

Prevalence factors included the predicted population with asthma, self-reported population with asthma, and re-

corded death rates for adults and children from asthma. Risk factors included com-prehensive annual pollen measurements, average length of peak pollen seasons, out-door air quality, poverty and uninsured rates, state school inhaler access laws, and smoke-free public laws.

Medical factors included ER visits for asthma, rescue medication use, controller medication use, and the number per pa-tient of board-certifi ed adult and pediatric allergists and immunologists, and pulmo-nologists.

ER visits represent a signifi cant chunk of asthma care-related costs.

“Many ER visits are from people with severe asthma, but not all of them,” said Mario Castro, MD, professor of medicine and pediatrics at Washington University School of Medicine in St. Louis, discuss-ing the average of more than 2,300 visits to ERs for asthma in each U.S. city, with one in four admitted to a hospital. “Many people with less severe asthma show up to the ER, too. But much of this is avoidable with new treatments for severe patients and better prevention and care for those with less severe disease.”

Making StridesEarlier this year, the Supreme Court

upheld the U.S. Environmental Protection Agency’s (EPA) Cross-State Air Pollution Rule, which aims to reduce the amount of pollution drift from certain states into oth-ers, prompting health issues for residents in those states. The Supreme Court also

noted the rule is an effective way to con-trol emissions, and melds with the EPA’s mission under the Clean Air Act.

The AAFA is collaborating with state chapters to mandate or improve on the requirement of stocking epinephrine in schools for severe allergic reactions. For example, California is considering legisla-tion to strengthen its existing epinephrine-stocking law to require schools to stock the medication and train a volunteer to administer it. Illinois is considering legis-lation to require, rather than simply allow, schools to stock epinephrine. All states in Medical News markets have epinephrine-stocking school policies in place, with the exception of North Carolina, which at press time had pending legislation.

The AAFA has banded with other national health advocacy groups to sup-

port increased research funding, which in-cludes lobbying against proposed budget cuts for the National Institutes of Health, Centers for Disease Control and Preven-tion (CDC), Agency for Health Resources and Quality, and other agencies with research relevant to asthma and allergic diseases.

For example, the CDC’s National Asthma Control Program has helped decrease asthma mortality rates by more than 45 percent since its inception in 1999.

“There are many things that we can improve now to make life better for people with asthma,” says AAFA spokesperson and asthma patient, Talisa White. “Our Asthma Capitals report helps to shed light on the asthma burden in each city, but it also pro-vides a roadmap for improvements.”

Taking Your Breath Away How cities in the Southeast ranked in the new annual asthma report

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Past president of the American Acad-emy of Allergy, Asthma and Immunology (AAAAI), and executive vice president since 2008, Casale has focused his re-search on asthma in varied areas: the role of mast cell mediators in the pathophysi-ology of allergic asthma and lung infl am-mation; the role of cigarette smoke in the pathogeneses of airway hyperresponsive-ness in asthma; novel therapies of allergic and respiratory diseases; the role of Rho A and RGS2 in airway hyperresponsiveness and asthma; and the link between vitamin D and asthma.

What’s the upside of these gloomy asthma statistics?

The upside is the death rate for asth-matics has gone down. That’s a refl ection of the excellent medications we have avail-able to treat asthma. The problem is get-ting those treatments to the patients in a way they understand how and when to use them, and afford to use them.

What measures could the medical community take to offset the rapidly rising asthma prevalence rate?

Primary care providers and special-ists need to make sure that asthma pa-tients adhere to treatment plans. It’s one of greatest challenges with asthma, as with all chronic diseases.

In a recently published review of studies examining the adherence to pre-scribed inhaled corticosteroid regimens in children with asthma, half of all stud-ies showed an adherence rate of 50 per-cent or below, and the majority report rates less than 75 percent! Older studies

indicate that adult asthmatics who refi lled their prescription for an inhaled cortico-steroid after the fi rst prescription is only 31 percent! An inhaled corticosteroid is clearly our best drug for the treatment of asthma. It’s a fundamental problem when half to three-fourths of patients don’t ac-tually adhere to the medication regimen we prescribe for asthma. Because we have good medicines for asthma, most patients’ asthma can be very well controlled.

As physicians and healthcare provid-ers, we need to take a hard look at barri-ers that impair adherence, and deal with them. For example, asthma can be an episodic, symptomatic disease; an asth-matic may feel very good for months. It’s diffi cult to convince a patient to take their medication at a time when they don’t have symptoms.

What primary barriers impact asthma treatment adherence?

Some parents have concerns about possible adverse side effects from their children taking inhaled corticosteroids (ICS). In most doses we prescribe, they’re fairly safe. A Cochrane review just pub-lished showed that regular use of ICS at low or medium daily doses is associated with a mean reduction of 0.48-cm/y in linear growth velocity and a 0.61-cm change from baseline in height during a one-year treatment period in children with mild to moderate persistent asthma. However, it’s important to emphasize the adverse consequences of not taking pre-scribed medication, especially the inability to play and work without restrictions and symptoms. Also, some parents equate the steroids we use to treat asthma with ones

used by some professional athletes. Those are completely different types of steroids and can certainly have some side effects.

There’s a lot of room for healthcare providers to educate patients and their families on the chronic infl ammatory na-ture of asthma, and how we’re trying to treat or control the underlying infl amma-tion so that patients with asthma can carry on with normal activities. Then if they get a respiratory tract infection – one of the biggest contributors to asthma exacerba-tions – they can handle it better. We need to do a better job educating patients and their families about the importance of ad-hering to medication plans.

Another problem: The high cost of some asthma medications. Some inhalers cost $200 to $350. That’s a lot of money, especially for patients without good health coverage. Providers and pharmacists can help with that problem. For example, some pharmaceutical companies have coupons for inhalers to help defer some of the cost.

As prescribers of these medications, we have to be aware of the type of insur-ance coverage a patient has, and match a regimen that will be covered to the best degree under their insurance plan. Pre-scribing a drug that a patient can afford and we know will be effective is vital.

Why is treatment adherence more challenging for patients with asthma versus other chronic diseases?

Asthma is unique in that it’s not typi-cally treated with a pill. There’s a learning curve with using different types of inhalers appropriately. If a patient is switched to

a different inhaler, we have to make sure they’re aware of the nuances of using that inhaler appropriately or the medication won’t be delivered to the lower airways when needed.

There’s no question that primary care providers will manage a vast majority of asthma patients. They must devote staff time to make sure that if they prescribe these inhalers, somebody teaches their pa-tients how to effectively use them.

Specialists tend to spend more time with asthma patients teaching parents and patients how to use their medications ap-propriately, on a regular basis, and what to do if they have an acute onset of symp-toms not being controlled with their cur-rent medications.

Why are asthma specialists (pulmonologists and allergist-im-munologists) in short supply?

The simple answer is, pulmonologists often get pressured to do more in-patient care and critical care medicine. They do it very well and run a lot of ICUs. As a result, they may not see as many patients on an outpatient basis for asthma. For allergist-immunologists like me, it’s a big part of their practice. It’s what they’ve been trained to do and enjoy doing be-cause they don’t spend a lot of time with inpatient work. It’s more of an outpatient specialty.

The more complex answer is, the trend (of lacking suffi cient specialists per capita) goes along with the shortage of pri-mary care physicians and specialists across the board nationally.

Does it surprise you to learn that 75 percent of adults with asthma don’t have Asthma Action Plans, according to the “Health: Burden of Asthma in Florida” study released last fall?

No, it doesn’t (sigh). Asthma Action Plans are especially useful for people with more moderate to severe asthma, but they can be of value to anybody with asthma.

Sometimes, there’s confusion about what to do with an Asthma Action Plan. It behooves us again as healthcare providers to make those plans very understandable and very easy to implement.

It’s especially important for school-children to have easily understandable Asthma Action Plans because of the de-crease in the number of school nurses resulting from budgetary cutbacks. The acute management plan needs to be very simple so that patients or parents/school nurses can manage asthma to a better degree. Then they’ll know when to call a healthcare provider for an adjustment in medications versus when to go to the ER.

How does obesity impact asthma?

Obesity makes asthma trickier to di-agnose. If you’re obese, you’re going to be short of breath and not able to do as much. On the other hand, asthma could be more of a problem in obese patients. Several studies suggest that obese people

Understanding the Rise in Asthma Prevalence, continued from page 1

(CONTINUED ON PAGE 8)

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By LyNNE JETER

Florida’s not faring very well for people living with asthma, yet strides are being made to improve the environment.

In the “2014 Asthma Capitals” report, released by the Asthma & Allergy Foundation of America (AAFA), the Sunshine State represents 9 percent of the list. Con-ditions have worsened since the 2013 list debuted, with “the most challenging places to live with asthma,” collectively dropping 117 spots.

A few startling Florida statistics:• From 2000 to 2010, lifetime asthma

prevalence among adults increased by 52 percent, and asthma-related hospitalizations statewide rose by more than 32 percent.

• Between 2006 and 2012, the life-time asthma prevalence among middle and high school students increased by 21 percent.

• In 2012, more than 2.6 million Florida adults

and children had life-time asthma, and

a p p r o x i m a t e l y 1.6 million had current asthma. That statistic represents one of eight adults with lifetime asthma

and one in 12 with current asthma; and

one of fi ve children with lifetime asthma, and one in

10 with current asthma. “Asthma rates and healthcare

utilization for asthma have increased dramatically over the last 30 years in all populations in Florida, and across the United States,” wrote John H. Armstrong, MD, FACS, surgeon general and Secretary of Health, in the Sept. 2013 report, “Health: Burden of Asthma in Florida.”

“Asthma incurs high expenses, in terms of cost of care, lost workdays and productivity, and lower quality of life for persons with asthma and their families,” he noted. “Asthma is a leading cause of preventable emergency department visits and hospitalizations.”

Before Florida became one of 36 states selected to receive funding and tech-

nical support from the Centers for Disease Control and Prevention’s (CDC) National Asthma Control Program, and established the Florida Asthma Program in 2009, the state had no systematic approach to state and local asthma surveillance, yet 15 per-cent of county health departments listed asthma as a priority health issue.

Now with the CDC’s support, the program has developed a comprehensive system for asthma data-gathering that provides easy, round-the-clock access to the latest county-specifi c asthma data, providing communities with information to better develop local Asthma Action Plans.

“One-on-one care between patients and doctors isn’t enough to really con-trol asthma,” said Julie Dudley, manager of the Florida Asthma Pro-gram. “Asthma requires coordinated care, and public health has the in-frastructure to create the connections and part-nerships needed to make that happen.”

Focusing on Children with Asthma

Among responses to asthma chal-lenges statewide, the Florida Asthma Program has launched its asthma control curriculum for child care providers and its Asthma-Friendly Childcare Award program. To receive an award, child care

centers must participate in asthma control training and keep Asthma Action Plans on fi le. Within two years of its impetus, nearly 1,000 child care providers had completed the training, seven child care centers had achieved silver-level recognition, and nine had achieved bronze-level recognition. As a result, a record number of child care centers across the state now have Asthma Action Plans on fi le.

The program’s partnership with the state chapter of the American Lung As-sociation has also infused asthma educa-tion in schools. By early 2013, more than 1,300 third, fourth and fi fth graders had learned how to better control their asthma through the Open Airways for Schools program, and some 600 school faculty participated in the Asthma 101 program.

“Identify schoolchildren with asthma at the beginning of each school year,” urged Armstrong. “This will en-able schools to track absenteeism, health room visits, 9-1-1 calls, and the num-ber of times children leave school with asthma-related issues. This will enable school staff to identify and monitor stu-dents in need for additional asthma man-agement support.”

Jason E. Lang, MD, a pediatric pul-monologist with Nemours Children’s Health System, said that measures taken by the Florida Asthma Program represent “a great step in the right direction to make it safe for children with asthma.”

Shining a Light on Asthma ChallengesHow Florida cities ranked for asthmatics

Groundbreaking Change

On June 13, Gov. Rick Scott signed into law the most comprehensive epinephrine-stocking legislation introduced to date in any U.S. state.

The Emergency Allergy Treatment Act, which will allow some public venues – Walt Disney World, restaurants, sports arenas – to stock epinephrine auto-injectors (epi-pens), improved upon previous legislation. It calls for trained personnel, or non-trained personnel in an emergency with authorization from a medical provider, to administer epi-pens.

Florida had previously passed similar stock epinephrine legislation for schools. However, that legislation only allows schools to stock epi-pens; it doesn’t mandate them. Only four states – Maryland, Nebraska, Nevada, and Virginia – require stocking epinephrine in schools. At press time, fi ve states had pending legislation to require schools to stock epinephrine auto-injectors – California, Illinois, Massachusetts, New Jersey and North Carolina.

Dr. John H. Armstrong

By LyNNE JETER

Florida’s not faring very well for people living

In the “2014 Asthma Capitals” report, released by the Asthma & Allergy Foundation of America (AAFA), the Sunshine State represents 9 percent of the list. Con-

• In 2012, more than 2.6 million Florida adults

and children had life-time asthma, and

a p p r o x i m a t e l y 1.6 million had current asthma. That statistic represents one of eight adults with lifetime asthma

and one in 12 with current asthma; and

one of fi ve children with lifetime asthma, and one in

10 with current asthma.

How Florida cities ranked for asthmaticsIn 2010, the

Florida Asthma Program convened the Florida Asthma

Coalition with 48 members representing 20 partner

organizations. Within three years, the coalition had grown to

150 members serving approximately

100 organizations.

Julie Dudley

(CONTINUED ON PAGE 6)

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Lack of Asthma Action PlansThe report also addresses another

startling statistic: Three of four adults in Florida with asthma (75.3 percent) report never having received an Asthma Action Plan from a doctor or other health profes-sional.

“It’s especially important for school-children to have easily understandable Asthma Action Plans because of the de-crease in the number of school nurses resulting from budgetary cutbacks,” said allergist-immunologist Thomas B. Ca-sale, MD, professor of internal medicine at the Ujniversity of South Florida’s Mor-sani College of Medicine in Tampa. “The acute management plan needs to be very

simple so that patients or parents/school nurses can manage asthma to a better degree. Then they’ll know when to call a healthcare provider for an adjustment in medications versus when to go to the ER.”

The “Burden of Asthma” lists action measures to prompt the development of these action plans:

For physicians and other primary care providers:

• Develop an Asthma Action Plan and review it with each patient to ensure the patient understands daily medications and proper usage techniques, how to avoid asthma triggers, and how to identify warn-ing signs that require quick-relief medications or additional medical interventions.

• Use data systems to track and moni-tor Asthma Action Plans and other components of asthma care.

For hospitals and emergency departments:

• Ensure patients have an Asthma Action Plan, provide or make refer-rals to self-management education, provide education and resources on managing environmental triggers in the home, and communicate with primary care and community care providers as needed.

For pharmacists:• Monitor your pharmacy’s asthma

medication order and refi ll inter-vals to identify patients with poorly

controlled asthma. Contribute to the community’s asthma manage-ment team by alerting prescribers about patients whose asthma may be poorly controlled

For healthcare professional associations:

• Include a link to the National Asthma Control Initiative on your website and promote the six priority action messages for members:

1. Prescribe inhaled corticoste-roids as indicated by the guide-lines.

2. Use written Asthma Action Plans to guide patient self-man-agement.

3. Assess asthma severity at the initial visit to determine initial treatment.

4. Assess and monitor asthma control and adjust treatment if needed.

5. Schedule follow-up visits at pe-riodic intervals.

6. Act to control environmental exposures that worsen asthma.

“Large disparities related to race/ethnicity, gender, age, and income exist when reviewing the most severe outcomes of the disease,” noted Armstrong. “While the prevalence of asthma in Florida is sim-ilar among all race/ethnicity groups, sub-stantial disparities exist in the rate of ED visits and hospitalizations, an indication of poorly controlled asthma.

“Improving asthma outcomes among disparate populations must be a priority for all partners involved in asthma man-agement.”

Shining a Light on Asthma Challenges, continued from page 5

Local Data ResourcesFlorida Community Health Assessment Resource Toolset (CHARTS), part of the

Florida Department of Health’s Division of Public Health Statistics and Performance

Management, is a one-stop-site for Florida public health statistics and community

health data: www.FloridaCHARTS.com.

Florida Environmental Public Health Tracking (EPHT) Program is grant-funded,

to identify and promote the use of nationally consistent data in partnership with the

Centers for Disease Control and Prevention and other grantee states: www.Florida-

Tracking.com.

2014 Asthma Capitals in Florida

No. 20: Jacksonville

No. 49: Orlando

No. 50 Tampa

No. 55: Lakeland

No. 58: Miami

No. 64: Daytona Beach

No. 75: Sarasota

No. 76: Palm Bay

No. 82: Cape Coral

t a m p a b a y m e d i c a l n e w s . c o m AUGUST 2014 > 7

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COMMUNIT Y is our middle name.

By CINDy SANDERS

In an effort to improve patient access to appropriate, evidence-based care, the North American Spine Society (NASS) recently released detailed policy recom-mendations for coverage of 13 common spine care treatments, procedures and di-agnostics.

The first-of-their-kind reference doc-uments outline when it is … and when it is not … appropriate to utilize each of the options based on an extensive review of current literature by a multidisciplinary team of experts.

William Watters, MD, president of NASS, said, “Maintaining patient access to high-quality, evidence-based and ethi-cal spine care is the single most important part of NASS’ mission. It is our hope that payers, spine specialists and their patients will use these evidence-based coverage recommendations as a reference to advo-cate for appropriate care for patients.”

Watters added the society was uniquely positioned to take the lead on such an extensive project because of the multispecialty nature of the organization, which includes the expertise of surgeons and allied health professionals. “We cover the full spectrum of spine care,” he noted.

Watters, who is a board certified or-thopaedic surgeon in private practice at the Bone & Joint Clinic of Houston and a clinical associate professor at both the University of Texas Medical Branch in Galveston and Baylor College of Medi-cine, said the society already had experi-ence weighing the evidence at the request of physicians, patients and payers. “NASS began a number of years ago becoming involved in third party payer coverage decisions,” he noted. However, he contin-ued, the turnaround time was often tight and the number of studies to consider ex-tensive.

“We decided to proactively create our own coverage decisions based on the best evidence available … and where evidence was lacking, based on the expertise in this group,” he explained. “We came up with what we feel is the most sound group of recommendations based on the best evi-dence available at this point and time.”

Watters continued, “One of the hopes that we have is that we bring a bit of uniformity to the whole process of spi-nal care.”

Christopher Kauffman, MD, health policy council director for NASS, con-curred. He said allowed treatments and diagnostics vary by state and by payer.

These recommendations outline the scope and clinical indications for a therapeutic measure when a patient meets appropri-ate inclusion criteria. They also clearly state scenarios in which employing the measure is not indicated.

While not recommending payers re-imburse for every procedure under every circumstance might be controversial among some providers, Kauffman said, “People who understand where medicine is going with outcome measures get it. So far, the re-sponse has been overwhelmingly positive.”

He added, “People may confuse cov-erage with medical appropriateness. The two are not equal. People assume pay-ment equals medical appropriateness. I can’t stress enough this isn’t true. Payment equals treatments where the literature has reached a certain bar of evidence.”

Kauffman, a board certified ortho-paedic surgeon in practice at Premier Orthopaedics in Nashville, said, “For everything we recommend, we think the evidence does reach the bar for coverage. This is what we think should be covered by any payer.”

However, he continued, it doesn’t mean other treatments being employed don’t have therapeutic benefits. “You can’t ever throw out the art of medicine.”

Yet, Kauffman noted, “If you’re falling outside the clinical guidelines, you have to expect that you’re going to do a peer-to-peer review, or it might not be a covered service.” He added the recommendations would be routinely revisited to incorpo-rate new evidence.

In addition to the 13 coverage pol-icy recommendations published in May, Watters said NASS is already in process or planning to create documents for 14 additional diagnostic and therapeutic mo-dalities including annular repair, cervical and lumbar radiofrequency neurotomy, cervical fusion, cervical laminectomy and laminoplasty, minimally invasive lumbar fusion, SI joint fusion and injec-tions, DNA-based scoliosis test and electri-cal stimulation for bone healing, among others. “The remainder will be released within a year,” he said.

“The plan is to reassess the literature at least every two years,” he continued, emphasizing the need to stay current as new studies are published and new treat-ment options become available. “This has to be a living document.”

He added it’s a nearly impossible task to ask physicians, surgeons, nurses, therapists and other providers to wade

NASS Takes a Proactive Approach to Evidence-Based Coverage Decisions

(CONTINUED ON PAGE 8)

8 > AUGUST 2014 t a m p a b a y m e d i c a l n e w s . c o m

“I think most doctors are past Option A. I think most doctors realize circling the wagons around a single specialty isn’t real-istic,” said Keckley. “Two out of three pri-mary care doctors have already cast their lot,” he continued of aligning with hospi-tals, payers or very large groups.

“Frontline specialists have already gone to bigger groups. Now they are moving to the next option … most look like they’re going to hospitals,” he added of orthope-dists, ENTs and OB/GYNs. As for other specialists, he said the decision to remain in-dependent, merge or consolidate is all over the board and is specialty dependent.

Going forward, Keckley said, “I think we’re going to end up with a very few pri-vate doctors in practice independently.” He predicts seeing a few more very large, multispecialty practices. “I think the ma-jority end up employed in the hospitals be-cause of these new payment mechanisms.”

In fact, he noted, “It’s been incentiv-ized for the hospitals to hire physicians.” Clinical integration, outcomes-based re-imbursement and bundled payments have created an environment where hospitals and doctors are increasingly co-dependent.

Although hospital administrators

and clinicians have always had to work together, Keckley said this new closeness highlights areas that must be addressed to maximize effectiveness. Three key stressors are administrative decisions, clinical per-formance, and … of course … allocation of money.

“There’s always going to be tension around operations,” he said of administra-tive decisions. “Each presumes the other’s operating is simpler than it really is,” he continued of the chasm between blue suits and white coats.

With reimbursement tied to outcomes, he said physicians and hospitals face tougher decisions around strategy. One issue is how to address physicians not prac-ticing effectively. “The hospital suits don’t do a very good job of changing the behav-ior of doctors. It takes peers,” he noted.

The biggest cause of tension is ex-pected to be around allotting payments to each of the partners in a vertically inte-grated delivery system. “And then you get down to money, and that’s where it gets ugly,” Keckley stated. However, he con-tinued, too often the perception among ad-ministrators is that it’s all about the money when it comes to physicians. “If it was just

about money, there are a lot of better ways to make money … and easier, by the way. Most doctors don’t go into it to be wealthy. It’s hard work. The average medical career is 30 years, and it’s a hard 30 years.”

That said, he added physicians do want to be successful, have a sense of sat-isfaction around their career choice and be well compensated for their work. How-ever, Keckley noted, “There’s such a differ-ence between the way doctors think things should be and the way they are.”

Keckley said too many physicians tend to dismiss data as unreliable or believe their patient is an outlier. Yet, he added, “The table stakes are you’ve got to have data. You can’t just have a bunch of opinions.” To bridge that gap, Keckley said he be-lieves it is going to take physicians willing to step into the hot seat and take criticism from their colleagues as the profession adapts to new economic realities.

“I think physician leadership is prob-ably going to be a theme over the next 10 years,” Keckley said. “The medical profes-sion is well respected and well compensated … that doesn’t change … but how that profession plays in the delivery system is very much a work in progress.”

Partnering in a New Paradigm, continued from page 1

through all the literature required to prac-tice evidence-based, contemporary medi-cine. Having the committee go through the best, most soundly crafted studies to create each of the 5-30 page recommen-dations, which include supporting details behind the rationale and a thorough list of references, simplifi es the process for prac-titioners and their patients. “These turned out to be remarkably educational docu-ments,” Watters stated.

Both Kauffman and Watters stressed at the end of the day, the coverage rec-ommendations are an effort to ensure patients have equal access to the best pos-sible treatments.

“It’s making sure that good spine care is available for patients across the U.S.,” Kauffman concluded.

Coverage Policy RecommendationsTo access the documents for each of the procedures listed below, go online to www.spine.org and click on the “Policy & Practice” heading.

• Cervical artifi cial disk replacement

• Endoscopic discectomy

• Epidural cervical spinal injections

• Interspinous device without fusion

• Interspinous fi xation with fusion

• Laser spine surgery

• Lumbar artifi cial dis replacement

• Lumbar discectomy

• Lumbar fusion

• Lumbar laminotomy

• Lumbar spinal injections

• Percutaneous thoracolumbar stabilization

• Recombinant human bone morphogenetic protein (rhBMP-2)

don’t respond as well to corticosteroids. Clearly there’s a link between inci-

dent asthma and obesity, but we don’t want to over-diagnose asthma because of similar signs and symptoms. Obesity it-self can be an infl ammatory disease. Fat cells produce a number of infl ammatory mediators that could in fact make asthma worse.

What environmental factors unique to a southern climate trigger asthma fl are-ups?

Allergies represent a major trigger because more than 80 percent of children with asthma have allergies. In adults, that number goes down to 50 to 60 percent. Al-lergens that tend to cause more problems are perennial: cockroaches, house dust

mites, pet dander. Those triggers could be very important in inner-city asthma. The cockroach has clearly been shown to be an important trigger in children.

Also, carpeted corridors in schools hold allergens, though we don’t see it as much in Florida as northern states. And even if children don’t have pets, you can look at clothing that schoolchildren wear

and coats they put on the back of their seats and see how pet dander invades the school environment.

What parting words about the state of asthma do you have for the local medical community?

We’re always looking for children and adults with asthma for research studies as we strive to fi nd better medications and treatments for the disease. Call (813) 631-4024 for information and appointments.

Understanding the Rise in Asthma Prevalence, continued from page 4

NASS Takes a Proactive Approach, continued from page 7

t a m p a b a y m e d i c a l n e w s . c o m AUGUST 2014 > 9

Loans | Treasury Management | Can-Do Attitude

© 2014 Regions Bank. All loans and lines subject to credit approval.

Since opening PHC Health in 1986, Dr. Hugh Durrence had envisioned creating a multiservice medical company to provide all

levels of care – from medical equipment and in-home nursing to outpatient rehab services – throughout the community. His vision

is now a reality, but as his business grew so did his banking needs. Finding most banks slow and infl exible, he turned to Brian

Ball, a Regions Business Banker who helped the company navigate the process of acquiring a new location. Finding such a smart,

prepared and passionate advisor was a turning point for Dr. Durrence, one that convinced him he’d found a banking partner to help

his business move forward. To see how we can help your business move forward when it’s at a turning point, turn to Regions.

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Hugh Durrence, M.D. PHC Health Get the whole story at regions.com/phchealth

10 > AUGUST 2014 t a m p a b a y m e d i c a l n e w s . c o m

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By ROBIN PIPER

Failed medications trials are frustrat-ing for the physician and patient. Until recently, the common practice in mental health was to assess a person, then try vari-ous medications until physician and client found the perfect combination of medi-cal therapy to alleviate symptoms with the least side effects. This process can be very long and discouraging to the patient who is not receiving immediate alleviation of symptoms. This further increases the likelihood that a client will not adhere to physician recommendations. Enter phar-macogenetic testing. With a simple collec-tion of saliva, the pharmacogenetic profile of a client can be examined, thereby shed-ding light on the person’s unique drug me-tabolism. Pharmacogenetics answers the questions of why some medications work outstandingly well for some and not at all for others; and conversely, why do some individuals experience marked side-effects and others do not, while using the same pharmacological agents. Mental health is

uniquely suited to this testing since psy-chiatric medications may take longer to demonstrate efficacy than, say, cardiac medications where a practitioner can see the drug’s effectiveness reflected within a few days.

Whether or not a drug works is dic-tated by the complex interaction of phar-macokinetics and pharmacodynamics in the body which ultimately are driven by each individual’s genetics and their expression. With this new technology, we can use the knowledge of someone’s unique enzyme activity, as dictated by their genes, to choose drugs that are me-tabolized and will therefore be clinically effective at lower, more efficient doses, with fewer side effects.

The question at this point is why is this not sweeping the medical field uni-versally? The answer to this comes down to cost and lack of coverage by insurance companies. However, we have not found this to be an issue within our community. All clients who present as candidates that would benefit from the application of the

testing are offered it. In the short time that our facility

has been offering pharmacogenetic test-ing, the feedback from clients has been overwhelmingly positive. Finally they feel that they have a chance at success in their medication therapy. The reality is that many attempting to recover from addic-tions have had numerous failures in their previous attempts. Be it failed medications for anxiety or other comorbidity issues, most feel like they were in the dark until they landed on effective medications. This is the first time these individuals have felt they can be smarter about their treatment options. We can now harness the science of personalized medicine and avoid side-effects while targeting the most effective medication for each client. This is a bur-geoning field and as the research grows, it is an exciting time for the field of mental health. In an era of evidence-based medi-cine, doing the right thing the first time has never been more important.

Robin Piper has been in the field of Mental Health and Addiction treatment since 1987. She is the CEO and clinical director for Turning Point of Tampa, providing quality care for those suffering from chemical dependency or eating disorders. Ms. Piper received her Bachelor’s Degree in Psychology from Ohio State University, earned her Master’s Degree in Administration from Springfield College, and her Master’s Degree in Mental Health Counseling from Capella University.  She is a Licensed Mental Health Counselor in the State of Florida, is a National Certified Counselor, and has been a Certified Addictions Professional for sixteen years. She can be reached through www.RehabisforQuitters.com.

Personalized Medicine in Addiction Medicine

CLARIFICATION: In our June issue on the opening of Weiss Pediatric Care in Sarasota, we discussed the clinic’s path toward becoming Sarasota County’s first Pediatric Patient-Centered Medical Home and the patient-centered approach to medical care. In discussing Dr. Weiss’ enthusiasm for the change, we stated that his former practice was “not centered on patients” versus not being a patient-centered practice model. There was no intention whatsoever in leaving a negative impression of the former practice. Dr. Weiss asked that we make clear he has the highest respect for his former colleagues. We apologize to the members and staff of the former practice for the juxtaposition of words and any negative impression we may have conveyed.

t a m p a b a y m e d i c a l n e w s . c o m AUGUST 2014 > 11

Joseph Hwang Appointed Assistant Administrator at Manatee Memorial Hospital

Kevin DiLallo, Chief Executive Officer Manatee Healthcare System, Group Vice President UHS of Delaware, Inc. announced the appoint-ment of Joseph Hwang to the position of Assistant Ad-ministrator at Manatee Me-morial Hospital.

In his most recent role, Joseph was the Interim Manager for the Patient Access Center at Lehigh Valley Health Network in Allentown, PA where he was re-sponsible for the oversight of operations in Central Scheduling and Patient Access. He has also served as the Administrative Fel-low at Lehigh Valley on a two-year, project-based leadership program with rotations in operations, ambulatory services, telehealth, clinical and service line operations, business development, and strategic planning.

Joseph completed his Administrative Residency at the University of Pittsburgh Medical Center. He holds a Master of Health Administration degree from Pennsylvania State University.

Northside Hospital Honored with Mission: Lifeline Quality Achievement Award

Northside Hospital has received the Mission: Lifeline® Gold Receiving Qual-ity Achievement Award for implementing specific quality improvement measures out-lined by the American Heart Association for the treatment of patients who suffer severe heart attacks.

Each year in the United States, ap-proximately 250,000 people have a STEMI, or ST-segment elevation myocardial infarc-tion, caused by a complete blockage of blood flow to the heart that requires timely treatment. To prevent death, it’s critical to immediately restore blood flow, either by surgically opening the blocked vessel or by giving clot-busting medication.

The American Heart Association’s Mission: Lifeline program helps hospitals, emergency medical services and communi-ties improve response times so people who suffer from a STEMI receive prompt, appro-

priate treatment. The program’s goal is to streamline systems of care to quickly get heart attack patients from the first 9-1-1 call to hospital treatment.

Northside Hospital earned the award by meeting specific criteria and standards of performance for the quick and appropri-ate treatment of STEMI patients to open the blocked artery. Before patients are discharged, they are started on aggressive risk reduction therapies such as cholesterol-lowering drugs, aspirin, ACE inhibitors and beta-blockers, and they receive smoking cessation counseling if needed. Eligible hospitals must adhere to these measures at a set level for a designated period to re-ceive the awards.

Nicole Dollison Named Chief Operating Officer at Manatee Memorial Hospital

Kevin DiLallo, Group Vice President, UHS Acute Care Division, CEO, Manatee Healthcare System is pleased to announce the appointment of Nicole Dollison to the position of Chief Operating Officer at Manatee Memorial Hospi-tal. “Nicole brings exten-sive healthcare leadership experience in the area of clinical and non-clinical op-erations to Manatee Memo-rial Hospital” stated Mr. DiLallo.

Prior to joining UHS, Nicole worked at Bergan Mercy Medical Center as the Vice President of Operations and was the Ex-ecutive Director of Project Management for the closure and consolidation of Creighton University Medical Center on the Bergan Mercy Medical Center campus. Among her other responsibilities, Nicole oversaw the enhancements of the Level 1 and Residen-cy Program. Nicole was also responsible for the growth and expansion of Cardiovas-cular Services, Outpatient Diagnostics and Radiation Oncology, NICU, and Ambula-tory Surgery. Prior to that, Nicole worked for Creighton University Medical Center in various administrative positions. She holds a Bachelor’s degree from the University of Nebraska-Lincoln and a Master’s degree in Hospital Administration from the University of Nebraska-Omaha.

Northside Hospital Welcomes Sam Veltri as Vice President of Human Resources

Northside Hospital is pleased to an-nounce the appointment of Sam Veltri as Vice President of Human Resources. Sam comes to Northside Hospital from within the HCA Pinellas County Market where he most recently served as the Chief Human Resources Of-ficer for St. Petersburg Gen-eral Hospital and Edward White Hospital. Prior to joining HCA, Sam practiced labor relations law.

Sam holds a Bachelor’s degree from the Ferris State University, and a Juris Doc-tor from Wayne State University School of Law. He began his new role at Northside Hospital on August 4.

Parallon Launches Program In 10 Florida Hospitals To Address Specialty Nurse Shortage

Parallon, a leading provider of health-care business process and operational ser-vices, has implemented its solution to pro-vide cost-effective training and onboarding of nursing graduates in the West Florida Division of Hospital Corporation of Amer-ica (HCA). The program–Specialty Train-ing Apprenticeship for Registered Nurses (StaRN)—addresses the industry’s challeng-es by helping hospitals develop specialty-

trained nurses. StaRN began operation in June with

a class of 52 recent nursing school gradu-ates who will be placed at 10 hospitals in the West Florida Division of HCA. StaRN is an intensive, 13-week program for nursing graduates that combines classroom instruc-tion, a robust simulation experience and hands-on clinical training done in conjunc-tion with a regional academic partner. The program helps hospitals and nurses over-come a “catch-22:” lacking the experience to staff a high-acuity unit, but unable to find the opportunity to gain that experience.

When hospitals can’t find specialty-trained nurses, they are forced to use costly alternative measures, such as hiring tempo-rary contract labor, which does not address the core problem: the shortage of experi-enced, specialty-trained nurses, according to Tony Pentangelo, executive vice presi-dent of managed services at Parallon Work-force Solutions business unit.

Upon completion of the program, nursing graduates will be equipped with the knowledge and skill that typically comes from more experienced staff nurses. StaRN is tailored to each individual hospital’s re-quirements and covers medical-surgical, telemetry and critical-care training.

Hospitals pay a placement fee that cov-ers all the costs of the StaRN program. To participate, nurses make a two-year com-mitment to work at the sponsor hospital.

GrandRounds

Joseph Hwang

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IN MOTIONLive Your Life

When you live life “on the go,” you don’t want pain to slow you down. That’s

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