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USDA Loan Program is a Lifeline for Rural Hospitals By steVe sPenCer
We are all familiar with the crisis that rural hospitals are facing. Because rural hospitals have fewer patients with private insurance compared to larger cities, they rely more on Medicaid which is severely limited in Alabama. As a result, 17 rural hospitals in Alabama have closed since 2005, and many are teetering on the edge of solvency. In fact, a recent report from the Center for Healthcare Quality and Payment Reform said that there were 30 hospitals in Alabama that were at risk for closure. Although there is no perfect solution, the United States Department of
Agriculture Rural Development has a loan program that can make a difference. With a loan portfolio over $224.5 billion, the mission of the Community Facilities Direct Loan & Grant Program is to provide funding for essential services to the local community, which includes hospitals, medical clinics, dental clinics, nursing homes or assisted living facilities. Depending on the circumstances, the program has several funding opportunities, including low interest direct loans, grants, or the Community Facilities Guaranteed Loan Program, which provides loan guarantees to eligible lenders for essential rural facilities. This (CONTINUED ON PAGE 4)
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Representative Terri Sewell speaks at the construction site of the Medical West replacement facility.
Oak Street Health Arrives in Birmingham By Jane ehrhardt
Anita Varkey, MD
A new type of primary care clinic has opened in Birmingham focused exclusively on seniors. “Oak Street Health’s mission is to rebuild healthcare as it should be, and we are passionate about bringing our unique model of care to older adults across the country,” says Anita Varkey, MD, senior medical director for the Southeast. Over the past nine years, Oak Street has opened 125 centers across 20 states. The organization looks for locations with a Medicare-eligible population that has been historically underserved in order to make healthcare easily accessible to that community. “Our decision to open a clinic in Birmingham, specifically in CenterPoint, was very in-
tentional,” Varkey says. They estimate the center will provide the new healthcare option to the nearly 15 percent of the city’s residents 65 years and older. Using a value-based model of care, Oak Street approaches interactions with their patients differently. “We are not focused on the volume of patients or services provided,” Varkey says. Instead, they aim at prevention and managing chronic conditions to avoid hospitalization through dedicated attention and meticulousness. For instance, patient relationship managers and nurses reach out to patients between visits by phone and even in-person for check-ins and problem solving. “Our goal is to prevent illness. We do that by being high-touch,” Varkey says. More vulnerable patients coming
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Disclosure of protected hea years and it is a simple way t out of the hospital or facingAs a new experience. theseridemands ous illness or complicated chronic conto relieve staff, dition mayway be seen at the clinic everyenhanc three to four weeks, even if they are assurances.
handling the situation well, since the mission is to prevent problems, not just respond to them. In return, Medicare does not pay the clinic for each service or procedure performed as with traditional health-OF IN RELEASE care, but rather with a monthly lump The benefits ofusing ou sum per patient dependent on their better Any patient health status and conditions. costscare all w retention beyond that amount, client Oak Street must rates w cover themselves. The freedom from fee-based reSUPPOR strictions opens Oak AUDIT Street Health to devising their own approach care. Our audittocoordinators “We operate in a team-based quickly,model,” economically (CONTINUED ON PAGE 10)
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Birmingham Medical News
The Princeton Baptist Cardiovascular Rehabilitation Center By Laura Freeman
Surviving a serious cardiovascular event can be frightening, as a person comes face to face with her own mortality. Some people use the fear as motivation to power their rehabilitation efforts. For others, the anxiety can be immobilizing. Stepping on a treadmill may feel like walking a tightrope over the Grand Canyon. That’s where testing your limits in a monitored environment like Princeton Baptist Medical Center’s Cardiovascular Rehabilitation Center can make a difference. It’s like learning to ride a bike with training wheels, along with a teacher who can step in if you need help. “From the moment a heart patient arrives at Princeton, our cardiovascular team works together to tailor the care for each individual in order to move them toward the best possible outcome,” said interventional cardiologist and director of Princeton’s Cardiovascular Rehabilitation program Vasudeva Goli, MD. “Physical therapy usually begins in the hospital. Depending on the patient’s condition and the procedure involved, he or she is usually ready to begin outpa-
(Left to Right) Shari Brazelton, Vasudeva Goli, MD, Lisa Williams, Michelle Mizerany.
tient rehabilitation in two to four weeks. We custom design a program based on the patient’s history and where he is now. Following a step-by-step plan, our rehab team helps patients move toward their goals as they regain strength, pulmonary capacity and function.” Completing a 12-week cardiovascular rehabilitation program has been
shown to make a significant difference in outcomes. “We recommended rehab for all our patients who have had a heart attack, heart surgery, a stent or who are experiencing stable angina. If we could persuade more people who qualify for cardiovascular rehab to get it, we could save thousands of lives and hospitaliza-
tions every year,” Goli said. When patients are referred to the rehab center, the first visit begins with a thorough assessment of each patient’s condition to determine the appropriate starting point. Nurse Manager of the Rehab Unit Lisa Williams said, “After going over the patient’s history, we listen to their heart and lungs, check their heart rhythm and rate, and their blood pressure. Next, we do a six-minute walk with them to get a baseline. No two people start at the same place. We start where they are and work to where they need to be. “Every day, usually three days a week for 12 weeks, we begin class by checking to make sure their condition indicates that they should be able to safely participate in the planned activities. One advantage for patients who choose rehab is that these check-ins allow us to spot things the patient’s doctor may want to know about now, instead of waiting for the next office visit. For example, if blood pressure readings remain consistently elevated, we might need to consult with the physician about whether medication needs to be increased or changed. (CONTINUED ON PAGE 10)
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USDA Loan Program is a Lifeline for Rural Hospitals, continued from page 1 is the program that Medical West tapped for their replacement facility. Medical West executives concluded that in order to provide the highestquality healthcare, they would need to replace the current facility, which was built in 1964. After working out basic plans for the new building, the group began studying financing options, and in July 2019, Keith Pennington and his team flew to Washington D.C. to learn more about the program. The hospital applied for and received a $350 million loan for the $400 million project. As part of the arrangement to complete the funding for UAB-affiliated Medical West, the UAB Health System bought the existing Medical West Hospital campus for $51 million, and is leasing it to Medical West until the new facility is completed. UAB has several options for the campus, including potentially turning it into a mental health hospital. On January 27, Deputy Agriculture Secretary Jewel Bronaugh and Congresswoman Terri Sewell traveled to the construction site of the coming replacement hospital to announce the loan to a gathering that included community leaders, media, and healthcare professionals. Two people were there to learn about the program for their own hospi-
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Birmingham Medical News
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tals - Loretta Wilson, the Administrator at Hill Hospital in Sumter County and Doug Brewer, who is CEO of Whitfield Regional Hospital in Demopolis. “This program is a huge help because there are not many funding options for small hospitals,” Brewer said. “Whitfield Regional currently has two applications pending with the USDA, both of which are grants that came through the CARES Act which is administered by the USDA. “One is for a partnership we’re working on with Wallace Community College in Selma. A building on our campus is in disrepair and Wallace wants to bring their nurse training program here. So we applied for $1 million loan to re-fit the building into a training center so those nursing students can train on our campus and walk right next door to our hospital to work with our nurses with hands-on care. There is no profit motivation here, which makes getting a loan more difficult. If we can get this approved, the USDA will help create good jobs in a field that needs people, and support a rural community strengthening itself.” The second application that Whitfield Regional has pending is for a funds to renovate and expand the Emergency Department. Whitfield executives anticipate that this project will cost $5.5 million and they are asking for a $1 million grant to help. “You need a bigger project than these two to access the loan program,” Brewer said. “We’re currently working on a master plan to upgrade our entire campus. For this, we’ll probably make a $25 to $30 million request to the Community Facilities Guaranteed Loan Program. We’re about a year away from completing these plans.” Given the hurdles so many rural hospitals in Alabama face, the USDA Rural Development loan programs can provide a critical lifeline, something that would be valuable for all our smaller hospitals to consider.
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Birmingham Medical News
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New Device for Chronic Nonallergic Rhinitis By Jane Ehrhardt
A new device can deliver some permanent relief to the estimated 19 million Americans who suffer from chronic nonallergic rhinitis. Cleared by the FDA in November, Neuromark Rhinitis Neurolysis Therapy (RNT) uses a multipoint array to deliver radiofrequency energy that disrupts the posterior nasal nerve. “The heat ablates the nerve,” says Michael Sillers, MD, rhinologist at Alabama Nasal and Sinus Center. “This seems to be a durable, permanent disruption of the nerve that is related to all the symptoms.” Sufferers of this form of chronic rhinitis endure runny noses, post-nasal drainage, and congestion due to the inflammation of the nasal mucosa. The triggers range from odors, weather, and temperature to medications and age. The condition can not only be an aggravating nuisance and impede nasal breathing, it can lead to chronic sinusitis, nasal polyps, and ear infections, along with diminishing a patient’s quality of life. “For some people, it can become a social issue,” Sillers says. “They quit eating around anybody because of the discomfort of blowing their nose at the dinner table.”
Michael Sillers, MD
Since the cause of nonallergic chronic rhinitis is not an immune response to allergens against which a patient can build an immunity, treatment has relied primarily on medications to deter the nasal membrane inflammation, including corticosteroids, anti-drip anticholinergic sprays, and antihistamines. However, few patients with a moderate or severe condition see much, if any, cessation of their symptoms. The ablation of the post nasal nerve to halt the inflammatory response, however, brings notable and permanent relief. “We see about 60 to 70 percent less symptoms,” Sillers says. With the diminished intensity of symptoms, medications can then offer greater impact. Neuromark is not the first to treat rhi-
nitis by blocking the post nasal nerve, nor to use low-temperature radiofrequency for this procedure. RhinAer, which also employs heat generated by radiofrequency, received FDA clearance in March 2020. The first device to be cleared for the noninvasive approach, however, was ClariFix in 2017, which applies controlled freezing to create the lesions that disrupt the nerve instead of heat. Initially, an immediate drawback to using cold was ice-cream headaches in about 10 percent of those treated. “Now we’ve figured out if you use the appropriate anesthesia—inject that area before the procedure—it reduces the likelihood of the headache,” Sillers says. “It doesn’t seem to be a big deal anymore.” The procedure for all three devices follows the same steps. The patient receives a topical or possibly a local anesthetic. Then the ENT inserts the rod-part of the device into the nostril for two or more inches to reach the nerve. Utilizing endoscopy to create a view on the monitor, the surgeon the applies the heat or cold to each of the four or five branches of the nerve along the lateral nasal wall. “It takes a minute or less on each side of the nose,” Sillers says. “The biggest time is spent administering the anesthesia.” Post-procedural discomfort
requires only a Tylenol. Between the two radiofrequency devices, the difference with Neuromark lies in the design and its biofeedback. RhinAer uses a single flexible probe. “It has a small tip with an electrode on the end. You treat one spot, then move on to the next, treating four to five areas in each nasal passage,” Sillers says. “It’s a short treatment of 12 to 15 seconds at each site.” The Neuromark device also enters the nostril as a single probe but with the push of a button, it deploys wire loops resembling the petals of a flower. With the wider array of electrodes, the ENT can acquire more tissue acquisition. “But you don’t treat all five leaflets at once. You treat one, then the next,” Sillers says. The Neuromark also monitors biofeedback from the tissue. When it determines enough energy has been delivered to ablate the nerve, it stops the treatment. That prevents mucosal damage that can cause sloughing and some bleeding while healing. Sillers, who consulted with the developers on all three devices, does not see one standing out over another in outcomes. “In early studies, they seem to be equivalent,” he says. “It’s really down to a physician’s preference.” (CONTINUED ON PAGE 11)
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MARCH 2022 • 7
Birmingham-Based VitalEngine Provides Cutting Edge Collaboration Platform By Laura Freeman
Frustration can be a powerful motivator, especially when lives are at stake. After all the advances in imaging, medicine and digital technology, physicians continue to struggle with basic collaboration tasks, such as sharing medical images and records, and simply finding the time to talk to each other. After double majoring in biomedical and electrical engineering at Vanderbilt, earning a PhD in biomedical engineering at UAB and serving on the faculty, followed by medical training and cardiology fellowship at UAB, Philip Johnson, MD, PhD knew there had to be a better way. “Sometimes waiting for images to be burned onto a CD and mailed just isn’t good enough. When you have a patient with an acute cardiac issue, time matters.” Johnson said. So combining what he knew from both the worlds of medicine and digital technology, Johnson set out to build a platform in 2015 that could handle data-heavy image transfer and communications so physicians didn’t have to be in the same place or even the same state to work together.
Philip Johnson MD PhD
Today, the creation that grew out of that effort is VitalEngine, a HIPAA compliant, cloud-based healthcare collaboration and workflow platform that allows for secure communication among healthcare professionals and robust data exchange. VitalEngine is now present in many hospitals and clinics around the US, including almost every major healthcare system, and even in countries as far away as Australia and New Zealand. “You can access VitalEngine on any internet browser, computer or smart
phone,” Johnson said. “For the best performance, you can download the desktop application and establish a VPN connection for easy information transfer. “We started out focusing on image exchange. VitalEngine can send and receive any DICOM image, including CT, MRI, ultrasound and nuclear, as well as patient records, along with a chat where the images can be discussed with colleagues. We’ve also developed additional communications and workflow capabilities including HIPPA compliant chat and texting, digital referrals, whiteboards to streamline workflow, telemedicine, and many other features. There is also a patient app that allows you to share images and content with patients and families.” The business model is a hub and spokes network where hospitals and larger clinics can get an annual subscription to the enterprise version, and referring physicians can use a free version. “One of the strengths of our platform is that we have an excellent account support team that comes in to set up the software and teach the office team how to use it and what it can do,” Johnson said. “Quite a few hospitals and clinics
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Birmingham Medical News
are already using it. We like to have time to train everyone on the software, but in emergencies, we can set it up on the fly. “For example, a vascular surgeon reached out to us one night and said he had an emergency with a possible dissected aorta coming by ambulance and it sounded like a complex case. He wanted to see imaging as soon as possible so he could be setting up the OR and planning the surgery. He asked if there was any way we could add on the outlying hospital quickly so they could send the CT and communicate. Our team got on the phone, talked the other hospital through setup to connect them online, and the images were in front of the surgeon before the ambulance arrived.” VitalEngine was created from the inspiration of a working cardiologist seeking a better way to transfer information on complex cardiac referrals, but it has grown to be a valuable tool for major medical centers and physicians in multiple specialties. “It’s great to be able to communicate back and forth on a consult in real time while you are both looking at the images,” Johnson said. “Not having to (CONTINUED ON PAGE 11)
Advanced Technology Replaces Coolers for Liver Donor Transports By Jane Ehrhardt
“An organ recovery and the subsequent transplant is truly a masterpiece—a logistical, chemical, surgical masterpiece,” says Lisa Anderson, CEO of Paragonix, the makers of a new device for the advanced cold storage and preservation of livers during transport to donor recipients. The traditional method for carrying livers from a donor site to the transplant center has relied on the common cooler, the same container filled with ice and used by tailgaters, campers and picnickers. But technology is now taking chance out of the equation. “LIVERguard is a medical device that makes that completely uncontrolled situation completely controllable,” Anderson says. “By doing that, we’re improving preservation even over extended distances.” Organs can be travel up to 1,500 nautical miles on their journey to a recipient. That number of journeys continues to rise in the U.S. In 2020, 33,309 transplant procedures were performed, setting a record for the eighth year in a row, despite a drop in April from the
Lisa Anderson
Andrew Shunk
influence of the COVID-19 pandemic, according to the U.S. Department of Health & Human Services. In Alabama, 1,233 people currently wait for that life-saving procedure, according to Legacy of Hope, the organ procurement organization in the state. “We’re a bridge in the organ donation process,” says Andrew Shunk, clinical director of the organization which is located in Birmingham. “When the organ is removed from the body, we make sure everything is prepped in coordination with the procuring surgeon
from UAB. We play a hands-on role through the entire process, including communicating with donors, identifying recipients, coordinating with transplant centers, and participating in the transport itself.” In January, Legacy of Hope partnered with the UAB Comprehensive Transplant Institute for the first clinical use of the new LIVERguard along with the Paragonix device for transporting the heart, SherpaPak, from the same donor. UAB is the only liver transplant center in Alabama and one of only 20
nationally that averages 100 or more liver transplants a year. “By partnering with them, we’re able to further advance preservation technology to improve organ graft function and that results in a better transplant recipient outcome,” Shunk says. Legacy of Hope sees notable advantages to using the advanced technology for transport. “The organ is able to cool faster, able to maintain at a constant known temperature, and it’s a sterile environment that’s also pressurecontrolled,” Shunk says. For cooling, the LIVERguard relies on passive cooling from a proprietary material versus an engine or device, meaning no power source is required. And unlike ice in a cooler, the temperature never reaches freezing. “Freezing injures the organ. It damages the very fragile tissue,” Anderson says. “A great analogy is frostbite. The ideal range for transport lies between four and eight °C. We’ve optimized the environment for that organ, so every organ can be transported in a completely standardized and controlled way within a narrow tempera(CONTINUED ON PAGE 11)
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MARCH 2022 • 9
Oak Street Health Arrives in Birmingham, continued from page 1
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Varkey says. At Birmingham’s CenterPoint clinic, staff consists of not just a primary care provider and nurse, but a social worker, patient relationship manager, and scribe, who inputs notes on the computer during the visit, allowing the care provider to completely focus on discussions with the patient. “So each patient has a full care team supporting them to ensure his or her needs are met,” Varkey says. The team interaction explains why clinic visits can last an hour, whereas most fee-based physician appointments last half that time. In addition to at least 20 minutes face-to-face with the provider, the patient may sit down with the social worker and the medical assistant to address anything that will help them manage their condition and keep them out of the hospital. Oak Street also provides free transportation to and from appointments within a certain distance from the clinic. The patient relationship manager offers a service appreciated by anyone with health insurance. “That individual helps demystify Medicare services for a patient,” Varkey says. “Insurance can be very confusing for a patient and their family. This approach only works with an investment in a multidisciplinary team. And that upfront investment is not something that many places are
willing to make.” In contrast to the dominant fee-forservice model which relies on volume, Oak Street Health does not get paid any more for doing more things. “We are paid to be accountable for the entirety of the medical costs for a patient, which helps manage the cost of medical care. But our goal is to improve the health status of all the patients,” Varkey says. According to the statistics based on data from the Centers for Medicare and Medicaid Services, they are succeeding. In October, Oak Street Health reported to investors that their accountable care organization (ACO), Acorn Network LLC, had the fourth highest savings rate of 513 ACOs in the Medicare Shared Savings Program in 2020—16.86 percent compared to the average of four percent. Yet over their nine year history of using the value-based model, Oak Street Health has reduced both patient hospital admissions and emergency room visits by 51 percent, compared to Medicare benchmarks, and generated a 42 percent reduction in 30-day readmission rates. “Everyone wants to avoid hospitalization, if possible, and that is what we trying to do,” Varkey says. “We are thrilled to come to Birmingham and the CenterPoint area and look forward to meeting new patients, and improving their health outcomes.”
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Birmingham Medical News
The Princeton Baptist Cardiovascular Rehabilitation Center, continued from page 2 “We also work to help patients modify the risk factors that caused the problem. This includes nutrition, smoking cessation, cholesterol and diabetes management, as well as the psycho-social impacts of living with heart disease, which can lead to depression and anxiety. “As patients do more and see what they are capable of, they gain the confidence to continue using what they have learned. It becomes a new way of life, so they can live healthier and enjoy this second chance they have been given.” The rehab center offers multiple types of exercise equipment, including recumbent bikes, treadmills and arm ergometers to strengthen the upper body when patients are ready. Safety equipment includes a crash cart. And program director Goli is just one flight of stairs away if questions come up, a patient isn’t feeling well or if he and the patient’s doctor need to compare notes. “Statistics show there is a major difference in long-term outcomes between people who completed the program and those who didn’t come back at the first visit, both in survival rates
and in the number of hospital readmissions,” Williams said. Goli said, “We’re pushing to make cardiovascular rehab an option for a more patients. While there is insurance coverage for many, the copays may be more than some patients can manage. Others may have difficulty finding transportation or getting off work three times a week for classes. They may live too far from a rehab center or may not understand how important rehab is to living a fuller life.” To work around some of the difficulties in access, cardiologists could recommend online and video resources people can use on their own schedule. Eventually, the technology that made two-way virtual classrooms possible during the pandemic could be a possibility, matching up patients and teachers anywhere. It’s not the same as having a monitored class with health professionals and equipment in the same room when you are first testing your limits, but it’s a step in the right direction.
New Device for Chronic Nonallergic Rhinitis, continued from page 7 The big difference lies in the hand piece and how it is utilized. “Neuromark is the most sophisticated in how it applies the energy,” Sillers says. “I do like the design of its handpiece and how it’s deployed.” Many sufferers of chronic nonallergic rhinitis never receive a chance at these treatments because of misdiagnosis. “For patients who complain of post nasal drainage, it can actually be reflux-related,” Sillers says, “because
about half of reflux patients never exhibit heartburn. It’s one of the biggest masqueraders of rhinitis.” Most rhinitis patients respond to medications to some degree, and a CT scan can rule out chronic sinusitis. “Do an exam on the voice box. If you see subtle features of inflammation, it’s not from rhinitis but from reflux,” Sillers says. “Treat them for two or three months for reflux, and you become their hero.”
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Birmingham-Based VitalEngine Provides Cutting Edge Collaboration Platform, continued from page 8 wait for images to be sent also speeds up turnaround time so physicians can schedule follow-up appointments with patients faster. Being able to show the images to the patients and families can also help them understand what’s going on. That helps them make better informed decisions about their health and treatment options.” The company also owns www.myheart.net, a site offering insights into cardiac care from a team of cardiologists, which has over 15,000 daily visi-
tors. The content is available for both medical professionals and patients who are looking for an informed perspective on heart health. In addition to being founder, Johnson continues his hands-on role as innovator, continuing to add improvements and new capabilities while constantly addressing new challenges in healthcare collaboration. “If there’s a better way, we want to find it,” he said.
Advanced Technology Replaces Coolers for Liver Donor Transports, continued from page 9 ture range. The device can maintain that range for over 40 hours.” The temperature is continually transmitted through a smartphone app, allowing everyone involved to monitor the status of the organ enroute. “We can click certain time marks for key events within the procurement or when the organ is put into the Paragonix device,” Shunk says. “So it keeps them updated in real time as to where we are in the process of the organ coming back to the transplant center.” In both of the Paragonix devices, the cooling system remains the same. But unlike in the Sherpa Pack where the heart stays in a rigid canister, the liver rests inside a flexible container within the LIVERguard. That adaptability accommodates sizes for pediatric to adult-size livers that range from two to five inches and up to three pounds. To begin studying the effects of transporting on the outcomes of organ donation, Paragonix started the Guardian Registry. Over 1,000 heart recipients have been tracked since March 2020. “The registry is not a clinical trial, it’s real-world data,” Anderson says.
Data sets from organs transported by both ice cooler and the advanced preservation technology are collected. A statistical method then compares recipients based on commonalities, such as age, transplant clinic, transport time, and how long the organ was outside the body, leaving the only major discrepancy that tends to influence outcome would be the transport container. “Then we can utilize the data to assess how temperature control during transport relates to improved outcomes,” Anderson says. Paragonix plans to report the first data sets from the Registry concerning LIVERguard midyear. “The striking jump in organ transport devices from hardwarestore coolers to advanced technology is completely logical,” says Anderson. “The donor patient is perfectly managed prior to and during the donation process. The recipient is also perfectly managed. It makes no sense to not monitor the precious organ that a heroic donor has given to another individual. Our product aims to ensure that gift is maximized.”
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Birmingham Medical News
MARCH 2022 • 11
Nephrology Associates Partners with Evergreen Nephrology to Transform Kidney Care By Laura Freeman
“In a time of great advances in kidney care, it’s exciting to see Birmingham leading the way in both research and in how care is delivered. Specialty practices across the country are watching Nephrology Associates’ transition to value-based reimbursement. The process could become a standard model, and it will be interesting to see how improvements made possible under a quality focus will benefit patients,” Adam Boehler said. Formerly Director of The Center for Medicare and Medicaid Innovation, Boehler was the Senior Advisor for Value-Based Transformation for the Secretary of Health and Human Services. He now serves as CEO of Rubicon Founders and its healthcare partnering company, Evergreen Nephrology. The transition to value-based reimbursement and away from fee for service began with primary care and is now moving into specialty practices.
Jeffrey Glaze, MD
Adam Boehler
“It’s a basic shift in perspective,” Jeffrey Glaze, MD, with Nephrology Associates PC, said. “Instead of paying for more procedures as the patient gets sicker, the focus of quality-based care is to be proactive to help keep patients healthier. Care provided in this manner focuses on preventing and slowing the progression of kidney disease, pursuing preemptive kidney transplants, and facilitating smooth transitions into dialysis
if it becomes necessary. “We learned a lot from a similar approach working with Medicare. We identified the services that could lead to real change, but under the fee for service model, the time and resources necessary to offer them were not always covered. Partnering with Evergreen Nephrology will allow us to structure our practice to care for patients proactively.” Boehler said, “One of the key
Welcoming two new Orthopedic Surgeons.
Christopher Palmer, MD Orthopedic Surgeon
problems with the old model is that nephrologists need to be brought in much earlier, when simpler interventions are still able to limit or at least slow down the damage.” Glaze added, “We need to educate patients so that they understand how both the length and quality of their life depend on what they are doing now. It’s going to take more one-on-one interactions to keep them on course and to spot potential problems early. It doesn’t always have to come from a physician. It may be a home visit by a nurse practitioner following up a hospital discharge, or a nurse calling to check on a patient’s blood pressure. It could be a social worker checking on a patient’s home environment or a dietician offering dietary advice that will help control diabetes, hypertension, and prolong kidney health.” Boehler said, “The goal is to prevent a crash that might precipitate the need for dialysis or to postpone it as long as possible. If the day comes when it is clear that dialysis will be needed, pa(CONTINUED ON PAGE 15)
Scott Seibert, MD Orthopedic Surgeon
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Birmingham Medical News
Medical West Hoover Health Center 5310 Medford Drive Hoover, AL 35244 P: (205) 481-8570 *Adjacent to the Medical West Feestanding Emergency Department
Making Sure You’re Not Surprised By The No Surprise Act By Lindsey Phillips
The No Surprise Act (the “Act”), which became effective January 1, 2022, creates federal protections against surprise medical bills. Surprise medical bills often arise when patients unknowingly receive medical care from out-ofnetwork hospitals, doctors, and other healthcare providers and are billed for the difference between the amount a patient’s health plan would pay for innetwork providers and the full amount charged for the medical services received. Studies have shown that this occurs in about one in five emergency room visits. It is estimated that the protections afforded in the Act will apply to approximately 10 million out-of-network surprise medical bills a year. The Act applies to 1) emergency services provided by non-participating providers and/or non-participating emergency facilities and 2) non-emergency services provided by a non-participating provider at a participating health care facility. While the Act applies to most emergency services, including air ambulance transportation and post-
Lindsey Phillips
emergency stabilization services, it does not apply to ground ambulance transportation. As set forth in the Act, the term “facilities” currently includes hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgery centers. Providers include, but are not limited to, physicians, anesthesiologists, and hospitalists. The Act prohibits out-of-network providers from billing patients for more than the in-network cost-sharing price. The Act also sets forth guidelines for determining payment for out-of-network services and a process for resolving
disputes. Additionally, the Act requires providers to notify patients about their surprise billing protections. The notice provided to patients must include information regarding 1) the prohibitions on balance billing for emergency or non-emergency services with which the provider or health care facility must comply; 2) any state laws governing balance billing with which the provider or facility must also comply; and 3) contact information for state and/or federal agencies that an individual can contact to report a suspected provider or facility violation of the Act or relevant state laws. Providers are required to share the notice using three methods: 1) public signage posted prominently at the provider or facility’s location (e.g. in a central location where patients check in or pay bills); 2) posting on a public, easily accessible website without any requirements for account sign-up or passwords; and 3) a one-page notice provided directly to individuals enrolled in a group health plan or group or individual health insurance coverage that must be delivered in-person or by e-mail or mail (as chosen by the in-
dividual). This one-page notice should be provided before the date and time payment is requested from the individual. The United States Department of Health and Human Services has provided, as part of CMS Form Number 10780, a model notice that facilities and providers can, but are not required to, use. Of note, in situations where a provider delivers care at the covered healthcare facility, providers and facilities can enter into written agreements stating that the facility is responsible for providing the one-page notice to individuals on behalf of both the facility and the provider. This single disclosure notice must outline the restrictions on surprise billing that apply to both the facility and the provider. If a written agreement is in place between the facility and the provider but the facility fails to provide notice as required by the Act, then the facility – not the provider – is considered in violation of the Act. The Act also requires providers and facilities to provide good-faith estimates of charges for care to uninsured or selfpay individuals and sets out continuity (CONTINUED ON PAGE 15)
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Birmingham Medical News
MARCH 2022 • 13
OIG Allows Employer to Retain Profits from Employed Nurse Anesthetist in Surgery Center By nate LyKins and denise BurKe
The Department of Health and Human Services Office of Inspector General (OIG) published an advisory opinion recently permitting a pain management practice to retain the profits it received from billing for the anesthesia services that an employed certified registered nurse anesthetists (CRNA) provided at an ambulatory surgey center (ASC) partially owned by the practice’s physician-owner. As described in Advisory Opinion 21-15, a pain management practice wholly owned by one physician employed a CRNA to provide anesthesia services at the practice’s office and an ASC co-owned by the practice’s physician-owner and another physician. Under this agreement, the CRNA reassigned his billing rights to the practice while the practice assumed responsibility for the CRNA’s performance of anesthesia services, billed for the CRNA’s services, paid the CRNA a salary, and performed other duties typically expected of employers. In reviewing the employment agreement, the OIG identified two streams of remuneration: (1) the salary payments
Denise Burke
Nate Lykins
from the practice to the CRNA and (2) the profit the practice could earn by billing for the CRNA’s anesthesia services under the reassignment of billing rights. According to the OIG, both streams implicated the Anti-Kickback Statute - the salary payments because the CRNA ordered and arranged for items and services that might be reimbursable under Medicare or Medicaid, and the potential profit because the practice arranged for the purchase of the CRNA’s services or referred patients to the CRNA for services that might similarly be reimbursed by Medicare or Medicaid. Notwithstanding the conclusion that both reimbursement streams implicated the Anti-Kickback Statute, the
OIG declined to impose sanctions for either one. The OIG concluded that the first stream was protected by the safe harbor for employment agreements, and the second stream, while not protected by a safe harbor, presented a sufficiently low risk of fraud and abuse because it was a “straightforward” arrangement under which the practice assumed duties that were typical of an employer. In reaching its conclusion about the second reimbursement stream, the OIG noted that reassignment arrangements are common in the health care industry and explicitly authorized by Medicare statutes and regulations. Although Advisory Opinion 21-15 indicates that the OIG is unlikely to
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impose sanctions on parties who enter reassignment arrangements as part of straightforward, bona fide employment agreements, it may not provide much clarity since many health care providers likely already believed that such arrangements were permitted. The OIG is correct that reassignment agreements like the one described in Advisory Opinion 21-15 are quite common, so reaching any other conclusion would have been extremely disruptive to the industry. Moreover, in reaching this conclusion, the OIG has also indicated that reassignment arrangements implicate the Anti-Kickback Statute because they give the party accepting assignment the opportunity to earn profit from services. This statement could impact parties whose relationships are less straightforward. Interestingly, Advisory Opinion 21-15 did not discuss whether the anesthesia services were paid at Fair Market Value (“FMV”). Nevertheless, compensation paid to anesthesia providers should always be consistent with fair market value rates (supported by reliable surveys, valuations or market data). Otherwise, it seems likely that (CONTINUED ON PAGE 15)
Nephrology Associates Partners with Evergreen Nephrology to Transform Kidney Care, continued from page 12 tients will be given support and more education to understand their options.” The news that a patient’s kidneys are going to need help doesn’t necessarily mean he is doomed to spend much of his weekly waking hours attached to a machine at a dialysis center. Peritoneal dialysis at home can be a good option for many patients. In this case, the patient can treat himself during sleep, freeing up time for other things. This also means that transportation won’t be a problem, and if he has other health problems with a weakened immune system, he can stay safe at home. “We also make sure patients understand early on that the best time for many people to receive a kidney transplant is before reaching a point of needing dialysis,” Glaze said. “We teach them about transplant lists and steps they can take to increase the odds of finding a living donor if they need one.” Once a patient’s kidneys become severely damaged, the odds can go against them quickly. There are thousands more
people on the waiting list than the number of donor kidneys available, and every year many die waiting for a match that doesn’t come, or they get moved off the list because their health has deteriorated too much for a transplant to succeed. “This is one more example of why it’s important to focus on keeping patients as healthy as possible,” Glaze said. The partnership between Evergreen Nephrology and Nephrology Associates is now working on the details of ramping up to launch the transition to a valuebased reimbursement structure. While Boehler and Evergreen negotiate with insurance companies and other payers, Nephrology Associates is staffing key positions and building infrastructure. “If you don’t change the way you do things, outcomes won’t change either,” Glaze said. “We’re changing to give our kidney patients the very best care we can deliver and a better chance at a good quality of life.”
Making Sure You’re Not Surprised By The No Surprise Act, continued from page 13 of care protections to certain individuals when a provider or facility ceases to be an in-network provider due to a termination of contract. Continuing care patients are those who are: 1) undergoing treatment from a provider or facility for a serious and complex condition; 2) undergoing a course of institutional or inpatient care from the provider or facility; 3) scheduled to undergo nonelective surgery from the provider or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery; 4) pregnant and undergoing treatment for pregnancy from the provider or facility; or 5) terminally ill and receiving treatment for such illness from the provider or facility. For a continuing care patient whose provider or facility’s contract termination
leads to a change in network status, the plan must: 1) timely notify the patient of the termination and their right to elect continued transitional care from the provider or facility; 2) provide the patient an opportunity to notify the plan or issuer of the need for transitional care; and 3) permit the patient to elect to continue to have the same benefits provided, under the same terms and conditions that would have applied under the plan or coverage had the termination not occurred, with respect to the course of treatment furnished by the provider or facility. This election may last for up to 90 days. Lindsey Phillips is an associate at Burr & Forman LLP practicing exclusively in the firm’s Healthcare Industry Group.
OIG Allows Employer to Retain Profits from Employed Nurse Anesthetist in Surgery Center, continued from page 14 the OIG would take the position that the difference between the fair market value rate for the CRNA’s services and the actual compensation amount paid to the CRNA constitutes a payment to the referring physician(s) in exchange for referrals of anesthesia services.
Denise Burke is a partner with Waller who advises healthcare clients on regulatory and compliance issues. Nate Lykins is an associate with Waller who specializes in the regulatory aspects of healthcare transactions including mergers, acquisitions, joint ventures, and divestitures.
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MARCH 15 Courtney Haun, PhD of Samford University Harnessing Change: Higher Education for Healthcare Leaders MARCH 22 Harveen Sodhi, MD of Medical West Mental Health MARCH 29 Cayce Paddock, MD of Birmingham Recovery Center COVID and Alcohol Use APRIL 5 Hernando Carter, MD of Whitaker Clinic of UAB Hospital My Inspiration APRIL 12 Lauren Pearson, CFP® of Somerset Advisory Knowing Your Wealth Trajectory as a Female Physician TO VISIT OUR BLOG Go to www.birminghammedicalnews.com and click blog on the far right column or go directly to www.birminghammedicalnews.com/mod/blogpress/index.php While there, you are welcome to scroll down for past blog articles.
Birmingham Medical News
MARCH 2022 • 15
Billing Under Another Provider’s Name Can Land Physicians in Hot Water By Raj Shah
When it comes to Medicare, billing under the wrong physician’s ID can cost doctors and hospitals – literally. Consider these three recent incidents that, taken together, resulted in more than $7 million in penalty payments to the government: • In 2018, CityMD, the largest urgent care company in the New York area, paid more than $6.6 million to resolve allegations under the False Claims Act that non-credentialed physicians billed the government using the National Provider Identification (NPI) numbers of physicians who did not provide the services. • Similarly, in 2021, a West Virginia hospital had to pay the government more than $320,000 to resolve allegations that it had filed claims for services performed by a noncredentialed physician who used the NPI of a credentialed physician. • And an Oklahoma physician agreed to pay the government $580,000 to resolve allegations that he violated the False Claims Act by allowing his employer to use his NPI to bill Medicare for physical therapy
Raj Shah
evaluation and management services furnished by other providers. While it is possible to bill for services by one provider under the name and NPI of another provider, healthcare organizations must be intimately familiar with the rules and requirements where such billing is allowed. The following is an explanation of the law that applies and best practices to follow, so physicians and healthcare organizations stay out of trouble. Know Your Medicare Rules
Medicare-funded services generally must be billed under the name and NPI of the provider who actually performed the services. Billing under one provid-
er’s name and NPI for services that are furnished by another provider may be fraudulent if the identity of the person performing the services would be material to the government’s decision to pay the claim. The government does, however, generally permit the services of one provider to be billed under the name and NPI of another provider in two circumstances: • First, where the services of auxiliary personnel (including both physicians and non-physician practitioners) are billed “incident to” the professional services of a physician. • Second, where the services of a substitute physician are billed under the regular, but unavailable, physician’s name and NPI on a temporary basis (locum tenens1 and reciprocal billing arrangements). The “incident to” billing rules have strict requirements and only apply to certain services. The requirements can be found in the Medicare Benefit Policy Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/bp102c15.pdf Starting at section 60, Locum tenens and reciprocal billing arrange-
ments have very specific and stringent requirements that can be found in the Medicare Claims Processing Manual in sections 30.2.10 and 30.2.11. https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/ Downloads/clm104c01.pdf Failure to comply with the requirements for each billing arrangement could subject providers to significant liability under the False Claims Act, which imposes fines and penalties in cases when a person knowingly submits false claims to the federal government. Best Practices when Billing Under Another Physician’s NPI Number
Know your health plan contracts It’s important to note that the “incident to,” locum tenens and reciprocal billing rules are Medicare rules and may not apply in the context of private payer billing. This means it’s critical that doctors understand their health plan contracts and what they do and don’t allow. Billing providers will indicate whether they cover billing under these arrangements in their contracts. Permissible “incident to” billing (CONTINUED ON PAGE 17)
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Billing Under Another Provider’s Name Can Land Physicians in Hot Water, continued from page 16 requires direct supervision from the supervising physician, so be sure to include direct supervision attestation statements in those cases. Such statements should document how the physician supervised the non-credentialed physician during the patient encounter. Document everything when billing under these arrangements A healthcare organization must retain records of a locum physician’s NPI and all the services that individual provided. This documentation will benefit the organization in the event of an audit. Develop processes and procedures for system billing edits Errors are common with locum tenens and reciprocal billing arrangements. Billing incorrectly can lead to audits and regulatory penalties. Clearly defined procedures and communication among practitioners, clinical staff and billing staff (if applicable) are essential. In particular, locum tenens and reciprocal billing include requirements for when to bill the substitute or regular physician. Tracking how long the regular physician has been absent and how long the locum tenens physician has been at the organization will help pre-
vent mistakes. Billing under another provider’s name and NPI without complying with Medicare’s strict requirements can carry significant penalties, violate commercial payer contracts and subject an organization or physician to criminal liability under federal law. Practicing medicine is complicated enough these days. Doctors should understand those (and other) Medicare billing rules so they can focus on their patients, not administrative errors that can be avoided with knowledge and care. 1 The Centers for Medicare & Medicaid Services (CMS) now uses the term “fee-for-time compensation arrangement” to refer to locum tenens billing arrangements. This article uses the historical term “locum tenens” for these arrangements. As a regulatory attorney, Raj Shah provides consultation to MagMutual policyholders regarding federal and state regulatory matters in the healthcare arena and prepares risk management educational materials on best practices regarding healthcare compliance.
GRAND ROUNDS
BlueCross BlueShield of Alabama Provides Medical School Scholarships BlueCross BlueShield of Alabama has selected 27 medical students from four medical schools in Alabama to receive scholarships. As a condition of these scholarships, the recipients agree to practice as primary care or behavioral health physicians in underserved areas of Alabama after graduation. The schools are Edward Via College of Medicine Auburn campus; University of Alabama at Birmingham; University of South Alabama; and Alabama College of Osteopathic Medicine. “I commend these students,” said Tim Vines, CEO of BlueCross BlueShield of Alabama. “We are grateful for their willingness to provide care to those who live in the underserved areas in our state.”
Poll: Alabamians Support Use of ARPA Funds to Protect Rural Hospitals Alabama’s likely voters overwhelmingly support using federal COVID-19 relief funds to increase funding for mental health and rural hospitals, according to a new Alabama Arise poll. More than four in five respondents (81.1 percent) supported using a portion of Alabama’s funding under the American Rescue Plan Act (ARPA) to
invest in rural hospitals and increase rural Alabamians’ access to health care. And nearly three in four likely voters (73.6 percent) said lawmakers should boost mental health funding to increase access to services across Alabama. Among Republican voters, 80.1 percent supported investments in rural hospitals and 67.7 percent supported more mental health care funding.
Kassouf Promotes Ten Kassouf & Co promoted ten team members in January, naming two employees as managers. “We are proud of these team members Kami West, CPA and their accomplishments. They exemplify our firm’s principles around leadership, client care, and accountability,” said Kassouf Director Gerry Kassouf. Kassouf’s new managers include Julie Parker and Kami West. A graduate of UAB, Parker is part of the firm’s Assurance Services Group, performing audits and other assurance services for an array of industries. A University of Alabama alumna, West works in Kassouf’s Healthcare Group, providing accounting and advisory services to healthcare organizations.
Birmingham Medical News
MARCH 2022 • 17
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Kirklin Receives Lifetime Achievement James K. Kirklin, MD, director of the James and John Kirklin Institute for Research in Surgical Outcomes, has been named an inauguJames K. Kirklin, MD ral recipient of the Pediatric Heart Transplant Society Lifetime Achievement Award. Kirklin is a professor in the Division of Cardiothoracic Surgery in the UAB Marnix E. Heersink School of Medicine and currently holds the James K. Kirklin Endowed Chair of Cardiovascular Surgery. He served as director of the Division of Cardiothoracic Surgery from 2006-2016. In his clinical role, he provided support to the UAB Cardiovascular Institute, which is among the largest programs of its kind in the Southeast. In 1990, Kirklin and his colleagues at UAB established the Cardiac Transplant Research Database, which generated the first multi-institutional collaborative research in heart transplantation. In 1993, he and his research group initiated the Pediatric Heart Transplant Study Group, which continues to lead the field in multi-institutional studies. Kirklin was first author on the pre-
mier textbook on heart transplantation and co-author of the fourth edition of the Cardiac Surgery textbook. He has written more than 500 scientific publications. In 2020, he also received a Lifetime Achievement Award from the International Society for Heart and Lung Transplantation. “This is a great honor,” Kirklin said. “A major part of my career has been dedicated to heart transplantation and pediatric cardiac surgery, and our research and clinical advances will only continue to grow from here.”
Vulcan Imaging Associates Acquires Women’s Imaging Associates Vulcan Imaging Associates (VIA) has acquired Women’s Imaging Associates, an independent telemammography practice, established by Caroline Reich, MD, that offers breast imaging expertise in women’s health services. VIA, a full-service practice with roots that can be traced back to 1915, has a reputation for subspecialty proficiency among referring physicians. This addition unites two market-leading practices to build a team of board-certified, fellowship-trained breast radiologists to provide quality care to both the local communities as well as across
the country through partnerships with hospitals, healthcare facilities and other radiology groups. “We are thrilled to have this opportunity to expand our Women’s Division, continue our growth with Dr. Reich and provide the highest level of quality in breast imaging,” said Eric Blackman, CEO of Vulcan Imaging Associates.
Brown Joins OrthoSports Michael Brown has joined OrthoAlabama Spine & Sports, serving as practice administrator, where he is overseeing day-to-day operations, Michael Brown as well as working to improve efficiencies and profitability in the practice’s processes. He specializes in streamlining and optimizing procedures, including sales, business-to-business relationships, staff scheduling and other projects. Brown earned his Bachelor of Science degree in business management with a concentration in health care management. Prior to joining OrthoAlabama Spine & Sports, he worked as a clinic manager of Fagan Sports Medicine and then transitioned to UAB Sports Medicine to work as the administrative manager.
The University of North Alabama Partners with St. George’s University St. George’s University has partnered with the University of North Alabama to establish a pathway for qualified North Alabama graduates to gain immediate entry to the St. George’s Schools of Medicine. The partnership establishes a program, in which students spend four years at each institution. Those who wish to qualify must express their interest at the time they apply to the University of North Alabama. To ensure they can proceed to St. George’s, students must complete all undergraduate coursework, meet minimum GPA, and score competitively on the Medical College Admission Test. St. George’s will waive application fees and fast-track students in the program for application review, interviews, and admission decisions. All students in the program offered medical school admission are guaranteed a $10,000 scholarship. After two years of study at the St. George’s campus, accepted students will have two years of clinical rotations at St. George’s-affiliated hospitals in the United States or United Kingdom, with elective opportunities available in Canada.
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Birmingham Medical News
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UAB Emergency Team Awarded by ASNA EDITOR & PUBLISHER Steve Spencer VICE PRESiDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Katy Barrett-Alley CONTRIBUTING WRITERS Cara Clark, Ann DeBellis, Jane Ehrhardt, Laura Freeman, Cindy Sanders, Marty Slay Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400, 35242 205.215.7110 Ad Sales: Jason Irvin, 205.249.7244 All editorial submissions should be mailed to: Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: editor@birminghammedicalnews.com —————————————— All Subscription requests or address changes should be mailed to: Birmingham Medical News Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242
The Nurse Legion of Honor Medal is the highest award presented by the Alabama State Nurses Association in its 109 year history. The criteria mirrors that of the Medal of Honor for the military. Nurses who preform acts of courage with risks beyond those normally associated with the profession are nominated and screened by their peers to qualify for the Medal. Two UAB ER nurses, India Alford and Sherichia Hardy received medals. Alford and Hardy assisted in the field amputation to save a victim of the 2021 Fultondale tornado. On the night of the tornado, the two nurses rushed to the victim’s home, where they set up IVs and blood to stabilize him until Donald Reiff, MD and Courtney Blayke Gibson, MD arrived. With the house on the verge of collapse, the team determined the only way to save Hernandez was to perform
Donald Reiff, MD; Blayke Gibson, MD; Sherichia Hardy, RN; India Alford, RN an on-site amputation, which the nurses did while Drs. Reiff and Gibson conducted a field amputation to free a trapped
resident and save his life. Drs. Reiff and Gibson also received the ASNA Outstanding Medical Practice Award.
UAB Starts Hip Preservation Program UAB recently launched its Hip Preservation Program, which is designed for people with hip deterioration, whether it is just beginning or a long term problem. Hip specialists in the program can slow or reverse progression of degenerative changes in the hip and utilize minimally invasive techniques to treat many hip disorders. “As our understanding of hip conditions expands, newer techniques are allowing us to better diagnose and treat hip conditions that may not previously have been recognized,” said Amit Momaya, MD, chief of the Sports Medicine Section in the Department of Orthopaedic Surgery. “These interventions can be life-changing, but require a specific skillset and training to be able to implement them effectively.” As patients are increasingly staying active and participating in sports, there
New techniques are leading to new ways to treat hip deterioration.
has been more demand for specialized hip treatment. The people in need of these services can be the recreational weekend runner, the elite professional athlete or anywhere in between. “Through improvements in hip preservation surgery, we are now able to intervene earlier and treat conditions such
as hip impingement, labral tears, hip tendon tears and hip dysplasia,” said Aaron Casp, MD, orthopedic surgeon and director of the newly formed program. “While some of these surgeries are not brand-new, it takes a special group of medical staff and personnel to refine the care of this complex joint.” The team at UAB’s Hip Preservation Program includes orthopedic surgeons, primary care sports medicine physicians, radiologists and other musculoskeletal health professionals. Not every patient with hip pain requires surgery, so the team also uses many non-surgical approaches such as injections, anti-inflammatories and physical therapy.
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