December 2009 >> $5 PRSRT STD U.S. POSTAGE PAID FRANKLIN, TN PERMIT NO.357 ONLINE: M.MEMPHIS MEDICAL NEWS.COM ON ROUNDS PRINTED ON RECYCLED PAPER September 2014 >> $5 FOCUS TOPICS ONCOLOGY MEDICARE/MEDICAID PERSONALIZED MEDICINE BY RON COBB In 1920, only nine years after the founding of what is now the University of Tennessee Health Science Center (UTHSC), administrators O.W. Hyman and A.H. Wittenborg gave back part of their salaries to help keep the College of Medicine open. A century later, executive dean David M. Stern, MD, doesn’t need to deliver that measure of devotion, but he is nonetheless on his way to leaving his own indelible stamp on the College of Medicine. Since taking over in UTHSC’s centennial year of 2011, Stern has undertaken an im- pressive number of initiatives, including: • The formation of two new departments, Radiation Oncology and Genetics, Genom- (CONTINUED ON PAGE 12) HealthcareLeader David M. Stern, MD, Executive Dean UTHSC Raising the profile of the College of Medicine Stephen B. Edge, MD PAGE 3 PHYSICIAN SPOTLIGHT SPECIAL OFFERS FOR AMA MEMBERS Mercedes-Benz of Memphis Be the first to drive! THE ALL-NEW 2015 C-CLASS FOR ADDITIONAL FLEET PROGRAM DETAILS VISIT: mercedesmemphis.com/2015-c.htm Available for qualified customers only. AVAILABLE NOW FOR TEST DRIVE Tennessee Facing Litigation Over Medicaid Delays in TennCare Determinations at Heart of Lawsuit BY CINDY SANDERS Tennessee became one of the first states in the nation to face litigation over its Medicaid prac- tices in the post-reform era when three advocacy groups filed suit on behalf of clients they say have waited far beyond the legal limit for a determination of TennCare eligibility. The Southern Poverty Law Center, Tennessee Justice Center and National Health Law Pro- gram filed suit on July 23 in the U.S. District Court for the Middle District of Tennessee. Darin Gor- don, Larry B. Martin, and Raquel Hatter, PhD, in their respective official capacities as director of (L-R) Attorneys Michele Johnson and Sam Brooke are joined by Melissa Wilson and Ricky Reynolds in announcing the lawsuit against TennCare. Wilson and Reynolds’ wife April are two of the plaintiffs who have waited more than five months without receiving any word on their enrollment applications. (CONTINUED ON PAGE 14) “Combination of insurmountable obstacles” Blamed for Crittenden’s Closing Gene Cashman, CEO of Crittenden Regional Hospital in West Memphis, blamed this month’s closing of the facility on a “combination of insurmountable obstacles,” including “a changing healthcare industry, a recov- ering economy and one of the toughest reimbursement climates in the nation.” Cashman’s comments were part of an internal memo to the 400 employees of the hospital that was sent August 25, the day the an- nouncement of the closure was announced. The hospital said it would stop admitting patients effective August 25, and close permanently on September 7. The hospital’s media release said the decision was made by the board of trustees and leadership after “exploring all possible op- tions with legal and financial advisors.” In the announcement, Cashman said, “We are deeply saddened to have to make this decision after all the attempts that have been made to preserve the hospital for our community. With counsel from national healthcare consulting firms and the passage of a county- (CONTINUED ON PAGE 16)

Memphis Medical News September 2014

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In 1920, only nine years after the founding of what is now the University of Tennessee Health Science Center (UTHSC), administrators O.W. Hyman and A.H. Wittenborg gave back part of their salaries to help keep the College of Medicine open.

A century later, executive dean David M. Stern, MD, doesn’t need to deliver that measure of devotion, but he is nonetheless on his way to leaving his own indelible stamp on the College of Medicine .

Since taking over in UTHSC’s centennial year of 2011, Stern has undertaken an im-pressive number of initiatives, including:

• The formation of two new departments, Radiation Oncology and Genetics, Genom-(CONTINUED ON PAGE 12)


David M. Stern, MD, Executive Dean UTHSCRaising the profi le of the College of Medicine

Stephen B. Edge, MD





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Tennessee Facing Litigation Over MedicaidDelays in TennCare Determinations at Heart of Lawsuit


Tennessee became one of the fi rst states in the nation to face litigation over its Medicaid prac-tices in the post-reform era when three advocacy groups fi led suit on behalf of clients they say have waited far beyond the legal limit for a determination of TennCare eligibility.

The Southern Poverty Law Center, Tennessee Justice Center and National Health Law Pro-gram fi led suit on July 23 in the U.S. District Court for the Middle District of Tennessee. Darin Gor-don, Larry B. Martin, and Raquel Hatter, PhD, in their respective offi cial capacities as director of


(L-R) Attorneys Michele Johnson and Sam Brooke are joined by Melissa Wilson and Ricky Reynolds in announcing the lawsuit against TennCare. Wilson and Reynolds’ wife April are two of the plaintiffs who have waited more than fi ve months without receiving any word on their enrollment applications.


“Combination of insurmountable obstacles” Blamed for Crittenden’s Closing

Gene Cashman, CEO of Crittenden Regional Hospital in West Memphis, blamed this month’s closing of the facility on a “combination of insurmountable obstacles,” including “a changing healthcare industry, a recov-ering economy and one of the toughest reimbursement climates in the nation.”

Cashman’s comments were part of an internal memo to the 400 employees of the hospital that was sent August 25, the day the an-nouncement of the closure was announced. The hospital said it would stop admitting patients effective August 25, and close permanently on September 7.

The hospital’s media release said the decision was made by the board of trustees and leadership after “exploring all possible op-tions with legal and fi nancial advisors.”

In the announcement, Cashman said, “We are deeply saddened to have to make this decision after all the attempts that have been made to preserve the hospital for our community. With counsel from national healthcare consulting fi rms and the passage of a county-


2 > SEPTEMBER 2014 m e m p h i s m e d i c a l n e w s . c o m

m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 3


After 21 years at Roswell Park Can-cer Institute in Buffalo, New York, Ste-phen B. Edge, MD, was ready for a new challenge. He found that and more when he took over as director of the Baptist Cancer Center in August 2013.

Edge is overseeing construction of a new building that will be the centerpiece of Baptist Memorial Health Care’s cancer services. The building is scheduled to open in 2016.

Edge also will be highly involved in clinical research funded by a five-year grant totaling more than $3 million that was awarded last month by the National Cancer Institute. Baptist will be one of 12 cancer centers in the United States to ad-dress disparities in cancer outcomes for minorities and other underserved groups, with the focus on Memphis because of its disturbingly high mortality gap.

Edge will be Baptist’s principal inves-tigator in the NCI’s Community Oncol-ogy Research Program.

“Our biggest challenges are looking at ways to enhance the value of what we pro-vide to our patients, remembering that we

have to always have a special focus on those who have the hardest time accessing us,” he said. “You and I have good health insurance and good contacts, and hopefully we won’t have a need for cancer services. But if we do, we know we can get the best care pretty quickly. But many in our commu-nity don’t have that kind of access, and we can’t just say, ‘Oh, we’ll do a better job.’ We need to actually do real research into understanding how we can do a better job.”

Edge grew up in Chicago, the son of a music teacher and a lawyer. He has a brother who is a musician and a sister who is a primary care physician, and Edge is married to a pediatrician. It was while he was an undergraduate at Tufts University that he became interested in medicine.

“They had a six-week program be-tween semesters where you had to do something in community work and I spent time in a hospital,” he said. “I was inspired by the doctors and staff who worked there.”

At medical school at Case Western Reserve in Cleveland, he had a chance to work with oncology specialists and de-cided then to specialize in cancer, in part, he said, because “you’re able to marry to-gether the human aspects of medical care with the very technical aspects of scientific

issues in cancer. It’s an intriguing field.”

Edge did his internship and resi-dency at University Hospitals of Cleve-land and then com-pleted his fellowship at the National Can-cer Institute. At Ro-swell Park, his roles included chair of the department of health services and chief of the breast division in the department of surgical oncology.

When the oppor-tunity came to join

Baptist, Edge liked the idea of joining “a program like this that would extend across a large community.”

“It’s a terrific city with really nice people,” he said of Memphis, “so my wife and I really enjoy living here. Profession-ally it’s a great medical community with critical needs in terms of cancer care. The disparities in cancer care are striking here in Memphis, even more so than at many other places in the country. There’s an enormous need across our entire network, which extends from Jonesboro in Arkan-sas to Columbus, Mississippi.”

The disparity in cancer outcomes generally runs across socio-economic lines and is particularly large among African-Americans.

“Overall in the United States,” Edge said, “a black woman who has breast can-cer has about a 20 percent higher chance of dying compared to white women. In

Memphis, the mortality rate is more than double. That’s the largest disparity in the United States. Baptist is committed to ad-dressing the problem, and has been for some time.

“A lot of these disparities have to do with access to care, and there are many cultural barriers as well. Obviously the National Cancer Institute and we can’t solve all the socio-economic issues affect-ing American cities. But (we’re) looking to identify ways to revamp the way care is delivered when people have a suspicion of cancer or have cancer, and develop ways to include those people in high-quality care.”

Edge believes Baptist’s new cancer center building will be part of the equation of delivering better care. A major purpose of the center will be to create a smoother-running operation.

“The value is to bring a team of peo-ple together who are working on cancer care,” he said. “Cancer care is not deliv-ered by single physicians. Cancer care is provided by physicians, nurses and profes-sionals. In many disciplines, and in most communities, including Memphis, people work in different offices and the care can be quite disjointed.

“There is enormous value for patients to have people working in the same build-ing and even in the same parts of that building who are focused on their type of cancer and their conditions and needs who’ve been communicating with each other on an hourly basis rather than com-municating by email or letter. It’s much more efficient and timely for patients. More and more cancer care will be cen-tralized into these kinds of centers.”

Stephen B. Edge, MDBaptist Cancer Center’s director has plenty on his plate


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With so much at stake, why didn’t GM act sooner?

The answer, according to many people familiar with the automaker, is a corporate culture reluctant to pass along bad news. “These investigations always reveal the person(s) who dismissed potential problems,” said Maryann Keller, an independent consultant who wrote a book about GM. Keller said GM has long been known for hiring people who “individually were the best and brightest but who were later channeled into a system that rewarded conformity.” (I refer to this as drinking the punch.)

In terms of healthcare, here are some facts from the national MGMA’s July, 2014, newsletter, Medical Practice Today:

• “Three of the biggest challenges to providers in this year of all-consuming and more legislation than I have ever seen in healthcare are Meaningful Use, ICD-10 and Administrative Simplification. This year is expected to be a watershed year in the area of health information technology.”

• “Processes upon processes with a changing target, there can be no positive outcomes, the providers and patients will most definitely know consequences why the Affordable Care Act will fail. It is really not if it will fail it is when it will fail, unless change and management with HHS/CMS changes and changes fast.”

• “The NCQA (National Committee for Quality Assurances) recognizes that more than 6,800 physician practices are medical homes.

In a study in JAMA, Rand researchers compared 32 NCQA-recognized practices in southeast Pennsylvania with 29 that were not. Over three years, a significant association with utilization of costs was found.

In March the NCQA announced it will unveil revised IT standards to show IT recognition process value. They will shift their focus to align with HHS ( I think that is sometimes referred to as the fox watching the hen house) requirements for information technology, enhance team-based care, target high-need populations and advance the triple – aim goals of increasing quality, lowering costs and improving patient experience.”

• “This is not just the Affordable Care Act under the Obama administration, but goes back to Clinton, and W. Bush. (Three two term presidents equals 24 years. The Clinton administration, with the failed attempt of Hillary Care, but with programs and increased regulations that led to falling off the cliff. Under the W. Bush administration, the announcement made at Vanderbilt Hospital that medical records would happen during the next five years. Then the Affordable Care Act which added an always-moving target with overwhelming processes and regulations for health care providers.” (source; “CMS Hasn’t Got a Clue!,” Memphis Medical News, April 2014, J. William Appling)

“The ability to plan for the future is increasingly difficult for MGMA members, who are overwhelmed by new rules and regulations in addition to regular responsibilities, which include keeping practice doors and supporting the delivery of high-quality care, according to this

year’s Medical Practice Today (MPT): what members have to say survey.

“I feel like there are so many guns pointed at my head,” said one member. “I increasingly see my job as a risk manager.”

“Expecting digital sharing between providers when no network exists is unreasonable,” said another member. “Many of the requirements are ahead of existing technology.”

Respondents to the 2014 MPT survey cited an onslaught of issues – from frustration with duplicate quality reporting measures and onerous regulations to mandated technology changes before industry partners and infrastructure are ready.

Since 2008, MGMA has created an applicability-weighted index. It showcases challenges to colleagues that are the most pressing. In other words, these are the most intense challenges that are applicable to the most members. Here are the top 10 2014 AWI challenges for all organizations.

(Category, Challenge, AWI rank and AWI score)

1. Other – Preparing for the transition to ICD-10 diagnosis coding. 0.75

2. Financial management – Dealing with rising operating costs. 0.67

3. Financial management – Preparing for reimbursement models that place a greater share of financial risk on the practice. 0.65

4. Financial management – Preparing for value-based payments (e.g. shared savings, capitation / global payments, quality / outcomes. 0.64

5. Financial management – Managing finances with the uncertainty of Medicare reimbursement. 0.64

6. Payer relations – Understanding payers’ criteria for physician performance ratings and the impact on provider networks and tiering. 0.58

7. Financial management – Collecting patient due balances (self-pay, high deductibles and HSAs) 0.58

8. Information technology – Preparing in the CMS HER Meaningful Use Incentive program 0.53

9. Payer relations – Negotiating contracts with payers. 0.53

10. Financial management – Understanding the total cost of an episode of care. 0.49

One of the biggest challenges beyond the financial aspects of practice management is developing a highly functioning team with effective group dynamics and a culture that supports collaboration. Integrating patient-centered care concepts into the organizational and operational culture is more than lip service. It involves a dedication to doing the right thing even before the financial rewards are evident in the changed reimbursement environment. No one is better-suited for this task than administrators who have demonstrated their knowledge and skills.

Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC.  He is a national speaker, presenter and a published author.  He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood.  For more information contact Bill at [email protected].

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With the help of the thousands of infinitesimal clues to the origin and treat-ment of disease that have been excavated since the Human Genome Project was completed in 2003, doctors and researchers at St. Jude Children’s Research Hospi-tal are discovering new in-formation about the genetic variations of medicine in hu-mans.

The St. Jude study is one example of how the treasury of re-sulting genetic discoveries is moving the medical community closer to personalized medicine, which the Food and Drug Ad-ministration defi nes as “tailoring medical treatment to the individual characteristics, needs and preferences of a patient in all stages of care, including prevention, diag-nosis, treatment and follow-up.”

St. Jude has transferred genetic knowledge into clinical practice through a personalized medicine study initiated in 2011 called PG4KDS. The aim is to even-tually enroll all patients in this research protocol focusing on pharmacogenetic tests, which measure genetic differences

in how people break down medicine in the body.

“The purpose of the study is to move pharmacogenetic test results from the lab into the patient medical record, so that the test results are available to pre-emptively infl uence prescribing,” said Mary V. Rel-ling, PharmD, chair, pharmaceutical department, St. Jude. “Only test results for which we have built adequate clini-cal decision support are moved into each patient’s electronic health care record. Clinical decision rules and alerts provide point-of-care support to clinicians so that they can use pharmacogenetics to guide prescribing.”

Study objectives are:• To test patients for hun-

dreds of genetic variations im-portant for drug use. Strong scientifi c evidence will move a few genes into the medical record if it shows the result can improve the prescribing of drugs for patients

• To estimate how often results are moved from re-search tests into a patient medi-cal record

• To use methods to choose which tests are to be included in the medical record

• To use computer-based tools in the electronic medical record to help doctors use gene test results when prescribing

• To measure patient and patient family concerns about genetic testing in-formation being included in their medical record.

The direct benefi t to the patient is that therapeutic care can be customized to the child’s genetic makeup, avoiding serious adverse effects of some medicines, optimizing the drug response and avoid-ing ineffective therapies. This medical information can then travel through the patient’s life so that fruitless treatments are not repeated.

Relling said St. Jude uses Clini-cal Pharmacogenetics Implementation Guidelines (CPIG) as well as the hospital’s Pharmacogenetics Oversight Committee to prioritize which drugs and genes are put into the medical record. There may be hundreds or thousands of gene variations important to drug use. The priority is to decide which ones are used for patient care. It is a painstaking process.

“We use an array-based approach to test for 230 genes, but only 14 of these are ready to use clinically now,” she said. “Thus far we have fi ve genes implemented for our patients.”

The fi ve “priority genes” are: Cy-tochrome P450 2C19 (CYP2C19); Cytochrome P450 2D6 (CYP2D6); Dihy-dropyrimidine Dehydrogenase (DPYD); SLCO1B1; and Thiopurine Methyltrans-ferase (TPMT).

For example, in the 1990s, St. Jude researchers associated life-threatening complications with the important fam-ily of cancer drugs linked to Thiopurine Methyltransferase (TPMT). TPMT is an enzyme metabolizing thiopurines, which include the medications 6-mercaptopu-rine (6-MP), 6-thioguanine (6-TG) and azathioprine.

The drugs 6-MP and 6-TG are useful

Project Advancing Personalized MedicineSt. Jude study helps transfer genetic knowledge into clinical practice

www.familycancercenter.com | 901.747.9081

©2014 Family Cancer Center

It’s not what we treat, it’s who.

‘‘The purpose of the study is to move

pharmacogenetic test results from the lab into the patient medical record, so that the test results are available to pre-emptively infl uence

prescribing.’’— Dr. Mary V. Relling


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Deadly and defiant, pancreatic can-cer was one of the major oncologic threats Congress hoped to address with passage of the “Recalcitrant Cancer Research Act,” which was signed into law at the beginning of 2013.

Garnering broad bi-partisan support, the statute honed in on cancers with five-year relative survival rates below 50 per-cent. Starting with pancreatic and lung cancer, the law calls for the National Can-cer Institute to develop a scientific frame-work and strategic plan to move the science forward at a more rapid pace to address these deadly diseases.

Leading the call to pass the legislation and increase research, collaboration and patient resources is the Pancreatic Can-cer Action Network (PanCAN). Formed in 1999, the California-based national or-ganization will have awarded almost $23 million in grants to 110 research scientists around the country by year’s end. Ad-ditionally, the Patient & Liaison Services (PALS) has shared current, reliable infor-mation with more than 80,000 patients and family members, including a comprehen-sive clinical trials database to link patients with the latest treatment options and re-search studies.

A PanCAN research study published in Cancer Research this past May predicted pancreatic cancer would become the sec-ond leading cause of cancer-related deaths by 2020 and also estimated the increase in liver cancer deaths would make lung, pan-creas, liver and colorectal the top four can-cer killers in the country by 2030.

“When we think of ‘big picture’ can-cers, we think lung, breast, prostate and colorectal,” said Lynn Matrisian, PhD, MBA, vice president of scien-tific and medical affairs for PanCAN. More than 800,000 Americans will receive a diagnosis of one of these types of cancer

this year (see box). Yet, noted Matrisian, pancreatic

cancer, which is the 12th most commonly diagnosed cancer, is currently the fourth leading cause of cancer deaths in the United States. “Pancreatic cancer sur-passed prostate cancer a couple of years ago and is expected to surpass breast can-cer in the next year or two and the colorec-tal cancers around 2020,” she explained.

While great strides are being made in lowering overall cancer death rates, Matri-sian said it has been much more difficult to gain traction in improving pancreatic can-cer survival. “For pancreatic cancer, we haven’t made any change much at all in the death rate since we began keeping records. The five-year survival rate is 6 percent. An estimated 73 percent of patients die within the first year of diagnosis.” She added, “It’s the only one of the major cancers with that five-year survival rate in the single digits.”

The reasons for the high mortality rate are multifactorial and include a need to better understand the pathogenesis of the disease and to identify it earlier when treat-ment options have a greater opportunity for success. “The pancreas is deep within your body. The symptoms are pretty vague and can be attributed to multiple diseases so it’s often diagnosed quite late,” Matri-sian said. She added, an aging and grow-ing population is anticipated to increase the number of cases of pancreatic cancer in coming years, which in turn is expected to lead to pancreas cancer becoming the number two cancer killer considering its mortality rates.

Yet, she stressed, “It doesn’t have to happen if we can change things now.” Ma-trisian said she sees the information as a call to action and pointed to the preventive, di-agnostic and treatment successes that have occurred in many diseases through focused research efforts.

Stand Up To Cancer (SU2C) is an-swering that call with the formation of their second pancreatic cancer Dream Team. Announced in April, the SU2C-Lustgarten Foundation Pancreatic Cancer Convergence Dream Team is focused on

immunotherapy and is being led by noted physician-scientist Elizabeth M. Jaffee, MD, professor of oncology at Johns Hop-kins School of Medicine and co-director of the Gastrointestinal Cancers Program at the Sidney Kimmel Compre-hensive Cancer Center at Johns Hopkins in Balti-more.

University of Penn-sylvania translational research expert Robert H. Vonderheide, MD, DPhil, has joined Jaffee as co-leader of the project — “Transforming Pancreatic Can-cer into a Treatable Disease.” The mul-

tidisciplinary team includes seven other principals from around the country plus three patient advocate members. Funding for the $8 million, three-year grant is a col-laborative effort of SU2C, The Lustgarten Foundation and the Fox Family Cancer Research Funding Trust.

The Dream Team will use the grant to develop new therapies to engage a patient’s own immune cells in the battle against pancreatic cancer. Jaffee has led the charge on creating an immunologic response, de-veloping a novel pancreas cancer vaccine with colleagues more than a decade ago targeting pancreatic ductal adenocarnino-mas (PDAC), the most common form of

Teaming Up to Turn the Tide on Pancreatic Cancer

Dr. Lynn Matrisian

Dr. Elizabeth M. Jaffee

Resources for Your Practice & Your Patients:National Cancer Institute: cancer.gov/cancertopics/types/pancreatic

NCI’s Scientific Framework for Pancreatic Ductal Carcinoma (Released February 2014): deainfo.nci.nih.gov/advisory/ctac/workgroup/pc/pdacframework.pdf

Pancreatic Cancer Action Network: pancan.org

PALS: The Pancreatic Cancer Action Network’s Patient and Liaison Services (PALS) offers one-on-one support and educational information. Patients and family members can call 877-272-6228 or email [email protected]. Additional information is also available online at pancan.org under the “Facing Pancreatic Cancer” tab.

Stand Up to Cancer (SU2C): standup2cancer.org

SU2C Pancreatic Dream Team: standup2cancer.org/dream_teams

8 > SEPTEMBER 2014 m e m p h i s m e d i c a l n e w s . c o m


Which region of the country has the fewest states that opted to expand Med-icaid, the highest rate of uninsured non-elderly adults, leads the nation in chronic conditions such as obesity and diabetes, and fi nds the majority of its states have poverty levels above the national average? No surprises here … it’s the South.

Jessica Stephens, a senior policy ana-lyst with the Kaiser Family Foundation’s Commission on Medicaid and the Unin-sured, has been instrumental in working on several KFF projects this year assess-ing coverage and care in Southern states, along with opportunities and challenges the region faces to pro-vide increased health-care access and equity. Stephens, who received both her undergraduate degree and master’s in Health Policy and Ad-ministration from Yale, is also part of the Disparities Policy Project for KFF.

In looking at expansion decisions by region, Stephens noted KFF uses the U.S. Census Bureau defi nition of the South, which includes 16 states – stretching west-

ward to Texas and northward to Dela-ware – plus the District of Columbia.

“Six states including D.C. have implemented the Medicaid expansion,” Stephens said, listing Delaware, Mary-land, the District of Columbia, Arkansas, Kentucky and West Virginia. “They’ve all taken slightly different approaches,” she noted. “Arkansas, in particular, has adopted a private option where they are using Medicaid funds to assist newly eligible adults pay for private cover-age through the marketplace,” Stephens added of a waiver granted by the Centers for Medicare & Medicaid Services to allow the state to provide premium assistance.

Nationally, Stephens continued, 26 states plus the District of Columbia have implemented Medicaid expansion, which means nearly half of the U.S. states elect-ing not to expand at this time are located in the South – 11 of the remaining 24. “In the West and Northeast, the majority of states have (expanded). In the Midwest, a larger number are not, but it’s still more than in the South.”

The reasons for not implementing expansion are multifactorial. Stephens said that in addition to general political opposition to the Affordable Care Act in many Southern states, there is also a con-cern over the sustainability of maintaining expanded Medicaid rolls even though the phased down match rate of 90 percent is still much higher than the general Med-icaid population. And, she continued, “There are concerns over the Medicaid program overall … how it’s run in gen-eral.”

On the fl ip side, though, there is mounting concern over what the decision to not expand means for a large number of people. Stephens said more than a third of the nation’s population, 37 percent, live in the South, and the region is also home to 4 of 10 people of color. “The expan-sion was important, in part, because it was going to expand Medicaid to adults who were historically excluded from the pro-gram,” she said.

A very large percent of those who make too much for traditional Medicaid but not enough to qualify for federal sub-sidies reside in the South. “Overall in the South, there are 3.8 million people who fall into this gap, and nationally, there are 4.8 million … so nearly 80 percent of all those who fall into the gap nationally are in the South,” Stephens stated.

She added people are often surprised to fi nd out just how little a family could make in order to qualify for traditional Medicaid. Citing median levels, she noted, “For a family of three – one adult and two children – that family cannot earn more than approximately $12,000 a year for the parent to be eligible.” Stephens con-tinued, “Non-disabled, childless adults remain ineligible regardless of how much

Southern ExposureThe Medicaid expansion haves … and mostly have nots … in the South

Jessica Stephens

State Current Medicaid Expansion Decision

Alabama No

Arkansas Yes

Delaware Yes

District of Columbia Yes

Florida No

Georgia No

Kentucky Yes

Louisiana No

Maryland Yes

Mississippi No

North Carolina No

Oklahoma No

South Carolina No

Tennessee No

Texas No

Virginia No

West Virginia Yes


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10 > SEPTEMBER 2014 m e m p h i s m e d i c a l n e w s . c o m

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in treating leukemia or lymphoma.Effi cacy and adverse effects differ in

patients due to variations in the TPMT gene, meaning that as many as one in 10 patients may need a lower dose of the drugs; one in every 400 individuals needs a substantially lower amount to avoid potentially deadly side effects. Everyone can be classifi ed into one of three possible genotype groups. St. Jude uses a differ-ent starting dose of 6-MP and 6-TG for these groups. Varying the dose based on a patient’s genotype means there are fewer side effects due to low blood counts.

A more common drug example is the familiar codeine. About 10 percent of the population are genetically “poor metabo-lizers” who cannot activate codeine into

morphine and get no pain relief from it. “Ultra rapid metabolizers” comprise 1 to 2 percent of the population, and they are at risk from toxic effects like respiratory depression.

“Some hospitals have removed co-deine from their formulary because, without genetic testing, one doesn’t know which patients will benefi t and which will not,” Relling said. “This is a problem, be-cause codeine is one of the few narcotics for which patients can get refi lls, so many of our clinicians wanted to maintain it on the formulary for the 88-89 percent of the patients who might benefi t. By using genetic testing, we were able to keep this valuable medication available to our pa-tients with pain.”

Work continues today to identify which of the estimated 18 million gene variations in the human population play an important role in drug response. One gene can impact the workings of 30 to 40 drugs. More pervasive usage of genetic re-search and lower costs for the blood tests required mean early treatment testing and less time lost on ineffective or more toxic medications on patients.

“Eventually, we don’t want pharma-cogenetics to be delivered in a research protocol; we want it to be incorporated into routine healthcare. It is the future of medicine,” Relling said. “It will depend on healthcare changing so we have a univer-sal electronic healthcare record that fol-lows the patient from birth to death.”

Project Advancing Personalized Medicine, continued from page 6

they earn.” Without expansion, she said, Medicaid eligibility for adults remains very limited.

Additionally, Stephens noted the de-cision not to expand Medicaid also further exacerbates healthcare disparities with people of color being disproportionately impacted by the choice. “Six in 10 blacks who would have been eligible for Medic-aid in the South, about 1.2 million people, are not because they fall into the coverage

gap.”Among states that did expand cov-

erage, Stephens said reports are coming in that those states have been able to im-prove the effi ciency and function of their Medicaid programs by taking advantage of a number of ACA provisions. “We can tell the Affordable Care Act and the Med-icaid expansion has important potential to change delivery,” she said. “It also has the potential to reduce disparities in access to coverage and care by race and ethnic-ity and also by geography if the Southern states would expand.”

Even without expansion, though, Ste-phens said outreach and consumer assis-tance is critically important to chip away at the 21 million in the region still lacking any type of coverage. About 48 percent of the South’s uninsured currently qualify for existing programs.

“Of the 21 million uninsured in the South, we have 7 percent who are Med-icaid-eligible adults, 11 percent who are Medicaid- or CHIP-eligible children, 30 percent who are eligible to obtain tax credits to purchase private coverage through the marketplace, 18 percent who

are in the coverage gap, 21 percent who are ineligible for fi nancial assistance who have incomes above the tax credit limit or an offer of employer-sponsored coverage, and 13 percent who are ineligible due to their immigration status,” Stephens out-lined.

Ultimately, improving health out-comes will largely depend on the creation of dependable channels to access care … whether through the expansion of Medic-aid, implementation of other solutions to address the needs of the uninsured, or a combination of both.

Southern Exposure, continued from page 8

m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 11

To learn more, visit healthcare.goarmy.com/y941 or call 1-888-550-ARMY.

I was deeply disturbed to read the front page story on what doctors and nurses say about each other in the May 2014 Memphis Medical News. Questioning the accountability of nurse practitioners based on a statement by an unnamed phy-sician who “recounted a story he heard from a colleague about a patient who…” is unconscionable and to publish it, even more so. And the statement from this same physician that “the nursing board feels a nurse can do anything a doctor can do by taking a weekend course” is so wrong it would be laughable if it weren’t such a clear example of how some doctors view advanced practice registered nurses (APRN).

APRNs are nurses with advanced graduate education and board certifi ca-tion in their practice focus. Dozens upon dozens of research studies have shown that quality care outcomes for nurse prac-titioners are as good as physician out-comes and patient satisfaction is generally higher. It would serve the Memphis Medical News better if it refrained from publishing inaccurate, uninformed hearsay and stuck to accurate, researched information.

Sharon Adkins, MSN, RN, Executive

Director, TN Nurses Association

Editor’s note:Although it is not general policy for Mem-

phis Medical News to use unnamed sources, it was done in the case of the two articles mentioned above. The intent was to get candid and truthful remarks from doctors and nurses about working with each other without fear of retribution and to open dialogue between the two professional groups.

The Memphis Medical News welcomes letters. To be published, letters must be signed and the writer’s contact information should be included. Letters, comments and suggestions should be sent to [email protected].

Letter to the Editor

By EMILY ADAMS KEPLINGER In June, BlueCross BlueShield

(BCBS), the largest health insurance pro-vider in Tennessee, reorganized its offi ces in Jackson. Making a clean sweep of it, BCBS let its staff of fi ve go. Yet it did not close its operation.

What’s going on?According to Mary Danielson, di-

rector of corporate communications for BlueCross BlueShield of Tennessee, “The staffi ng changes were driven by business decisions concerning needs and service capabilities. Our Provider Network Con-tracting Team felt it could more effi ciently serve doctors and hospitals in the west Tennessee region by consolidating opera-

tions in Memphis and Nashville.”Formerly, there were three divisions

in middle and west Tennessee: Memphis, Jackson and Nashville. However, in terms of staffi ng, the management and contract-ing functions have been consolidated with Memphis and Nashville. But there is still a presence in Jackson.

In April, prior to the reorganization, BlueCross BlueShield of Tennessee ap-pointed Marc Barclay as vice president of provider networks and contracting. He is based in Nashville, where he is re-sponsible for the day-to-day operations associated with BlueCross’ extensive pro-vider networks, including contracting, and continued efforts to remain the pre-ferred insurance partner of providers in Tennessee. Barclay came to BlueCross after working with network management at CENTENE Corporation and United Healthcare of Tennessee, and provider contracting at Humana.

“Maintaining healthy, mutually benefi cial relationships with healthcare providers in Tennessee is critical as pay-ment models in our industry continue to shift from fee for service to a higher focus on quality care,” said Larry Nall, senior vice president of provider network man-agement at BlueCross. “Our members want affordable access to their preferred doctors, and Marc will make sure we con-tinue to be able to offer them that peace of mind.”

BlueCross BlueShield did not replace the Jackson Provider Network Contracting

employees with new employees. Instead, it redistributed the Jackson PNC team’s workload to existing BlueCross BlueShield Tennessee employees, specifically con-tracting and provider relations employees, already located in its Memphis and Nash-ville market offi ces.

The only new person brought in was Tom Winston. In August, Winston was named to fi ll the vacant director position of provider contracting for west and mid-dle Tennessee. In this role, he is respon-sible for defi ning and directing contracting strategies and negotiations for physicians, hospitals and other providers in these two regions. He is based in BlueCross’ Nash-ville office. Prior to this appointment, Winston served as corporate director of revenue and relationship management for Novant Health, Inc., in Charlotte, N.C. Winston has returned to BlueCross after serving as a senior fi nancial analyst in the late 1990s.

When asked what the impact of the re-organization was on doctors and other pro-viders who utilize the BlueCross BlueShield system, Danielson said, “The answer is simply ‘none.’ There are no discernible differences that our providers should ex-perience due to the recent changes in our Jackson offi ce. We are always trying to op-erate as effi ciently as possible in order to keep costs down for our customers.”

Danielson went on to explain, “Many of the people who functioned for the Jack-son offi ce were telecommuting in various capacities. On occasion they went to an

actual facility for tasks such as holding a meeting or running reports. Since the con-solidation, the staff is based out of Mem-phis and Nashville. Yet our providers (doctors, hospitals and other medical care givers) sense no difference because so much of our business is conducted via email or telephone. Or business is conducted in person with a visit to the provider. That latter aspect remains the same, with the ex-ception that our staff may have to travel a little further. All said, in light of our recent changes, we are able to maintain the same relationships with our providers.”

Some of the effi ciencies created by the staffi ng changes, as cited by BlueCross BlueShield, included:

The BCBS Provider Network Con-tracting Team was able to take advantage of new technologies that allowed each em-ployee to take on more provider assign-ments -- without affecting service levels to those doctors and hospitals they serve.

The organizational changes actually allowed one of the former Provider Net-work Contracting Team staffers based in Jackson to fi ll a newly created role that deals with improving quality for its Medi-care Advantage members.

BCBS Consolidation Aims for Effi ciencyInsurance provider reorganizes its Jackson offi ce

REPRINTS: Want a reprint of a Medical News article to frame? A PDF to enhance your marketing materials? Email [email protected] for information.

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ics and Informatics.• The recruitment and hiring of more

than a dozen prominent doctors from lead-ing hospitals and universities across the na-tion.

• The formation of a citizens advisory board composed of community leaders such as current and former CEOs and ex-ecutives, an educator, a restaurateur, a TV news anchor, the mayors of Memphis and Shelby County and the Tennessee Senate Majority Leader, Mark Norris. The board is chaired by David Levine, former CEO of ResortQuest International.

One of Stern’s goals is to raise the profi le of the College of Medicine, and by extension UTHSC, in Memphis and in so doing boost the reputation of the school na-tionally. The College of Medicine is one of six colleges that make up UTHSC.

Speaking of his relationship with com-munity leaders, Stern said, “I run a con-cierge service. I give out my cell phone number to everybody. I say, ‘You call me if you have a problem, and if you do, I’ll fi nd you a doctor on the spot and help you link up with that doctor.’

“I always say there’s a charge for using my concierge service. And what’s the charge? I say you have to be my ambas-sador and say UT cares. So I’m trying to build a little different brand around the medical school.”

To take it a step further, Stern’s plan centers on an increased involvement in the healthcare needs of the underserved seg-ments of Memphis’ population.

“I’m exceedingly interested in making it that the medical school really addresses the unmet medical needs and the problems of Memphis,” he said. “I feel the medical school has been somewhat isolated. When people think of medical care and medical problems in Memphis, they don’t think of the University of Tennessee. I’m aiming to change that.”

That theme is very much a part of Stern’s recruiting pitch to the doctors he has brought to UTHSC.

“The way that I recruit people to Memphis is I talk to them about the impact they can have here,” he said. “Let’s say when I recruited a wonderful guy from the University of Pittsburgh, Bennie Weksler (chief of the Division of Thoracic Surgery), I said I wanted to see a difference in the mortality of lung cancer in this city.”

The recruitment of doctors, the in-volvement in the city, the formation of a citizen’s advisory board – they’re all inter-twined within Stern’s vision for the College of Medicine.

The advisory board, formed just over a year ago, has met a half-dozen times or so.

“They make suggestions, and I’m lis-tening,” Stern said. “I can’t be more grate-

ful to this group because it’s worked in every way I can think of.”

As for his overall vision, he says he is “always remembering that caring for the vulnerable population, from children’s health to the aged, veterans, the under-served population of the inner city, that’s one of the special areas where we can have a very great impact. And, of course, the rea-son for that is that they don’t have the level of care we wish they had.

“If you think that the combination of obesity, diabetes, some substance abuse . . . those things kind of provide a substream for increased mortality and morbidity throughout the life cycle, from infant mor-tality to stroke to cardiovascular disease and cancer. Because we have those things on a scale that is greater than many other places, that’s the opportunity for my recruits to have an impact.

“So in a sense I say to them, ‘Your laboratory is Memphis.’ I don’t mean that the people here are guinea pigs in a nega-tive sense, but tools that you have to (help) improve the health of this population. This is the place to do it here, and if it works here it’s going to be a model that’ll be robust enough most likely to work elsewhere.”

Stern grew up on Long Island. His mother was a music teacher and his father the owner of a small jewelry store. He at-tended Yale and then earned his medical degree at Harvard.

“Except for a brief sojourn at the Okla-homa Medical Research Foundation, I was at the College of Physicians and Surgeons at Columbia in New York, and that’s where I spent a portion of my career where I was a scientist. I studied blood vessels. That was my thing.”

At Columbia he ran a center for vascu-lar and lung pathobiology.

“That was one of the big research operations that the university had,” Stern said. “I began being more used to building programs than actually doing the science. I enjoyed building programs. So I thought maybe I can run a medical center instead of just a vascular biology institute. It’s sort of like a conductor, instead of conducting a wind ensemble, maybe I could conduct the whole orchestra.”

Stern’s desire is to not only improve UTHSC’s reputation but, more tangibly, its place in various national rankings. While rankings can be a bit of a beauty contest, he says, and UTHSC is hampered somewhat by not having its own hospital, the fact that UT-trained physicians are working at facili-ties throughout Memphis is a major plus.

“I want you to know that I do have a national focus,” he said. “I’m very in-terested in making it so that by having an impact locally, we’ll have an impact nation-ally.”

David M. Stern, MD, continued from page 1

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m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 13

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the Bureau of TennCare, commissioner of the Tennessee Department of Finance and Administration and commissioner of the Tennessee Department of Human Services have been named as defendants.

In a conference call with statewide media representatives, lawyers for the plaintiffs alleged the state was playing politics by adopting policies that have de-prived vulnerable citizens of healthcare coverage for which they are eligible and kept others, who might or might not ulti-mately be eligible, hanging in limbo with no determination date in sight. The at-torneys said the Centers for Medicare and Medicaid Services have long required eligibility decisions be made within 45 days of an individual fi ling an application. However two of the plaintiffs, each facing

a health crisis, had already waited more than 140 days without receiving any de-termination.

“No one wants to be here today,” said Michele Johnson, co-founder and ex-ecutive director of the Tennessee Justice Center (TJC). “The state of Tennessee has failed its citizens. The results have been unimaginable and unacceptable.”

Sam Brooke, a senior staff attorney at the Southern Poverty Law Center, stated, “We have fi led a federal lawsuit today, Wilson v. Gordon, because Tennessee is frankly playing politics with the lives of their citizens.”

He added that Tennessee has made it more diffi cult than any other state in the nation to enroll in its Medicaid program. “They’re throwing a monkey wrench into

their own Medicaid program so they can demonize the federal government. People in dire need of medical care are being sac-rifi ced,” Brooke said.

He noted the 45-day requirement for determining eligibility isn’t a new rule, nor is the requirement that calls for a hearing if a denial or no determination is made. “What is new is Tennessee’s decision to ignore both these requirements,” he as-serted. The attorneys said failure to render a decision or to offer a channel to settle a dispute violates an applicant’s right to due process.

The group added they have been meeting with TennCare offi cials for sev-eral months to address a variety of issues, several of which were outlined in a sternly worded mitigation letter from CMS to TennCare in late June accusing the state of failing to meet six of seven critical suc-cess factors required by federal healthcare law. “To their credit,” said Brooke, “they have addressed some of the other issues but have drawn a line in the sand on this.”

Johnson said the backlog stems from a decision to end in-person assistance for residents trying to apply for TennCare. Tapping into federal funds, Tennessee has invested $35 million in an upgraded com-puter system that will hopefully alleviate the situation. However, Johnson said 100 people in county offi ces who served as in-person resources for applicants were laid off before seeing if the computer system functioned properly … it didn’t.

Now, TennCare offi cials seem unable to offer a timeline as to when the system will be operational. Instead all applica-tions for TennCare are being funneled through the federal marketplace website, healthcare.gov, which Johnson said was neither set up for nor intended to process and determine eligibility for TennCare’s 27 unique categories.

Jane Perkins, legal director for the National Health Law Program, said, “It is clear Tennessee is a national outlier. We are monitoring enrollment in other states,

and at this point, Tennessee is among the worst … if not the worst … offenders.” She added, “This is the fi rst case that has been fi led to challenge a state’s failure to process applications in a timely manner.”

The phones have continued to ring at the TJC as individuals share stories of their battles with red tape and radio silence from anyone who could make a determination on their status. “We’ve got-ten about 160 calls in the last six weeks about this issue,” Johnson said last month. “We’d never gotten a call before Jan. 1 from someone who was waiting 45 days.”

While there were 11 plaintiffs in the original fi ling, the attorneys have asked the court to certify the suit as a class ac-tion. They are also seeking emergency help for those stuck in limbo. Johnson said they are asking for a court injunc-tion requiring a decision be made within 72 hours after it has been brought to the attention of TennCare offi cials that an in-dividual has waited more than 45 days for an eligibility determination.

“On August 14, the state responded and fi led a motion to dismiss the whole case,” Johnson continued. “They said we should have sued the federal govern-ment.” She added the state’s take on the situation seemed to be that the enrollment delays were tied to failings with the federal marketplace and healthcare.gov site cou-pled with the ongoing problems with the state’s new computer system. However, Johnson noted every other state has man-aged to get its computer system working except Tennessee. Other states also offer in-person assistance to help individuals navigate a complex system. Johnson re-iterated the federal online marketplace “was never meant to be the only door to obtain state coverage.”

A hearing on the requests by both the plaintiffs and defendants was set for Aug. 29. In the meantime, costs and frustra-tions continue to mount.

“Charity care clinics often require, rightfully so, some kind of proof that you’ve been denied coverage, but these folks can’t get that because they can’t get any answer,” said Johnson. “Tell them yes. Tell them no. But tell them some-thing.”

Tennessee Facing Litigation Over Medicaid, continued from page 1

The Impact on IndividualsTennessee has long had presumptive eligibility for newborns, but coverage is

now being terminated for a number of these tiny infants once they leave the hospital … even though this is in opposition to Tennessee’s own child health plan, CoverKids.

Michele Johnson, executive director of the Tennessee Justice Center, shared the story of one mother who called the TJC in utter frustration. Within hours of giving birth via C-section, the new mom was handed a computer and told to apply for her child’s coverage through healthcare.gov. One problem … you can’t apply without a Social Security number. Johnson said that makes perfect sense for adults seeking coverage in the federal marketplace but leaves newborns in limbo for several weeks while parents apply … and then wait for … a Social Security number to be assigned. It’s one example, Johnson said, of why the federal website was never intended to be the sole option to access state Medicaid coverage.

In another case, a newborn needed the services of the NICU. After growing stronger, the baby would have been allowed to go home but would still need oxygen. Although coverage was applied for on the day the baby was born, the application still hadn’t been processed weeks later. Without coverage, the parents couldn’t afford the oxygen, and the hospital couldn’t release the child. While everyone … including those with the state … agreed the child should be covered, it took intervention by the TJC before the issue was ‘mostly fi xed.’ At press time, the hospital, which had absorbed all the inpatient costs, was still waiting to hear if they would be reimbursed.

“Those are the kinds of calls we’re getting on a daily basis,” said Johnson. “We have so many people who are getting caught between the cracks.”

Michele Johnson

Go Online for UpdatesAn important hearing regarding

this case was scheduled for Aug.

29, which fell after our print

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issue. Please go online

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m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 15


Are you still trying to decide if there is a return-on-investment available through the use of social media? While you’re waiting you’re losing. Losing future dol-lars. Losing relevance. The value of your voice in the community is depreciating as patient-driven physicians are amassing new wealth in the form of clout. Clout with fu-ture patients and clout eventually becomes dollars.

Those doctors or healthcare organiza-tions aren’t necessarily better at medicine than you. They’re simply better at culture. Your value proposition in the marketplace is what you know about achieving positive health outcomes. You’re pretty good at connecting that to a patient’s experience in the exam room, through a prescription or in surgery. But how’re you doing out there? You know, online via social media.

Still looking for something to prove it’s the right thing for you? Well, how about letting me debunk some healthcare social media myths for you. You know, tell you what it is (and what it’s not).

It’s not a road to nowhere. It is a path to connectivity with patients, their families, future patients and others who influence health choices.

It is a way for you to maintain a gen-eral conversation with the community that demonstrates a willingness to share infor-mation that might make a difference in

their wellbeing. By the way, people who share make more friends. Friends refer friends. Friends are patients, too.

It’s not date night. Your patients are not asking you to out to dinner. They’re simply looking to connect through their preferred channel. And this one has emerged to be that.

It is, by all evidence, an affordable conduit to the future as those with options choose providers, and those within plans sort one doctor or organization from an-other based on word of mouth, ratings, and social media manner—like bedside manner but on your smartphone.

It’s not a drive-through window. Pa-tients are not likely to ask for a diagnosis of some ailment. They’re too private for that. They’re just looking for something that might help them sift through clues about what ails them and you’re their most trusted source for that kind of information.

Look, I don’t profess to know much about making money but I have learned this, people connect with those who care. And caring starts with sharing. Social media is that.

Tim C. Nicholson is the President of Bigfish, LLC. His Memphis-based firm connects physicians, clinics and hospitals to patients and one another through healthcare social media solutions, branding initiatives and websites. His column, “Hey Doc”, appears here monthly. Find him on twitter @timbigfish or email [email protected]

Hey Doc, Get Online

Apply at: https://jobs.etsu.eduInquiries can be directed to: Stephen Geraci, M.D., Professor and Chairman of

Internal Medicine via Karen A. Heaton, Quillen College of Medicine, Box 70622,

Johnson City, TN 37614. Phone (423)439-6367; email: [email protected].

Academic Internal Medicine Opportunities

Quillen College of Medicine, Department of Internal Medicine at East Tennessee State University is seeking BC/BE (at time of hire) Internists to join their groups in Johnson City and Kingsport, Tennessee at the Assistant/Associate Professor level. Responsibilities include teaching residents and medical students ambulatory care in our University practices, with in-patient attending at our community partner teaching hospitals, and the opportunity for clinical research. Scholarship is an expectation of all faculty with protected time for scholarly activities. Competitive pay, comprehensive benefits package, CME allowance and relocation support provided. Women and minorities are encouraged to apply. AA/EOE

Quillen College of Medicine is a community-based medical school whose mission emphasizes primary care. Located in the beautiful mountains of northeast Tennessee, Quillen College of Medicine serves the healthcare needs of over 1 million people. The Tri-cities area boasts low crime rate, low cost of living, award-winning public school systems and no state income tax.

PAs to Help Alleviate Shortage of DoctorsAging of baby boomers produces need for more medical care


2008 699,100 706,500 7,400

2010 709,700 723,400 13,700

2015 735,600 798,500 62,900

2020 759,800 851,300 91,500

2025 785,400  916,000 130,600

Last column detailing “Physician Shortage” is for all specialties.

Source: Association of Medical Colleges Center for Workforce Studies/June 2010 analysis

Linda Reed


The warning in a recent report by the Association of American Medical Colleges is stark. “Unless we act now, America will face a shortage of more than 90,000 doc-tors in 10 years,” it says.

The reasons for that projection are many, but one of its primary drivers is a vastly increased patient load. Not only are more baby boomers turning 65 every day, and therefore in need of greater medical attention, but the Affordable Care Act is adding a vast layer of patient demand to what’s already been characterized by the U.S. Department of Health and Human Services as an impending doctor shortage.

The government agency expects that in the next 10 years the sup-ply of doctors – primary care and otherwise – will increase by only 7 per-cent, while the pool of people age 65 and older will surge by 36 percent. That, of course, doesn’t account for the roughly 31 million patients expected to be added to the health insurance rolls under the ACA.

Linda Reed, EdD, PA, chair of the Department of Physician Assistant Studies in the College of Health Professions at the University of Tennessee Health Science Center, finds herself at the forefront of the issue. Reed has been working at the institu-tion since July, but prior to that was on its steering committee to prepare the depart-ment for its first crop of 25 students who enrolled in January and are expected to graduate in December 2015.

Like nurse practitioners, physician as-sistants work under the auspices of a medi-cal doctor, although regulations governing that relationship vary from state to state. PAs supplement practices by helping di-agnose, treat and make more entry-level clinical decisions for patients, whether in primary care or specialty areas.

“More schools are seeing the future

need for increased pa-tient care . . . knowing that PAs might be able to fill in those needs and gaps projected by the Department of Health and Human Services by 2020,” Reed said.

While the average doctor attends four years of medical school followed by an additional four years of graduate residency training, physician assis-tants train for about 27 months after earn-ing their bachelor’s degrees. At UTHSC, the amount of time needed to earn the PA designation is 24 months, Reed said. Guy Reed, MD, chair of the Department of Medicine at UTHSC (no relation to Linda Reed), says limited residency positions for students training to be doctors also is at least partly responsible for a shortage in care. Since 1997, the number of federally funded residencies has been limited. That year, Con-gress capped total U.S. residencies for first-year trainees at 26,000 under the Balanced Budget Act. In 2011-2012, only 113,000 federally funded residencies were available nationwide, an increase of only 17,000 over a decade ear-lier, the New York Times has reported.

“What that is doing increasingly is making it more and more difficult for med-ical students to find residency slots,” Guy Reed said.

That, in turn, affects patient access.“This part of the country has had

a shortage of primary care like many other places, and it is more of a prob-lem the farther outside the large urban areas you go, where access to primary care and prevention is still a challenge for those with fewer resources,” he said. Medical positions tend to be distributed more heavily in urban areas because phy-sician lifestyles and working conditions generally are better there, particularly for those who specialize. It’s no secret that pri-mary care doctors are on the lower end of the compensation spectrum. Referring to the most recent numbers from a Medical Group Management Association report, Guy Reed said the median income for a primary care physician is about $192,000 a year. A doctor specializing in internal medicine at a private practice earns about $201,000 annually. In gastroenterology, the median income jumps to $466,000 a year, while in cardiology (invasive), the yearly compensation increases to $497,000.

Regardless, the AAMC not only pre-dicts a general physician shortage in com-ing years, but a deficit of 46,000 surgeons and medical specialists as well.“I think ev-eryone knows we need to do something to increase the number of residencies because we will need more doctors,” Guy Reed said. “There is no doubt about that.”

Guy Reed

16 > SEPTEMBER 2014 m e m p h i s m e d i c a l n e w s . c o m

pancreatic cancer. “Pancreatic cancer suppresses the

body’s anti-tumor immune response,” Jaffee explained. “These tumors do not allow immune cells that can recognize and kill them to even enter the pancreas. We think we can use vaccination to acti-vate anti-tumor immune cells and then use other agents to get those cells into the pan-creas where they can attack the tumor.”

Most recently, she noted, “We tested our newer vaccine, which is a combina-tion of two vaccines – the first primes the immune system and the second targets cancer cells – and we now give a boost to the immune system.” She continued, “We’ve tested this in advanced patients who have failed all other chemotherapies, and we showed it significantly improved survival.”

Jaffe added the median survival dou-bled from three months to more than six-and-a-half months. “Patients who did well are doing well long-term,” she added, not-ing some of these advanced patients have now survived more than a year out from the immunotherapy. “There really aren’t side effects so the patients have a better quality of life,” she added of another plus. The outcomes have resulted in accelerated approval status from the Food & Drug Ad-ministration.

While Jaffee and her colleagues at Johns Hopkins have made important prog-ress, she noted bringing the Dream Team together will enhance everyone’s work.

“Each center has come up with a project based on the science they were develop-ing,” she said of the two Phase I studies and three multicenter Phase 2 trials being launched. “We’re going to combine now and share our technologies to analyze the different clinical trials. We’ll compare mechanisms to see if we should combine agents,” Jaffee continued.

Calling the Dream Team an “all out massive attack on pancreatic cancer,” Jaffee said it is a wonderful opportunity to bring experts from eight different centers together to advance pancreatic research. She also said it’s possible immunotherapy could be widely available to patients in the next two years pending outcomes of cur-rent trials.

While improved treatment clearly would be a critically important advance, Jaffee said there is another exciting devel-opment underway. She and her team have recently published their first paper show-ing prolonged progression of the disease in animal models.

“We don’t know when the first ge-netic changes are occurring and at what age,” Jaffee noted. However, she contin-ued, “Cancer starts to develop 20-30 years before you see it.” By looking for early changes, such as mutated KRAS, the hope is to target a pre-malignancy and keep it from ever developing into pancreatic can-cer.

“Our goal is to eventually prevent this disease from the start,” Jaffee concluded.

Teaming Up, continued from page 7

wide sales tax, we had identified a long-term strategic plan that had set our organization on a path to improvement. This summer’s fire, and the subsequent shutdown, derailed that plan’s success.”

There were two fires this summer, the most significant shut down the facil-ity for more than six weeks.”

In June, residents of Crittenden County approved a one-percent local sales tax increase in hopes of getting the hospital out of debt. Collection of the tax will not begin as scheduled.

“The sales tax campaign was a tre-mendous testament to the community’s support for Crittenden Regional and we are thankful for that,” says David Rains, Board of Trustees Chairman. “The fire decimated our cash position. We are not able to finance our operations until December when the tax revenues would have been received.”

In addition to the hospital, CRH clinics and home health/hospice services also were to cease operations Septem-ber 5.

Hospital leaders have been contact-ing healthcare organizations that may be willing to consider the possibility of keeping key physician services in the area, and for opportunities for displaced employees.

“Crittenden Regional has been home to many dedicated, talented phy-sicians and employees, who have served patients and their families here in Crit-tenden County for the past 60 years,” Cashman said. “We are grateful for their service and will make every effort to

help them find new employment close to home.”

The employees’ pension plan is cov-ered by a federal insurance program run by the Pension Benefit Guaranty Cor-poration (PBGC) which is expected to terminate the pension plan, take it over, and pay the benefits under the plan, without interruption, subject to legal limits on the guarantee.

The news release observed, “Change is occurring at every hospital in the nation, and nowhere is it having a greater impact than on rural hospi-tals such as CRH. Long before recent health reform measures, the decline was already growing. In 1992, there were 2,285 rural hospitals; by 2012, that number had fallen to 1,980. Since the start of 2013, 27 hospitals have ceased operating.”

Hospital officials said the facility also was impacted by a significant num-ber of physician departures.

Even the expansion of Medicaid in Arkansas and impressive enrollment rates in the Private Option by citizens in the service area were not enough to overcome these issues. Over the last five years, the CRH Board and leader-ship executed a number of initiatives to preserve the acute care hospital, services and jobs. These initiatives included a nationwide search for a hos-pital or health system partner or buyer, attempts to secure additional sources of new capital, recruitment of physicians and implementation of service enhance-ments.

Combination, continued from page 1

m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 17

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The Memphis medical community mourned the death of Gene H. Stoller-man, MD, former chair of the Department of Medicine at what is now the Univer-sity of Tennessee Health Science Center (UTHSC), who died peacefully at his home in Hanover, New Hampshire, August 1. He was 93.

University officials noted his contri-butions to medical education, the fields of infectious diseases, rheumatic diseases and immunology, geriatrics, the compassion-ate care of the elderly and palliative care as an enduring legacy. He will also be re-membered for his stand in 1969 when, as a member of a blue-ribbon advisory panel of physicians, he was a strong voice in opposi-tion to the decades-long Tuskegee Syphilis Experiment.

Born in New York City in 1920, Stoll-erman graduated from Dartmouth College in 1941, and received his medical education at Columbia University College of Physi-cians and Surgeons. Following residency at Mount Sinai Hospital, he was inducted into the United States Army Medical Corps.

His research training at NYU set the stage for a lifelong passion to understand the diagnosis, treatment and prevention of streptococcal infections, acute rheumatic fever and rheumatic heart disease, which were rampant during and after World War II.

After the war, Stollerman became medical director of Irvington House in New York City, one of three prominent medical facilities in the country dedicated to caring for children with rheumatic heart disease.

While at Irvington House, he proved that monthly injections of a new long-act-ing formulation of penicillin could prevent recurrences of rheumatic fever in children, and thus, ameliorate the long-term conse-quences of rheumatic heart disease. This so-called “secondary prevention” strategy remains the most effective method for con-trolling rheumatic heart disease around the world.

As an advisor to the Naval Medical Research Unit at the Great Lakes Naval Station, Stollerman established himself as an international figure in medicine and re-search when he advocated mass penicillin prevention of streptococcal infections in new recruits, which halted the epidemics of rheumatic fever. The practice was later extended to all military recruits and is still in use today.

Stollerman seized an opportunity to more broadly impact medical education, practice and research by assuming the posi-tion of chair of the Department of Medicine at the University of Tennessee in Memphis in 1964. He recruited some of the top re-searchers, clinicians and educators to head the new subspecialty divisions, thereby enhancing the stature of the university. He influenced the careers of thousands of medical students and residents during his 17 years as chair. He also continued his intense interest in the development of vac-

cines designed to prevent streptococcal in-fections and rheumatic fever.

Stollerman continued to serve as a member of the Commission on Strepto-coccal and Staphylococcal Diseases of the United States Armed Forces Epidemiologi-cal Board. He also later served on the Cen-ters for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP), which provides expert guidance on the use of childhood and adult vaccines.

While attending a meeting of the ACIP at the CDC in 1969, Stollerman was invited to participate in a blue-ribbon panel to advise on the fate of the long-run-ning “experiment” on the natural history of untreated advanced syphilis in hundreds of black men in a town near Tuskegee, Ala-bama.

After his successful tenure at the Uni-versity of Tennessee, he accepted a position in the general medicine division of Boston

University School of Medicine. In 1992, Stollerman retired to Hanover, where he had spent his days at Dartmouth.

Stollerman’s unfinished work aimed at vaccine prevention of streptococcal infec-tions and acute rheumatic fever continues at UTHSC, conducted by his students and their students. His teaching and counsel were recognized in 2004 when the Infec-tious Diseases Society of America presented him with its Mentor Award.

Gene Stollerman, MD, Former UT Chair, Leaves Important Contributions

18 > SEPTEMBER 2014 m e m p h i s m e d i c a l n e w s . c o m

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The Village at Germantown Breaks Ground on Healthcare Center Expansion

The Village at Germantown has broken ground on its new healthcare center.

The Village at Germantown is a con-tinuing care retirement community that offers levels of care corresponding to the needs of its residents as they age. The Vil-lage provides independent and assisted living, as well as skilled nursing care, and memory care.

The new health care center expansion will add an additional 52,000 square feet. The current memory care and assisted living suites will be relocated to the new building where additional space will be available to build more suites for both levels of care. The number of assisted living suites will increase from 13 to 32. The number of memory care suites will increase from 8 to 16, and the number of individuals who can participate in memory care daycare will increase from three to 10.

Skilled nursing suites will be built in the current space that houses the memory care and assisted living rooms. This space will allow for additional skilled nursing rooms, increasing the current number of 30 suites to 50.

The 1,800 square feet at the entrance to the health care center will be designed as a physical, speech, and occupational thera-py complex that will better accommodate

state-of-the-art equipment and counseling areas.

The $22 million expansion and reno-vation project will be funded through tax exempt bonds. The expected completion date for the assisted living project is the middle of 2015. The entire project is expect-ed to be completed by the middle of 2016.

Methodist University Hospital is First in Tennessee to Implant Non-Surgical, Leadless Cardiac Pacemaker

Methodist University Hospital is the first facility in Tennessee to implant the Nanos-tim™ leadless pacemaker, the world’s first retrievable, non-surgical pacing technology, as part of the LEADLESS II Clinical Trial. De-veloped for patients with bradycardia – a heart rate that is too slow – the Nanostim device is designed to be placed directly in a patient’s heart without the visible lump, scar and insulated wires (called leads) required for conventional pacemakers.

The implant took place as part of the LEADLESS II pivotal trial, a prospective, non-randomized, multi-center, international clinical study designed to evaluate the safe-ty and effectiveness of the Nanostim lead-less pacemaker in patients indicated for the device in the U.S. The study is expected to enroll approximately 670 patients at 50 cen-ters.

James G. Porterfield, M.D., F.A.C.C.,

F.H.R.S, an electrophysiologist with Arrhyth-mia Consultants, performed the implant procedure.

The Nanostim revolutionizes treatment for certain heart rhythm disorders in which the heart beats too slowly explained Dr. Por-terfield. The implantable device offers pa-tients a less-invasive procedure that reduces complications such as device-related infec-tion of the surgical pocket and lead failure.

Dr. Porterfield’s wife, Linda Porterfield, PhD, F.H.R.S., a professor of medicine at the University of Tennessee Health Science Center was very excited when this research protocol came across her desk.

Implanted via the femoral vein with a steerable catheter, the Nanostim leadless pacemaker offers physicians at Methodist a less-invasive approach compared to tra-ditional pacemaker procedures that require more extensive surgery. The miniaturized device is designed to be fully retrievable so that it can be readily repositioned during the implant procedure and later retrieved if necessary.

The Nanostim leadless pacemaker is less than 10 percent the size of a conven-tional pacemaker and is the least invasive pacing technology available today. The small size of the device and lack of a surgi-cal pocket, coupled with the exclusion of a lead, improves patient comfort and can re-duce complications, including device pock-et-related infection and lead failure. The elimination of the visible lump and scar at a conventional pacemaker’s implant site, in addition to the removal of patient activity re-strictions that are routinely put in place in an attempt to prevent dislodgement or dam-age to a conventional lead, will potentially improve the quality of life for patients with this technology by allowing most to con-tinue living active, uninhibited lifestyles. The device is supported by the St. Jude Medi-cal Merlin™ Programmer, which is also used to interrogate and program the company’s other pacemakers and implantable cardio-verter defibrillators (ICDs).

The Nanostim leadless pacemaker re-ceived CE Mark approval in 2013 and is now available in select European markets. The device is not available for sale in the U.S.

Select Specialty Hospital Makes Additions

Select Specialty Hospital is pleased to announce the following new additions to their staff. Donna Grisham joins as their Chief Nursing Officer. Grish-am previously worked at the Regional One Health and comes with over 20 years of experience in nursing, edu-cation and leadership roles.

Mark Kimball joins as Chief Executive Officer. He comes from Archbold Med-ical Center in Thomasville, Georgia. He has over 20 years experience in opera-tions, physician recruitment & retention, business de-velopment, finance, opera-tions, regulatory compliance, and commu-nity involvement.

Donna Grisham

Mark Kimball

m e m p h i s m e d i c a l n e w s . c o m SEPTEMBER 2014 > 19

Thomas Beasley, MD, Joins Methodist Healthcare

General surgeon Thomas Beasley, MD, has teamed up with Methodist Healthcare to join Methodist Surgical Associates Olive Branch, Miss. He will primarily op-erate at Methodist Olive Branch Hospital.

Dr. Beasley earned his Bachelor of Arts degree from the University of the South Sewanee. He received his medical degree from the University of Tennessee College of Medicine, Memphis.

Baptist Cancer Center Awarded $3 Million NCI Grant

The National Cancer Institute recently designated the Baptist Cancer Center as one of 12 centers nationwide to spearhead clinical research focused on disparities in cancer care among minorities and histori-cally underserved groups.

The work will be focused in Memphis, a city with among the highest disparities in cancer mortality in the U.S.

Baptist Cancer Center locations in Oxford, Miss., Columbus, Miss., and Jones-boro, Ark., will also participate under the Baptist Cancer Center umbrella.

The five-year grant, which totals more than $3 million, will distinguish Baptist as a minority/underserved site and will pull together the resources of a number of lo-cal organizations under the NCI’s Commu-nity Oncology Research Program, known as NCORP. The organizations, which all have a commitment to effectively address-ing health care disparities, include Meharry Medical College, which previously served as a minority-based community oncology program for the NCI. Other partners in-clude the Vanderbilt Ingram Cancer Center, the University of Memphis School of Public Health, the Church Health Center, and oth-ers.

The grant will fund the enhancement of clinical trials, outreach for clinical trial edu-cation and enrollment, and support practic-es serving minority and rural populations. In collaboration with community primary care centers, the program will also address clini-cal research in screening, prevention and cancer surveillance. In addition, the NCORP program is addressing how cancer care is delivered through “cancer care delivery re-search.”

According to the NCI, Baptist was cho-sen because of its strength in the communi-ty and because of the demographics of the surrounding areas the health care system serves, which is among the poorest in the nation and comprises 40 percent African-Americans, five percent other minorities, and 25 percent rural areas.

Dr. Stephen B. Edge, director of the Baptist Cancer Center, will serve as the Bap-tist NCORP Principal Investigator with med-ical oncologist Dr. Raymond Osarogiagbon serving as the leader of the cancer care delivery research team, and Dr. Philip Lam-mers as the lead investigator at the Meharry Medical College.


Dr. Thomas Beasley

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