Ohio Pediatrics - Summer 2013 - Ohio AAP

A small provision was slipped intothe state operating budget (HB59) by the House that would haveallowed chiropractors to clearathletes to return to play withoutconsulting a physician.

Under the leadership of the OhioAAP, and the assistance of otherhealth-care organizations, theChapter adamantly opposed the

In This Issue• Sports Shorts - Pre-ParticipationPhysical Exam

• Case Study: Little League Elbow

• The Learning Connection

• Coding Corner: ICD-10

As of July 12, approximately 9,000Ohio physicians had begun to re-ceive the Medicaid Enhanced Re-imbursement rate increase fromOhio Medicaid.

Physicians who completed theattestation process by the Aug. 16deadline will have their eligibilityto receive the enhanced pay-ment backdated to Jan. 1, 2013.

The Ohio Chapter, along withother health-care advocates,pressed for expansion during com-mittee hearings, at Statehouse ral-lies, and on editorial pages.

“We have a long way to go be-fore the MOC increased pay-ments begin in October, andneed our members continuedsupport and outreach on thisissue,” said Melissa Wervey Arnold,

See Concussions..on page 27

Ohio physiciansreceive Medicaidrate increase

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See Medicaid...on page 27

Chapter scores majorvictory in concussions

New Chapter office

Thanks to the efforts of theOhio AAP, chiropractors arenot allowed to clear athletes toreturn to play.

The Ohio AAP moved into new office space in July. The largerspace will allow for more meetings to be held in-house, aswell as accommodate our ever growing staff. When you arein Columbus, please stop by for a visit!

change, and continued to presslegislative leaders to remove theprovision since it dangerously ex-panded the scope of practice forchiropractors. A line-item veto let-ter was sent to Gov. John Kasichin June stating that this would putkids at risk, plus undermine the en-tire process of HB 143 which creat-ed a statewide concussion man-agement standard for young ath-letes. The Ohio AAP was victori-ous.

The Ohio AAP led the charge in

36604_Peds Summer 2013_Ped Spring 2007copy 4 co copy 2 9/4/13 1:05 PM Page 1

www.ohioaap.org Ohio Pediatrics • Summer 2013

A Publication of the Ohio Chapter, AmericanAcademy of Pediatrics

OfficersPresident....Judith Romano, MD

President-Elect....Andrew Garner, MD, PhD

Treasurer....Robert Murray, MD

Delegates-at-large:Jill Fitch, MDAllison Brindle, MDMike Gittelman, MD

Executive Director:Melissa Wervey Arnold94-A Northwoods Blvd.Columbus, OH 43235(614) 846-6258, (614) 846-4025 (fax)

Lobbyist:Dan Jones Capitol Consulting Group37 West Broad Street, Suite 820Columbus, OH 43215(614) 224-3855, (614) 224-3872 (fax)

Editor:Karen Kirk(614) 846-6258 or (614) 486-3750

Ohio Insurance Exchange takesshape; enrollment begins Oct. 1With less than two months to gobefore open enrollment begins,we are finally seeing some detailson Ohio’s insurance exchange.Gov. John Kasich declined toestablish a state-run exchangeand instead opt for a federally-facilitated exchange. Under thismodel, Ohio will retain most ofthe regulatory functions while thefederal government will handleenrollment and outreach. Openenrollment is expected to beginon Oct. 1, and coverage is tostart on Jan. 1, 2014.

Under the federally-facilitated, orhybrid exchange model, Ohio willreview plan offerings from insurersto determine whether or not theyare a qualified health plan(QHP). QHPs must meet severalrequirements including ‘essentialhealth benefits’ coverage; thesemandatory 10 areas of coverageare more expansive than mostplans and could significantlydrive up the cost of insurance.The Ohio Department of Insur-ance (ODI) released the final listof QHPs in late July. The U.S. De-partment of Health and HumanServices (HHS) is now conductinga final review of Ohio’s plans inadvance of the open-enrollmentstart date.

For the individual marketplace,there will be a total of 200 plansoffered from 12 different compa-nies. You shouldn’t be over-whelmed by the number ofplans. Many of the plans are simi-lar in coverage and only vary interms of total amount of health

care costs paid by the plan.Under the ACA, plans were re-quired to provide multiple levelsof cost coverage, often referredto as “metal tiers;” they arebronze (60%), silver (70%), gold(80%), and platinum (90%). Addi-tionally, plan availability will varydepending on geographic re-gion. For the small group market(50 or fewer employees) there willbe 184 plans offered from six dif-ferent companies.

To help ease awareness of, andenrollment in the new insurancemarketplaces, the ACA allows for‘insurance navigators’ to assistconsumers. Under the hybrid ex-change model, Ohio will licensenavigators. Legislation was pas-sed earlier this year to establishnavigators in Ohio. Additionally,several non-profit groups, foun-dations, and even celebritieshave started outreach programsto promote the new insurancemarketplace. Some conservativegroups, including Americans forProsperity, have also started run-ning ads in Ohio casting doubton the insurance exchanges.

According to Ohio Lt. Gov. Mary

Taylor, who heads ODI, healthinsurance premiums in Ohio will in-crease an average of 41% due tothe ACA; insurers could see costincreases up to 83% as well. Thesestatistics are based on a prelimi-nary analysis of rate filings submit-ted to ODI last month ACA sup-porters lashed out against Lt. Gov.Taylor arguing that the figures re-leased by ODI are exaggeratedand do not include federal subsi-dies and other cost assistance.Some independent studies andestimates, as well as figures fromselect other states project a de-crease in health premiums. Giventhe diversity in the insurance mar-ket, which is largely state-regulat-ed, no two states are alike; there-fore the impact of the ACA willvary among Ohio and states of

Update from the Statehouse

2

“Health insurance premiumsin Ohio will increase an

average of 41% due to theACA; insurers could see cost

increases up to 83%“ –Ohio Lt. Gov. Mary Taylor,

who heads the OhioDepartment of Insurance

See Legislation...on page 8


www.ohioaap.org Ohio Pediatrics • Summer 2013

President’s Message

Leave a legacy in Ohio AAP: How canthe Chapter help fulfill your passion?

3

For the past several years, theleadership of the Ohio AAP hashad a summer retreat to reviewthe previous year and to strate-gize for the future. As you mayrecall, at last year’s retreat theleadership made a bold decisionto reorganize the committeestructure of the Chapter.

The work of existing committees,as well as all projects, are orga-nized around our four pillars ofAdvocacy, Child Health, Prac-tice of Pediatrics, and Opera-tions. The structure has allowedfor the expansion of our Execu-tive Committee to include ex-perts interested in turning theirpassion into a project.

This year’s retreat was attendedby the Board of Directors and 20passionate pediatricians repre-senting leadership in our sevensuccessful projects as well as theleadership of our four pillars. Theretreat was enhanced by the

attendance of the entire staff ofthe OAAP. Updates provided oneach project allowed the leader-ship to be aware of the widescope of activities of the Chap-ter.

The current projects are :• Chapter Quality Network(CQN) Asthma• Building Mental Wellness (BMW)• Bike Helmet Safety Awareness• Injury Prevention/Safe Sleep• Maximizing Office-BasedImmunization (MOBI)• Obesity Prevention• Prevent Blindness Ohio (PBO)

All of these projects bring mem-ber value by offering quality im-provement to practices, MOC,and improvement of pediatriccare to our patients. The retreatalso included updates from thephysician leadership of each pil-lar and the responsible staff.

Highlights from each pillar:Advocacy Pillar: William Cotton,MD, and Jill Fitch, MDActivities around advocacy in-cluded many legislative winsaround Medicaid enhancedreimbursement, concussion legis-lation, a gubernatorial veto oflanguage around chiropractorsreturning athletes to play afterconcussion, and Medicaidexpansion.

Child Health Pillar: Mike Gittel-man, MD, and Andy Garner, MDThe Child Health Pillar has beenactive in membership recruit-ment and retention, as well as

surveying members and usinginformation to prepare for theAnnual Meeting that will repre-sent the priorities identified bythe Chapter, while implementingefforts to increase attendance.Specifically, this group is workingto increase subspecialist mem-bership and engagement as wellas that of young physicians. Theupcoming Annual Meetingpromises to be the best ever withstrong sponsorship, specific pro-grams for young physicians andresidents, as well as a QI pro-gram learning session. This groupwas also responsible for providingsuggestions for the new websitedesign.

Practice of Pediatrics Pillar:Gerald Tiberio, MD, Jill Fitch, MD,and Allison Brindel, MDThis Pillar has been active in tar-geting young physician and resi-dent engagement. This year’sAnnual Meeting includes a resi-dent track plus an advocacyday. The Pediatric Care Councilhas expanded its membershipwith 30 new doctors in atten-dance at the last meeting. Theydeveloped a Health Plan Assis-tance Guide which was distrib-uted in the spring issue of OhioPediatrics. They are also planninga coding webinar, as well as acoding corner to be included inthe new website.

Operations Pillar (Planning, Im-plementing, and Performance):Robert Murray, MD, and KateKrueck, MD

President Judy Romano, MD

See Pillars...on page 7


www.ohioaap.org Ohio Pediatrics • Summer 2013 4

The Ohio AAP is veryexcited to have beenawarded one ofeight new HealthyTomorrows Partner-ship for Childrengrants for 2013-2018.These five-year grantsprovide funding toimprove maternaland child healththrough community-based initiativesfocused on preven-tion and access to health services. This is a federalgrant awarded by the Maternal and Child HealthBureau and the American Academy of Pediatrics.

A needs assessment in Ohio shows that injury con-tinues to be a significant cause of morbidity andmortality. According to the Ohio Department ofHealth, an average of three Ohio infants suffer asleep-related fatality each week, and 66% ofthese occur in infants who were sharing a sleepsurface with another person. The Centers for Di-sease Control estimates that infant sleep-relatedfatalities cost Ohioans more than $51 million inmedical care and productivity loss annually.

This grant funding, combined with money from ourpartnership with Ohio Children’s Trust Fund, will al-low us to expand our Injury Prevention LearningCollaborative with the following goals:

• Increase the proportion of Ohio infants placedto sleep on their backs from a baseline of 72%(Ohio PRAMS)

• Pediatricians and primary care providers whocurrently discuss safe-sleep practices 40% of thetime will provide targeted advice and guidanceat the newborn, 2-month, and 4-month well-childvisits 90% of the time

• Parents who use safe-sleep practices only 50%

of the time or less will increase to 80% by the 4-month well-child visit.

The Injury Prevention Learning Collaborative is aQuality Improvement Program for communitypediatricians and family practice doctors. Theprogram offers physicians developmentally ap-propriate and targeted screening surveys thatenable them to screen families for injury risks atwell-child visits in the first year of life. Based onparent answers, pediatricians can target anticipa-tory guidance to high risk areas, providing moremeaningful and efficient advice.

In Wave 2 of theInjury PreventionLearning Collabo-rative, participantswill learn:• How to screenfamilies who are cur-rently using unsafesleep practices• Standarizedscreening tools andtalking points forsafe sleep• Talking points forother injury topics• Receive sleepsacks to give to fam-ilies at newborn well-child visits• 25 MOC Part IV credit• $500 practice stipend

If you would like to participate, or would like moreinformation about the Injury and PreventionLearning Collaborative and safe sleep project,please contact Sean O’Hanlon, Program Mana-ger, at (614) 846-6258 or [email protected].

Sarah Denny, MD, Co-ChairInjury Prevention Committee

Ohio AAP receives HealthyTomorrows Grant for safe sleep


5www.ohioaap.org Ohio Pediatrics • Summer 2013

Chapter’s website gets a faceliftThe Ohio AAP website has recent-ly been redesigned with a newcleanier layout to make it moreuser-friendly.

Our hope is that the new websitewill be more interactive for ourmembers whether it is through the“personal stories” section, twitter,or sharing resource materials.

The first thing you will notice whenvisiting the homepage is the rotat-ing image that lists upcomingevents and Chapter projects. Thiswill be updated often. We hopethis constant reminder of eventsand projects will increase atten-dance at special events, as wellas increase involvement in ourprojects.

Another new feature is the pass-word-protected section only ac-cessible to Ohio AAP members!

Here you will find legislative up-dates and resources on a varietyof topics. If you have presenta-tions, articles or handouts youwould like to share with members,visit the “Resources” tab and fol-low the link to “Resource Submis-sion Form.”

These are just a few of the many

new features on the website. We’dlike to hear your feedback. Youcan either fill out the “Share YourThoughts” form on bottom of thehomepage, or visit the WebsiteFeedback station at the AnnualMeeting. Those providing feed-back will be entered to win a freeticket to next year’s Ohio AAPFoundation summer fundraiser.

Donation provides more than 140,000books to 100 practices around the stateThanks to a generous donation of$200,000 from the Ohio Depart-ment of Health and Gov. JohnKasich and his administration,more than 140,000 children’s bookswere distributed to nearly 100 phy-sician practices around the state.

The Ohio AAP Foundation wouldalso like to thank Jessica Foster,MD, for her role in ensuring thefunds could be used to supportearly literacy around the state.

Anna Winfield, MD, Reach Out andRead site coordinator, whose prac-tice was one of the recipients said,

“WOW, Westown Physicians Centerjust received more than 15 boxesof Scholastic Books for our ReachOut and Read program. This bookdonation was very timely as weare low on grant funding.” Dr. Win-field added, “Your generous contri-bution will keep our much deserv-ing patients well-supplied withbooks for the remainder of 2013.”Now, the biggest problem for thepractice is finding storage space.

Early literacy has always been,and will continue to be, a main pri-ority for the Ohio Chapter. Al-though we no longer have our

Reach Out and Read Ohio pro-gram, the Chapter continues tosupport physician practices thatoperate Reach Out and Read sitesthroughout the state.

“The Chapter believes that teach-ing children to read increases theirsucceess in school, and increasestheir opportunites to live longerand healthier lives,” said MelissaWervey Arnold, Ohio AAP’s Execu-tive Director. “Children who areread to regularly at a young ageare better equipped to developvocabulary and language skills,preparing them to excel.”



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PAA is helping practices of all sizes and specialties nationwide

The Chapter Quality Network (CQN3) Asthma Learn-ing Session 3 will take place Friday, Sept. 20, from 8a.m. to 5 p.m. during the Ohio AAP Annual Meeting.Topics will include: a rapid-fire session around the keydrivers; motivational interviewing; star practice paneldiscussion; spirometry; planned-care approach usingthe registry; and action period 3 overview.

As the Learning Collaborative progresses to the half-way point, there are some impressive results and sta-tistics to report. For example:

39 – The number of practices participating acrossfour states (Ohio, Alabama, Arkansas and Arizona).Twelve of these practices are Ohio based.

216 – Team members involved in CQN3

118 – Clinicians have entered data

3,094 – Encounters havebeen entered (1,013 fromOhio)

Ohio Specific Data – Goal90%• 94% of practices haveachieved Optimal AsthmaCare• 97% of practices have reported using an AsthmaAction Plan

Learning Session 2 took place as a webinar on July18. This meeting focused on celebrating action peri-od successes, applying reliable strategies to care de-livery process, and proper coding for asthma care.

For more information, please contact Elizabeth Daw-son at [email protected] or (614) 846-6458.

CQN3 Asthma Learning Session 3 willbe held Sept. 20 at Annual Meeting



The PIP Committee (as it is affectionately called) hasthe important task of evaluating ideas and proposalsfor development of QI projects. They are developinga quality improvement manual to facilitate this impor-tant work. It is anticipated this manual will be in highdemand from other chapters within the AAP. To pro-tect the Integrity of the work, the manual Is beingcopyright protected.

The retreat covered an amazing array of topics. Per-haps of most importance was the group’s thoughtsand insights in how to continue to move the Chapterforward. The way to do this is to provide an opportu-nity for our members to address their passion. TheChapter has the structure in place to allow growth ofnew programs and initiatives. Perhaps a topic you

have seen here inspires you and you would like to joinin the work already taking place. Or perhaps youwould like to share your particular passion with ourleadership to develop it into a legacy for Ohio’s chil-dren. Join us in Columbus for the 2013 Annual Meet-ing beginning with an Advocacy Day on Thursday,Sept. 19. An Executive Committee (all are welcome)meeting will be held on Friday, Sept. 20 as well aseducational programming, and our Casino Nightfundraiser. We will conclude on Saturday, Sept. 21with our Ohio AAP business meeting and 20 point PartII QI activity.

Judith T. Romano MD, FAAPOhio AAP President

Pillars...from page 3

Register today for theOhio AAP Annual Meeting

Casino Night!The Ohio AAP FoundationCasino Night fundraiser is fastapproaching. This event willtake place on Friday, Sept. 20from 7-10 p.m. Your support ofthis event will be greatly ap-preciated, either through do-nations or through attendingthe event.

Try your luck at blackjack,roulette, craps, and poker,and support the Ohio AAPFoundation at the same time.

Spouses and guests are alsoinvited to attend. Cost is $60per person. Your admissionprice includes: two drink tick-ets per person (cash bar avail-able), hors d’oeuvres, andgaming chips.

To purchase tickets, visit: www.ohioaap.org/foundation/casi-no-night/casino-night-tickets.

Last year’s event raised morethan $3,200 for the Ohio AAPFoundation.

The 2013 Ohio AAP Annual Meet-ing promises to be a weekend oflearning, networking, and fun formembers, spouses and exhibitorsin attendance.

Annual Meeting will be held Fridayand Saturday, Sept. 20-21 at theColumbus Sheraton Hotel on Cap-itol Square, with a Pre-AnnualMeeting Advocacy Workshop atthe new Ohio AAP Chapter Officeat 94-A Northwoods Blvd., Colum-bus on Thursday, Sept. 19.

The Advocacy Workshop will giveyou a chance to let your voice beheard. You will hear from our leg-islative team on key issues beingconsidered in the Ohio GeneralAssembly, and during the “Advo-cacy Game,” you can play law-maker and see firsthand the chal-lenges lawmakers and lobbyistsface. A wine and cheese recep-tion will follow from 4:30-5:30 p.m.

Topics on Friday, Sept. 20 include:• CQN3 Asthma Learning Session 3• The Role of the Pediatrician inSchool Violence• Technology in Medicine: What isthe Future of Our Practices?• Speed Mentoring• MRSA Update• Poster session• Concussions: The Law, the Logic,and the Logistics

An Awards Reception will follow at5:30 p.m., with the Ohio AAP Foun-dation fundraiser – Casino Night –beginning at 7 p.m.

The Ohio AAP Annual BusinessMeeting will be held at 8:30 a.m.Saturday, Sept. 21 followed by theMOC Part II - Pediatric Sports Med-icine Self Assessment session.

Time is running out...register today!Visit the Ohio AAP website atwww.ohioaap.org.



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Building Mental Wellnessrevamps program

At what age do you, orother providers in yourpractice, start screeningchildren for mentalhealth disorders? Do youwait until they are teen-agers and screen fordepression and alcohol? Or do you start as early as the newborn well-child visit to ensure the family environment is safe?

For five years, the Ohio AAP has dedicated resources and training forOhio pediatricians in the screening and identification of developmentaldelays, social-emotional concerns, autism, depression, and alcohol/sub-stance abuse in children and adolescents through the Autism DiagnosisEducation Pilot Project (ADEPP), the Concerned About DevelopmentLearning Collaborative (CADLC), and most recently the Building MentalWellness Learning Collaborative (BMW). Over the next two years, theOhio AAP will continue to provide practitioners in Ohio with multipletools to strengthening their awareness of, and knowledge about, com-mon mental health conditions in children by building upon the BuildingMental Wellness Learning Collaborative.

“In order to achieve optimal mental wellness for all of Ohio’s children assoon as possible, we must engage a broader audience with the goal oftransforming pediatric practice so that mental health is seen as main-stream pediatrics,” says John Duby, MD, medical director for the BuildingMental Wellness projects. “Pediatric clinicians must be given the oppor-tunity to develop the breadth and depth of clinical skills to assure thatthey have the medical knowledge, competence, and confidence toprovide family-centered, coordinated care to children and families af-fected by emotional, developmental, and behavioral issues within themedical home.”

To develop practitioners with the competence and confidence to pro-vide family-centered and coordinated care within the medical home,BMW is taking a two-pronged approach beginning in July 2013 and run-ning through June 2015, which includes an 11-module series of BuildingMental Wellness Online Learning Modules and a Building Mental Well-ness Learning Network.

The BMW Online Learning Modules will be interactive, stand alone mod-ules that participants can access through the Ohio AAP or Pediatric

Online Learning Modules and a Learning Network highlight new additions

See BMW...on page 15

Legislation...from page 2

similar size and population.

Despite reports from the Gov-ernment Accountability Of-fice that raised concerns withACA implementation, andthe recent one-year delay inthe employer mandate, theObama Administration con-tinues to insist the insurancemarketplaces will be readyby January 1. This didn’t stopCongressional Republicansfrom holding a record 40thvote to repeal Obamacarelast month. According to theCongressional Budget Office,delaying the employer man-date for a year will cost $12billion and potentially leavehundreds of thousands ofAmericans without coverage.

The bottom line is that the im-pact of the new insurancemarketplace and other por-tions of ACA are impossible todetermine. With the MedicaidExpansion fight ongoing inColumbus, many low incomeOhioans will look to the insur-ance marketplace for cover-age. According to the HealthPolicy Institute of Ohio, in thelast seven years the rate ofuninsured Ohioans has in-creased roughly 31%, whilethe number of Ohioans withemployer-sponsored insur-ance has fallen by 12%. Theneed is definitely present,there are still many piecesthat need to fall into placeover the next few months.

Daniel Hurley, LobbyistCapitol Consulting Group



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Pediatricians Standing Behind Ohio’s Children focus

“Thank you for sharing the Lions, Literacy and Lunch opportunity with our foster families! A great time was had by all!”

“Please pass on to everyone there a big thank you to all there for a wonderful day Saturday. It was so kind and generous of you. Thanks also for all the books, stuffed animals, water bottles and bike helmets. I deeply appreciate it and all of it will go to these children.”

Annual Foundation Fundraisers Help Support Signature Programs

Children gather for a bike ride showing the safety of helmet use.

“On behalf of everyone at the Leap Beyond Adaptive Bike Center, we would like to thank you once again for allowing us to participate with you in the 2013 Helmet Safety Awareness Week!”

“As a small village, we are very grateful for the donation of the helmets!”

A member of the Columbus Zoo staff reads to attentive children during Lions, Literacy and Lunch.

Members of AAP enjoy Casino Night at last year’s Annual Meeting.

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Physicians across the country turn to ChildLab because we care about your patients as much as you do.

For a complete list of our pediatric laboratory tests and pathology services, visit www.childlab.com or call 800-934-6575.

National AAP’s children endowmentfunds need help from pediatriciansAs a physi-cian youare a com-munitychampionfor childhealth andgoodsocial out-comes forchildren.As physi-cian lead-ers, we setthe agenda for the AmericanAcademy of Pediatrics.

Frontline pediatricians recognizedin 1990 that children were starting

to become overweight. These pri-mary care pediatrician leadersbrought the concern to the An-nual Leadership Forum (ALF) andobesity prevention became a pri-mary concern and agenda itemfor the AAP.

When overweight and obesity be-came the highest priority on theAAP Strategic Plan, money fromthe Friends of Children’s Endow-ment helped finance the pro-gramming in the form of HealthyChildren 2010 Grants. In 2013, theTomorrows Children Endowmentstrengthened the AAP commit-ment to obesity prevention andtreatment by giving a $75,000

grant to develop the AAP ObesityInstitute. The Institute incorporatesbest practice and translates evi-dence for obesity prevention intopractice at the individual pediatri-cian level and at the system inwhich care is delivered as awhole.

Won’t you contribute to one ofthese two funds – Friends of Chil-dren (short-term program) and/orTomorrows Children Endowment(long-term big projects)? The im-pact we make for children is di-rectly related to having the mon-ey available to carry out the pro-grams we pediatricians deem im-portant. I thank you, and the AAPthanks you.

Ellen Buerk, MDPast President Ohio AAP

Send your contribution to:Friends of Children Endow-ment American Academy ofPediatrics Development LockBox 38367 Eagle WayChicago, Illinois 60678-1383

Please include:• Your name• Address• Where you want to earmarkyour contribution, if you areunsure state “where mostneeded” • Indicate if you would likemore information on theTomorrows Children Endow-ment

Ellen Buerk, MD

Send contributions



Dedicated to improving health care for your patients.

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To learn more about Paramount Advantage: 419-887-2535 | 1-800-891-2542www.paramounthealthcare.com

Getting care right in Ohio.



In My Opinion

Editor’s note: This is an opinionpiece submitted by Ohio pedi-atrician Arthur Lavin MD,FAAP, a member of Doctorsfor Health Care Solutions. Hisopinions do not necessarily re-flect those of the Ohio Chap-ter, American Academy ofPediatrics, or national AAP.

By Arthur Lavin, MD, FAAP Ohio Pediatrician

In June of 2013, the biennial budget of the State ofOhio was passed. In a rather remarkable turn ofevents, a few amendments were slipped into thebudget bill (HB 59) that then were signed into law.And so, without the public aware, a number ofstatutes that take aim at our standing as doctors inour state became law.

These amendments were designed to be part of theabortion debate, but important elements of the lawactually threaten the very nature of what it means tobe a doctor in Ohio. And so, not only does this lawthreaten the health of the women of Ohio, but couldimpair the ability of all doctors, across all specialities,to practice medicine. Further, the success of this strat-egy has emboldened Ohio lawmakers to proposeeven more attacks on the very concept of a medicalprofessional in a proposed bill, HB 200.

What are the provisions of the now established law(from HB 59) and the proposed law (HB 200) that vio-late our standing as trusted professionals?

For HB 59, the law currently, independent of whatgood medical practice might require:• Forces doctors to perform medically unnecessaryprocedures.• Dictates to doctors exactly what words they mustsay to their patients.• Invites the public to sue doctors. • Cuts off a doctor’s ability to practice where the

Editor’s note: Daniel Hurley is alobbyist for Capitol ConsultingGroup.

By Daniel Hurley Capitol Consulting Group

Last month State Sen. KrisJordan (R-Powell) introducedSenate Bill 165, which prohibitsphysicians from submitting apatient’s medical informationto an electronic databasewithout approval from the patient and also prohibitsa physician from asking a patient, prospectivepatient, or patient’s representative about firearmownership. While asking about gun ownership anddiscussing gun safety with patients serves a legiti-mate medical purpose, the pro-gun lobby contendsthat this information is simply not the business of aphysician.

Led by the National Rifle Association (NRA), pro-gunadvocates have started a nationwide push to passsimilar legislation prohibiting physicians from talkingto patients about gun ownership and safety. This is-sue stems from an unlikely source – the AffordableCare Act (ACA). In 2010, the NRA worked with mem-bers of Congress to include language that prohibiteddoctors from refusing care and insurance companiesfrom charging higher premiums to patients whoowned firearms. The ACA also discouraged the re-porting of data regarding gun ownership to any cen-tralized databases like those being established at theU.S. Department of Health and Human Services andthroughout select states as part of the insurance ex-change network.

Following the tragedy in Newtown, Conn., PresidentObama issued a series of executive orders intendedto address the growing concern over school shoot-ings and other public acts of gun violence. One ofthe executive orders addressed some of the ambigu-ity in the ACA by clarifying that physicians can dis-

Ohio law takes aim atthe medical profession

Senate Bill 165 would prohibit gun questions

See Profession...on page 22 See Guns...on page 22

Arthur Lavin, MD Daniel Hurley



GUIDELINES FOR PHYSICIANS

Pre-Participation Evaluation (PPE)The sports pre-participation evaluation (PPE) has evolved over the years to promote the health and safety of athletes at multiple lev-els. It consists of a history and a physical exam to screen for life-threatening conditions, particularly causes of Sudden Cardiac Death(SCD), as well as injuries or illnesses that may affect an athlete’s health and performance.

The 12-element AHA Recommendations for Pre-ParticipationCardiovascular Screening of Competitive Athletes

What are the goals of the PPE?Primary Objectives• Screen for conditions that may be life-threatening or disabling• Screen for conditions that may predispose to injury or illnessSecondary Objectives• Determine good health• Serve as an entry point to the health-care system for adolescents• Provide an opportunity to initiate discussion on health-relatedissues

When and where should the PPE be performed?• 6 Weeks prior to season’s start to allow for additional treatment/testing• PCP or Station-Based ScreeningThe Ohio High School Athletic Association (OHSAA) requires a physi-cal exam (PE) and a signed medical form within the past year, priorto the season’s first practice. The PE is valid for one year.

Who can perform the PPE?Any MD, DO, NP, or PA who is licensed to practice medicine and iscomfortable performing the exam.

Sudden Cardiac Death (SCD)• The leading cause of non-traumatic death in young athletes• Many conditions have a strong genetic component• In the U.S., the most common cause of SCD is Hypertropic Cardio-myopathy• The incidence of SCD in U.S. athletes is estimated to be 1:200,000• The current recommendations for H and P are based on the ideathat physiologic demands of competitive athletics increases the riskfor SCD.

Importance of HistoryA large percentage of medical and musculoskeletal conditions canbe identified through the medical history alone.• Heart disease or SCD in family members• Screen for previous concussions and head injuries.• Screen for previous or ongoing musculoskeletal injuries

Additional Testing• Consider testing for iron deficiency• Universal screening with ECG or ECHO is not recommended

Clearance of the Athlete• The goal is to safely clear athletes• Less than 2% of athletes are excluded yearly• 3-13% require additional evaluation

Considerations:1. Does a problem put the athlete or others at increased risk? 2. Can the athlete participate safely without treatment?

Past Medical History*• Exertional chest pain/discomfort• Unexplained syncope/near-syncope +

• Excessive exertional and unexplained dyspnea/fatigue, associated with exercise• Prior recognition of a heart murmur• Elevated systemic blood pressure

Family History• Premature death before age 50 years due to heart disease, in ≥1relative• Disability from heart disease in a close relative <50 years of age• Family members with: hypertrophic or dilated cardiomyopathy,long-QT syndrome or other ion channelopathies, Marfan syndrome,or clinically important arrhythmias

Physical examination• Heart murmur ‡• Femoral pulses to exclude aortic coarctation• Physical stigmata of Marfan syndrome• Brachial artery blood pressure (sitting position)§

* Parental verification is recommended for athletes+ Judged not to be neurocardiogenic (vasovagal); of particular concernwhen related to exertion.‡ Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic leftventricular outflow tract obstruction§ Preferably taken in both armsCirculation. 2007;115:1643-1655

3. Can the athlete participate while treatment is being initiated? 4. Are there other activities that could be substituted?

Clues for further workup:Symptoms of exertional syncope, chest pain, or palpitations, orexcessive exertional dyspnea. Athletic participation should berestricted until this workup is completed.

Additional Resources:• Medical Conditions Affecting Sports Participation: Committee on SportsMedicine and Fitness. Pediatrics 2008;121 No.4 2008: 841-848;• 36th Bethesda Conference Eligibility Recommendations for Competitive AthletesWith Cardiovascular Abnormalities; Journal of the American College of CardiologyVol. 45, No. 8, 2005:1313-1375• American Academy of Family Physicians, American Academy of Pediatrics,American College of Sports Medicine, et al. Preparticipation Physical Evaluation.In: Roberts W, Bernhardt D, editors. 4th edition. Elk Grove (IL): American Academyof Pediatrics; 2010.

Author: Kate Berz, DO, Cincinnati Children’s Hospital



GUIDELINES FOR PARENTS AND ATHLETES

WHAT ARE THE GOALS OF THE PPE?• Screen for conditions that may be life-threatening or dis-abling• Screen for conditions that may predispose to injury or illness• Determine good health• Provide an opportunity to discuss health-related issues

WHEN SHOULD THE PPE BE PERFORMED?• Within the past year, prior to the season’s first practice. Theexam is valid for one year. • The best time to get a PPE is at least 6 weeks prior to the startof the athletic season to address any issues that may come upin the evaluation.

WHERE CAN IT BE PREFORMED?• It can be performed at your doctor’s office, some urgentcare centers, or in a group screening at your school. • Your primary doctor usually has access to your previous med-ical history and may be able to spend more time with you dis-cussing health issues that are important to you. Typically an ap-pointment is required, and the usual fees for seeing your doctorwill apply. • A group screening is typically less expensive, does not requirean appointment, and may include specialists in the screeningprocess. The disadvantages are less privacy, less opportunity todiscuss relevant health issues, and if additional testing or treat-ment is required, may require an additional visit to your doctorto coordinate care.

WHO CAN PERFORM THE PPE?Any MD, DO, NP, or PA who is licensed to practice medicineand is comfortable with performing a PPE.

THE PHYSICAL EXAMThe examination part of the PPE will include things that youwould experience during a typical well-child check. A bloodpressure measurement, weight, heart rate, and vision screenshould also be performed. The medical provider will examineyour muscles, joints, and bones, focusing on areas that havebeen injured in the past or that will get more use, dependingon the sport that will be played.

ADDITIONAL TESTINGNo lab tests are routinely recommended, but your doctor mayorder some if needed. Tests for the heart, such as an electro-cardiogram or echocardiogram, are usually only ordered if in-dicated based on the athlete’s symptoms, personal history, orparts of the family history concerning heart problems.

Clearance of AthleteOnce the history and physical exam are completed, the med-ical provider uses the collected information to advise whetherthe athlete is “cleared” for sports participation. • Cleared for all sports without restriction• Cleared for all sports with recommendations for further evalu-ation or treatment• Not cleared (Pending further evaluation; for any sports; forcertain sports)The goal is to exclude as few athletes as possible while stillkeeping the athlete and others safe. Physical activity is advo-cated as part of a healthy lifestyle and beneficial to childrenboth physically and psychologically. Each year, less than 2% ofathletes are not cleared for sports participation with 3-13% re-quiring additional evaluation for reasons ranging from heartproblems, musculoskeletal injuries that need treatment or reha-bilitation, skin infections, concussions, and other medical prob-lems. After additional evaluation or treatment, the athlete maybe cleared or advised in what capacity it would be safe forthem to participate.

SummaryThe sports PPE is recommended or required for most organizedsports participation. Make sure the question part of the evalua-tion is filled out fully in advance to help the medical providermake an informed decision. The goal is to keep the athletesafe, not to exclude the athlete from participation.

Most PPE forms include a long list of questions that are de-signed to identify previous health problems or potentialhealth problems. There will also be questions about healthproblems in family members since some diseases run in fami-lies. Many of the questions focus on the heart and symptomsexperienced during exercise that may suggest an underlyingheart problem. Other questions will ask about previous headinjuries, musculoskeletal injuries, asthma and breathing prob-lems, skin infections, diet and weight issues, and menstrualhistory for the females.

The history is an important part of the evaluation and shouldbe filled out by the parent prior to arrival for the PPE. Manymedical conditions can be identified through the questionsso answer them as honestly as possible and give explana-tions as needed to give the medical provider as much infor-mation as you can.

THE HISTORY SECTION

Pre-Participation Evaluation (PPE)

This information is available on the Ohio AAP website www.ohioaap.org

The sports pre-participation evaluation (PPE) has evolved over the years to promote the health and safety of athletes atmultiple levels. It consists of a history and a physical exam to screen for life-threatening conditions, particularly causes ofSudden Cardiac Death (SCD), as well as injuries or illnesses that may affect an athlete’s health and performance.

Author: Kate Berz, DO, Cincinnati Children’s Hospital



BMW...from page 8

Proper pediatricvision screening QI to launch in JanuaryThe Ohio AAP is pleased to announce that aspart of a continued partnership with PreventBlindness Ohio, we will launch a quality im-provement (QI) learning collaborative in Jan-uary 2014 to promote and implement properpediatric vision screening for health-care pro-fessionals such as pediatricians, family practicephysicians, residents, nurses, and safety netproviders.

Currently in the design phase of the program,practice recruitment will kick-off at the OhioAAP 2013 Annual Meeting in September andcontinue through December. The collaborativewill run from January thru June 2014 and willprovide participants with CME as well as 25Part 4 MOC credits through the AmericanBoard of Pediatrics Performance ImprovementModule (PIM). Lisa Ziemnik, MD, of WilmingtonMedical Pediatrics will serve as medical direc-tor along with Samantha Anzeljc, PhD, as quali-ty improvement consultant.

Benefits to practitioners participating in thePreschool Vision Screening Learning Collabo-rative:• Improve vision screening within practice• Introduce quality improvement topics slowlyto help practices meet MOC requirements• Equipment to assist in providing appropriatepediatric vision screening• $1,000 stipend for participation of a practice

The Chapter is very excited to offer yet anotherQI opportunity free of charge to our members.A more detailed recruitment packet will hityour mailboxes and emails in September.

If you would like more information, or to re-serve a space for your practice, please con-tact Elizabeth Dawson, Program Manager, [email protected] or (614) 846-6258.

Psychiatry Network (PPN) websites. Each module willrun approximately 60-90 minutes and will provideCME to participants. The modules will focus on:• Introduction to Quality Improvement• Preparing your office to support the emotional, de-velopmental, and behavioral needs of your patientsand their families • Purposeful Parenting• Screening and Surveillance• Psychopharmacology• Mental Health and Children with DevelopmentalDisabilities• Identifying and Supporting Children Exposed toTrauma• Recognizing and Managing Caregiver Depression• Positive Parenting During a 15-Minute Visit• Sleep Problems• Identification and Initial Management of SubstanceUse

Each module will be produced on a rolling basis, withthe first three modules expected to be launched inlate fall 2013.

The Building Mental Wellness Learning Network is tar-geting a minimum of 30 practices to participate in alearning network to:1. Develop and implement a family-centered systemof care for building mental wellness using QualityImprovement science2. Obtain skills to support the promotion, early identifi-cation, and management of mental health concernsin primary care by demonstrating competency andconfidence in these areas3. Establish integrated models of mental health ser-vices in primary care

This ongoing learning network will feature rollingentry. Learning Sessions will be held:• Saturday, Nov. 9, 2013 at the Athens CommunityCenter in Athens, Ohio • Saturday, Feb. 22, 2014 at the Cincinnati Children’sHospital Medical Center Liberty Campus • Saturday, April 26, 2014 at Sawmill Creek Resort inHuron, Ohio

For more information on the learning sessions, and toparticipate in BMW, contact Sean O’Hanlon, ProjectManager, at (614) 846-6258 or [email protected].



�� Kids spend 2000 hours every year in school,which makes that the smart place to encourage kids to eat right and get moving.

American College of Sports Medicine, American School Health Association, GENYOUth Foundation, National Dairy Council, The Wellness Impact: Enhancing Academic Through Healthy School Environment, March 2013.

�� Programs like Fuel Up to Play 60 empower students to take actions like starting breakfast programs and walking clubs. Community leaders, businesspeople and health professionals can also assist schools in providing opportunities.

Only

of all teens eatbreakfast every day.

38%Students who eat breakfast have better attention and memory.

of physical activity,brain activity improves.

After just

20minutes

What is the right answer?

Extra credit:

high school students are active for the recommended 60minutes each day.

Only of 25%��

Read The Wellness Impact: Enhancing Academic Success Through Healthy School Environments at NationalDairyCouncil.org

Learn more about how Fuel Up To Play 60 is helping schools to take action at FuelUpToPlay60.com

��Better Students

Healthy Students are

Healthy Eating + Physical Activity = Improved Academic Performance

©2013 National Dairy Council. Fuel Up is a service mark of National Dairy Council.



What is the Learning Connection?There is a new national conver-sation about “The LearningConnection,” a term that de-notes the strong science linkinga child’s health, diet, physicalactivity, fitness and academicperformance in school.

Neuroscience has shown thata person’s cognitive ability iscomprised of many variables.Although genetics, socioeco-nomic status, demographicsand culture are not easilyaltered, many of the child’s external and internalcharacteristics can be influenced. Research showsthat the structure and function of a child’s brain de-velops in response to their experiences – not juststronger synaptic connections, but greater brain vol-ume, cell number, cell longevity, capacity and con-nectivity. A child’s play activities, diet quality, sleepand daily structure are major environmental contribu-tors. Most importantly, a child’s external support – notonly from family but also from other nurturing care-givers, such as in child care, preschool, and school –help the child use their experiences for positive devel-opment.

Four interacting areas of the brain are particularlycritical to the Learning Connection: • The amygdala• The hippocampus• The hypothalamic-pituitary axis (HPA)• The prefrontal cortex (PFC)

The amygdala, located in the limbic region, is in-volved in our most basic emotions, such as fear,anger, frustration and pleasure. The amygdala’sheightened emotional content tends toward unre-strained, impulsive outbursts. Close linkage with theHPA allows the amygdala to generate whole bodyexperiences, particularly through the HPA’s “fight orflight” chemical surges. Because emotions are soclosely tied to memories, the amygdala also plays acentral role in which memories are stored and howthey affect the child. Together with the hippocam-pus, a limbic system that encodes new memories inrelation to prior memories, the amygdala/hippocam-pus/HPA represents what one researcher calls “hot

intelligence.” What keeps all these basic, immediate,impulsive emotions in check is the prefrontal cortex.

The PFC is involved in planning, decision-making,moderating social behavior and orchestrating think-ing. It controls “executive function,” the critical role ofweighing risk-to-benefit, reconciling conflicting infor-mation, dealing with abstractions, planning for thefuture and working toward a goal. As such, the PFCutilizes the relational memory of the hippocampus,but in a highly constrained, productive and sociallyacceptable manner. It represents “cool intelligence.”Executive function is neither inherited nor static.Rather, this aspect of cognitive function is malleableand “epigenetic,” a reflection of how environmentdirectly impacts cognition and behavior – for betteror worse.

For a child to perform optimally in school the moreprimitive characteristics of memory, attention andemotion must be filtered through the highly controlledfilter of the PFC. Dysfunction in this relationship resultsin poor planning, time management, information pro-cessing, persistence toward tasks, handling multipletasks at once, in addition to retaining new informa-

Robert Murray, MD

Ohio Summit discusses state of school healthOn May 7, educational leaders and members ofschool health organizations from across the stategathered in Columbus to discuss what has be-come a national conversation surrounding theLearning Connection. Sponsored by Ohio Actionfor Healthy Kids, the Ohio Summit built upon thefirst national discussion presented by Gen Youthin the fall 2012. Both events introduced the con-cept of a direct relationship between nutrition,physical activity, and a child’s ability to learn.This Ohio Summit provided the foundation fordialogue regarding the state of school healthamong Ohio’s children.

The morning agenda was packed with informa-

See Learning...on page 19

See Summit...on page 18



tion from the science of early brain development, to food insecurity,school meals and cognition, physical activity, and breakfast in school.

Ohio’s First Lady Karen Kasich opened the Summit voicing her concernsabout obesity in Ohio’s youth, and offered her support for making posi-tive changes in schools. In addition, national leaders such as AudreyRowe, administrator for the USDA; Duke Storen with Share our Strength;and Ann Marie Krautheim from The American Dairy Council/Gen Youthvoiced support and shared knowledge with the more than 150 atten-dees. Cathy Ramstetter, MD, explained the critical role of recess inschool, followed by “Recess before Lunch” with former NFL and Buck-eye football player, Greg Bellisari, MD. Joined by some young tastetesters, the group was charged for the afternoon where individuals dis-cussed their own approaches to school wellness, and challenges thatthey faced in their districts. Engaged in a discussion led by Doug Lessells,former ABC News sportscaster and supporter of the cause, and guidedby Mike Thompson, PhD, the Summit participants were able to develop30- and 90-day plans for how to begin to make change in their owncommunities.

The American Academy of Pediatrics has long promoted the benefits offree play, physical activity, and quality diet as a foundation to help allchildren achieve their highest potential, but it can be challenging toconvey this message to parents.

The Ohio AAP’s Home and School Health Committee, led by RobertMurray, MD, has recently restructured in an effort to improve access ofinformation. Established programs such as “Ounce of Prevention” and“Pound of Cure” have been paramount in promoting awareness ofobesity prevention and intervention for pediatricians, but new focus onfuture efforts will be placed on reaching out directly to parents viasocial media and will be linked to the Ohio AAP website.

The Ohio AAP welcomes you to join the initiative. If you have sugges-tions, or would like to get involved, please contact the Chapter officeat (614) 846-6258, or [email protected].

Elizabeth Zmuda, MDNationwide Children’s Hospital

Summit...from page 17Additional Information

1. GenYouth (http://www.genyouthfoundation.org/),The Wellness Impact Report

2. AFHK (http://www.action-forhealthykids.org/), TheLearning Connection Report

3. Share Our Strength(http://www.strength.org/school_breakfast/strategies_for_closing_the_breakfast_gap/), The importance ofbreakfast and nutrition onclassroom outcomes

4. Robert Wood JohnsonFoundation and the Alliancefor a Healthier Generation(http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2012/rwjf66585), how to make ourschools healthy

5. Robert Wood JohnsonFoundation (http://www.bridgingthegapresearch.org/_asset/r08bgt/WP_2010_report.pdf), the potential forschool wellness councils toimpact school health

6. The Food Research andAction Center(http://www.frac.org), foodinsecurity and its impact onchild health

7. National Association ofSports and Physical Educa-tion, and The AmericanAlliance for Health, PhysicalEducation, Recreation andDance (http://www.aahperd.org/), showing howPE and sports promote activi-ty and fitness in schools forlifelong health

The Dairy Association Mid East is sponsoring the LearningConnection portion at this year’s Annual Meeting on

Sept. 20-21. Please visit the Dairy Association’s display in the Exhibit Hall.



Learning...from page 17

tion while using it (working memory). A child with poorexecutive function is every teacher’s nightmare.

Recent studies show that there are several ways toencourage PFC development. An acute bout of aer-obic physical activity simulates blood and nutrientflow to specific areas of the brain, such as the motorand sensory areas, obviously, but at the same time tothe PFC region. During exercise the frontal cortexlights up on brain scans. Obese children who improvetheir aerobic fitness show improved measures of ex-ecutive function based on neuro-cognitive testing,even without losing weight, which emphasizes an im-portant finding: cognitively, all children benefit fromregular activity and fitness.

Diet quality is no less important for cognitive perfor-mance. Currently, American children consume 30-40% of their daily calories as snack foods and bever-ages, described as energy-dense and nutrient-poor.There are many factors behind this statistic, povertybeing among the foremost. Consider that 1 of every 5children in the U.S. is food insecure; that is, they donot have consistent access to food. Hunger bluntsdevelopment, increases risk of behavioral problems,limits attention and reduces cognitive performanceand academic success. For decades, data has ac-cumulated linking poor nutrition with impaired braindevelopment and inappropriate social behavior.

We have many options to strengthen the LearningConnection. New USDA rules for school meals andvended foods closely align with the Dietary Guide-lines for Americans 2010. The nation’s nutrition safetynet extends its influence on children further by provid-ing after school snacks, summer meal programs, andmeal subsidies for preschoolers and in-home childcare sites. But we have never fully established thenutrition safety net. For instance, of 32 million childrenwho consume school lunch daily, only 10 million con-sume a school breakfast, and fewer than 3 millionconsume summer meals, despite ready availability offederal funds. Breakfast is fundamental for optimalclassroom performance. A simple innovation, theGrab-n-Go breakfast, ensures universal breakfastwithout cutting instruction, causing a mess, or involv-ing extensive food service staff time.

Regular physical activity will augment, not threaten,academic achievement. Many innovative ways ofengaging kids in activity have been promoted, rang-

ing from walking to school and/or bus stops to schoolgardens to before-school warm up exercises. Thesehave joined after-school programs as ways to layeractivity into a child’s day. Neuro-imaging and neuro-cognitive studies clearly show the benefits. But addi-tional pressure to increase teaching time for greateracademic achievement has eroded physical educa-tion, recess, as well as the arts (different forms of play)in schools. A CDC meta-analysis of 50 studies on cut-ting physical activity or physical education to allowmore academic time showed no observable benefitsof doing so. “Cramming” working memory actually iscounter productive to cognition. Optimal cognitiveprocessing requires regular breaks between periodsof concentrated academic activity.

The most well-established break in the class day, re-cess, also is being cut. In January, the AAP Council onSchool Health (COSH) published a policy statemententitled, “The Crucial Role of Recess,” based on a lit-erature review by Cathy Ramstetter, MD, a memberof the Ohio AAP’s Home and School Health Commit-tee (http://pediatrics.aappublications.org/content/131/1/183.full pdf). COSH laid out the science sup-porting recess from several perspectives: fitness, cog-nitive performance, classroom behavior, and perhapsmost importantly, social and emotional learning.

Unstructured play may stimulate the most potent formof learning because it encompasses not only move-ment, but also opportunities to practice social andemotional skills. Free play teaches the child those skillsthat we value most in adults – creative exploration,negotiation, cooperation, teamwork, sharing, andproblem-solving, all honed through the joy of role-playing and socialization. Also, during play a childlearns to manage stress, practice coping skills, exer-cise self-control and exhibit patience and persever-ance. Nowhere else in the school environment arethese skills practiced so effectively.

Ohio AAP members can promote this extraordinarybody of information as a means to optimize the cog-nitive potential of our children. We may not be ableto increase a child’s IQ, and we aren’t their teachers,but if allowed, we in health care can help put a bet-ter student in the chair.

Robert Murray, MD Home and School Health Committee



Editor’s note: The authors of this case study are Charles F.Ware III, MD, Michael E. Smith, ATC, Steven Cuff, MD,Anastasia Fischer, MD, Nationwide Children’s Hospital Divi-sion of Sports Medicine, Columbus, Ohio.

History: A 12-year-old male baseball player presents to clinic withright-sided elbow pain. He is a right-hand dominant, twosport athlete, who participates in both basketball and yearround baseball. He complains of right medial elbow painwith throwing for the past two weeks. There is no specificinjury noted, but it was first apparent during baseball prac-tice. He notices increased pain with pitching, loss of throw-ing speed and diminished accuracy. He reports no previoushistory of injury. He denies neurological symptoms, includingany radiating pain, numbness, or tingling. The pain hascaused him to stop throwing.

Physical Exam:This is a healthy appearing young male in no acute distress.Examination of his right arm reveals no swelling, erythemaor ecchymosis. He is point tender at the medial epicondyle.He has full range of motion and full strength in his elbowmotions. Pain is exacerbated with valgus stressing of thejoint, but no laxity is appreciated. He has a positive milkingmaneuver. He is neurovascularly intact with normal sensa-tion throughout, normal pulses and capillary refill.

Differential Diagnosis:Medial epicondyle apophysitis, medial epicondylitis, medialepicondyle avulsion fracture, ulnar collateral ligament in-jury, ulnar neuritis, subluxating ulnar nerve, olecranon frac-ture, capitellum fracture, osteochondrosis (panner’s dis-ease), osteochondritis dissecans, flexor-pronator musclestrain or tear.

Tests/Results: AP radiograph of the right elbow reveals widening of themedial epicondyle apophysis.

Final Diagnosis:Right Medial Epicondyle Apophysitis (Little League Elbow)

Treatment:The patient was removed from throwing, batting andcatching activities, but was permitted to participate inlower extremity conditioning, such as jogging. He was re-stricted from all throwing activities for 4 weeks. He was notimmobilized, but was instructed to use ice and NSAIDS asneeded for pain. Following his period of rest, repeat examrevealed resolution of tenderness, with full range of motionand strength. He was referred to rehabilitation, where hisrecovery focused on strength, range of motion, and pro-gression into sport with special attention to proper throwing

mechanics. As he remained pain free, he gradually re-turned to full throwing with continued emphasis on properthrowing techniques. A one-month follow-up after the com-pletion of PT, revealed the patient to be symptom free,demonstrating a full recovery. He was advised of the possi-bility of recurrence, though cleared to return to all sportswithout restrictions.

Discussion: Medial epicondyle stress lesions are referred to as medialepicondyle apophysitis, or more commonly, “Little LeagueElbow.” This injury often presents in throwing athletes, mosttypically baseball pitchers, between the ages of 9-15, withinsidious onset of medial sided elbow pain. The mechanismrelates to the repetitive forces of valgus overload throwersexperience during the late cocking and early accelerationphases of throwing. The presenting complaints are typicallya triad of symptoms consisting of medial elbow pain duringthe throwing motion, loss of velocity and control.

Physical examination begins with a focus on inspection andpalpation, followed by a comparison of range of motion,strength, and stabilityof the affected el-bow to the contra-lateral arm. Specialtests can be done toassess medial stabilityof the elbow, and in-clude valgus testingand/or the milkingmaneuver. Neurovas-cular testing, con-centrating on theulnar nerve, shouldbe completed toinclude Tinel’s testand assessment forsubluxation.

X-rays consisting ofAP and lateral viewsmay be used to visu-alize apophyseal maturity, and rule out other abnormalitiessuch as fractures, osteochondral defects, tumors and infec-tions. These may be performed bilaterally to differentiatebetween true pathology, or normal age-related develop-ment. The affected elbow may reveal widening of theapophyseal line in comparison to the contralateral elbow,but up to 85% of the time the radiograph is normal. Otherless common findings include medial epicondylar aphoph-ysis hypertrophy, avulsion, or fragmentation of the epi-condyle ossification center. MR imaging may be consid-

Case Study: MedialEpicondyle Apophysitis

See Case Study...on page 21

Milking Maneuver: The examiner placesthe patient’s forearm in the supinatedposition with elbow flexion exceeding 90degrees. The examiner then pulls thepatient’s thumb creating valgus stress. Apositive test is appreciated if the patientexperiences apprehension, instability orlocalized pain to the medial elbow.



Case study...from page 20

ered for any patient who lacks full range of motion (espe-cially in extension), exhibits instability of the medial elbowon exam, or shows evidence of an osteochondral defecton the capitellum, or less commonly, the radial head. MRcan aslo be considered for those found to have an elboweffusion without a clear mechanism of injury.

RehabilitationThe underlying goal of functional rehabilitation is to returnthe athlete back to his/her pre-injury level of competition asquickly and safely as possible.

Phase 1 of treatment focuses on a resting period rangingfrom a minumum of 4 weeks to upward of 3 months. Duringthe early stages of recovery, symptomatic managementfocuses on elimination of painful motions and stimuli. Typi-cally the athlete becomes pain-free within 4-6 weeks, atwhich point the initiation of rehabilitation can be consid-ered.

Most elbow injuries are the result of poor proximal stability,limited neuromuscular control, or improper throwing mech-anics. Therefore, phase 2 addresses range of motion, flexi-bility, posture, scapular and glenohumeral stability/mobility,core strength, neuromuscular control, balance and proprio-ception. Deficits in any of these areas will increase stress onthe elbow complex and must require special attention be-fore consideration of resuming any throwing activity.

Phase 3, the strengthening phase, begins when the athletehas full range of motion as well as minimal pain with palpa-tion and applied manual resistance. Early strengtheningstarts with isometric contractions and later progresses to iso-tonic contractions concentrating on the upper extremity.Exercises are also prescribed for core strengthening, improv-ing balance, scapular stability and rotator cuff strengthen-ing.

Once the athlete demonstrates full pain-free range of mo-tion, no tenderness to palpation, adequate muscularstrength, proper glenohumeral rhythm, and adequatescapular stability, the late strengthening phase begins. Theathlete is prescribed total body exercises with progressionto sport specific strengthening. These exercises emphasizerhythmic stabilization, neuromuscular control, plyometricexercises and overall endurance.

The final rehabilitation phase includes a 4-12 week intervalthrowing program with emphasis on throwing mechanics,while continuing to advance throwing distance, intensity,and frequency. Video analysis may be helpful to aid in ob-servation of detailed throwing mechanics and further exer-cises may be prescribed to improve any deficits found.

PreventionRecommendations and guidelines have been published tolimit pitch counts, avoid certain types of pitches prior topuberty, and address the “throwing seasons” of youngthrowers, encouraging them to throw competitively for no

greater than 9 months per year.

SummaryLittle League Elbow is a multi-factorial preventable injury,focusing on the position of the adolescent athlete, cumula-tive number of pitches, type of pitches, and specificallytheir technique. There must be increased concern regard-ing throwing pain in young pitchers and all of these warrantproper evaluation. Recognizing these injuries allow for earlyintervention, which results in minimizing any long-term com-plications or permanent injury to the adolescent athlete.The foundation of treatment starts with prevention and wemust continue to identify at risk adolescent athletes, whileimproving prevention management with increasing aware-ness and education to avoid future injury.

Charles F. Ware III, MD, Michael E. Smith, ATC, Steven Cuff,MD, Anastasia Fischer, MD Nationwide Children’s Hospital, Division of Sports MedicineColumbus, Ohio

REFERENCES1.) Benjamin, H., & Briner, W. (2005). Little league elbow. Clin Sport Med. 2005; 15(1): 37-402.) Greiwe, M., Saifi, C., & Ahmad, C. (2010). The athleteselbow: Pediatric sports elbow injuries. Clinics in SportsMedicine. 2010; 29(4): 677-7033.) Hoang, Q., & Mortazavi, M. (2012). Advances in pedi-atrics pediatric overuse injuries in sports. Advances inPediatrics. 2012; 59(1): 359-3834.) Klingele, K., & Kocher, M. (2002). Little league elbow: val-gus overload injury in the paediatric athlete. Sports Med.(2002); 32(15): 1005-10155.) Madden, C., Putukian, M., Young, C., & McCarty, E.(2010). Netter’s Sports Medicine. Philadelphia, PA: SaundersElseiver.6.) Patel, N., Thomas, S., & Lazarus, M. (2103). Imaging ofathletic injuries of the upper extremity throwing injuries ofthe upper extremity. Radiologic Clinics of North America.2013; 51(2): 257-277 7.) Osbahr, D., Chalmers, P., Frank, J., Williams, R., Widmann,R., & Green, D. (2010). Acute, avulsion fractures of themedial epicondyle while throwing in you baseball players: avariant of little league elbow. Journal of Should and ElbowSurgery. 2010; 19(7): 951-9578.) Southard, J. & Benson, E. (2011). Elbow injuries: gettingkids back in the game. The Journal of Family Practice. 2011;60(10): 586-592


need is.

For HB 200, the law would:• Force doctors to perform MORE medically unneces-sary procedures.• Dictate to doctors a set of lies they must tell theirpatients – specifically that abortions cause breastcancer. • Establishes a $1 million fine and first degree felonypenalty for first violations of this law – this would im-poverish, strip the license from, and incarcerate doc-tors.

There will always be issues that divide us, but the in-tegrity of the medical profession should always uniteus. Laws are now passed, and others are threateningto pass, that take direct aim at the very notion of amedical profession.

At its heart, the notion of the state licensing a groupof professionals is based on trust. The deal offered isthat if a group promises to attain a certain level of ex-pertise and commits to putting that expertise to thebenefit of the community, the state will grant thatgroup the autonomy necessary to allow it to practiceits profession. Inherent in that trust, and in the prac-tice of medicine, is the understanding that the state

will not force its medical professionals to perform cer-tain medical procedures, tell its patients a dictatedscript that could include falsehoods, and invite thepublic to sue the professional should they disagreewith the public.

Whenever a state takes such a direct action againstthe very core of our standing as professionals, it be-comes time to let the public know, and to do whatwe can to recover the basis of our professionalism. Ifnot for our own sake, but for the sake of our patients,the people of Ohio and the children of Ohio. Manyprofessional societies are weighing options for takingactions that will restore the professional integrity ofmedicine here at home, we look forward to themembership of the Ohio AAP joining these efforts.

If you would like to let us know you support theseefforts, simply email me at: [email protected]. Every pediatrician in Ohio is also invited toattend a major rally to be held in Columbus onWednesday, Oct. 2, 2013, at the State Capitol from11:30 a.m. to 2 p.m. White coats are welcome as amajor point of this rally will be to let the public knowthat doctors are aware that their profession has beenendangered and would like it to be re-established onfirm ground.


cuss gun ownership and safety with patients and thatinformation may be collected in a centralized data-base for the purposes of accident prevention andgeneral public health. The NRA was already workingon legislation in Florida when this executive order wasreleased and pro-gun advocates across the nationramped up their rhetoric and advocacy on the issueof physicians discussing gun possession with patients.

SB 165 is the latest effort in a long line of pro-gun billsintroduced during the 130th General Assembly. Otherbills would loosen restrictions on conceal-carry licen-ses, allow guns to be carried in more public spaces,and enact ‘stand your ground’ laws similar to thecontroversial Florida statute at the center of theTrayvon Martin case. Many of these provisions are in-cluded in House Bill 203, a pro-gun bill sponsored byRep. Terry Johnson (R-McDermott), the only physicianin the Ohio General Assembly. We expect some ofthese pro-gun measures to see action this fall and seethe physician gun safety issue as a potential amend-

ment to one of these broad and controversial mea-sures.

Only Florida has passed legislation to prohibit physi-cians from asking about gun ownership, and that lawhas been held up for more than two years in FederalCourt. The Florida Chapter of the American Acad-emy of Pediatrics and allies won a key victory lastyear when a U.S. District Judge granted a permanentinjunction on the grounds that the bill is unconstitu-tional. The NRA filed an appeal in the 11th CircuitCourt, which is ongoing. In Ohio, it is unclear if orwhen this bill may receive a committee hearing, butgiven the national attention around gun-related is-sues we need to be proactive. Regardless of yourposition on gun control and ownership, this debatecannot be allowed to come between a pediatricianand his/her patients.

Profession...from page 12

Guns...from page 12



Coding Corner

Despite a previous one yearreprieve, ICD-10 will be man-dated Oct. 1, 2014. This is adefinite, despite the AMA ask-ing for additional delays. It isnow time to prepare andmake ready. This transition isone of the biggest changes toaffect health-care informaticsin many years. Don’t wait untilthe last minute to address thischallenge to your future cod-ing. In order to be HIPAAcompliant and to maximizebenefits to your practice, consider the following sixstep planning and implementation strategy to pre-pare and transition to the new code set.

1) PLAN – Complete by Winter 2014Create an implementation plan. This should establishthe structure and leadership over the project. Deter-mine who is responsible for ICD-10 implementation;this should include a physician champion, as well as,the office manager.

2) COMMUNICATION – OngoingThis is an ongoing task and should occur now, andcarry on through implementation. This will create anawareness of the change, its importance, and will re-duce anxiety related to the initiative. Education andplanning with confidence is important.

3) ASSESS – NowReview business and policy impacts with the prac-tice. Specifically, the technology impacts should beaddressed. This should include a complete evaluationof current vendors and their readiness to accommo-date the change. Ideally it should include the abilityto code both ICD-9 and ICD-10 during the transition.This assessment must be completed before imple-mentation and testing can occur.

4) IMPLEMENTATION – To FollowOperational implementation includes identification ofsystem issues, addressing business and technicalmodifications, and preparation for training. Trainingshould occur six months prior to implementation.

A staff member, who will be identified in testing,should be educated now. Hospitals, the AAP, and theAMA will be scheduling ICD-10 coding programs andinitiatives, as well as, providing ICD-10 coding books.

5) TESTING – Early 2014Thorough testing will assure minimal delays in yourclaims’ payments and assure accurate informationflow. This involves internal and external testing withinthe practice. This complete testing will involve ven-dors, payers, and any third-party administrators orbilling companies. Contact third-party payers to de-termine a timeline that accommodates testing andretesting, if necessary. Many payers are willing towork with you as you address your ICD-9 to ICD-10transition.

6) TRANSITION – Summer 2014The final phase – Prepare the go-live environment forOct. 1, 2014. Ongoing support and communicationwill be necessary. Look to your vendor for customizedsupport in the process.

In summary, if you have not implemented a process,start your planning for the transition from ICD-9-CM toICD-10-CM diagnostic coding. The time is now!

Richard H. Tuck, MD, FAAP, ZanesvilleOhio AAP Coding Expert

ICD-10 – A definite in 2014

Richard H. Tuck, MD

Principles of Pediatric ICD-10-CM Coding – Auser-friendly complete ICD-10 text with a pedi-atric focus.

Pediatric Code Crosswalk ICD-9-CM to ICD-10-CM – Designed as a quick reference crosswalkfor pediatric diagnosis coding.

ICD-10 Coding Webinar: ICD-10-CM: Postponed,Not Cancelled! – 6/25/2013, Jeffrey Linzer, MD,FAAP; archived and available on the AAP web-site, Practice Management Online

AAP resources for the ICD-10 transition


1. Select 2. Select 3. Select 4. Select 5. Select (under Activity Name) 6. Select

www.WiseAboutEyes.org

1. Contact

y




The parents of patients in myoffice in recent weeks fre-quently express great con-cern, bewilderment, frustrationand distress about thechanges in health insurancecoverage that is emerging thisfall. Media hype laced withinformation and misinforma-tion adds fuel to the fire daily.The mother of a patient withcomplex chronic medicalneeds today stated, “Mymother’s tax advisor told methat unless I buy health insurance for myself, my childcan no longer be covered by Medicaid.” Indeed theissues are complex and vary from state to state butmothers like my patient do not know where to turn.Appropriately, they turn to their most trusted source,their pediatrician, and I suspect you are receivinginquiries frequently as well. Few of us are experts onthis topic but it is essential that we know where todirect parents for help.

Our AAP chapters can help by discerning the detailsat a state level and hopefully that will happen foreveryone as the still developing process unravels inthe weeks ahead. The AAP Department of StateGovernment Affairs is diligently working to ensurestate chapters have the counsel they need to ensurethe needs of all children are addressed in theprocess.

The Center for Medicare and Medicaid Services(CMS) has scheduled a series of stakeholder confer-ence calls for states with federally facilitated ex-changes or state partnership exchanges that arealso referred to as marketplaces. The calls are statespecific and require registration that can be acces-sed at: http://marketplace.cms.gov/.

Two federal websites of which you should be awareinclude: • http://www.HealthCare.gov has information for

District V Report

Marilyn Bull, MD

Confusion reigns! How the pediatrician can help

consumers on application, enrollment, plans, andmore. • http://marketplace.cms.gov/ has PR materials,graphics, logos, and more that you can use for youreducational materials.

Our responsibility as pediatricians is to advocate forchildren and their families as the process developsfrom state to state to ensure the needs of childrenare incorporated wherever possible and every chap-ter is very involved. You can also stay current by fol-lowing progress on the State Government Affairspages at MyAAP.

Confusion reigns, but we can help provide calm bydirecting our patients to the appropriate resources.Seek the help needed from the resources above andyour state chapter. Order will eventually emerge andwe can be a positive force in the process.

Marilyn Bull, MD, FAAPDistrict V Chair

Lions, tigers and bears...Stuffed animalsthat the Ohio AAP had amassed over theyears, were donated to several pediatri-cian offices this summer. JonathanThackery, MD, medical director of TheCenter for Family Safety and Healing inColumbus displays his collection.



Two FREE Opportunities for PRESCHOOL VISION SCREENING in a Primary Healthcare Setting from Prevent Blindness Ohio!

1. TRAINING: Attend (or send nursing/allied health staff) a training to learn how to perform stereopsis and distance visual acuity screening for your preschool age patients. Receive FREE equipment ($300+ value), educational materials and certification! Log onto www.WiseAboutEyes.org for more information.

2. ON-DEMAND WEBINAR: Pediatricians Dr. Chris Peltier and Dr. Jeffrey Jinks provide information on children’s eye diseases and disorders and discuss the importance of conducting screenings for ocular alignment and visual acuity. FREE patient education materials! Register at https://oh.train.org. (search Preschool Vision Screening or Course ID 1035426).

Funded by the Ohio Dept. of Health, Bureau of Child and Family Health Services, Save Our Sight Program



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advocating for standards that en-couraged awareness and safety inthe Return-to-Play Law. As original-ly passed, the Return-to-Play Lawstipulates that after showing signsof a concussion a youth athletemust be removed from play andkept out for at least 24 hours, andonly after they are cleared by ahealth-care professional. Non-physicians must consult with a phy-sician before clearing an athleteto return to play.

“The Ohio AAP lead this importantbattle to overturn this provision,and we are grateful to our mem-bers who made calls and reachedout to the governor to stop it frommoving forward,” said Melissa Wer-vey Arnold, Executive Director ofOhio AAP.

Concussions will be the the topic

of the plenary session at the OhioAAP Annual Meeting on Friday,Sept. 20 at 4 p.m. This is just oneresponse the Chapter is taking tothe growing needs of pediatriciansto be informed on this issue in lightof the recently passed legislation.Ohio AAP members are poised toplay key roles in the developmentand implementation of materialsand procedures to meet the re-quirements of this new law. Thelaw now requires greater contribu-tions from pediatricians.

This session will look at the areaspediatricians will encounter relat-ing to concussions. To provide ex-pertise on all aspects of this issue,the session will feature a panel ofspeakers with various backgroundsdiscussing the law, the logic andthe logistics.

Concussions...from page 1 Medicaid...from page 1

Executive Director of the OhioChapter, AAP.

More work remains to be done tomake sure Medicaid pays appro-priately beyond 2014. The tempo-rary increase must be made per-manent in order to ensure accessto care in the long-term for allOhio children.

The Chapter will be following thisissue closely and will keep you in-formed through our publicationsand on our website.

If you have questions, please con-tact the Medicaid Provider CallCenter at 1-800-686-1516. You canalso visit their website at: http://jfs.ohio.gov/ohp/provider. stm.


The Ohio AAP announces the following meetings and events.

Sept. 19-21 – 2013 Ohio AAP Annual MeetingSheraton Columbus Hotel at Capitol Square

A few of the topics to be discussed:– Concussions: The Law, the Logic, and the Logistics– The Role of the Pediatrician in School Violence– MOC Part II: Complete Your Requirements

Oct. 18, 2013 – Injury Prevention Learning SessionNew Chapter Office94-A North Woods Blvd., Columbus

Building Mental Wellness Wave 3 Learning Sessions

• Nov. 9, 2013 – Athens Community Center, Athens, OH

• Feb. 22, 2014 – Cincinnati Children’s Hospital Medical Center Liberty Campus

• April 26, 2014 – Sawmill Creek Resort in Huron, Ohio

Visit our website for more details www.ohioaap.org

Calendar of Events

Dues remitted to the OhioChapter are not deductibleas a charitable contribution,but may be deducted as anordinary and necessary busi-ness expense. However, $40of the dues is not deductibleas a business expense be-cause of the Chapter’s lob-bying activity. Please consultyour tax adviser for specificinformation.

This statement is in referenceto fellows, associate fellowsand subspecialty fellows.

No portion of the candidatefellows nor post residencyfellows dues is used for lob-bying activity.

Ohio ChapterAmerican Academy of Pediatrics94-A Northwoods Blvd.Columbus, OH 43235

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Permit No. 156U.S. Postage

PAIDDUBLIN, OH

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Documents

Ohio Pediatrics - Summer 2013 - Ohio AAP