By Emma Cecil, JD

On February 9, 2018, Congress passed and the President signed into law the Bipartisan Budget Act of 2018 (BBA), a comprehensive piece of legislation that provides for a two-year budget agreement and funds the federal government through March 23, 2018. The BBA’s sweeping measures address federal spending for the military, domestic programs, and disaster relief, and contain several provisions impacting federal healthcare programs.

Among other things, the BBA:
• Permanently repeals the Medicare payment cap for therapy services;
• Expands certain telehealth services;
• Eliminates the Independent Payment Advisory Board (IPAB) under the Affordable Care Act;
• Postpones cuts to Medicaid Disproportionate Share Hospital (DSH) payments for another two years;
• Removes the requirement that drug reimbursements be included when calculating MIPS payment adjustments;
• Extends the Children’s Health Insurance Program (CHIP) for an additional four years beyond the previous Continuing Resolution’s six-year extension;
• Removes from the Social Security Act language mandating that HHS require more stringent measures of meaningful use, thus reducing the volume of future EHR-related significant hardship requests; and
• Includes a $6 billion increase in funding for opioid abuse and mental health treatment.

Of particular significance, the BBA dramatically increases civil money penalties (CMP) and criminal fines, as well as prison sentences, for violations of federal fraud and abuse laws. For example, the BBA doubles CMPs for, inter alia, contracting with or employing excluded individuals, submitting false claims, and retaining overpayments; quadruples criminal fines for making false statements and soliciting or receiving illegal kickbacks from $25,000 to $100,000; and doubles sentences for felonies involving false statements and Anti-Kickback Statute violations from a maximum of five years to a maximum of 10 years.

Finally, the BBA eases some of the burden of Stark Law compliance by codifying revisions to CMS’s Stark regulations that became effective in 2016. Pursuant to these changes, the writing requirement for compensation arrangements may now be satisfied by a collection of documents, including contemporaneous documents evidencing the course of conduct between the parties involved, and the signature requirement for written documents may be satisfied so long as the parties obtain the required signatures within 90 days of the date on which the compensation arrangement became noncompliant. Additionally, the Stark Law revisions allow indefinite holdovers on space and equipment leases and personal services contracts following expiration of the contract term so long as the original arrangements satisfied a statutory exception and the holdover arrangements are on the same terms and conditions.

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By Micah Fisher, MD

The area of pulmonary hypertension has seen an ex-plosion in interest and therapeutic options over the past 25 years. The first World Health Organization (WHO) international symposium was held in 1973, leading to a standardized definition, a classification system and calls for further investigation. That first classification system, dividing patients between primary and secondary pulmo-nary hypertension, has since been expanded significantly as we have developed a better understanding of the different types of pulmonary hypertension.

The current WHO classification system, last modified in 2013, consists of five types of pulmonary hypertension: 1. Pulmonary arterial hypertension, 2. Pulmonary hyper-tension due to left heart disease, 3. Pulmonary hypertension due to chronic hypoxemia and respiratory diseases, 4. Chronic thromboembolic pulmonary hypertension, and 5. Pulmonary hypertension due to multi-factorial or unclear mechanisms. While our understanding of all these types has improved significantly, at this point, we only have effective targeted therapy for types 1 and 4.

Idiopathic pulmonary arterial hypertension, formerly known as primary pulmonary hypertension, is the prototypic form of pulmonary arterial hypertension. This remains a rare disease with prevalence estimates around 6 people/million. Survival with modern therapy has significantly improved compared to original descriptions, which showed a median survival of 2.8 years.

We now have multiple drug options in each of the three main pathophysiologic pathways, including oral, inhaled, subcutaneous infusions and continuous intravenous infu-sion therapies. These therapies have been very effective in significantly reducing the need for lung transplantation.

Despite the opportunities for ongoing education prompted by the advances in therapeutics, there remains a significant challenge in assuring the right diagnosis is made and appropriate therapy is started. This was highlighted by the multi-center study by Deano et al., published in 2013, which showed that a third of patients who had been given a diagnosis prior to referral had been misdiagnosed, and that more than 50 percent of the patients who had been started on therapy were receiving it contrary to guidelines.

Given the significant side effects and expense of these therapies – some of them costing $150,000 or more a year –this is an issue that needs greater emphasis. Despite our increased understanding, appropriate diagnosis and management remains challenging, which is why all of the major pulmonary hypertension guidelines recommend referral to a center with expertise in managing these patients.

Since the approval of riociguat, an oral soluble guanylate cyclase stimulator, for chronic thromboembolic pulmonary hypertension (CTEPH) in 2013, this disease has received a lot more attention. CTEPH occurs in patients who have incomplete dissolution of pulmonary emboli, leading to chronic pulmonary vascular obstruction and resultant pulmonary hypertension. This appears to be a relatively uncommon complication of pulmonary embolic disease, with most studies suggesting a prevalence between 1 percent and 4 percent of patients followed prospectively after acute pulmonary embolism.

Interestingly, upwards of 50 percent of patients diagnosed with CTEPH will not have a clear history of deep vein thrombosis or pulmonary embolism prior to diagnosis.

Subsequently, all patients being evaluated for pulmonary hypertension, regardless of history of venous thromboembolism are recommended to be screened for CTEPH with a ventilation perfusion scan, which has significantly better sensitivity compared to a CT scan.

Patients diagnosed with CTEPH should be further assessed for surgical candidacy. The operation, a pulmonary endarterectomy, is a major surgery only performed with expertise at a few centers nationwide. The world leader in this operation is the University of California at San Diego, where they perform several hundred annually with published perioperative mortality ranging from 2 percent to 4 percent based on preoperative hemodynamics. Most patients have normalization or near normalization of their pulmonary hemodynamics with surgery and have normal life expectancy after successful surgery, with the only ca-veat that they must remain on life-long anticoagulation.

For years, the only options for CTEPH patients was a pulmonary endarterectomy or lung transplantation. Therapies that had been shown to be effective for pulmonary arterial hypertension had unimpressive results when trialed in patients with CTEPH. That was until riociguat was shown to improve hemodynamics and functional capacity in patients who had inoperable disease or had significant residual pulmonary hypertension after surgery. While these outcomes were robust, they are small compared to the potential outcomes from surgery at an expert center and should not be used to justify not referring patients for a more definitive surgical treatment.

The field of pulmonary hypertension has changed significantly in recent years with updates to the classification system and multiple new therapies. This has led to a significant increase in education targeted at multiple providers. While this has increased awareness, it has also led to a significant amount of over-diagnosis and over-prescribing. Despite these advances, patients with pulmonary hypertension continue to be a diagnostic and management challenge necessitating referral to a pulmonary hypertension center.

American College of Cardiology – Georgia Chapter Annual Meeting

Georgia Academy of Family Physicians – Annual Scientific Assembly

Patients living with dementia often need a unique kind of care. They can also benefit from extra help managing their dementia symptoms as well as other chronic conditions. And while not every provider has the time or flexibility to offer this level of comprehensive care, the Emory Healthcare Integrated Memory Care Clinic does.

Emory’s Integrated Memory Care Clinic is a level 3 patient-centered medical home that provides the kind of individualized, complete care dementia patients need, yet so often cannot find. Their team has extensive experience and expertise working with dementia patients. They understand the effects dementia can have on patients, their other potential illnesses and medical issues.

In the primary care clinic, patients receive comprehensive, team-based health care services. Nurse practitioners collaborate with geriatricians and neurologists to manage dementia and other chronic conditions. By managing medications, taking a palliative care approach, providing caregivers with support and education, and coordinating community services, the Emory’s Integrated Memory Care Clinic is changing care for people living with dementia and their families. Emory’s Integrated Memory Care Clinic leverages the resources of the Emory Healthcare system.

Nationally recognized, patient-centered care

In 2016, the Emory Integrated Memory Care Clinic earned the National Committee for Quality Assurance’s (NCQA) highest level of recognition. This Patient-Centered Medical Home Level 3 Recognition demonstrates Emory’s ability to coordinate care among all health care providers and other community-based resources.

Being a Patient-Centered Medical Home (PCMH) is more than a name. Research shows this approach to care delivers markedly improved results. Patients in PCMHs report increased access to care, lower costs, and higher quality care.¹

In fact, at less than 1%, the Emory Integrated Memory Care Clinic’s rate for ambulatory sensitive hospitalizations is well below the national average of 13%. The patient satisfaction rate for its providers was 97% for the period of September 2016 through August 2017.

Working as a team for an individual

Approaching care as a team, a nurse practitioner, a registered nurse, a clinical social worker, and a patient care coordinator work alongside the patient, their family members and caregivers to achieve the best outcome for the patient.

The Emory Integrated Memory Care Clinic team replaces the patient’s primary care physician and manages their chronic conditions to ensure patients reach and stay at their most well. The Clinic develops individualized treatment recommendations and offers several additional services to established patients. The Emory Integrated Memory Care Clinic solicits ongoing feedback from their patients and families. The Emory Integrated Memory Care Clinic’s Patient and Family Advisory Council drives the design and delivery of care.

A Caregiver’s Experience

Leah Humphries was struggling to find adequate care for her mother, Carol. “Our lives changed from the moment we connected with the Emory Integrated Memory Care Clinic,” Leah said. “Dad was scared, but the support the Clinic provided, especially the Savvy Caregiver class, really empowered him.”

Additional Services

• Chronic Care Management – Eligible patients are enrolled in Medicare’s chronic care management in order to coordinate services outside of clinic visits.
• Care Coordination – the Emory Integrated Memory Care Clinic provides recommendations and referrals to community-based resources. The team also coordinates referrals to other healthcare services.
• Caregiver Classes – Social worker offers educational classes for caregivers covering common difficult behavioral symptoms, end-of-life concerns, and other relevant topics.
• Family Meetings – the clinic offers opportunities to discuss care goals with family members and caregivers.
• Transition of Care – Staff can coordinate transitions to higher levels of care and post-hospitalization discharge.
• After Hours Call – Established patients have access to nurse practitioners during evenings, holidays and weekends.

Learn More or Refer a Patient

If you’d like to learn more about Emory’s Integrated Memory Care Clinic or think one of your patients could benefit from the services, please call 404-712-6929 or learn more at emoryhealthcare.org/imcc.

1 http://www.ncqa.org/Portals/0/Consumer%20Landing%20Page/2013%20PDFs/pcmh%202011%20fact%20sheet.pdf

Georgia Orthopaedic Society Annual Meeting

July 20

MAA House of Delegates Caucus Meeting

New Northside Hospital Cherokee to Open

Northside Hospital Cherokee’s replacement hospital will open for patients on Saturday, May 6, 2017.

The new hospital is located off I-575 at the Ga. Hwy 20 exit.

“This is a huge move forward for Cherokee county and the surrounding areas,” said Billy Hayes, CEO of Northside Hospital Cherokee. “Our new hospital is the culmination of a lot of hard work by many people over many years. The entire Northside Cherokee family is proud of what we’ve accomplished, and we look forward to a new era of health care service.”

Construction is complete on the new hospital, which will open with 105 inpatient beds and more than twice the square footage as the current hospital. Northside staff is now focused on training and education, while overseeing the installations of equipment and furniture.

A medical office building opened on the 50-acre campus in early January. Several physician practices and Northside Hospital Radiation Oncology have opened their offices and are seeing patients. Additional Northside services and physicians will move into the building over the next several months.

Northside is planning an open house for late April to give everyone a chance to tour the new hospital campus before patients are moved and accepted there on May 6.

June 17