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Published by akemppainen, 2016-11-10 21:30:00

medicina October-November 2016

medicina October-November 2016


fter a months-long listening tour with nearly Reflecting feedback from providers, CMS made
100,000 attendees and nearly 4,000 public adjustments to the proposed rule to help small, inde-
comments, the Centers for Medicaid and Medicare pendent practices participate.
(CMS) recently released the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) Final Those who fall below the requirements of at least
Rule. CMS indicated that a common theme in the $30,000 Medicare Part B charges or 100 Medi-
input they received was the need for flexibility, care patients are exempt from participating in
simplicity, and support for small practices. In re- 2017.
sponse, they made specific policy changes in the
proposed rule issued last spring to help physicians CMS estimates this represents 32.5 percent of clini-
make the transition including: cians, but accounts for only 5 percent of Medicare
spending. CMS is also offering an option for small
 more flexible options in the first year, practices and solo physicians to join together in vir-
 adjustment of the low-volume threshold for small tual groups and submit combined MIPS data (these
virtual groups will not be implemented in the 2017
practices, transition year, however, presumably CMS needs
 establishing the advanced APM as a standard to more time to execute the systems changes neces-
sary to do so).
promote participation in value-based care models,
 simplifying "all-or-nothing" EHR requirements, and (continued on page 4)
 establishing the medical home model to promote

care coordination.


President’s Perspective President
___________________________ 3 David Walsworth, MD, FAAFP

Letter from the Editor-In-Chief President-Elect
___________________________ 4 J. Randy Hillard, MD

Continued: _M_A_C__R_A__F_in_a_l_R_u_l_e____________ 5 Secretary-Treasurer
Updates from Across the County Joseph Wilhelm, MD, FACS

___________________________ 6 Immediate Past President
Medical Schools Updates Amit Ghose, MD

___________________________ 7 Itfiker Ahmad, MD
Member Spotlight: Narasimha Gundamraj, MD Farhan Bhatti, MD
Steven Cross, Student Representative
___________________________ 8 Douglas Edema, MD
Kenneth Elmassian, DO
Advocacy Alert– Physicians Lead the Way on Ved Gossain, MD
Physician-Led Teams Narasimha Gundamraj, MD
Raza Haque, MD
___________________________ 9 Richard Honicky, MD
Join ICMS Today Ronald Horowitz, MD
James Richard, DO
___________________________ 10 Dawn Springer, MD

Chief Operating Officer
Angie Kemppainen, CAE


n October 20, 2009, nearly 1,200 physicians, advanced practice nurses as part of a physician-led
fellows, residents and medical students came team, and SB 1019, dangerous legislation that would
together to help defeat the Quality Assurance remove physician anesthesiologists from doctors’
Assessment Program (QAAP), otherwise known as offices and operating rooms across Michigan, and
the physician tax. end physician supervision of anesthesia care. One
bill was developed with input from physicians to as-
Based on faulty premises and the lure of Federal sure patient safety while improving access to care.
matching dollars, the Michigan House of Represent- The other was rammed through the Senate with the
atives passed the physician tax on October 6, 2009. support of the Michigan Association of Nurse Anes-
The Ingham County Medical Society, Michigan State thetists and Michigan Hospital Association, with only
Medical Society and their partners in organized organized medicine standing on the side of physi-
medicine acted quickly to rally efforts to oppose this cians- and only organized medicine still fighting to
legislation through a 1,200-participant march on the see that this dangerous legislation does not pass the
Michigan capitol. The result of the march, and the House as well.
hundreds of calls and emails to Senators’ offices
resulted in the Michigan Senate ultimately voting As we come to the end of our membership year, we
down the bill, saving every physician in Michigan up thank you, our members, for your continued support
to an estimated 3 percent of their gross revenues in keeping the voice of physicians strong in Ingham
each year. County and in Michigan. We also urge you to stress
the importance of organized medicine to your
The strength of the march on the capitol and the ulti- colleagues. Remind them that without united voices
mate defeat of the physician tax demonstrated the of physicians, they would have lost nearly 3 percent
power, impact, and necessity of organized medicine of their income for each of the past seven years.
– Ingham County’s former State Senator, Gretchen And warn them that without the united voice of
Whitmer, voted against the physician tax. physicians, their anesthesiologist colleagues may be
the first of many physicians to be supplanted by
In our Advocacy Alert on page 9, we compare HB non-physicians in caring for their patients.
5400, a bill that would safely expand the scope of

ccording to the American Cancer Society, death available.” Sadly, it was often
rate from cancer in the US has declined steadily not true then. However, sometimes it really is true
over the past two decades. The cancer death rate now.
for men and women combined fell 23 percent from
its peak in 1991 to 2012, the most recent year for Since being diagnosed with metastatic HER-2+ ade-
which data is available. This translates to more than nocarcinoma of the stomach in 2010, I have been
1.7 million deaths averted during this time period. receiving Herceptin, which is what is keeping me
alive. Herceptin was approved for metastatic breast
This is truly wonderful news! cancer in 1997, but was approved for metastatic
stomach cancer only weeks before I was diagnosed.
However, thousands of preventable cancer deaths
continue to occur every year because of smoking, So, here’s to declining cancer deaths, helping pre-
alcohol consumption, neglect of routine cervical and vent future cases, and looking forward to the day
colon cancer screening, and failure to inoculate when cancer is wiped out for good.
against HPV.
J. Randy Hillard, MD
On November 17, the Great American Smoke Out
provides us with the opportunity to emphasize again ICMS President-Elect &
the importance of smoking cessation. Also, for the medicina Editor-in-Chief
third year in a row, Governor Snyder has designated
November “Curing Stomach Cancer Month.”

When I was in medical school and residency, we
heard patients say things like “If I can just hold out a
little longer, maybe a new treatment will become


Providers who are ready to start collecting perfor- Advanced APMs
mance data can begin as early as January 1, 2017. Participation in an advanced APM allows physicians
However, CMS is offering providers the option to to earn a 5 percent lump sum incentive payment
start anytime between January 1, 2017 and October each year from 2019 through 2024 and avoid MIPS
2, 2017. No matter when providers begin collecting reporting requirements and payment adjustments.
data, it is due to CMS by March 31, 2018. The data The final rule firms up details on what programs will
collected in the first performance year will determine qualify as advanced APMs. First, to qualify, ad-
payment adjustments beginning January 1, 2019. vanced APMs must meet three requirements: Use
certified EHR technology, base payments on quality
The final rule includes two pathways for provider measures comparable to MIPS and require provid-
participation: the Merit-Based Incentive Payment ers to bear more than nominal risk. Beyond that,
System, or MIPS, and the Advanced Alternative advanced APMs must also be an approved model
Payment Model, or APM. The first pathway, MIPS, by CMS. The final rule identifies the following as
is designed for providers in traditional, fee-for- advanced APMs for 2017:
service Medicare. The second, Advanced APM, is
designed for providers who are participating in  Comprehensive ESRD Care Model (LDO and
specific value-based care models. non-LDO two-sided risk arrangements)

MIPS  Comprehensive Primary Care Plus Model
MIPS is the “base” program for MACRA—if provid-  Medicare Shared Savings Program Tracks 2 and 3
ers don’t participate in it or gain an exemption from  Next Generation ACO Model
it, they receive a payment cut (even in the first
year). MIPS rolls together and sunsets three legacy CMS has also signaled it plans to create additional
CMS programs: Meaningful Use, the Physician pathways for participating in the advanced APM
Quality Reporting System (PQRS) and the Value- track, including a new accountable care organization
Based Payment Modifier. Physicians will earn Track 1+ model, the Comprehensive Care for Joint
payment adjustments based on performance in four Replacement and the Medicare Diabetes Prevention
categories linked to quality and value that will be Program. CMS plans to add these programs in 2017
similar to the previous programs. Payment adjust- or 2018.
ments in the first year will be neutral, positive or
negative up to 4 percent. This will grow to 9 percent
by 2022.

Since CMS rolled out the proposed MACRA rule,
it has settled on a gradual ramp to full participa-
tion, allowing physicians to pick their pace be-
tween the following four options in 2017:

 No participation and an automatic 4 percent nega-
tive payment adjustment.

 Submission of a minimum amount of data — i.e.
one quality measure — and a neutral payment

 Submission of 90 days of data for a potential small
positive payment adjustment or a neutral adjust-

 Submission of a full year of data for the potential to
earn a moderate positive payment adjustment.

Ingham County News

Sparrow Physicians Mark McLaren Awarded for Treatment
Groundbreaking 50th Pacemaker of Stroke Patients

Procedure McLaren Greater Lansing has received the American
Heart Association/American Stroke Association’s
Sparrow cardiologists have marked a milestone by Get With The Guidelines®-Stroke Silver Plus Quality
completing their 50th procedure to implant a leadless Achievement Award with Target: StrokeSM Honor
pacemaker, a device that aids patients with heart Roll. The award recognizes commitment and suc-
arrhythmia without invasive surgery. Sparrow is one cess in ensuring that stroke patients receive the
of the few hospitals nationwide with access to the most appropriate treatment according to nationally
technology. recognized, research-based guidelines based on the
With more than one million people globally receiving latest scientific evidence.
pacemakers annually, the new technology has the
potential to revolutionize how patients are treated — Stroke is the number five cause of death and a lead-
and how they recover. At less than 10 percent the ing cause of adult disability in the United States. On
size of a traditional pacemaker, the new leadless average, someone in the United States suffers a
device is implanted using a catheter procedure that stroke every 40 seconds, someone dies of a stroke
allows physicians to place the device directly inside every four minutes, and nearly 800,000 people suffer
the heart, without subjecting patients to invasive sur- a new or recurrent stroke each year.
gery or possible complications.
Sparrow cardiologist John Ip, MD, an investigator “We’re thrilled to be recognized by the American
with the Sparrow Clinical Research Institute (SCRI), Heart and American Stroke Associations for our
was one of the first to implant the leadless Nanostim commitment to providing exceptional care for our
device in February 2014. stroke patients,” said Colleen Drolett, RN, BSN,
“Sparrow is a national leader in research and pio- stroke and trauma program manager at McLaren
neering new methods of care, and our work with the Greater Lansing.
new leadless pacemaker is a perfect example of why
it’s important to our patients and our community that “Every second counts when treating a stroke, and
we continue to participate in rigorous, groundbreak- this award is further recognition of our team’s com-
ing work,” Dr. Ip said. “As doctors, we always want to mitment to treating stroke patients as quickly and
give our patients the best care and smoothest recov- safely as possible.”
ery possible. This technology helps us continue to
make strides in both.” To receive the Silver Plus Quality Achievement
Award, hospitals must achieve 85 percent or higher
adherence to all Get With The Guidelines-Stroke
achievement indicators for at least 12 consecutive
months and during the same period achieve 75 per-
cent or higher compliance with five of eight Get With
The Guidelines-Stroke Quality measures. To qualify
for the Target: Stroke Honor Roll, hospitals must
meet quality measures developed to reduce the time
between the patient’s arrival at the hospital and
treatment with tPA.

Developed with the goal to save lives and improve
recovery time, Get With The Guidelines®-S has im-
pacted more than 3 million patients since 2003.


n October 1, Norman Beauchamp, Jr. , MD, “Doctor Beauchamp has a
returned home to become the Dean of the MSU unique understanding and
College of Human Medicine. Born and raised in appreciation of the complex
Saint Johns, he earned an undergraduate degree in mission of the College of
biology and his medical degree from MSU. He then Human Medicine,” said MSU
served a medical residency and fellowship at Johns Provost June Pierce Youatt.
Hopkins University. He joined the faculty there in
1996 and served as vice chairperson for clinical “He understands the impera-
operations and as interim chairperson. tive to support research in
critical areas, to deliver the
In 2002, Doctor Beauchamp joined the Department highest quality preparation for
of Radiology at the University of Washington. During the next generation of physi-
his tenure, he served as president of the UW Physi- cians, and to continue to add value to the communi-
cian Practice, vice chairperson and chairperson of ties in which we are engaged. He aspires for the
the University of Washington Faculty Senate, and college to be a leader in each of these areas and to
medical director of the Seattle/King County Clinic. In expand the contributions it makes to our state, our
addition, he was a professor of neurological surgery students, the profession and the quality of life of
and industrial and systems engineering at UW. those we serve.”

Four research studies conducted during MSUCOM’s and creating a type-specific vaccine, should be uti-
2016 Peru Global Outreach Elective earned awards lized.
from the Bureau of International Osteopathic Medi-
cine (BIOM) during the AOA’s OMED conference in Samantha Ward, 2nd Place
Anaheim, California. Urine Arsenic and MDA Levels in the Adult Popula-
tion of Pataz Peru
George Park, Best Overall, Outreach & Research
The Detrimental Effects of Biomass Sugarcane Samantha collected and tested urine and blood sam-
Burning on Human Airway Epithelial Cells ples from 102 patients from the Pataz province and
found that 93.1 percent of them showed elevated
By looking at cellular-level changes, George and his urine arsenic levels, compared to only 5.3 percent
team studied the link between exposure to particu- of control patients. She concluded that the popula-
late matter and increased incidence of respiratory tion in Pataz has renal impairment due to the high
disease. This collaborative project provides deeper levels of arsenic in the water and would certainly
insight into the cellular and molecular mechanisms benefit from water filtration to prevent further dam-
that lead to respiratory disease. age.

Laura Harding, 1st Place, Research Taylor Dickey, 2nd Place, Outreach
Use of Region-Specific Human Papilloma Virus An Innovative Approach to Improving Water Quality
Serotypes in Improving Cervical Cancer Prevention along the Amazon River Using Biosand Filters
Methods in Peru
Taylor distributed 25 specially designed water filtra-
Laura collected cervical cell samples from across the tion systems to villages in the Loreto region, using
country for DNA analysis. Harding concluded that locally available materials and designed to be simple
the current HPV vaccination alone may not be suffi- to use. She concluded there is still much to be done,
cient to protect against cervical cancer in Peru, and including further education on the importance of safe
that additional strategies, such as early screening drinking water.

ichigan is experiencing a growing problem with prescrip-
tion drug abuse and overdose related deaths. The
number of drug overdose deaths – a majority of which are
from prescription drugs – has tripled since 1999. Most of these
are due to prescription opioids and heroin.

According to a 2014 report from the Michigan Department of
Community Health, Michigan has experienced a four-fold
increase in unintentional fatal drug poisonings since 1999.
Overall, 4,772 Michigan residents died from 2009 to 2012 due
to unintentional or undetermined intent poisonings. Of these
overdose deaths, 19.4% were definitively opioid-related, more
than any other category of drugs.

Last October, a task force led by Michigan Lt. Governor Brian Calley gave recommendations to address the

Under prevention, they recommended additional training for all professionals who will be prescribing con-
trolled substances; strong relationships among state and local agencies; more prescription drop-off bins; and
determining the best route forward to eliminate doctor and pharmacy shopping. They also recommended a
multifaceted public awareness campaign.

Under treatment, the task force recommended allowing pharmacists to dispense Naloxone to the public; in-
creased public awareness of Good Samaritan for administering Naloxone; possible limited statutory immunity
for low-level offenses involved in reporting an overdose and seeking medical assistance; and increased ac-
cess to care by increasing the number of addiction specialists practicing in Michigan. In addition, they recom-
mended additional training for law enforcement in the area of recognizing and dealing with addiction; expan-
sion of treatment courts; and requiring a bona-fide physician-patient relationship prior to prescribing controlled

Finally, under regulation, they recommended legislation to better define and identify pain management prac-
tice for the purposes of licensing; updating regulations to delineate licensing for clinics based on the popula-
tion being treated; exempting pharmacists from civil liability when they act in good faith and have reasonable
doubt regarding prescription authenticity or belief that the prescription is being filled for non-medical purpos-
es; and developing best practices regarding the use of opioid analgesics with a focus on providing pain relief
that is appropriate and safe for the illness being treated.

As physicians, we cannot ignore the elephant in the room. Whenever a drug related incident occurs, attention
is drawn towards the physicians who prescribe the medications and the good intentions to treat the patient
are questioned. While some physicians are at a dilemma whether to prescribe or not, some have taken a
stand to not prescribe opioids at all. Such decisions have placed a burden on other physicians who are
obliged to take over the prescriptions of patients who indeed genuinely need the medications.

(continued next page)


n mid-September, the House Health Policy Unfortunately, the bill’s backers rammed SB 1019
Committee reported out HB 5400, a bill that would through another earlier this summer after only a few
safely expand the scope of advanced practice nurs- minutes of testimony. It was then quickly passed by
es as part of a physician-led team. Physician leaders the Senate with the support of the Michigan Associa-
worked closely with state legislators on the bill that tion of Nurse Anesthetists and Michigan Hospital As-
would amend the public health code would, among sociation, with only organized medicine standing on
other changes, allow advanced practice nurses to the side of physicians- and only organized medicine
prescribe a nonscheduled prescription drug. Howev- still fighting to see that this dangerous legislation
er, physician delegation is still required for prescrip- does not pass the House well.
tions of controlled substances included in Schedules
two to five of Part 72. It’s a tale of two bills that perfectly illustrates the con-
tinued importance of organized medicine. With the
This will improve access to care by allowing APRNs unified voice of physicians, patient access can be
to assume more duties as part of a physician-led safely expanded within the state. Without united
team without sacrificing patient safety by allowing voices of physicians, anesthesiologists may be the
them to practice outside of the scope of their educa- first of many physicians to be supplanted by non-
tion. physicians in caring for patients.

Compare that bill with SB 1019, dangerous legisla- What: Senate Bill 1019
tion that would remove physician anesthesiologists
from doctors’ offices and operating rooms across Where: House Health Policy
Michigan, and end physician supervision of anesthe- Committee
sia care. Originally introduced as SB 320, the bill
stalled in the Senate Health Policy committee after Committee Member:
physician leaders demonstrated again and again to Tom Cochran (D-67)
committee members how dangerous the legislation
really is.

Preventing Opioid Abuse (cont.)

With updated knowledge of the problem and enforcing prevention strate-
gies, physicians can be leaders in decreasing the incidence of opioid abuse
and overdose. Patient education and community awareness about the
problems of opioids is an easy initial strategy for prevention of the problem.
Whenever we prescribe opioids (even a short course) we can take an extra
minute to address the proper use and disposal of these medications. Initia-
tion of a patient on chronic opioids should be done with caution. When
maintaining a patient on chronic opioids, routine and random monitoring
with follow up visits, Michigan automated prescription service (MAPS) and
urine drug screening may help identify outliers.

The last week of October was National Red Ribbon week in schools all
over the country. Easy access to opioid medications in young kids serve as
a gateway for them to abuse other illegal substances. What has gone
unrecognized for the last many years has come to the limelight now. With
aggressive education, awareness campaigns, vigilance with prescriptions
and treatment of individuals who succumbed to this problem, we can
hopefully prevent opioid related overdose deaths in the future.

120 West Saginaw Street | East Lansing, Michigan 48823
517-337-1351 | [email protected] |

Application Code: MEMBStaEteRanSdHCouInPty AMePdiPcalLSoIcCieAtyTION
Join MSMS and your County Medical Society online at
m I am in my first year of practice post-residency. m I work 20 hours or less per week.
m I am in my second year of practice post-residency. m I am currently in active military duty.
m I am in my third year of practice post-residency. m I am in full, active practice.
m I have moved into Michigan; this is my first year practicing in the state. m I am a resident/fellow.

m Male m Female County Medical Society Use Only
First (legal) Name:_________________ Middle Name: ____________ Last Name: _________________________ m MD m DO
Nickname or Preferred Form of Legal Name: _______________________________ Maiden Name (if applicable)__________________ Reviewed and Approved by:
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Home Address m Preferred Mail m Preferred Bill m Preferred Mail and Bill
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*Please base my county medical society membership on the county of my (if addresses are in different counties): m Office Address m Home Address
*Birth Date: ____ / ____ / ____ Birth Country________________ MI Medical License #: _________________ ME #: ____________
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Marital Status: m Single m Married m Divorced Spouse’s First Name: ________________ Spouse’s Last Name: ________________
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Within the last five years, have you been convicted of a felony crime?: m Yes m No If“yes,”please provide full information:_____________
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If“yes,”please provide full information:______________________________________________________________________

I agree to support the County Medical Society Constitution and Bylaws, the Michigan State Medical Society Constitution and Bylaws, and the Principles of
Ethics of the American Medical Association as applied by the AMA and the MSMS Judicial Commission.
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