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Association Announces New Online, OnDemand Education Center

Association Announces New Online, OnDemand Education Center

Did you know that as a member of the Medical Association, you have access to our new online, OnDemand Education Center? Featured are seven Alabama Opioid Prescribing courses that meet the Alabama Board of Medical Examiner requirements for holders of an ASCS and are FREE to Medical Association members.

The Medical Association’s new OnDemand Education Center is easily accessed through our website, www.alamedical.org/onlinecme. Simply sign in using your Medical Association username and password and add course(s) to your shopping cart.

“We joined this partnership as a way to bring our members the best educational courses available at the click of a button,” said Executive Director Mark Jackson. “Being a physician is a lifelong learning experience, and we wanted to deliver that opportunity in the easiest, most affordable way possible to Alabama’s physicians and other health care providers. This program was designed for physicians who are busy and have little time to spare but who want to continue expanding their educational prospects to the best of their abilities. Our new online, OnDemand learning experience provides an exciting venue to learn from our own courses in the catalog as well as from others across the country.”

Included in the OnDemand package are the seven Alabama Opioid Prescribing Courses, which meet the CME requirements for the Alabama Board of Medical Examiners:

  • Mitigating Risk When Prescribing Opioids
  • Resist the Opioid Pendulum: Understanding Opioids and Pain and How They Relate to Addiction
  • Use and Misuse of Benzodiazepines
  • Fighting the Opioid Crisis: The Prescription Drug Monitoring Program (PDMP)
  • Basic Principles and Advanced Concepts in Pain Management
  • CDC Guidelines for Prescribing Opioids for Chronic Pain
  • Issues from the Alabama Board of Medical Examiners

OnDemand courses are contributed not only by the Medical Association but also other medical associations and societies across the country. Categories currently include:

Addiction
Alabama Opioid Prescribing
Prescribing
Specialty-specific Topics
Billing and Coding
Ethics
Family Medicine
HIPAA
ICD-10
Internal Medicine
Legal
Medical Staff Leadership
Medico-Legal
Obesity

Opioid Prescribing
Pain Management
Patient Safety
Physician Health
Practice Management
Primary Care
Public Health
Regulatory and Compliance
Risk Management
Substance Abuse
Technology
Tobacco
Women’s Health

Click here to go to the OnDemand Education Center. Log in using your Medical Association username and password. For more information about the new OnDemand Education Center, contact the Education Department at (800) 239-6272.

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Stay Safe During Hurricane Michael

Stay Safe During Hurricane Michael

As Hurricane Michael takes aim at Alabama, all families in affected areas should take health and safety precautions in connection with tropical storm force winds associated with the storm. Listen and follow all health and safety warnings communicated through the news media, and below are some tips to stay safe during the next few days.

Food Safety

Power outages associated with tropical storm force winds can cause concerns about the safety of frozen and refrigerated foods. As a general rule, a full upright or chest freezer will keep foods frozen for about two days without power.

A partially full freezer will keep foods frozen for about one day. This time may be extended by keeping the door shut. A refrigerator will keep foods cool for four to six hours if the door is kept closed as much as possible.

Any thawed foods that have been at room temperature for more than two hours should be discarded. Foods still containing ice crystals can be refrozen, although the quality of the food may decrease. Foods that have thawed to refrigerator temperatures (that is, no more than 40 degrees Fahrenheit) can also be cooked and then refrozen.

Carbon Monoxide

The public should never use generators, grills, camp stoves or other gasoline, propane, natural gas, or charcoal-burning devices inside a home, basement, garage or camper–or even outside near an open window. Keep these devices at least 20 feet away from any door, window or vent and also use a battery-operated or battery back-up carbon monoxide (CO) detector any time you use one of these devices.

CO is an odorless, colorless gas that can cause sudden illness and death if breathed. When power outages occur during emergencies such as hurricanes, people often try to use alternative sources of fuel or electricity for heating, cooling or cooking. CO from these sources can build up in a home, garage or camper and poison the people and animals inside. Look to friends or a community shelter for help. If you must use an alternative source of fuel or electricity, be sure to use it only outside and away from open windows.

Exposure to carbon monoxide can cause loss of consciousness and death. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain and confusion. People who are sleeping or who have been drinking alcohol can die from CO poisoning before ever having symptoms. Consult a health care professional right away if these symptoms occur.

Important Tips

  • Never use a charcoal grill, hibachi, lantern or portable camping stove inside a home, tent or camper.
  • Never run a generator, pressure washer or any gasoline-powered engine inside a basement, garage or other enclosed structure, even if the doors or windows are open, unless the equipment is professionally installed and vented. Keep vents and flues free of debris, especially if winds are high. Flying debris can block ventilation lines.
  • Always set up a generator at least 20 feet from your home, doors, windows, and vents. Follow the advice linked here:
    a. English:https://www.cdc.gov/co/pdfs/generators.pdf
    b. Spanish:https://www.cdc.gov/co/pdfs/flyers_Spanish.pdf
  • Never run a motor vehicle, generator, pressure washer or any gasoline-powered engine outside an open window or door where exhaust can vent into an enclosed area.
  • Never leave the motor running in a vehicle parked in an enclosed or partially enclosed space, such as a  closed garage.

Animals

Stray animals can pose a danger during a storm. Most animals are disoriented and displaced, so do not corner an animal. Certain animals may carry rabies; therefore, care should be taken to avoid contact with strays. Although rabies is rare, it may be transmitted in Alabama by foxes, bats, raccoons or rarely other animals.  If you are bitten by an animal, seek immediate medical attention as soon as possible. If an animal must be removed, contact your local animal control authorities.

Injury Prevention

The public should follow these safeguards against injury while using a chain saw:

  • Operate, adjust and maintain the saw according to manufacturer’s instructions provided in the manual accompanying the chain saw.
  • Properly sharpen chain saw blades and properly lubricate the blade with bar and chain oil. Additionally, the operator should periodically check and adjust the tension of the chain saw blade to ensure good cutting action.
  • Choose the proper size of chain saw to match the job, and include safety features such as a chain brake, front and rear hand guards, stop switch, chain catcher and spark arrester.
  • Wear the appropriate protective equipment, including hard hat, safety glasses, hearing protection, heavy work gloves, cut-resistant leg wear (chain saw chaps) that extend from the waist to the top of the foot, and boots which cover the ankle.
  • Avoid contact with power lines until the lines are verified as being de-energized.
  • Always cut at waist level or below to ensure that you maintain secure control over the chain saw.
  • Bystanders or coworkers should remain at least two tree lengths (at least 150 feet) away from anyone felling a tree and at least 30 feet from anyone operating a chain saw to remove limbs or cut a fallen tree.
  • If injury occurs, apply direct pressure over site(s) of heavy bleeding; this act may save lives.

For Downed Power Lines

If power lines are lying on the ground or dangling near the ground, do not touch the lines. Notify your utility company as soon as possible that lines have been damaged, or that the power lines are down, but do not attempt to move or repair the power lines.

Avoid driving through standing water if downed power lines are in the water. If a power line falls across your vehicle while you are driving, continue to drive away from the line. If the engine stalls, do not turn off the ignition. Stay in your vehicle and wait for emergency personnel. Do not allow anyone other than emergency personnel to approach your vehicle.

For more information on hurricane safety, please visit www.alabamapublichealth.gov.

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Navigate the New Medicare ID Transition in 9 Steps

Navigate the New Medicare ID Transition in 9 Steps

Due to a legislative mandate in MACRA passed in 2015, Medicare will no longer use social security numbers to identify individuals. Instead, a new randomly generated Medicare Beneficiary Identifier (MBI) will be assigned to all 58 million Medicare recipients. New Medicare ID cards containing the MBI are currently being sent to recipients.

“It is a big change,” said Phillip Allen, billing service manager with MediSYS. “MACRA requires that social security numbers be removed to protect beneficiaries from social security number theft, identity theft, and illegal use of benefits.” Which is why the gender and signature line will not be printed on the new Medicare cards either.

The MBI replaces the Health Insurance Claim Number (HICN) used for Medicare transactions like billing, eligibility status, and claim status. Whereas the HICN started with the 10-digit social security number and ended with a letter or two designating a policy type, the 11-digit MBI will contain both letters and numbers throughout.

The transition to these new cards is a big step for patients as well as providers. “All providers, vendors, and other stakeholders must be ready to accept, receive, and transmit the new MBI  … particularly for the new beneficiaries coming into the program,” said Monica Kay, acting director of the CMS division of program management.

Here are nine steps your practice should take to ease the transition and avoid payment delays:

  • Educate practice staff about the rollout of the new Medicare cards with the new MBIs.
  • Contact practice-management system vendors about what system changes need to be made to accommodate the MBIs.
  • Alert your Medicare patients that they will be receiving new Medicare cards with their new MBIs.
  • Remind Medicare patients to confirm that the Social Security Administration has their correct address on file to ensure that they receive their new Medicare cards.
  • Tell Medicare patients to bring their new Medicare cards to their next appointment after they receive it.
  • Begin using the new MBI in Medicare transactions as soon as it is available for the patient.
  • Monitor eligibility responses for messages that indicate the patient was mailed a new Medicare card.
  • Starting Oct. 1, 2018, monitor remittance advices for messages that provide the patient’s MBI.
  • Sign up for the MBI look-up tool via your regional MAC portal.

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ALBME Names New Executive Director

ALBME Names New Executive Director

Norris Green was recently named executive director of the Alabama Board of Medical Examiners. Green originally joined the ALBME in July 2015 as the associate executive director and was officially named director following the retirement of Larry Dixon in December 2016.

Prior to coming to the ALBME, Green worked for 39 years with the Alabama Legislative Fiscal Office and served as its director for his last four years with the organization.

“Since joining the ALBME, I’ve enjoyed working with our staff members and getting to know Alabama’s physicians who serve as members of the board,” Green said. “We are all working together to shape our state’s health care future. This can be challenging, yet very rewarding work, and I’m excited about continuing to move Alabama forward in our changing health care climate.”

Green has a Bachelor’s degree in Business Administration from Auburn University, a Juris Doctor degree from Jones School of Law, and is a member of the Alabama State Bar. During his career, he received recognition by the National Association for Legislative Fiscal Offices for outstanding contributions to the Alabama Legislature as well as recognition of the fiscal office by the Center on Budget and Policy Priorities as a model legislative agency.

“The Medical Association is excited to work with Norris and continue our strong relationship with the ALBME,” said Association Executive Director Mark Jackson. “His ability to work with complex issues with his experience of the inner workings of state government will be a tremendous asset to our physicians.”

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Alabama Power Warns of Power Scam

Alabama Power Warns of Power Scam

*Editor’s note: After being contacted by several physicians, we contacted Alabama Power for additional information concerning the resurgence of an old scam.

The Medical Association is joining Alabama Power to warn customers about a new wave of an old scam.

In this instance, scammers call from toll-free numbers claiming that the customer’s account is past due and the customer’s service will be discontinued if the customer does not make a payment.

The number features a recording claiming to be Alabama Power; however it is not. Alabama Power does not conduct business in this manner.

If receiving a call, do not rely on caller ID, as thieves alter the number on those devices to appear local, or even display “Alabama Power” or “Customer Service.”

Customers who receive suspicious calls are encouraged to hang up, and report it to law enforcement. The next call should be to your utility company’s billing department to confirm your account status and alert them of the scam.

Over the past few years, scammers targeting both residential and commercial customers have become more sophisticated in their tactics, including:

  • Calling from a local number posing as an Alabama Power technician threatening to disconnect service if a payment was not made immediately with a “money pack” or prepaid card – an untraceable disposable debit card. The scammers ask customers to buy a prepaid card from a local retailer (such as Walmart, CVS or Walgreens).
  • Using a number with “Alabama Power” appearing on the caller ID asking for immediate payment by money pack or prepaid card. The customer is then directed to call a different number with an answering machine that says “This is Alabama Power” and leave the prepaid card information.
  • Going to customers’ homes impersonating Alabama Power employees offering to reduce energy bills by conducting an energy audit. The fake employee offers to immediately credit the account by accepting a cash payment on the spot.
  • Targeting customers in chat rooms posing as employees of companies or organizations that help pay bills for disadvantaged families.
  • Going door to door and posing as clergy telling customers they are assisting people with paying their energy bills and asking for a prepaid card.

Most scams seem obvious after the fact, but scammers are smart and know they do not need to make sense; they just need to scare the intended victim. Their goal is to make the victims believe they are in trouble and that the scammers are the only ones who can help. This type of emotional manipulation is easy when it comes to a vital service such as electricity that customers depend on.

“If someone calls and says your electricity is being turned off unless you make an immediate payment, we urge customers to hang up and call their local authorities,” said Security Manager Scott Stover. “These are crimes that should be reported to law enforcement.”

Stover said after notifying local authorities, a customer’s next call should be to the Alabama Power customer service line to confirm their account status and alert the company of the scam.

“Due to the variety of scams, it is important our customers know the ways in which we conduct business so they can spot a scam and report it to authorities and to us,” Bellamy said.

How to protect yourself

Alabama Power customers should remember:

  • Alabama Power employees will never come to your door and demand an immediate payment.
  • No employee will ever call and ask you for bank information or a credit card number.
  • Any Alabama Power employee who comes to your door for any reason will have company identification that he or she will gladly show. If you have any questions about whether the person works for Alabama Power, call 1-888-430-5787 and do not let the person inside your home until you receive proper verification.
  • Scammers sometimes claim they represent a public agency or government office offering grants that can pay your Alabama Power or other utility bill. Never provide anyone making this claim your credit card information, your Alabama Power Company bill information or account number, or any personal banking information. If someone makes this claim, call Alabama Power or your local police department to report it.

If you ever have any question about the status of your Alabama Power account, do not hesitate to call the company. You can reach Alabama Power Customer Service day or night, seven days a week, at 1-888-430-5787.

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Larry Dixon to Retire as Executive Director of the Alabama Board of Medical Examiners

Larry Dixon to Retire as Executive Director of the Alabama Board of Medical Examiners

MONTGOMERY – After serving as executive director of the Alabama Board of Medical Examiners for more than 35 years, Larry Dixon has announced his retirement at the end of the year.

“We are like family here,” Dixon said. “It has been my privilege to serve Alabama’s physicians and our staff because we are so much like family. We’ve been a part of each other’s lives for so many years, and I’m going to miss that. We’ve done great things together, but I know there are still great things to come.”

Dixon brought his experience with continuing education to the Medical Association of the State of Alabama in 1972 and established the Association’s education department, which has continued to flourish by producing original continuing medical education programs for Alabama’s physicians, as well as nurse practitioners and certified registered nurse practitioners.

“The Medical Association has one of the strongest education departments in the country due largely to the foundation on which it was given when Larry Dixon created it,” said Medical Association Executive Director Mark Jackson. “Since then, he has been the driving force behind the ALBME and making the organization one of the best in the nation year after year. He put his stamp of excellence on both organizations, and we are equally better for it.”

Dixon served four terms on the U.S. Federation of State Medical Boards and was the first president of the Administrators in Medicine, an organization he helped charter. He has also served on committees of both AIM and FSMB. In 2009 he received the Meritorious Service Award from FSMB, and in 2014 FSMB awarded him the Lifetime Achievement Award. He was inducted into the Alabama Healthcare Hall of Fame in 2016, and also earlier this year, the Medical Association honored him by renaming the building that houses the Alabama Board of Medical Examiners to the Dixon-Parker Building.

During the years, Dixon has watched as downtown Montgomery has grown up outside his office window, both figuratively and literally. After serving a term on the Montgomery City Council in 1975 to 1978, he was elected to the Alabama House of Representatives. In 2010 Dixon retired after serving seven terms in the Alabama Legislature – four years in the Alabama House of Representatives before being elected to the Alabama Senate.

His many accomplishments include being a member of the board of directors of the Montgomery Airport Authority; board member of the finance committee and past member of the administrative board of First United Methodist Church; charter member of the Certified Medical Board Executives; member of the advisory committee of the Prescription Drug Monitoring Program; and member of the board of directors of the FSMB Research and Education Foundation.

 

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Changing Health Care Delivery: Concierge Model Takes Hold

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Editor’s Note: This article was originally published in the Inaugural Issue of Alabama Medicine magazine

Time. In today’s crazy world, we seem to have so little of it. Who couldn’t use a few more hours to spend with family and friends hanging out on the weekends? Or a few more hours during the day to check off a couple of items on that to-do list?For physicians and patients alike, time is a precious commodity. Patients find it more and more difficult to take time off work when they feel they need their physician, and physicians’ offices are filled to the brim with patients sometimes waiting hours on end due to overbooking issues having caused massive wait times in the waiting room.

For physicians and patients alike, time is a precious commodity. Patients find it more and more difficult to take time off work when they feel they need their physician, and physicians’ offices are filled to the brim with patients sometimes waiting hours on end due to overbooking issues having caused massive wait times in the waiting room.“I felt as though I was falling short as a physician,” said Dr. Mary Casals of Montgomery. “I couldn’t treat the whole patient the way I wanted to, the way I felt my patients deserved to be treated. But, now I can.”

“I felt as though I was falling short as a physician,” said Dr. Mary Casals of Montgomery. “I couldn’t treat the whole patient the way I wanted to, the way I felt my patients deserved to be treated. But, now I can.”

Dr. Casals, who practices internal medicine and endocrinology, found a way to deliver what she believes is better care to her patients and still find time in her day to spend with family. It’s called concierge medicine, or private medicine. While she’s not the first physician in Alabama to change to this business model, she is the first in Montgomery.

According to the American Academy of Private Physicians, concierge medicine has been around for more than 20 years. A concierge physician delivers patients a higher attention of service, which includes same-day or next-day appointments, 24/7 access and comprehensive wellness plans. This type of attention to patient care comes with a fee, either called a membership fee or retainer, set by the physician.

The AAPP estimates the average patient load a primary care physician carries today is between 2,000 and 4,000 patients, about 25 or more patients a day with appointments limited to 15 minutes or less. With this schedule, patients have little time to ask questions and physicians have less time to educate their patients. This can leave very little room for patients and physicians to develop the trust necessary for a strong relationship, and patients often leave feeling frustrated at what little time they had to spend with their doctor.

While concierge physicians were considered an elite service for the upper class in the early years of the model, these days concierge medicine can be an affordable way families can receive health care on their own terms.

“Education is a large part of the doctor-patient process,” Dr. Casals said. “I wear a lot of hats – counselor, physician, teacher. But it takes time to understand what’s going on with my patients and time also to educate my patients on their disorders. I had to make a change. It wasn’t an easy decision because I knew not all of my patients would make the change with me, but I knew it would be for the best for everyone.”

For Dr. Casals, the change from traditional fee-for-service to concierge medicine began with town hall meetings with her patients to explain what the new model would offer. The initiation fee gives her patients full-time access to her by email and cell phone, nights and weekends as well. They can make appointments easier, or she will visit them at home if necessary. Her patients are responsible for filing their insurance paperwork, but her office does have someone to lend a hand with the claims.

“I didn’t realize just how many patients I had been treating until we held the town hall meetings!” Dr. Casals laughed. “There were a lot of patients! We were surprised at how many decided to come on this journey with us. We wanted to make sure it was well worth the change for those patients, too.”

Aside from the name, Dr. Casals said there were many misconceptions with concierge medicine. First, she said, the name harkens back to a time when the practice of this type of medicine was mostly for the upper class. Second, there’s a feeling that if a physician is dropping patients, then patient care is being affected as well.

Dr. Casals and Dr. David Fernandez of Northport agreed neither tale is true.

Dr. Fernandez, who spent the last 15 years of his career in urgent care, not only felt he needed to offer his patients more options, but he also didn’t like the path he saw medicine itself beginning to take. So, he decided it was time for a change.

“I’ve always felt like I needed more time to discuss my patients’ needs and to see them on a more frequent basis,” Dr. Fernandez explained. “And, my patients felt it was an inconvenience to find the time to make an appointment in an already packed schedule. If we’re trying to get patients back to where they’re taking better care of themselves, how do we do that if we as physicians can’t make the time to properly explain each patient’s situation? The medical system is becoming too impersonal.”

As both physicians began to change the way they practiced medicine, it gave them the opportunity to reboot their practice and provide care the way today’s patient needed – including wellness support, education and preventive medicine. In fact, both physicians feel they have added more services to their concierge clients under the private medicine model than they could have under the traditional fee-for-service they left behind.

For patients, the concierge model might fit a family’s budget better than a traditional deductible. For example, if a family has a higher deductible health plan with a lower premium, having a concierge physician may help them save money.

“We are a society of instant gratification,” said Dr. Fernandez. “Back when my father was practicing, it was easier to see a doctor. Times have changed. There’s more paperwork and more patients today. Making the switch to concierge medicine isn’t an easy decision to make, but I think we will see a lot more concierge physicians in the future.”

Article by Lori M. Quiller, APR, director of communications and social media

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Rural Medicine at a Crossroads

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Editor’s Note: This article was originally published in the Fall 2015 issue of Alabama Medicine magazine

Part 1 – Feeling the Physician Shortage Pinch

Living in a small town means everyone knows everyone, a tip of the hat speaks volumes, and the nearest neighbor may be a mile down the road. Physicians in these communities are often called upon for a variety of reasons from treating flu and pneumonia, to setting broken bones, to delivering babies. Oftentimes, today’s rural physician is a jack of all trades.

There are many challenges to living in an area that may only have one grocery store or gas station. But, when it comes to the health of Alabama’s residents, many rural counties are further struggling with access to proper health care. As older physicians retire, they leave behind shoes that are tough to fill as fewer young doctors are willing to practice medicine in rural areas.

With Alabama’s rural health care at a crossroads, where do we go next?

Alabama’s 5 million residents routinely struggle with some form of access to health care. Whether it’s finding a specialist or one in primary care, there simply are not enough physicians in Alabama, especially in rural areas…and the shortage is projected to only get worse.

“Already having a relative shortage of physicians compared to urban areas, the trend, which is more pronounced in rural areas, of an increasing proportion of the population who are elderly, has increased the need for rural physicians,” said John Wheat, M.D., professor of community and rural medicine at the University of Alabama’s College of Community Health Sciences and School of Medicine and director of the Rural Medical Scholars Program at the University of Alabama School of Medicine.

Sixty-two of Alabama’s 67 counties have been designated as whole or partial health professions shortage areas, or HPSAs, in which there are not enough physicians to meet the needs of the population. Eight counties have seen their hospitals close, and others are fighting to keep their doors open.

In addition to an older population as compared to urban areas, Medicaid is the primary source of insurance in these rural areas. One-in-four rural residents is eligible for Medicaid benefits, about 10 percent higher than in urban areas. There are many uninsured Alabamians in rural areas who, despite their lack of insurance, still have health care needs.

The shortage of physicians is compounded by the number of older doctors who will retire in the next few years with relatively few young physicians in the pipeline to take their place. This was one of the main reasons the Medical Association worked to pass the Interstate Medical Licensure Compact earlier this year.

“The Compact will allow board-certified doctors with clean records a much faster path to medical licensure in Alabama,” said Buddy Smith, M.D., president of the Medical Association, and a family physician from Lineville. “We want to be able to recruit and attract quality physicians and have them begin treating patients immediately.”

Part 2 – Life in a Small Town

The waiting rooms were packed with nearly every seat occupied on this day as most days for David Arnold, M.D., and Dale Mitchum, M.D. Dr. Arnold, a family physician, and Dr. Mitchum, a general surgeon, work in Geneva County where the population is around 27,000. Dr. Arnold is one of a handful of family physicians in the county, but Dr. Mitchum is the only general surgeon.

Life here moves at a slower pace, with shopping and dining opportunities limited. The challenges of a rural lifestyle require Drs. Arnold and Mitchum to approach their patients and practices in unique ways.

As a family physician of more than 30 years, there’s not much Dr. Arnold hasn’t seen, so he and his staff make sure there is time in their busy schedule during the day for unexpected events that “pop up,” such as cases of sick children or elderly patients or even broken bones.

“Most of my staff have been with me for at least 15 years. We’ve learned to anticipate each other, so our teamwork is exceptional. We wouldn’t be able to see as many patients as we do if we didn’t work so well together,” Dr. Arnold said.

For Dr. Mitchum as the county’s only surgeon, the physician shortage isn’t unique to Alabama. He also treats patients in nearby Bonifay, Fla., and sees how a shortage of physicians anywhere can strain a community’s health care system. As many physicians that have come from his home county of Geneva, he’s seen them leave for a host of reasons to practice elsewhere. Those who stay tend to do so because of family connections.

“It’s hard work,” Dr. Mitchum said. “If you have a relative who is going into medicine who can look to you as a mentor, they can acclimate to the situation. It’s really a nice place to live, but you have to acclimate to the day-to-day slower style of living. It can be culture shock if you’re not used to it.”

Dr. Mitchum understands firsthand about coming back home to take over the family practice. His father, O.D. Mitchum, M.D., was a long-time family physician in Geneva when his son worked as an orderly in the local hospital. After medical school and residency, he came home to stay and eventually practiced with his father for about 20 years before the elder Mitchum retired.

For Dr. Arnold, it was his intention all along to practice rural medicine. The pull of small-town life and the close relationships that often develop between rural physicians and their patients was enough to bring Dr. Arnold to the City of Geneva.

“Now I’m seeing the children I delivered back in the day that have grown up and have children of their own,” Dr. Arnold said. “In these rural counties, the patients are so spread out. Staying in touch with our patients presents its own challenges. I can’t say that we don’t have our own special challenges.”

It’s those “special challenges” and a shrinking number of physicians dealing with them that makes provision of rural health care so different. This is especially true in primary care, where there are fewer students in medical schools across the country choosing primary care as a focus or willing to practice in areas that are designated health profession shortage areas, or HPSAs.

Another challenge for the rural physician, Dr. Mitchum said, comes when a patient needs a specialist. According to him, rural physicians have to deal with all types of problems out of necessity.

“I’m not saying rural physicians are any better at those jobs than physicians in other places, but we deal with those types of things every day. A family physician in a rural setting requires more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times and do more with less.”

As Dr. Arnold explained, one of his biggest concerns may be access to care, but that’s just the tip of the iceberg. Geneva County has a hospital that’s connected to a nursing home, and he and Dr. Mitchum see patients at both facilities. In addition to the special challenges rural medicine faces, these physicians also have the same burdens of federal regulations to deal with, such as ICD-10, electronic health records, Meaningful Use, etc.

“After seeing patients all day, the next biggest challenge for me is keeping the chart gods happy,” Dr. Arnold said. “Making sure the charting is complete is a huge part of my time when the software required by government regulations will only do so much. The rest is up to me to make sure what goes into the chart is correct.”

Both Drs. Arnold and Mitchum own their practices, and they bear the burden of financing these federal mandates on their own. While these are certainly not easily absorbed by any practice, solo practitioners have an even more difficult time with such expenses. With the current transition to ICD-10, questions remain about reimbursement, delays in payment, and other mandates yet to come.

All three physicians agreed the outlook for rural medicine could be and needs to be improved. The belief that it’s cheaper to practice in a small town is a misconception, they said.

Steven P. Furr, M.D., former president of the Medical Association, and a family practitioner from Jackson, Ala., agreed the regulatory burdens on rural physicians make it more difficult to sustain a medical practice. In fact, Dr. Furr argues the time physicians take to satisfy these federal regulations from Meaningful Use to maintenance of certification to ICD-10, as well as the quality initiatives by insurance companies, negatively affect patient care by overwhelming the physician and staff.

“All physicians are facing these problems, but in rural areas there’s often the lack of staff and training resources to help them migrate through these minefields,” Dr. Furr said.

Physicians enduring the “normal” challenges of practicing medicine and also the special challenges of providing rural care are tremendous assets to the communities they serve.

Dr. Smith stressed that physicians are uniquely situated to help improve both health and the economy, but for rural communities in particular, attracting and keeping them is key.

“When you realize the economic footprint of just one physician is more than $1 million, that’s huge for a small town,” Dr. Smith said. “If you can attract one or two doctors to a rural area, the health and financial benefits to the surrounding area are tremendous.”

Part 3 – From School to Practice…The Making of a Rural Physician

The shortage of physicians is a national problem, and Alabama’s rural communities are certainly feeling the pinch.

According to Allen Perkins, M.D., MPH, professor and chair, Department of Family Medicine, University of South Alabama, one contributing factor for the physician shortage in Alabama could be that medical schools cannot keep up with the health care needs of the state.

“It is clear the overwhelming majority of the medical students come from the urban counties yet the average age of our rural physicians is over age 55. We have an acute lack of mental health services in rural Alabama and yet not training professionals in rural settings,” Dr. Perkins explained.

While not a cure-all for Alabama’s rural health crisis, more physicians is a good thing, and programs to increase the number of physicians in rural areas like the Rural Medical Scholars Program (RMSP) at the University of Alabama’s College of Community Health Sciences and the Board of Medical Scholarship Awards (BMSA) are part of the solution.

RMSP is a highly selective pre-med and medical education program allowing 10 qualified students annually to take graduate level courses, participate in farm field trips, shadow rural physicians, conduct or assist with health fairs and screenings or other community service projects and attend lectures and workshops pertaining to rural community health topics. RMSP is one of several rural health care pipelines in Alabama working to put family physicians into rural areas.

Of the nearly 200 rural Alabama students that entered the RMSP during the past 20 years, about 70 percent entered family medicine and almost 60 percent went on to practice in a rural area. More than 90 percent of RMSP graduates remain in Alabama, yet not all remain in primary care, Dr. Wheat said, as some have gone on to other medical specialties.

Drs. Wheat and Perkins also agree the need for greater funding of the BMSA is key to not only attracting young medical students to the field but keeping them on track for a career in family medicine in Alabama.

The BMSA began in the 1960s as a state-funded incentive program to increase the supply of family practice, internal medicine, and pediatric physicians, and encourages practice in Alabama’s rural medically underserved communities. Several hundred loans have been awarded since the BMSA was created. Students who receive the loans agree to return to a pre-approved medically, underserved community to practice primary care.

“The scholarship board needs to be fully funded,” Dr. Perkins said. “Support for the scholarships that place physicians in rural communities is necessary here.”

Dr. Wheat said he feels the medical schools do their part to train the students, but the scholarships also go a long way to getting the students into the schools. He said the Medical Association’s work to keep and increase the amount of scholarship money available each year helps students decide to stay and practice in rural Alabama.

“More than 90 percent of the first 30 RMSs who chose rural practice were recipients of this [BMSA] award,” Dr. Wheat said. “We see this playing out to the benefit of communities. With a bit more effort on the parts of each of our partners, even the most persistently underserved rural areas of the state will see positive results.”

Family physician Terry James, M.D., said the RMS program was invaluable to him. “I might have had to make different arrangements early on in my career,” Dr. James said. “If not for the RMS, I don’t know if we would be addressing the health care shortage in rural areas at all. I think it goes a long way to fill that void.”

Outside of the state’s two allopathic schools – The University of Alabama School of Medicine and The University of South Alabama College of Medicine – the state has two new osteopathic schools, the Alabama College of Osteopathic Medicine (ACOM) in Dothan, and the Edward Via College of Osteopathic Medicine (VCOM) in Auburn.

“For a state the size of Alabama to have four medical schools is a very big deal,” Dr. Smith said. “Graduating more medical students is a piece of the puzzle and we are very glad to have these two new osteopathic schools here in Alabama.”

Osteopathic medicine is fast-growing with the number of D.O.s having increased more than 200 percent in the past 25 years. Estimates indicate there are more than 92,000 D.O.s practicing in the United States and 540 are in Alabama.

ACOM’s first graduating class will be May 2017, and according to Dean and Senior Vice President Craig J. Lenz, D.O., FAODME, expectations are high for these third-year students who are just now finishing their clinical experiences. According to Dr. Lenz, the real test will be to see how many ACOM graduates come back to their rural beginnings.

“Dothan may not seem like a rural area, but from a medical care point of view, we are. It’s primary care; it’s family medicine; it’s general internal medicine…those are the defined specialties where the need here is the greatest,” Dr. Lenz said.

VCOM-Auburn is also getting its footing and hopes are equally high for the school’s first crop of students. VCOM is a private college that is part of the Edward Via College of Osteopathic Medicine system of campuses across the South.

Gary Hill, D.O., VCOM-Auburn’s Associate Dean for Clinical Affairs, believes more D.O.s entering rural medicine can help solve Alabama’s physician shortage.

“Much misconception about osteopathic medicine is a result of lack of exposure to the osteopathic profession and physicians,” Dr. Hill said. “Many of the old arguments have vanished as osteopathic physicians now have complete practice rights in every state and are fully recognized and accepted in the U.S. armed forces.”

Dr. Mitchum said while the need for more physicians in rural areas is immediate, the solutions may take more time.

“We have a real need here,” Dr. Mitchum said. “More funding for scholarships and gearing residency programs for rural health care should be a priority. We require more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times. To do that properly, young physicians need extra training, which means we need better funding for scholarships and opportunities. That begins in the schools.”

Part 4 – Rural Medicine…Medical Association Seeks Solutions

Not just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

In many counties lacking significant industry or large employers, Medicaid is the most common form of insurance. As Medicaid reimbursements barely cover or don’t at all cover the cost of providing that care, rural practices’ ability to keep their doors open seems under constant threat. just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

Alabama has historically offered some of the most meager benefits yet highest qualification thresholds in the nation for its Medicaid program. This leaves many individuals who would otherwise qualify for Medicaid in another state unable to under Alabama’s plan, driving up the rate of uninsured residents, estimated to be close to 750,000 people statewide. But lack of insurance doesn’t stop many rural physicians like Dr. Mitchum from treating a patient even though he must absorb the cost of that treatment entirely, further burdening his practice.

“Every time I hear where we have people without health care, I cringe,” he said. “We do a lot of charity care because we don’t turn away someone in need.”

With higher numbers of uninsured and Medicaid patients in rural areas and with practice visits increasing, Dr. Smith said as far as the Medical Association is concerned, two things the Governor and Legislature could do to improve the outlook for rural medicine are increasing all physicians’ Medicaid payments to Medicare levels and providing Medicaid coverage to the working poor.

“Raising payments rates for Medicaid will cost the state some funds in the short term but should save considerably more over the long term as the anticipated increased access to medical care allows patients’ health to be better managed,” Dr. Smith said. “Untold Medicaid dollars could be saved by preventing costly hospitalizations and long-term care stays whenever possible, in fact that is one of the chief goals of Alabama’s fledgling Regional Care Organization program. The RCOs need enough doctors of all specialties participating so the frequency of those types of costly stays can be mitigated.”

Dr. Smith said the sooner state officials act to address the issue of insurance coverage for the working poor the better.

“Without health insurance, not only are some of these individuals who would qualify for Medicaid suffering but the cost of care provided is borne by the entire health care community,” Dr. Smith said. “It is my hope the Governor and Legislature would work swiftly to tackle this issue.”

While additional funding for scholarships and training, recruiting and attracting more physicians willing to locate in rural areas can go a long way, these alone cannot solve Alabama’s rural health challenges. Dr. Furr said he still believes other incentives are needed to retain physicians in rural areas.

“Whether that is debt service, some type of reduction in income taxes, not just for those who initially come out to practice, but also for those who continue to stay, or perhaps some kind of protection against medical liability for those who practice in underserved areas,” he said.

Delivery of rural medicine is about the ensuring the viability of the people who make up rural communities, Dr. Smith says, mentioning that large employers and economic developers often review an area’s education and health care systems in determining where to next locate a project.

The physicians who call these communities home are vital to rural Alabama’s future, he believes.

“Rural medicine is indeed at a crossroads, but rural communities themselves are as well,” Dr. Smith said.

“What happens in the next several years will determine the fate of ‘country doctors’ and – I think you can say – their patients, too. It’s my sincere hope that we’ll look back in a decade and see the present as just another mile marker, not the end of the road.”

Article by Lori M. Quiller, APR, director of communications and social media

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Between Doctors & Patients…Technology in the Treatment Room

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Editor’s Note: This article was originally published in the Spring 2016 issue of Alabama Medicine magazine

Love them or hate them, electronic records are here to stay.

Electronic health records, or EHRs, are an evolution of the electronic medical records, or EMRs, that some medical practices use internally. EMRs are a digital version of the paper charts containing the medical and treatment history of the patients in one medical practice. EMRs have advantages over paper records in that they allow physicians to track patient data over time, identify which patients are due for preventive screenings and check ups, and monitor overall quality of care within the practice.

EMRs, however, are not built to travel easily outside the medical practice should the physician need to send the patient to another physician. This is where EHRs are intended to pick up and be more effective. EHRs are built to share patient information between medical practices, laboratories, hospitals and other health facilities. Should your patient be seen in the emergency room, EHRs are supposed to allow you to view those charts and results, including all the physician’s notes, labs and any films.

That’s how the system is supposed to operate. While the EHR systems work well for some, mostly larger practices and specialty physicians, they cause more problems than they solve for others, particularly smaller practices and family care physicians.

The surgeons with Alabama Orthopaedic Specialists, PA, in Montgomery, began looking for a solution to their charting issues in 2006, long before federal regulations started to trickle down concerning electronic records. Finding the best solution for the practice didn’t happen
overnight. It was a process, according to practice manager Ron O’Neal.“It took a little while for us to discover exactly what this would mean to the practice…the good and the bad…and it needed to be something everyone was on board with,” O’Neal explained. “It took time for us to come up with a checklist of everything we wanted and needed our EHR to do. It was important we found a system that would work for our practice instead of our practice working for that system, so we took our time.”

“It took a little while for us to discover exactly what this would mean to the practice…the good and the bad…and it needed to be something everyone was on board with,” O’Neal explained. “It took time for us to come up with a checklist of everything we wanted and needed our EHR to do. It was important we found a system that would work for our practice instead of our practice working for that system, so we took our time.”

Michael Davis, M.D., a surgeon with Alabama Orthopaedic Specialists, helped lead the search to find the perfect EHR for the group and agreed with O’Neal that while the search for the best system may have seemed long, it was for a good reason.“Historically we had paper charts. So, when a patient would be seen by one of our physicians yesterday and referred to me today didn’t really have any idea why they were seeing me and would expect me to know why they were here. It would take time for me to collect the paper chart, if everything was there, and sometimes re-interview the patient. That took a lot of time. If you don’t have to filter through all those notes to get to the bottom of the problem when someone else already has, you save a lot of time. You’re not duplicating tests and x-rays, and patients aren’t exposed to more tests or irradiated more than once just because you can’t get your hands on those results,” Dr. Davis said.

“Historically we had paper charts. So, when a patient would be seen by one of our physicians yesterday and referred to me today didn’t really have any idea why they were seeing me and would expect me to know why they were here. It would take time for me to collect the paper chart, if everything was there, and sometimes re-interview the patient. That took a lot of time. If you don’t have to filter through all those notes to get to the bottom of the problem when someone else already has, you save a lot of time. You’re not duplicating tests and x-rays, and patients aren’t exposed to more tests or irradiated more than once just because you can’t get your hands on those results,” Dr. Davis said.For Dr. Davis, having the EHR in hand can make explaining a complicated procedure a bit smoother when the tool can be used to illustrate the nuances of a surgical procedure by showing the patient his or her x-rays, MRIs, and other test results. But, the EHR is just that…a tool, which Dr. Davis is quite mindful of making sure doesn’t become an intrusive object in the treatment room.

For Dr. Davis, having the EHR in hand can make explaining a complicated procedure a bit smoother when the tool can be used to illustrate the nuances of a surgical procedure by showing the patient his or her x-rays, MRIs, and other test results. But, the EHR is just that…a tool, which Dr. Davis is quite mindful of making sure doesn’t become an intrusive object in the treatment room.

Yet, Dr. Davis and O’Neal agreed EHRs work better for specialties than with family practices when considering the diagnostic possibilities family physicians face with their patients. What’s streamlined in a specialty is often wide ranging in family practice.

Maarten Wybenga, M.D., a family physician in Prattville, hasn’t made the switch from paper charts to EHRs and doesn’t have any plans to in the immediate future. For Dr. Wybenga, e-prescribing and electronic billing are sufficient to keep the federal mandates at bay.

“I’m always going to be ‘pro-the-patient.’ I never jump on the bandwagon when something new comes out. I want to read the research, see how it works first before I start using it with my patients. It’s the same with technology in the medical office,” Dr. Wybenga said. “I’ve wanted to stand back and watch it a little rather than jump right in. When things started getting interesting with electronic records, we talked about it. Should we do this, or should we wait and see what’s going to happen? Should we give it a year or two? As we watched the technology arena grow and grow, the software companies exploded. There were just too many offering too much. We keep watching, but I’m just not satisfied, and I haven’t made that decision. To this day, we’re still on handwritten medical records.”

According to Amy Wybenga, Dr. Wybenga’s practice manager and immediate past president of the Alliance to the Medical Association of the State of Alabama, the number of reasons against using EHRs in the practice simply outweighed the positive outcomes.“No one could give us a good, sound reason of what benefit it would be to us or our patients if we changed over. For our practice, the negative reasons definitely outweigh the positive reasons,” Wybenga said. “We would have to cut down on the number of patients we could serve for at least a year because it could take up to that long for us to switch everything over, and it would slow us down too much. Being a family practice in a rural area, there’s just no way we can cut back on the number of patients we see. Those patients have to be seen. Why would we go to a system that would slow us down even more, something that we can’t share with anybody, would still have to print off information to fax or email to other doctors because it won’t communicate with other systems…where’s the benefit?”

“No one could give us a good, sound reason of what benefit it would be to us or our patients if we changed over. For our practice, the negative reasons definitely outweigh the positive reasons,” Wybenga said. “We would have to cut down on the number of patients we could serve for at least a year because it could take up to that long for us to switch everything over, and it would slow us down too much. Being a family practice in a rural area, there’s just no way we can cut back on the number of patients we see. Those patients have to be seen. Why would we go to a system that would slow us down even more, something that we can’t share with anybody, would still have to print off information to fax or email to other doctors because it won’t communicate with other systems…where’s the benefit?”

For one gastroenterologist who just started a new practice in January using paper charts, Bradley Rice, M.D., of Huntsville, who is also a member of the Association’s Board of Censors, is working to make the transition to EHRs a seamless one for his staff and patients. “I actually try to use the computer a small amount of time while in the room with a patient. I talk with the patient and take notes on a sheet I have designed,” Dr. Rice noted. “I prefer to speak with the patient instead of talking to them while looking at a computer, so I wait until the end of the appointment to then work on the computer, then escort them up to the check-out area. My goal is to make sure the patient feels comfortable and understands that I am there to meet with them instead of focusing on the computer in the room.”

“I actually try to use the computer a small amount of time while in the room with a patient. I talk with the patient and take notes on a sheet I have designed,” Dr. Rice noted. “I prefer to speak with the patient instead of talking to them while looking at a computer, so I wait until the end of the appointment to then work on the computer, then escort them up to the check-out area. My goal is to make sure the patient feels comfortable and understands that I am there to meet with them instead of focusing on the computer in the room.”

Dr. Rice and his staff have seen both sides of the EHR coin and agree with Dr. Davis and O’Neal that the initial setup of a system can be difficult and costly. It takes time to scan and input data into a new system, but once the system is online, it can help with documentation and accountability.

Interoperability was one of the initial selling points for EHRs from the Office of the National Coordinator for Health Information Technology. Fully functioning EHRs are designed to “talk” to other systems. However, many physicians are finding this may not be the case, and after years of voicing complaints through their medical societies and associations, their concerns seem to be getting through.

Department of Health and Human Services Secretary Sylvia Burwell recently announced the nation’s top five health care systems and companies, which provide EHRs covering more than 90 percent of hospital patients, have agreed to principles designed to improve patient access to health data and eliminate the practice of data blocking. These groups have also agreed to adopt federally recognized, national interoperability standards by 2018.

To unlock the data and make it useful to physicians, the companies have agreed to:

  • Implement application programming interface (API) technology so smartphone and tablet apps can be created, facilitating patient use and transfer of health care data.
  • Work so physicians can share health data with patients and other physicians whenever permitted by law, while not blocking such sharing either intentionally or unintentionally.
  • Use the federally recognized Fast Healthcare Interoperability Resources data standard.

In late 2015, the Medical Association led a coalition of nearly 40 Alabama specialty and county medical societies in asking to the Alabama Congressional Delegation to support the Patient Access and Medicare Protection Act, which granted the Centers for Medicare & Medicaid Services the authority to expedite applications for hardship exemptions from Meaningful Use Stage 2 requirements for the 2015 calendar year. President Obama signed the bill. Because CMS didn’t publish the MU Stage 2 final rule until Oct. 16, physicians weren’t informed of the requirement until fewer than the 90 required days remained in the calendar year, leaving most in a penalty-assured lurch. CMS extended the deadline for physicians to apply for MU hardship exemptions to EHR incentive program. The new deadline is now July 1, 2016. The extension is being granted “so providers have sufficient time to submit their applications to avoid adjustments to their Medicare payments in 2017.” The new application forms and instructions to file a hardship exemption are on the CMS website.

Because CMS didn’t publish the MU Stage 2 final rule until Oct. 16, physicians weren’t informed of the requirement until fewer than the 90 required days remained in the calendar year, leaving most in a penalty-assured lurch. CMS extended the deadline for physicians to apply for MU hardship exemptions to EHR incentive program. The new deadline is now July 1, 2016. The extension is being granted “so providers have sufficient time to submit their applications to avoid adjustments to their Medicare payments in 2017.” The new application forms and instructions to file a hardship exemption are on the CMS website.

For physicians contemplating switching from paper charts to EHRs, Dr. Rice and his office staff offer these tips:

  1. Always remember, “Treat the patient, not the computer”
  2. Think about the big picture in terms of technology and how the flow and setup will affect the office. For example, how many screens, what type of computers, scanners, etc., should I choose? Who will be using these computers? Laptops vs. desktop computers in treatment rooms? A personal analysis needs to be conducted of what type of layout/format fits your practice.
  3. Choose a good program that has excellent technology support. Make sure to choose the correct computers and equipment necessary for the EHR program that is chosen for your practice.

Article by Lori M. Quiller, APR, director of communications and social media

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Official Statement on Legalization of Non-FDA Approved Marijuana Substances

Official Statement on Legalization of Non-FDA Approved Marijuana Substances

March 18, 2016 – “The use of marijuana for the treatment of various symptoms of diseases is an evolving discussion in this state and nation. Two years ago, the Alabama Legislature wisely decided and the Medical Association supported putting the discussion surrounding the efficacy of cannabidiol (CBD) in the treatment of neurologic conditions in children to the test by establishing and funding a strictly controlled drug trial. The preliminary results of that study indicate promise for more widespread use of CBD in patients. The exact CBD drug itself and dosages administered to patients in this drug trial were strictly regulated to ensure the safety of those involved. As physicians, our Hippocratic Oath demands we ‘first, do no harm.’ As well, the practice of medicine is evidence-based whereby the treatments and procedures we use are extensively researched and tested to make certain they are as safe as possible for the patients under our care. Given these bedrocks of the medical profession, the Medical Association cannot support the expansion or legalization, whether by legislation or ballot initiative, of marijuana or marijuana products in any form that have not received the same FDA approval as other medicinal compounds. Taking any position otherwise would not be based on scientific evidence and could unnecessarily place patients at risk.”

– Buddy Smith, M.D., president, Medical Association of the State of Alabama

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