As suspicion – or acknowledgement – that many cases of opioid use disorder (OUD) were iatrogenic and the opioid crisis grew, both federal and state governmental health agencies sought to develop and issue guidance for physicians. Having been fed misinformation by pharmaceutical companies for years, physicians needed evidence-based guidelines to appropriately treat their non-cancer chronic pain patients. The Centers for Disease Control and Prevention (CDC) responded definitively by issuing guidelines after seeking input from experts and stakeholders and combing through the evidence and responses. In addition, legislatures put strict limitations on prescribing in certain situations. It is clear that compliance with opioid prescribing legislation is mandatory, but what about compliance with guidelines?

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Our country is undeniably becoming the home to an ever-increasing number of individuals from distinct racial and ethnic backgrounds. According to the U.S. Census Bureau, Statistical Abstract of the United States 2001, between 1980 and 2000, while the country’s white population grew by 9%, the African American population increased by 28%, the Native American population increased by 55%, the Hispanic population by 122% and the Asian population grew by more than 190%. The abstract goes on to state that Asians and Native Americans already account for more than half of California’s population. Forty-five percent of Texans self-identify as members of minority groups, as do one in three residents of New York, New Jersey and Florida.

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Opinion

Editorial …………………………..362
Pocket MBA
Deval (Reshma) Paranjpe, MD, FACS

Editorial …………………………..364
A voice of one
Richard H. Daffner, MD, FACR

Editorial …………………………..366
When the music stops
Andrea G. Witlin, DO, PhD

Editorial …………………………..368
‘Generation A’ comes of age
Anthony L. Kovatch, MD

Miller Time ………………………372
High-dose opiates and benzodiazepines in end-of-life care
Scott Miller, MD, MA, FAAHPM

Perspective………………………374
An ode to Planet Nine Pluto: A human hospice physician sharing a pet hospice experience
Keith R. Lagnese, MD, FAAHPM, HMDC

Perspective………………………380
A case for diversity in the Pittsburgh workforce
William Simmons, MD

Departments

Membership Benefits………..378
Society News …………………..383
• Pittsburgh Ophthalmology Society
• Pennsylvania Geriatrics Society – Western Division
Activities & Accolades………384

Articles

Feature……………………………..386
Moving physicians from burnout to wellness a priority for new PAMED President

Materia Medica …………………388
Bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy®)
Kevin Wissman, PharmD
Erica Wilson, PharmD, BCPS

Legal Summary………………..390
Opioid prescription guidelines: Are they mandatory?

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October 2019 Bulletin“History does not repeat itself, but it rhymes,” according to a popular proverb misattributed to Mark Twain. Healthcare trends tend to be cyclical, and the 1990s trend of publicly traded physician practice management (PPM) companies infusing investor capital into medical practices has returned from oblivion in the form of private equity (PE) transactions. Like the ill-fated PPMs, PE deals offer physicians cash up front and ownership in management companies that are designed to be sold in the future at a profit, and like PPMs, PE deals claim to be in a position to consolidate physician groups to achieve greater profitability. The results may not be in for a few years, but PE firms hope to avoid falling prey to the mistakes which led to the meteoric rise and fall of the PPM industry.

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Congratulations to Jared Knickelbein, MD, PhD, whose photo, “Mount Hood Reflection,” was the first-place winner of the 2019 ACMS Bulletin Photo Contest. His photo will appear on the January 2020 cover of the Bulletin.

Additional winners include: Frederick B. Doerfler Jr., MD – “PPG City Reflections;” Elias Hilal, MD – “Kennywood Splash;” Leo Bastiaens, MD – “Monet;” Thaddeus Osial, MD – “White Pocket, AZ;” Alexanndra Kreps, MD – “Sunset over Cranberry Township;” Mark E. Thompson, MD – “Jelly Fish, Atlanta Aquarium;” Andrew W. Eller, MD – “Bridges on Mon;” Alan Klein, MD – “Sunset over Canon Beach;” Terence W. Starz, MD – “Land of the Free;” Kimberly Hennon, MD – “Wildflowers;” and Marc Garfinkel, MD – “Light at the End of the Tunnel.”

View all photos

These photos also will appear on 2020 Bulletin covers.

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ACMS 2019 October Bulletin“There is a tide in the affairs of men.
 Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and miseries.
On such a full sea are wow afloat,
And we must take the current when it serves,
Or lose our ventures.”

– Shakespeare, W. Julius Caesar, Act 4, Scene 3, 218-224

 

Shakespeare was a keen judge of human nature and as such knew that opportunity to accomplish a goal may only come once in a lifetime. For me, that opportunity for a career change came in 1982 as the result of a chance meeting.

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“Send me a note on MyChart” were the last words my doctor uttered as she exited the exam room. I complied with her request 24 hours later and received a prompt and pertinent response. In contrast, six months earlier, I queried a different specialist through MyChart. It wasn’t urgent, but nevertheless, I failed to get a response. The note had been opened. I had a visit six weeks later with another physician in the same group. I asked my question and correspondingly commented on the lack of response to my electronic query. This second physician gently chided me: “Let me tell you how the sausage is made.

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Dr. Neal Bernard recently wrote a JAMA Perspective that “Ignorance of Nutrition is No Longer Defensible.”1 He recounts clinical scenarios in which physicians failed to (accurately) convey dietary advice to patients, concluding with five action steps: nutrition-related continuing medical education, partnering with registered dieticians, EMR resources, convincing physicians to change the way they eat and systemic improvements in food availability. With the amount of commercial and public health messaging about healthy habits, it boggles the mind to think anyone, let alone a physician whose professional organization asks him to categorize the mere presence of large body size as a disease,2 could fail to have absorbed knowledge about nutrition.

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Opinion

Editorial …………………………..322
Physician life hacks
Deval (Reshma) Paranjpe, MD, FACS

Editorial …………………………..324
Taking the tide
Richard H. Daffner, MD, FACR

Editorial……………………………326
The Jekyll and Hyde of EMRs
Andrea G. Witlin, DO, PhD

Perspective ……………………..329
Knowledge of nutrition is power: What will you do with yours?
Kristen Ann Ehrenberger, MD, PhD

Perspective ……………………..331
How to advise your patients when they ask about stem cell treatment for osteoarthritis
Paul S. Lieber, MD

Departments

ACMS Alliance News ……….333
Community Notes……………..333
Society News …………………..334
• ACMS hosts first MPHC event
• Pittsburgh Ophthalmology Society
• Pennsylvania Geriatrics Society – Western Division
Activities & Accolades……….340

Articles

Materia Medica …………………342
Switching between P2Y12 inhibitors: Considerations in dosing and timing
Aubrey Dusch
Kylie Horvath
Maleia Ruane
Suzann Sebastiani
Courtney A.

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On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) issued the proposed Medicare Physician Fee Schedule (PFS) changes for the 2020 calendar year. 

A. Payment for evaluation and management (E/M) services

The E/M proposals will probably be the most complicated and will impact the most physicians. I will outline them here and then present a later Bulletin article dedicated specifically to E/M Services.

  • The CPT coding changes retain five levels of coding for established outpatient, but reduce the number of levels to four levels of E/M visits for new patients.
  • The code definitions are revised, as well as the times and medical decision-making process for all codes.
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