Kentucky Academy of Family Physicians

Article on HB1

Gerry Stover — Thu, 17 May 2012 06:49:27 +0000

How Does Kentucky’s Latest Pain Management Legislation Impact Physicians? Q&A With Dr. Laxmaiah Manchikanti of ASIPP

Written by Taryn Tawoda | May 16, 2012

Kentucky last month signed into law a bill requiring physicians to consult the state’s online drug database, Kentucky All Schedule Prescription Electronic Reporting, prior to prescribing pain medication to a patient. The bill, HB 1, targets the overprescribing of opioids and introduces stricter definitions and standards for pain management clinics.

Laxmaiah Manchikanti, MD, chairman of the board and CEO of the American Society Of Interventional Pain Physicians and the Society of Interventional Pain Management Surgery Centers, discusses the impact of the bill for both physicians and patients, and how Kentucky now aligns with other states on policies to curb prescription drug abuse.

Q: Why is HB 1 important for both patients and physicians?

Laxmaiah Manchikanti, MD: HB 1 essentially could be a win-win situation for both physicians and patients, along with law enforcement, by curtailing opioid abuse while still maintaining access to appropriate opioid therapy for patients who need it. Even though it may not be appreciated by many physicians at the present time, it does include many features which do help physicians. One of the major issues of concern for physicians was moving KASPER to the attorney general’s office. That did not happen; it continues to stay with the Cabinet for Human Resources.

HB 1 provides a definition of a pain clinic, even though it does not go far enough. Based on this law, all pain clinics must be run by pain physicians who are board certified by an ABMS Medical Specialties Board, American Osteopathic Board, American Board of Pain Medicine or American Board of Interventional Pain Physicians, or must have completed an accredited fellowship in pain medicine. Further, any clinic which provides prescriptions for more than 50 percent of opioids or more than 50 percent of patients are treated with opioids will be considered a pain clinic.

This protects patients as they will only be able to go to legitimate pain clinics, thus avoiding potential abuse. It also saves the patient from spending exorbitant amounts of money that non-legitimate pain clinics charge.

It is good for physicians because they are now essentially forced to perform appropriate evaluations and documentation through the now-mandatory KASPER program. They must also meet the indications and medical necessity criteria prior to embarking on chronic opioid therapy and document procedures.

Physicians have another advantage in addition to mandatory KASPER: the physician will be informed immediately of any investigation by authorities. Further, KASPER lifts its restrictions of disclosure after July 12, which will become part of the medical chart, falling under the same confidentiality regulations under HIPAA.

Q: How will this law affect patients and physicians in the short-term?

LM: In the short-term, of course there will be multiple misunderstandings and fear among physicians. We are already seeing this. However, once physicians understand the essence of the law, its impact will be minor if they are willing to follow the rules and regulations with proper assessment of the patients, documentation of medical necessity and indications, adherence monitoring with mandatory KASPER, and other evaluations.

Q: What do you hope it will accomplish long-term?

LM: In the long-term, if all the components are followed, it will reduce opioid abuse in the state by at least 50 percent. However, we need to understand that in the majority of opioid fatalities patients supposedly receive appropriate doses. Forty percent of the fatalities are from 10 percent of the patients who receive high-dose opioids which have been defined as greater than 100 mg of morphine per day, whereas 20 percent of fatalities are from low-dose opioids defined as less than 100 mg of morphine a day. Finally, 40 percent of the fatalities are due to drug abuse. We should be able to substantially reduce the fatality rate and abuse rate and also those receiving high doses of opioids.

It was recently illustrated that since opioid guidelines were implemented in Washington state in 2007, opioid prescriptions have reduced along with a 50 percent reduction in fatalities related to opioids. Research showed that prescriptions of long-acting opioids decreased by 27 percent and the proportion of workers on doses greater than 120 mg or greater dosages of morphine equivalents was reduced by 35 percent, with a 50 percent decrease from 2009 to 2010 in the number of deaths. Above all, the main impetus of HB 1 in the long-term is that it will curtail abuse without affecting the access.

Q: What sort of training and changes will physicians need to undergo in their practices now that the bill has been signed into law?

LM: All physicians need to be empowered through education rather than enforcement. It is well known that physicians receive very little education in controlled substance management, and also long-term chronic pain management. Thus, additional education is essential not only for pain physicians, but for all physicians.

There are numerous ways of improving education to meet the appropriate medical necessity, indications criteria, evaluation of chronic pain patients, adherence monitoring, etc. One way is through the educational courses provided by American Society of Interventional Pain Physicians such as controlled substance management, comprehensive review courses and competency certification examinations. Another source is the American Society of Addiction Medicine and the American Academy of Pain Medicine.

Physicians must learn how to properly document and also properly assess the patients. This will also weed out many abusers.

This bill also provides for the governor, at his or her discretion, to appoint specialty representation necessary on the Kentucky Board of Medical Licensure, which continues to be the most important organization in monitoring physician compliance. It will facilitate the governor to appoint pain physicians to the board, which also in turn would facilitate development of appropriate guidelines to for chronic opioid or controlled substance management.

Q: Were there any parts of the bill that were not ultimately signed into law? If so, which parts? And do you plan to pursue future legislative action to get them approved?

LM: One of the main important aspects which did not pass the law was a pill dispenser – PillGuard. This would have been a great addition to adherence monitoring, which would have further reduced abuse.

Q: The Kentucky Medical Association has argued that running multiple KASPER reports throughout the day may be very challenging for busy physicians because the reports can take up to 10 minutes per patient. What is your response to this?

LM: To some extent, we agree with the Kentucky Medical Association; however, this can be accomplished by medical assistants and other staff. It is not necessary for a physician to do this personally. However, once the physicians are organized and understand the system it will only take about five minutes or less of ancillary personnel time to provide this information to the physician. This will provide clarity to the physician and provide appropriate care to the patient. This is essence reduces physician time rather than increase it. In my office, we have been implementing this technique for about eight years now and have not found it to be very difficult. In the past we ran KASPERs initially and then every six months; however, now we will be running them every 3 months. I believe that this is a great option and I strongly support mandatory KASPER.

Q: Now that the bill has passed, how does Kentucky stack up to other states in terms of prescription drug monitoring?

LM: Kentucky has been at the forefront with the availability of KASPER; however, the majority of physicians have not used it. Because of KASPER, we actually were able to enact National All Schedules Prescription Electronic Reporting Act (NASPER) at the national level which provides funding for each state with the requirement that they meet certain criteria and provide a physician friendly process, along with communication with contiguous states. The same principles are adapted or being attempted by Harold Rogers program which essentially blocked NASPER. After it was signed into law in 2005, NASPER was funded for only 3 years. Even then it had an enormous affect with almost all the states now having implemented such a program (only Missouri and New Hampshire have pending legislation) and 41 states already have active programs. Even still, KASPER continues to be number one in prescription drug monitoring.

source:http://beckersorthopedicandspine.com/pain/item/11964-how-does-kentuckys-latest-pain-management-legislation-impact-physicians?-qa-with-dr-laxmaiah-manchikanti-of-asipp

Tell Us Your Story

gerrytolbert — Wed, 16 May 2012 13:39:34 +0000

After the AAFP National Conference of Special Constituencies, which included 5 amazing days of discussion and camaraderie, I returned to Kentucky with the unofficial title of Social Media Editor for the Kentucky Academy of Family Physicians and a head full of ideas.

Social media serves to tell the stories of the people around us. Each person gets their own opportunity, using all the various media from print to video, to show the world what matters. A unique opportunity exists to be as ubiquitous as the cellular telephone but as poignant as silent film. We as a community can create content using simple tools and broadcast it to the whole world.

While that may be a bit overzealous, the concept holds true. What better way to communicate with our patients and our colleagues than meeting them where they are. Telling them our story. I see so much potential for our academy and the folks who we serve, both clinically, politically and socially. We can all tell our stories. We can all show those who will listen what really matters.

Here’s my story:

My goal is to create a process for putting together those with a story and the people who can put that story out there. If you have something to share, let me know. E-mail me via gtolbert at tapnky dot com. We’ll work to make sure you’re heard.

James W. Middleton, Jr., MD KAFP 2012 Citizen Doctor of the Year

Josh Hechesky — Wed, 16 May 2012 01:47:57 +0000

First Blog

r.waldridge — Mon, 14 May 2012 17:24:05 +0000

What an exciting start to my presidency in KAFP!!

I had a great time at ALF-NCSC in Kansas City the first week of May. It was very refreshing to meet family docs still excited for their profession and full of ideas to keep us all fired up! It was great to meet the young physicians from Kentucky that I hadn’t already met. I came away with a sense of calm regarding the future of our Academy after interacting with these future leaders.

My second week in office I was glad to be invited to the retreat for the UK Dept of Community and Family Medicine at Natural Bridge. They had a great program led by Dr. Tony Kuzel from the Medical College of Virginia family practice residency programs. He spoke on transitioning teaching in residencies to include PCMH. He is also very active with the VAFP and had some good ideas on partnering with medical schools/residency programs to bring CME to our members.

Please respond to this blog with areas of concern for you as an academy member. We are tackling issues of prescription drug abuse, and the new KASPER requirements, scope of practice issues with NPs in our state, rolling out an invigorated social media presence, and continuing efforts to ensure all Kentuckians have access to a family physician. Join in the discussion and help us lead our academy to the next level.

My First Post….Welcome to Zook’s Clinical Blog

zook — Thu, 10 May 2012 13:25:03 +0000

I am thrilled to be blogging for the KAFP. I would like to use this blog as an exchange of clinical conundrums, updates and stories among all Kentucky family physicians. I’ll post experiences from my practice under those headings and hope that you’ll read, contemplate and write in with your own ideas.

Here’s a case I’ve been struggling with for three years……

White Female, age 41

PMHx:

Hashimoto Thyroiditis
Diabetes Type II
NASH with cirrhosis (biopsy proven)
Crohn’s (biopsy proven)
Thrombocytopenia
Obesity (weight 190, height 54″)
Hyperlipidemia
Iron deficiency (but no anemia)

Meds:

Levothyroxine 600 mcg daily
Levemir 150 units twice daily
Novolog sliding scale
Lipitor 40 mg daily
Lisinopril 2.5 mg daily

Most recent labs (this month)

a1c 10.1
TSH: 0.88
LDL: 57
HDL: 47
TG: 127
microalbumin ratio: 13
AST/ALT 22/21
INR 1.0
Albumin 4.3
T. Bili 0.3
Iron % Sat 9
Hgb 12.0
MCV 90
Platelets 78K
She has previously had negative ANA titers, RF and anti-CCP antibodies.

Social History

Married, 2 children (and 2 step children)
Operates a foundary furnace
No tobacco Use
No alcohol use

I referred her to two different rheumatologists who do not think she has an auto immune problem because her titers are negative and she does not have findings of arthritis.

I referred her to an endocrinologist who told her to lose weight.

I referred her to hematology who said that her thrombocytopenia was idiopathic and to do nothing

I referred her to GI — they did the liver biopsy and told her to lose weight

Here is my clinical dilemma:

On her most recent visit (yesterday) — she now has a petechial (non blanchable) rash on her shins that itches and burns when exposed to hot water. I am concerned that she now also has a vasculitis — and will likely do a punch biopsy at her next visit.

I feel very strongly that this patient has a complex autoimmune problem and may benefit from a systemic immunomodulator therapy — or at least have a unifying diagnosis for all of these issues that seem to be auto-immune related. Unfortunately I cannot find a specialist who seems to be willing to look at the whole picture in the same way that I do……ANY THOUGHTS?

Also……do you have any patients who require SO MUCH thyroid hormone replacement and insulin?

Write in and give me your thoughts!

Dr. Z.

Nancy Swikert, MD Receives The 2012 Distinguished Service Award

Josh Hechesky — Wed, 09 May 2012 02:35:09 +0000

The 2012 Distinguished Service Award:

A Message From Your New President, Ronald Waldridge, II, MD

Josh Hechesky — Wed, 09 May 2012 02:34:52 +0000

View the Video Below:

KAN endorsement of the AAFP Office Champions Tobacco Cessation National Dissemination

Gerry Stover — Tue, 08 May 2012 19:56:01 +0000

Members of the Kentucky Ambulatory Network (KAN)

The Kentucky Ambulatory Network (KAN) is, as you know, Kentucky ’s primary care practice-based research network. The KAN General Advisory Council reviewed this new AAFP quality improvement project, and concluded that KAN can endorse the project. Therefore, we encourage you to consider participating. Kentucky is one of the 14 targeted states in which more than 20% of adults are smokers. The Office Champions project is built on the AAFP’s Ask and Act program, which is based on the evidence in the U.S. Public Health Service (USPHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008 update.
Both the Ask and Act program and the Office Champions pilot project have had positive results. The Office Champions website provides more information and a link to the application: www.aafp.org/online/en/home/clinical/publichealth/tobacco/officechampions.html.

The AAFP Office Champions project team will run the project. Its Project Manager, Sandy Sheehy, can answer your questions (ssheehy@aafp.org or 800-274-2237 ext 3141).

A Fax blast was sent to KAN members’ offices. The deadline to apply is May 8^th. (Today!) Only family medicine practices are eligible to participate. The Physician Champion has to be an active AAFP member. The Office Champion, however, can be a physician, PA, RN, LPN, MA, office manager – whoever you want it to be. Although no CME credits are offered, participating practices receive several benefits, including $2,000 and materials for patients.

As always, thank you for your involvement in KAN. We wish you the best with this and any other quality improvement efforts you may embrace!

If you are not a member of KAN but would like to know more –

EmailMs. Mary Barron at mabarr2@email.uky.edu or call (859)323-4889

KAN members that participate in research projects can qualify for up to 30 Prescribed AAFP CME credits per 3 year.

Closing Speech for The National Conference of Special Constituencies

Gerry Stover — Mon, 07 May 2012 20:02:34 +0000

Dr Jay Lee, from California and the convener of the AAFP National Conference of Special Constituencies gives a call to action to close out the conference.

More photos and information from the conference to follow. Stay Tuned!!!

Congrads Dr. Middleton – Arbor Day Award Winner

Gerry Stover — Wed, 02 May 2012 22:21:24 +0000

From http://news.blogs.cnn.com/2012/04/27/doctor-who-planted-750k-trees-gets-arbor-day-weekend-salute/

Doctor who planted 750K trees gets Arbor Day weekend salute
On this Arbor Day, when people are encouraged to plant trees, meet a Kentucky physician who has planted more than 750,000 of them on his own land.

Dr. James Middleton, 68, who also is a farmer and forester near Munfordville, Kentucky, began adding to his family’s land holdings in the 1970s, buying areas along the Green River that others had stripped of timber and abandoned. He’d plant trees such as oak and black walnut, and then harvest some of the wood, but replant.

iReport.com: Celebrate Arbor Day with us!

His sustainable management of 3,000 acres of woods not only makes money, but also reduces soil erosion along the river, preserving the river’s quality for communities miles downstream, the Arbor Day Foundation says.

On Saturday, the foundation will give him its annual Good Steward Award, which recognizes stewardship and conservation efforts on private land, in a ceremony in Nebraska City, Nebraska.

“All this was forest at one time. Mankind started farming it and opening it up, and now we’re trying to plant some of it back,” Middleton said by phone Friday.

Middleton says he has lived his whole life surrounded by trees. His rural family home, built by his grandparents in a family apple orchard, was constructed from and landscaped with trees that came from the farm.

Besides practicing family medicine in Munfordville and planting and harvesting trees – with the help of forestry people who advise him when to cut the land and then re-establish the forest – he farms and raises cattle. Until federal funding dried up in 2004, he grew tobacco as well. He has converted those tobacco patches to more timber fields, and sees forestry as a way forward economically for his fellow farmers in Hart County.

“If people see economic advantages to it, they’re more likely to put trees back on a hillside than run cattle on it,” Middleton said. “We try to promote good forestry – planting trees, taking care of our trees, re-establishing our forests. In the long run, our land is better off, and our landowners are better off, too.”

Middleton promotes forestry throughout the county – he hosts forestry students to let them examine the planning and projects that he and his forestry contractors have done – and in his doctor’s office.

“People ask every day in my clinic, ‘Doc, what do you think about this tree? What kind of trees should I plan at my place?’ That’s how I try to give them that understanding,” Middleton said.

The Arbor Day Foundation is honoring Middleton for his “lifetime commitment to stewardship,” and his community outreach, Arbor Day spokesman Sean Barry said.

“He’s been walking the walk in terms of conservation in Kentucky,” Barry said. “He proselytizes constantly … about conservation and the importance of taking care of the trees.”

Middleton will be one of 16 people and organizations receiving various awards from the Arbor Day Foundation on Saturday.

Friday is Arbor Day in the United States. It started in 1872 as a tree-planting holiday in Nebraska.