J-LSMS 2020 | March

Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.

As an advocate for our policyholders, LAMMICO continually monitors and responds to legislative and judicial activity based on the best interests of our insureds. In the face of challenges to our Medical Malpractice Act and cap on damages, we only support changes to Louisiana’s medical professional liability system that do not increase the overall cost of malpractice coverage to our policyholders. At LAMMICO, it’s more than a little something extra. As an advocate for our policyholders, LAMMICO continually monitors and responds to legislative and judicial activity based on the best interests of our insureds. In the face of challenges to our Medical Malpractice Act and cap on damages, we only support changes to Louisiana’s medical professional liability system that do not increase the overall cost of malpractice coverage to our policyholders. At LAMMICO, it’s more than a little something extra.

Dear LSMSMembers,

It is both an honor and a privilege to serve as your 140 th president of the LSMS. I cannot begin to thank you all for allowingme this opportunity and for placing your trust in me and my abilities. While I recognize that we may not agree on everything, please know that I, along with the other members of the LSMS leadership team, are absolutely committed to doing what is best for our organization and profession.

Throughout my career I have always been a strong advocate for physicians because I believe our voice is essential in maintaining quality healthcare in Louisiana. As physicians we are given the knowledge and training to have a meaningful impact on so many lives. Our identity as physicians is one that is intertwined with deeply personal connections with our patients that are unique fromall other types of relationships. As that identity becomes threatened by opposing forces to the practice of medicine, it is of the utmost importance that we stick together. We need to continue to build a community of physicians working together to a better end. We need to connect and reconnect with our peers for support and strength. We need to encourage them that it is not time to give up, but time do something about it. We need to stay true and stand up for issues that are important to the physicians and patients of Louisiana. I believe in our training. I believe in our profession. And I believe in you, the members of the Louisiana State Medical Society, that together, we can heal not just ourselves but the people of Louisiana.

Katherine Williams, MD

JOURNAL EDITORIAL STAFF

EDITOR D. LUKE GLANCY, MD ASSOCIATE EDITOR L.W. JOHNSON, MD

CHIEF EXECUTIVE OFFICER JEFF WILLIAMS MANAGING EDITOR/ ADVERTISING & SALES CHRISTOPHER LEBOUEF EDITORIAL ASSISTANTS SHAWN ZERINGUE & GINA GARNER

JOURNAL BOARD OF TRUSTEES VICE CHAIR, K. BARTON FARRIS, MD SECRETARY/TREASURER, RICHARD PADDOCK, MD ANTHONY P. BLALOCK, MD D. LUKE GLANCY, MD LESTER W. JOHNSON, MD FRED A. LOPEZ, MD LSMS 2019 BOARD OF GOVERNORS OFFICERS PRESIDENT, KATHERINE WILLIAMS, MD PAST PRESIDENT, LEE STEVENS, MD VICE PRESIDENT, R. REECE NEWSOME, MD SPEAKER OF THE HOUSE, T. STEEN TRAWICK, MD VICE SPEAKER, WILLIAM"BEAU"CLARK,MD SECRETARY/TREASURER, RICHARD PADDOCK, MD CHAIR, COL, DAVID BROUSSARD, MD COUNCILORS DISTRICT 1 MEMBER, GEORGE ELLIS, JR., MD DISTRICT 1 ALTERNATE, VACANT DISTRICT 2 MEMBER, ROBERT CHUGDEN, MD DISTRICT 2 ALTERNATE, GABRIEL RIVERA-RODRIGUEZ, MD DISTRICT 3 MEMBER, ALLEN VANDER, MD DISTRICT 3 ALTERNATE, VACANT DISTRICT 4 MEMBER, F. JEFF WHITE, MD DISTRICT 4 ALTERNATE, SUSAN VEILLON, MD DISTRICT 5 MEMBER, ADRIENNE WILLIAMS, MD DISTRICT 5 ALTERNATE, GWEN JACKSON, MD DISTRICT 6 MEMBER, MICHAEL ROPPOLO, MD DISTRICT 6 ALTERNATE, AZEEN SADEGHIAN, MD DISTRICT 7 MEMBER, BRIAN GAMBORG, MD DISTRICT 7 ALTERNATE, VACANT DISTRICT 8 MEMBER, LANCE TEMPLETON, MD DISTRICT 8 ALTERNATE, MICHAELDOLE,MD DISTRICT 9 MEMBER, ANDY BLALOCK, MD DISTRICT 9 ALTERNATE, VACANT DISTRICT 10 MEMBER, NICHOLAS VIVIANA, MD DISTRICT 10 ALTERNATE, JEREMY HENDERSON, MD SENIOR PHYSICIAN MEMBER, ROBERT MCCORD, MD SENIOR PHYSICIAN ALTERNATE, GREG LORD, MD YOUNG PHYSICIAN MEMBER, AMBERLY NUNEZ, MD YOUNG PHYSICIAN ALTERNATE, RANDALL G. WHITE, JR., MD RESIDENT/FELLOWMEMBER, OMAR LEONARDS, MD RES./FELLOW ALTERNATE, KEN EHRHARDT JR., MD MEDICAL STUDENTMEMBER, JACOB BOUDREAUX MEDICAL STUDENT ALTERNATE, DAN FRECHTLING

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The Louisiana State Medical Society (LSMS) can trace its history to the late 1800’s and is the only member organization in Louisiana that represents all physicians – regardless of specialty or location. With more than 6,000 members, LSMS is a strong advocate focused on protecting physicians and their right to practice medicine so they can focus on providing quality healthcare to the citizens of this state. You focus on patients. We focus on you! The primary focus for all physicians is their ability to provide quality healthcare to patients. Access to care, for both insured and uninsured patients, is an ongoing issue that presents itself in every year. Healthcare policy issues are numerous, diverse, and shaped by all branches of government. The LSMS continually advocates on behalf of physicians on the following issues: • Protecting the Cap – Aordable medical malpractice insurance • Protecting patient safety by ensuring the right professional is providing the right care permitted by his or her education, training, and skills • Making Medicaid sustainable and engaging providers • Ensuring an adequate healthcare workforce • Ensuring fair and transparent insurance markets for patients, employers, and physicians • Preserving the integrity of the practice of medicine • Understanding the impacts prescriptions have on the practice of medicine

• Reducing red tape, regulations, and the hassle factor • Utilizing technology to treat and care for patients

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Protecting the Cap. Louisiana has an established malpractice cap which provides stability and aordability of insurance assuring Louisiana’s health care providers that they will be able to obtain and maintain insurance and continue to practice medicine in the state. At the same time, the system provides a viable fund for compensating claimants. The law in place provides a total liability exposure for damages of $500,000 exclusive of medical expenses. Healthcare providers who choose to enroll in the Patient’s Compensation Fund – which is 100% self-funded by the participants - remain responsible for coverage for the rst $100,000 of each claim. The Fund then provides coverage for the second $400,000 plus lifetime related medical expenses for the injured party. The Louisiana Supreme Court has ruled that the legislature has sole authority to establish a cap which was instrumental in working toward continuing private and public healthcare costs. A shortage of physicians in Louisiana is acknowledged. Without this constraint on damages awarded for medical liability actions, wedrastically reduce the chances of attracting newphysicians or retaining the physicians currently providing healthcare in Louisiana. Protecting patient safety. Physicians currently practice in teams with other healthcare professionals to provide comprehensive patient care. These patient-focused teams are an excellent health care model but must be physician-led to ensure quality, continuity, and eciency in care. The LSMS strongly opposes any eorts to expand scope of practice beyond what is safely permitted by non-physician practitioners’ education, training, and skills. We further encourage legislators to support stronger self-identication rules to promote transparency and ensure that patients know and understandwho is providing their health care. Ensuring an adequate healthcare workforce. It’s no secret that Louisiana does not have enough physicians to meet demand. To address this shortage, it is critical that Louisiana ensures stable, state support for a physician’s education and training to help cultivate future generations of Louisiana physicians. In turn, this ensures stable access to healthcare for the citizens of this state. The LSMS believes we need to support physician-led healthcare teams that can safely meet the diverse needs of the state’s population. As a part of that, the Legislature is encouraged to consider innovative residency incentives suchas forgiving loans (inpart or inwhole) for residents willing towork for a specied time in underserved locations or looking at creating regional residency programs with neighboring states.

Making Medicaid Sustainable. Physicians are critical to Louisiana’s healthcare system if it is to be cost-eective, otherwise, the state’s eorts to increase preventative care, improve medically necessary treatment for the chronically ill, and reduce inappropriate emergency department utilization will falter. State leaders must realize that cutting physicians’ payments is not an eective tool for controlling healthcare costs and often exacerbates the cost of care. The already articially low Medicare reimbursement is considered the oor for payments, but in Louisiana, Medicaid reimbursements are now roughly two thirds of what Medicare pays. In recent years, physicians who care for Medicaid patients have seen reimbursement rates cut by 15 to 45 percent, depending on their specialty. Providers cannot continue to make ends meet and pay common business expenses at this threshold. Expanding Medicaid eligibility to individuals with income levels at or below 138 percent of the federal poverty level added thousands of patients into a system plagued with ineciency and facing regular budget shortfalls. Our duty is to address lingering issues hindering the Healthy Louisiana program to ensure adequate access and promote healthier outcomes for Louisiana’s most vulnerable patients. The LSMS continues to advocate for a Medicaid program that: • ProvidesMedicaid recipients with access to quality healthcare • Provides reasonable and timely payments to physicians who provide Medicaid services • Relieson fundingsources that arededicatedandstable, thereby allowing theprogramto remainscally soundandsustainable, even in timeswhen thestateof Louisiana is facingbudget decits • Contains choices for patients, i.e. traditional insurance plans, managed care plans, benet payment schedule plans, and purchasing pools to enable individuals to benet from group rate premiums • Prohibits discrimination against any physician specialty • Provides incentives such as small business tax breaks, limited malpractice caps, or other non-reimbursement incentives for physicians who accept Medicaid patients • Provides complete nancial transparency so taxpayers can easily determine if their dollars are being used in a manner that maximizes access to quality care

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Ensuring Transparency for patients, employers, and physicians. The LSMS continues to advocate for fair contracting in the regulated insurance market. We will continue to ght against eorts to interfere with the physicians’ right to contract and protect the right of physicians to seek payment for the services they render. The LSMS also works hard to provide more standardization when dealing with health plans, such as standardizing prior authorization forms for prescription drugs. We believe strongly that as the hassle factor is decreased and physicians can spend more time treating patients, overall outcomes improve. In recent years, surprise billing has been a big part of oered legislation. Physicians hear daily about patients’ problems with insurance and believe that any surprise billing conversation must include the following: increased transparency for patients to understand their insurance, network adequacy requirements that ensure patients can actually receive needed care and remain in-network, and dispute resolution mechanisms that recognize who the dispute is between and do not create an articial rate. Additionally, insurance is big business and they are in business to make money. Stronger regulation on how a claim is denied and what avenues patients have would be a welcomed relief to both patients and providers. Impact of prescriptions. Pharmacists and medication play a critical role in healthcare. A strong working relationship between pharmacists and physicians can help to optimize patient care. In recent years, these relationships have been stressed due to insurance-forced prior authorizations which make it dicult for a physician to treat patients and frustrating for a pharmacist to eciently complete their role. The back and forth volley that both are forced into PRESERVING THE PRACTICE OF MEDICINE Physicians are the best advocates for their patients. LSMS works tirelessly to defend physician-led medicine because the knowledge, skills, and experience that fully-trained physicians oer is unequalled. Ensuring that health care professionals’ scope of practice is reective of the training and education they have is essential to protecting the lives of adults and children from unsafe medical practices. The members of the LSMS are condent that state leaders and lawmakers —with input from patients, healthcare providers, employers, taxpayers, and others —can develop comprehensive solutions that are benecial for patients and taxpayers. Louisiana has a unique opportunity to provide its most vulnerable patients with access to quality health care and the LSMS stands at the ready, as it has since 1878, to assist the administration and lawmakers during this most challenging time.

does not enhance care collaboration. Additionally, the punitive reaction against both physician and pharmacist in the very real opioid epidemic has created further tensions. Many patients need medications to control pain at various times in life, such as post-surgery and for aging issues. When a physician writes a prescription, there is a reasonable expectation that it will be lled. A pharmacist has two options: ll the prescription or don’t ll the prescription. They are not legally allowed to change the medication prescribed or to short-ll it without physician approval. With today’s enforcement of opioid restrictions, more pharmacists are choosing not to ll the prescription at all, leaving patients in pain and without options. LSMS continues to support legislation that works to repair physician-pharmacist relationships and control an insurance companies’ ability to practice medicine. Physicians prescribe medications based on scientic research which targets the medication to the diagnosis and the amount appropriate to provide a patient based on a number of factors – including interactions with other drugs. This is what gives physicians cause for concern in the debate for medical cannabis. To date, there has been no long-term research that scientically shows health benets of cannabis or the impact to a patient already on a drug regimen. LSMS encourages more research to identify the health benets associated with the use of therapeutic cannabis. Reducing red tape, regulations, and hassle. We need legislative solutions to cut through the red tape, regulations, andother unproductiveelements that donothing to improve quality and everything to interfere with physicians’ ability to practicemedicine eciently and eectively.

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Physician manpower shortages, increasing practice business costs, and lower reimbursement rates are forcing physicians to make tough decisions. If patients cannot nd physicians to provide the care they need, their only alternative will be the hospital emergency room and costs will skyrocket. In time, not only Medicaid patients, but even privately insured patients will have diculty nding a physician and will be forced to absorb indirect costs associated with an inecient health care system. Using technology to treat patients. Expectations regarding healthcare quality, eciency, and patient safety are constantly evolving. When you add technology to the mix, determining how to adapt while still providing hands-on, quality healthcare is challenging. Several evolving areas ofmedicine that we see on the horizon could require legislative authority or oversight involvement Telemedicine is not new. What is new is the use of telemedicine between patients and corporate telemedics who don’t have history or background commonly associated with a patient/physician relationship. Any physician will tell you that being able to help an ill patient who’s traveling and has a video phone app enabling them to see the patient is convenient and worthwhile. But to turn patients over to corporate telemedics who are vastly removed fromour state and who have never personally treated that patient causes concern. In the past several years, Louisiana has enacted legislation, rules, regulations, and policy to oversee telemedicine in the state. LSMS expects there will bemore in the future and will carefully consider each piece on its merits and how it impacts Louisiana physicians.

years. However, in today’s world, human oversight is still required. Robotic and AI-assisted surgery have been proven to be less invasive and can shorten a patient’s recovery time. Using this technology allows physicians to use tiny incisions while performing complex procedures with more precision, control, and exibility. What is major surgery can now also be minimally invasive. It’s a new horizon that physicians have embraced and medical schools have adjusted curriculums to focus on both in training and in ethics. Electronic Health/Medical Records (EHR/EMR) and, in particular, how that information is used and shared along with Health Information Exchanges (HIE) are the newest components of medical technology. Individually, an EHR/EMR stores patient information and data for a specic physician on a specic patient. These systems make a patient’s record immediately available and in “real-time” during a medical appointment with that physician and were created as a way to manage/reduce paper charts, billing, and scheduling. With the advent of electronic prescribing of medications, the transfer of specic data one way became commonplace. With today’s advanced technology, the sharing of information is available which has the potential to allow primary care physicians and specialists to better coordinate care andmanage protocols on shared patients. Perhaps the greatest benet will be in government-subsidized healthcare arenas. The potential of sharing health records means that a patient who visits an emergency department will have their record shared with their primary care physician eliminating the duplication of costly tests and procedures. In coming years, LSMS expects there to be legislation related to how to successfully and condentially share this information among providers.

Robotics and other forms of articial intelligence (AI) in healthcare have made the biggest leap forward in recent

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P.H. JONES, MD, SCHOLARSHIP WINNER

Congratulations to the Jacob Boudreaux for being named a recipient of the P.H. Jones, MD, Scholarshipfor2020! Jacob is a fourth year medical student at the University of Queensland/ Ochsner Clinical School. He is a native of Houma, LA and graduated from LSU in

2016 with double majors in biology and French. Jacob plans to pursue a career in anesthesiology and is interested in health care policy as it aects all Louisianans. The Philip H. Jones, M.D., Memorial Scholarship Fund honors an extremely inuential member of Louisiana's physician community. One student from each medical school may be selected and awarded an annual scholarship of $4,000. The selection process was conducted by LSMS's Educational and Research Foundation Board. For more information about the scholarship program or application process, please visit www.lsms.org.

Woman’s GRACE Programcanhelp! Womans.org/GRACE • 225-924-8574

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HISTORICAL BRIEF: ERNEST HENRY STARLING AND THE LAW OF THE HEART Corresponding Author Hector O. Ventura, MD From the Department of Cardiology, Cardiomyopathy and Heart Transplantation Center Ochsner Clinic Foundation

English physiologist Ernest Henry Starling was born on April 17, 1866, in London. He worked mainly at the University College in London with his brother-in-law William Maddock Bayliss and both made many important contributions to medical science. Starling’s importance on the understanding of heart failure stems from his articulation of the Law of the Heart, published in 1918. He wrote, “The behaviour of the muscle tissue of the heart thus resembles that of muscular tissue generally, whether skeletal or unstriated, in which the contractile stress set up by each contraction is a function of the length of the bre. The greater the length of the bre, and therefore the greater amount of surface of its longitudinal contractile elements at the moment when it begins to contract, the greater will be the energy in the form of contractile stress set up in its contraction, and the more extensive will be the chemical changes involved. This relation between the length of the heart bre and its power of contraction I have called ‘the law of the heart.” (1) Starling designed an experimental model of heart failure that utilized a canine heart preparation and had a series of manometers to measure the various pressures of the system. By varying the venous pressure and measuring the cardiac output, Starling created the well-known curve that explained heart function and viewed heart failure as a hemodynamic syndrome. He stated “…The longer the muscle (within physiological limits) the greater the amount of chemical energy, heat production and tension set up when the muscle passes from the resting to the active condition…the law of the heart…is the same as that for skeletal muscle, namely that the mechanical energy set free on passage from the resting to the contracted state depends on the area of chemically active surface, i.e. on the length of the muscle bers…If for any reason the heart fails in its pumping action, the blood will remain in the auricles and ventricles and will prevent the

further entry of blood from the reservoir. The heart will dilate more and more after each inecient systole, while the pressure in the great veins will rise steadily; but this rise of pressure will be associated not with increased output from the ventricles but with diminished output. We have therefore to distinguish between a rise in venous pressure which is eective in dilating the heart during diastole and increasing its output and a rise of venous pressure which is passively induced by failure of the pumping action of the heart…” (2,3) The concept from Starling and his co-workers paved the way to cardiac hemodynamics as the principal mechanism for the development of heart failure. This clinical thinking dominated the knowledge of the concept of heart failure for more than 70 years. As an example, Tinsley Harrison in 1936, in his book Failure of the Circulation (4) utilized Starling principles to explain the clinical syndrome of heart failure and more recently in 1970, Jeremy Swan, William Ganz, James Forrester and coworkers reported their technique of bedside hemodynamic monitoring incorporating principles that Starling articulated early in the 1900’s. (5)

Ernest Starling after a very productive career died in Kingston Jamaica on May 2, 1927.

References 1) Starling EH: On the circulatory changes associated with exercise. J R Army Med Corps 1920; 34: 265–266 2) Patterson SW, Starling EH. On the mechanical factors which determine the output of the ventricles. J Physiol 1914; 48:357 3) Patterson SW, Piper H, Starling EH. The regulation of the heart beat. J Physiol 1914;48: 465 4) Harrison TR: Failure of the Circulation. Baltimore: Williams & Wilkins Co., 1936 5) Swan HJC, GanzW, Forrester J, Marcus J, Diamond G, Chonette D: Catheterization of the heart inman with use of a ow-directed balloontipped catheter. N Engl J Med 1970; 283: 447–451

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THANK YOU 2020 100% GROUPS to our

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HOUMA RADIOLOGY ASSOCIATES LOUISIANA CARDIOLOGY ASSOCIATES WEST JEFFERSON EMERGENCY PHYSICIANS

LAKE CHARLES ANESTHESIOLOGY ACADIANA RENAL PHYSICIANS JEFFERSON RADIOLOGY ASSOCIATES

Interested in your group joining this list? Contact Terri Watson, Sr. Director of Administration & Member Services, at terri@lsms.org or 225.229.7222.

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WHITE COATWEDNESDAY APRIL 1, 2020

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