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MEDICINE

Advancing the healthcare dialogue in Wyoming communities

wyoming

Volume 1. Number 2.

WWAMI 101
Election 2010
Gubernatorial
Candidates &
Health Care

Childhood and
Adolescent Obesity Growing
OurOwn
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content

Cover photo: Jesse Sullivan of


Freckle Photography. Featuring
Left to Right: Paul Johnson, MD,
community p9 Beth Thielen, Derek Nevins, MD, &
Five-year-old Jackson Sullivan
2010
cover story Growing Our Own
p10
Gubernatorial Wyoming WWAMI and Our Next Generation of Doctors
Candidates
Marguerite Herman
talk to the issues of health
care in our state and
what they will do to help
Wyoming’s future.
national perspectives
p12
Dennis E. Curran

Health Reform
The Fallout from the Congressional Shout-out

Kimble Ross

Around Wyoming Legal Corner To Your Health


P16 P19 P30

Jonathan Green offers a closer Dray, Thomson & Dyekman, PC Wyoming Pediatrician and
look at Wyoming WWAMI attorney Nick Healey, JD, and Former President of the American
students. Learn about the James (Jim) Dobbyn educate pro- Academy of Pediatrics State
students’ journeys in selecting viders about “Negotiating Reim- Chapter, W. Joseph Horam, MD,
medicine, choosing the University bursement In A Payor Contract.” speaks to the issues of “Childhood
of Wyoming and the University and Adolescent Obesity.”
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MEDICINE
wyoming
from The
August 2010
ediTor
By: Robert Monger, MD
The Wyoming Medical Society (WMS) is the premier Chief Editor
membership organization dedicated to promoting the
interests of Wyoming physicians and physician assistants Not many doctors practice Residency Programs in Casper
through advocacy, education and member services. medicine in Wyoming. and Cheyenne, the state has been
WYOMING MEDICINE (ISSN-2154-1681) is published With a total of about 1000 able to recruit a number of great
bi-annually by WMS at 122 East 17th Street, Cheyenne, physicians practicing in the state, physicians to our state.
Wyoming 82001. Contact WMS at (307) 635-2424 or Wyoming has the smallest number
sheila@wyomed.org of doctors of any of the 50 states.
I would like to take this opportunity
Perhaps more telling is the fact
to thank the four individuals who
that even for our small population
volunteered to be on our cover:
we have one of the lowest numbers Listed from left
to right, Dr. Paul
“Wyoming has the Johnson, Beth
WYOMING MEDICAL SOCIETY LEADERSHIP Thielen, Dr.
smallest number of Derek Nevins,
President Gerrie Gardner, DO
Vice President Cynthia Casey, MD practicing doctors of and old
five-year-
Jackson
Secretary/Treasurer Michael Tracy, MD any of the 50 states.” Sullivan.
Past President Reed Shafer, MD
AMA Delegate Robert Monger, MD All four were
AMA Alt. Delegate Stephen Brown, MD of physicians per 100,000 people: good sports about being cover
Executive Director Sheila Bush according to 2007 data from the models and very generous with
MAGAZINE EDITORIAL BOARD American Medical Association their time. Thanks also to the
Wyoming is 47th in the country in Governor’s mansion in Cheyenne
Chief Editor Robert Monger, MD number of physicians per capita. for letting us use their beautiful
Publisher Sheila Bush grounds for the photo shoot.
Member Steve Bahmer What can be done to recruit
Member Dennis Curran doctors to come to Wyoming? Dr. Johnson and Dr. Nevins are
Member Wendy Curran Our cover story in this edition examples of the WWAMI program
Member Dennis Ellis of WYOMING MEDICINE at its best. Both completed their
Member Pennie Hunt is about one of the truly great first year of medical school in
Subscriptions programs Wyoming has going for Laramie and then went on to
To subscribe to WYOMING MEDICINE, write to it: the WWAMI medical education finish their other three years of
WMS Department of Communications, P.O. Box 4009, program. medical school at the University
Cheyenne, WY 82003. Subscriptions are $10 per year. of Washington.
Through the WWAMI program,
Articles published in WYOMING MEDICINE represent Wyoming students have the Dr. Johnson is originally from
the opinions of the authors and do not necessarily reflect opportunity to attend medical Laramie, Wyoming. After
the policy or views of the Wyoming Medical Society. school and then return to Wyoming graduating from medical school
The editor reserves the right to review and to accept or after they finish medical school and and completing an ENT residency
reject commentary and advertising deemed inappropriate. residency to pay back their school at Columbia University he
Publication of an advertisement is not to be considered debt. The WWAMI program also returned to a serve Wyoming at a
an endorsement by the Wyoming Medical Society of the allows students from other states private practice in Cheyenne.
product or service involved. WYOMING MEDICINE is to spend time in Wyoming as part
printed by Print By Request, Cheyenne, Wyoming. of their medical education. Dr. Nevins is originally from
Wheatland and is now a second
Postmaster: Because of programs like year resident at the University
Send address changes to Wyoming Medical Society, WWAMI, as well as the University of Wyoming Family Medicine
P.O. Box 4009, Cheyenne, WY 82003. of Wyoming Family Medicine Residency in Cheyenne. Hopefully

6 wyoming medicine August 2010


from the editor WM

he will choose to stay in Wyoming after he completes his residency No matter who you decide to support in this year’s election, please
training. remember that we owe a debt of gratitude to all the candidates who
are running for elected office. Each one of these individuals spends
Beth Thielen is a M.D. /Ph.D. WWAMI student at the University many months away from their families traveling around the state,
of Washington. She is originally from Minnesota and is currently in the public eye, just for the opportunity to possibly become a
completing her 3rd year family public servant. Thanks to the six candidates
medicine clerkship at the residency we review in our story for making the time to
program in Cheyenne; she will return attend the WMS forum, and thanks to all of
to Wyoming next spring for a surgery
clerkship in Casper. Prior to her
“The WWAMI program is the candidates running for office this year for
your willingness to serve Wyoming.
participation in the WWAMI program more than just a one-way
Beth had never been to Wyoming.
street.” Congratulations to Nick Morris, M.D.,
a fine physician from Powell, Wyoming,
Beth is a good example of how the who is the winner of this year’s Wyoming
WWAMI program is more than just a Medical Society Community Service Award.
one-way street for Wyoming students The award is presented each year at the WMS
to go out of state to medical school. Annual Meeting, and you can read about
Through Wyoming’s participation in the WWAMI program, Dr. Morris’ many accomplishments in this edition of Wyoming
medical students and residents from other parts of the country Medicine. Nominations for the 2011 Community Service Award
have the opportunity to come to Wyoming for part of their medical will be taken by the WMS next spring, so start thinking now about
school or residency training. Hopefully some of them will fall in who you might want to nominate.
love with our great state and return here to practice someday.
We at WYOMING MEDICINE would like to hear from you! If
Wyoming voters have many options to choose from this year you have any questions, or suggestions about how we can make
for governor, and in another story in this issue we profile six of the magazine better, please email us at WMmagazine@wyomed.
the candidates. All six participated in a candidate forum at the org.
Wyoming Medical Society Annual Meeting at Jackson Lake
Lodge in June, and our article highlights some of their thoughts Thank you for reading Wyoming Medicine. WM
about health care issues.

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7 wyoming medicine January 2010


community WM

2010 gUBernaTorial elecTion


Can Wyoming’s Next Governor Heal Health-care Pains?

By: Dennis E. Curran

Will Wyoming’s next governor be a help Afghanistan and was chief of staff for Gov. making his third bid for the Republican
or a hindrance, a leader or a laggard, in Jim Geringer. nomination: and Tom Ubben, a Kinder
supporting quality medical and health care Morgan employee from Laramie.
in the state during the coming four years? Micheli is a fourth-
The answer appears to be positive, judging generation Wyoming The other Democrats are Al Hamburg,
from a recent Wyoming Medical Society rancher from Fort Bridger a retired house painter from Torrington
forum. in Uinta County. He served making his 17th bid for state or federal
16 years in the Wyoming elected office; Rex Wilde, a cabinet
While sometimes short on specifics, all six House of Representatives manufacturing company employee from
major candidates for governor say they are and headed the Wyoming Cheyenne; and Chris L. Zachary, a
committed to making quality health care a Department of Agriculture retired federal and state psychiatrist from
continuing top priority in Wyoming. Some under Geringer. Cheyenne.
even are championing another run at tort
reform. Simpson, a Cody lawyer, Scope of practice
has served 12 years in From the very first question, the candidates
And all of them are hoping for support the Wyoming House were quick to show their general support for
from the state’s medical community as of Representatives and the medical community. The first question
they square off in the Aug. 17 primary was speaker the last two involved scope of practice, and candidates
election to determine the Republican and years. He is the son of were asked specifically whether they would
Democratic nominees. former U.S. Sen. Alan K. support so-called “sunrise” legislation to
Simpson. require at least a year to study proposals to
The top contenders -- Republicans Matt allow various health-care professionals to
Mead, Rita Meyer, Ron Micheli and Colin Gosar, a Laramie expand their practices.
Simpson and Democrats Pete Gosar and businessman and pilot for
Leslie Petersen – were invited to answer the Wyoming Aeronautics Gosar said he thinks it is important to health-
questions about health care at an early- Division, is a political care consumers that they have confidence
morning candidate forum at the WMS newcomer but is actively in their providers, and he said he thinks
annual meeting in Grand Teton National campaigning and has name discussions about professional standards
Park June 12. recognition as a University of are important. He also used his opening
Wyoming football standout answer to emphasize the importance of
Meet the candidates two decades ago. good health care in general. “When wealth
Mead, a Cheyenne is lost, nothing is lost,” he said. “But when
attorney and rancher, is Petersen, a retired Jackson real estate broker, health is lost, something is lost.”
a former U.S. attorney was state Democratic Party
and the grandson of the chair until she entered the Mead spoke more directly to the sunrise
late Gov. and U.S. Sen. governor’s race. A longtime question, stressing the importance of giving
Clifford P. Hansen of conservation lobbyist, she as much notice as possible when discussing
Jackson. served for six years as a scope of practice issues to “avoid last-
Teton County commissioner minute consequences.” “Too often, you get
Meyer is completing her and ran unsuccessfully for in a rush to pass legislation, and too often
first term as state auditor, secretary of state in 1982. you get unintended consequences,” he said.
the state’s payroll officer.
She is a retired Wyoming The other Republican candidates are Alan Meyer, married to a dentist, recalled
Air National Guard colonel Kousoulos, a Wyoming Department of battles over allowing expanded practice by
with combat command Transportation employee from Cody; denturists and declared that “patient safety
experience in Kuwait and John Self, a retired Sheridan businessman is always paramount.”
Continued on page 14
August 2010 wyoming medicine 9
Growing
Wyoming
The obvious beneficiaries of

Our Own in
WWAMI are the medical stu-
dents and the Wyoming folks
who can find the medical
care they need, if not in their
hometown then in a commu-
nity close by. Other benefi-
ciaries are the hospitals Derek Nevins, MD ~ Resident
and clinics who hire these talented young physicians, the
University of Wyoming and the entire community of health care
By: Marguerite Herman providers in the state. So continuing support for WWAMI comes
from the Wyoming Medical Society and the Wyoming Hospital
Association and of course the Wyoming Legislature, which ap-
propriates money every two years to send Wyoming students to
“Grow your own” has become the conventional wisdom in Wyo- medical school.
ming’s efforts to recruit and retain physicians. By all indications,
the state has found the solution in the WWAMI program. After 13 Here Is THe “GrOWING yOur OWN” sCeNArIO IN WyOMING:
years, it has a stellar performance record in its mission to supply A high school student is interested in health sciences. A guidance
Wyoming’s rural residents with primary care and specialty physi- counselor encourages the student to check out the WWAMI pro-
cians. gram and talk to Assistant WWAMI Dean Matt McEchron, PhD,
at the University of Wyoming.
“It has vastly exceeded my greatest expectations,” said Wendy
Curran, who was the deputy director of the Wyoming Medical So- The student (who is a certified resident of Wyoming and might
ciety when the program began. “We believed if we got close to 50 be from Casper or Alpine or Saratoga) completes a pre-med un-
percent return rate for the students, we would be wildly success- dergraduate degree program at the University of Wyoming or any
ful.” In fact, about 70 percent of the Wyoming students who attend other college. The student applies to the University of Washington
medical school under the WWAMI program are coming back to School of Medicine. (WWAMI helps the student prepare for the
the state to practice. Medical College Aptitude Test and polish interviewing skills.)

The name represents the five states that participate in the same The student is interviewed by the WWAMI Admissions Commit-
contract program with the University of Washington to prepare tee in hopes of securing one of 16 slots for the Wyoming WWAMI
physicians to practice in a rural setting: Washington, Wyoming, class.
Alaska, Montana and Idaho.
Once admitted, the student takes the first year of medical school
The keys to success of WWAMI (pronounced “whammy”) are the in Laramie. Then the student has the option of participating in a
focus on rural medicine - for Wyoming residents - paid for by the four-week Rural/Underserved Opportunities Program (RUOP) ex-
state - with an obligation to come back and practice in the state perience throughout the WWAMI region. Wyoming has 14 RUOP
or repay the some $150,000 Wyoming has spent to send them to sites. So the Wyoming student we are following might spend a
medical school, with interest. Another key element is students’ month with Don Kirk, MD, in Thayne or Larry Kirven, MD, in
preparation at the University of Wyoming before going to Seattle. Buffalo or 12 other locations. The student then heads to Seattle to
complete the second year of medical school.
cover story WM

During the third and fourth years, this student may rotate through Curran, who is the health policy analyst for Wyoming Gov. Dave
all five WWAMI states and complete required and elective clerk- Freudenthal, said she has seen this connection of mentors to the
ship rotations with the following extra options: top-rated University of Washington medical school have the effect
• Apply to be one of 12 students from each WWAMI class of of retaining rural doctors in Wyoming. “Instead of just sitting in
200 to spend 20 weeks of the third year in one rural commu- your office in Buffalo, you make sure your skills are up to date,
nity. This is the WWAMI Rural Integrated Training Experi- and you’re working with brilliant young minds,” she said. The ex-
ence (WRITE), with rotations in family medicine, internal perience invigorates the doctor with a fresh perspective and con-
medicine, pediatrics and psychiatry. The student also com- nections with the cutting edge of his or her area of practice.
pletes an elective rotation. The WRITE sites in Wyoming
are in Powell and Lander. And there’s more. Dr. Hillman said the WWAMI students who are
• Apply for one of four Wyoming Rural Clinical Experience in Wyoming for the RUOP experi-
spots. If selected, the student will complete four or more of ence present a great recruiting op-
their six required third-year clerkships in Wyoming portunity for hospitals and doctors.
“You don’t have to spend $100,000
After the four years of medical school it is time to complete a resi- recruiting for unknown physicians,”
dency in a specialty and look for employment back in Wyoming. he said. About 300 students rotate
After graduation from residency, the WWAMI physician returns to through Wyoming for 4-6 weeks
Wyoming to practice medicine for three years, comfortable with each year. “The communities, hospi-
the practice of medicine in a rural environment, and wants to stay tals and doctors need to take advan-
for the long term. tage of that and recruit them when
they’re here,” he said. “This is a great Beth Thielen ~ WWAMI Student
And that is how it is playing out. opportunity we’re missing right now.” The WWAMI program is
relatively new in Wyoming, just 13 years old, and we’re still learn-
Richard Hillman, MD, is the clinical dean for WWAMI in Wyo- ing how to put all this together for the best for our state.
ming. He is a member of the WWAMI “team” for all the clinical
activities in Wyoming. (The WWAMI team includes the Univer- “It’s a lot better than recruiting doctors for Wyoming whom no-
sity of Washington, University of Wyoming, Wyoming Medical body wants,” he said.
Society and Wyoming Hospital Association). Dr. Hillman has the
critically important job of finding clinical sites for the third and A sign that the Wyoming program has reached a level of maturity
fourth year clerkships in Wyoming. is the participation of WWAMI alumni in recruiting and mentor-
ing current students. The doctors who have been “grown” are now
“We’re looking for quality physicians in their practice and in their cultivating future Wyoming physicians, for instance WWAMI grad
professionalism. They must be willing to teach and work with stu- Blaine Ruby, MD, who was a preceptor for rural surgery in Buf-
dents as a team,” Dr. Hillman said. “Part of the problem is these falo 2009-2010. Adam Peters, MD, of Cody, Gentian Scheer, MD,
physicians are so busy, they just can’t work with students.” and Justin Hopkins, MD, in Lander hosted students for the RUOP
experience in 2009.
For the physician mentors, the rewards are huge, Dr. Hillman said.
In addition to a small stipend, they get faculty status at the Univer- Another sign is the quality of students we are sending to Wash-
sity of Washington, and they have Internet access to its first-class ington. The University of Wyoming has sharpened its pre-med
research library. Plus, the University of Washington brings them to and first year programs, and other WWAMI team members have
Seattle once a year for continuing medical education. helped students with clinical experience, MCAT preparation and
Continued on page 24
The falloUT
from The
congressional shoUT-oUT:
The Downstream Flushing Effects of
What Congress Did, and Didn’t Do
By: Kimble Ross

Now that the multiple federal health system Thesis II: Integrate or Die: The macro peded out of the barn—Congress has been
‘reform’ deeds are done, the blogosphere trend in Horizontal and Vertical Integra- known to reverse itself. However, there are
and journals are flush with prognoses from tion—and its alter ego, consolidation—will considerable political barriers and econom-
cynics, polemicists, and optimists, left, accelerate, given the powerful incentives to ic realities this go-round:
right and centrist, on what’s next. Don’t come together (or starve out of network).
expect a consensus in your professional Does small group and solo practice go the 1. Payment realignments, the most sig-
lifetime. This kind of creative disrup- way of the brontosaurus? nificant inspiration among practice
tion transcends anything physicians have variable catalysts, were proceeding
experienced since Medicare was birthed Thesis III: Triple Threat in the Execu- with or without changes in federal law.
in 1965, or perhaps even when Abraham tive Branch: Congress did a triple play The SGR debacle, now in its 7th year,
Flexner produced his book-length, seminal handoff (to mix sports metaphors) to the is an unsustainable trend, a collision
report in 1910. agency side, creating three distinct entities course with physicians that sooner, not
that can, and will make unilateral decisions later, get a phase-in treatment. It is not
This article maintains that unless you are about who, where, and when to pay for ser- driving system reform, but rather is
a closeted policy wonk, there is little rea- vices without having to seek Congressional chasing it, if for no other reason than
son to wring your hands over esoteric and permission. because the patches continue to enable
out-of-your-immediate-reach concepts like an expiring payment methodology.
insurance exchanges, long-term health in- Thesis IV: Coming off the Bench? Phy- 2. Medicare’s pilots along the array of
surance and other risk pools, still pending sicians have been mostly on the sidelines ‘quality/value’ options such as episod-
federal transfers to buttress Medicaid or in this game by their disparate views, leav- ic payment, value based purchasing,
SCHIP, or even the tough federal over- ing the major players on the field—hospital pay for performance, and in-patient
sights of the health plans, especially when systems, payers, employers, and others on service bundling-- are on the precipice
the earth is moving in multiple directions the capital-intensive side of the ledger to of widespread adoption. Commercial
under your feet. The following proposes influence the next iterations. And therein payors are quick to adhere to those
five practice-specific, game changing the- lies their opportunity. policies, making any federal change
ses and offers some brief discussion on private-sector-metastatic. Think of
their underlying logic—all rebuttable and Thesis V: Providers Will Get RAC’d: An Never Events as the market adaptive
subject to contradiction—that they are ar- unprecedented consolidation of effort and model. In the fall of 2008, Medicare
guably the more influential factors at the resources by the feds to ‘recover’ fraudu- came up with six ‘never events’ they
exam room level in this phone-book thick lent services or simply overpayments will would not reimburse, and within
body of federal law: round up the usual suspects, then shotgun weeks the commercial payors said
the whole herd and separate the sheep from ‘me too’, followed by several hospi-
Thesis I: Forget Repeal - Get Real: the goats post mortem. Call it , ‘leave no tal systems. One system, Geisinger,
Really more a caveat than an independent outlier behind.’ raised the ante by guaranteeing some
variable in this grand lab experiment: Re- treatment episodes. AHIP has reported
versing what’s been done is problematic at Following that batting order, here is a little considerable interest among the plans
best, given the time lines and institutional more elaboration on the game changers to retool all contracts to an RBRVS
and legal barriers. There will undoubtedly within that medical practice context. methodology, and most contracts al-
be revisions and course corrections, but the ready include a clause hinging Medi-
general policy direction won’t change. Thesis I: Forget Repeal - Get Real: care reimbursement changes to their
It’s not just that those horses have stam- provider fee schedules.

12 wyoming medicine August 2010 Continued on page 26


Inaction vs
In actIon
:

ss The Litigation Center of the American Medical


Association and the State Medical Societies
is committed to protecting doctors and upholding the
highest standards of patient care.

In courtrooms across America, we are achieving legal


victories that preserve the rights of physicians, promote
public health and protect the integrity of the profession.

Whether we are challenging managed care


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autonomy of the hospital medical staff, one thing
remains constant: The Litigation Center is an active
force fighting for physicians’ rights.

Learn more on how The Litigation Center can help you:


www.ama-assn.org/go/litigationcenter

Membership in the American Medical Association


and the Wyoming Medical Society makes the work
of The Litigation Center possible.
Join or renew your memberships today.

www.ama-assn.org www.wyomed.org
WM
community
Continued from page 9

“This should be a process that includes such as pain and suffering, and doctors $300,000 -- is “too low.”
proper credentialing, education, and contend that this lack of “caps” is causing
training for all professionals,” she said, rates for medical liability insurance to Petersen said she is “somewhat open” to
calling for plenty of notice when scope of soar out of control in Wyoming. All six caps on damages if they are high enough.
practice issues are discussed. neighboring states allow caps on damages, She said she isn’t sure what the amount
and all have lower liability insurance rates. should be, but “I certainly do not think
Micheli said it’s important that “we do Wyoming voters in 2004 narrowly rejected that $300,000 is high enough.” She also
everything we can to make sure we have a proposed constitutional amendment that said she was not sure it has been “clearly
quality people” treating patients. “It’s would have allowed the Legislature to articulated” how caps would stabilize or
incumbent on all of us to make sure impose caps, and two candidates - Micheli reduce medical costs, but “overall, I have
people out there are qualified to provide and Meyer - urged the doctors to take up a very open mind on the question, and I
these services.” However, Micheli noted the battle again because they believe the appreciate your comments and wisdom.”
that as a 16-year veteran of the Wyoming political climate has changed.
Legislature, he was not sure how the Gosar said he looks at the issue as a patient
legislative logistics would allow for a one- “I would encourage you not to give up on and health consumer and thinks that “a
year notification period. this, and I would hope that the Wyoming common sense approach” is needed. “You
Medical Society would not back off on this have the world you would like, and you
Petersen issue,” Micheli said. “I believe you cannot have the world you have,” he said. “The
agreed the have a meaningful discussion about health- people of Wyoming rejected health care
sunrise care reform without a discussion about tort reform…. The Medical Review Panel
concept reform.” seems to me a common sense approach….
“is a grand (that could avoid going to court and
idea” and Meyer termed herself “a vocal advocate encouraging people) to sit across the table
said she for tort reform” and charged that medical and talk.”
certainly liability concerns “continue upward
is for pressure on the cost of health care.” Health IT hot topic
appropriate “It will not resolve all of our health care All six candidates voiced support for
credentialing of all health-care issues, but it is part of the equation,” she expanded use of information technology
practitioners, but she noted that “few things said. “We are surrounded, as you know, by in health and medicine, though they were
fly through the Legislature” anyway. “I can other states that have initiated tort reform, a little short on how to pay for it. “This
see where it would be very advantageous, and it’s working in those states.” is an opportunity for Wyoming, not only to
but in actuality I would think it’s unlikely,” help people but also to increase jobs,” said
she said. Review Panel alternative? Gosar. “I think that’s the future … and can
Mead said he hopes recent efforts to make your jobs (as doctors) easier.”
Simpson noted he has dealt with “quite a strengthen the state’s Medical Review
few scope of practice issues” during his Panel will help limit frivolous lawsuits and Mead agreed, calling health IT “vital” to
legislative tenure, and he said he wants avoid rising costs, but he said he views Wyoming. But he stressed that the state
to continue working with WMS on those tort reform as a “critical issue” because of must provide for uniformity in electronic
issues, because “patient safety is very the importance of quality health care for medical records. “We cannot have multiple
important.” But he said a one-year notice Wyoming residents and the importance systems,” he said. “The state has to take
requirement is “probably unrealistic.” of quality health care in economic charge on this. The state has to provide real
development and physician recruitment. leadership on this so we’re all on the same
New look at tort reform? page.”
The six candidates were less in agreement Simpson, viewed by many doctors as a
over alternatives to achieving meaningful tort reform opponent, said he voted for Meyer followed, saying the call for state
medical liability reform in Wyoming, the legislation in 2004 and is “open to leadership is fine, but the “big, big gorilla on
but they all appeared open minded to conversations and negotiations” about the backs of health-care providers is who’s
discussing alternatives. the issue, though he emphasized he also going to pay for it.” Some federal stimulus
believes “very strongly in personal rights dollars are available, but they won’t be
Wyoming’s medical liability laws do not and the right of a jury trial” and believes enough, she warned, “and there are vendors
limit damages for non-economic losses, the amount of the cap suggested in 2004 -- out there just waiting to snooker you.”

14 wyoming medicine August 2010


community WM

Micheli, noting that former Gov. Jim people for Wyoming. She also praised its and
Geringer was way ahead of his time in emphasis on preventive care and patient continue
connecting communities with information co-pays, ensuring that they “have a little to look at
technology, said health IT is “of the highest more skin in the game.” utilizing
importance.” “The trick now is to make primary
sure we have programs that talk to each Simpson supported the bill in the 2010 care
other,” he said. session and said, “It’s targeted and it should physicians
work well. It’s got great possibilities, and to monitor
Petersen also agreed that health IT is a it is a fine example of what states can do.” total care for their patients.
“high priority” for Wyoming and said the Gosar said, “Creative solutions are what
question really illustrates what Wyoming we need. I’m a big believer in personal Gosar said he thinks the state can help
needs to do overall with technology. “Our responsibility.” health practitioners avoid “death by a
whole future relies on being on the cutting thousand cuts” when routine makes a
edge,” she said. Specifically regarding Mead called it a “great project” and a model job less fresh and desirable, and he also
health IT, she said the state “very much has for “what we should be doing.” suggested possible state support for air
to take a leadership role, and it will take service for patients.
money.” Meyer, answering last, quipped, “I share
their love.” Mead said, “The state is involved in
Simpson noted his support for health IT in comprehensive health care, it’s a question
legislation he sponsored three years ago “There is no reason why Wyoming should of degree and how well we are doing.
and pledged to continue helping hospitals not be a leader in health-care reform,” she Good health care in Wyoming is not just
and physicians to expand health IT. “It’s added, calling the pilot project a small step a quality of life issue, it’s an economic
a wonderful opportunity for you and your that “could help us emerge as a leader.” issue.” He also said the state needs to lead
patients,” he said, “but I also understand in establishing electronic health records.
how it can burden you.” Comprehensive care
The final question asked candidates what, if Meyer said she sees medical care “kind of
Docs & patients, pilot project any, should be the state’s role in supporting coming full circle again,” with primary care
The candidates quickly followed Meyer’s comprehensive patient care in Wyoming, physicians using the concept of medical
lead in decisively answering “no” to a such as dental care and critical access homes and monitoring the total health of
question whether it would be “appropriate hospitals and trauma care. It stumped their patients. “People don’t expect to get a
for the state government to legislate some of the candidates but gave them an heart transplant in Thermopolis, Wyoming,”
or influence what takes place between opportunity to reiterate their support for a she said, “but they expect access to some
physicians and their patients?” That strong health-care system. level of care that incorporates a look at
relationship is “sacred,” several said. “I confess that I’m not able to easily answer themselves. Telemedicine will absolutely
this question,” said Petersen, the first to leverage these efforts.”
All six candidates also were unanimous answer, “but the state has to be nimble
in their support for a health pilot project and supportive of our doctors. I think that Micheli, the final speaker of the morning,
approved by the Legislature earlier this training and philosophical support of the said the state’s greatest role in supporting
year, Healthy Frontiers. The demonstration medical community is at the core of what medicine is in support for telemedicine.
project is intended to create a model for the state should be doing.” “I think Wyoming could be a leader in
health insurance and preventive health promoting telemedicine,” he said. “I think
care services designed to hold down costs, Simpson said the Legislature has been we have wonderful opportunities to do
decrease utilization and keep Wyoming struggling with comprehensive patient that.”
residents healthier. care for decades. “The state does have a
role in supporting comprehensive patient The field will be narrowed to two on Aug.
Micheli said the project addresses a very care because those hospitals can’t carry it 17. WM
critical problem in the state, and “as a state, themselves, and we are treating those who
we need to stand up and give it a shot.” are least able to help themselves or pay for Dennis E. Curran is publisher of the
that type of care,” he said. He also said the Wyoming Business Report, where a story
Petersen said the pilot project is state should continue supporting the five- about the WMS candidate forum appeared
“innovative” and was created by Wyoming state WWAMI medical education program in the July issue. He can be reached at
dcurran@wyoming.com or 307 638-3200.

August 2010 wyoming medicine 15


Wyoming medical sTUdenTs
a closer look By: Jonathan Green

Tyler Quest wants to be a doctor. That may care medical school by US News & World Lowe and Quest will pay $12,000 a year
be the easy part. Report, and in the top ten research medical for four years of medical school through
schools,” Quest notes. “Consistent” might the program, while the University of Wyo-
Quest also wants an excellent education be an understatement: Washington has ming will loan them the difference be-
at a top-notch school. He wants to avoid held the top spot for 16 consecutive years. tween that price and what UWSOM would
finding himself in a student loan hole mea- charge them as non-resident students. That
sured by dollars into six figures. He wants A good start indeed. But what about pay- difference was about $145,000 in 2009,
very much to help lower health care costs ing for that world-class education? according to a WWAMI fact-sheet.
in his native Wyoming without lowering
the quality of care. Enter WWAMI. An alliance of universi- If Quest and Lowe return to Wyoming af-
ties in Washington, Wyoming, Alaska, ter receiving their MDs and practice here
Elise Lowe also for three years, UW will
wants to be a forgive the loan.
doctor. Wit-
ness her eight Good school? Check.
years on ski Affordable? Check. A
patrol, her EMT chance to return to, and
certification help, Wyoming? Check.
and a fortnight
spent translating elIse lOWe
for a doctor in “I have wanted to be a
Honduras. Like doctor for as long as I
Quest, Lowe can remember,” Elise
is interested in Lowe says. “Growing up
quality educa- in the mountains of Wyo-
tion supported ming” – Lowe is from
by small class Sheridan – “I developed
sizes. “I love the a love of the outdoors as
Rocky Moun- well.”
tain West,” she
says, and would Even with her under-
like to prac- graduate, let alone med
tice medicine school and residency,
in Wyoming. studies still years ahead,
Money – read Lowe dove into the field.
“cost” – is also She says ski patrolling
important, but her goals are “much greater Montana and Idaho, the program gives is “the perfect combination” of her dual
than just the financial aspect.” students like Quest and Lowe a chance to loves of medicine and the outdoors.
study at UWSOM and at home. Wyoming
What to do? students spend their first year of medical “It gave me an introduction to patient care
The University of Washington’s School of school at Laramie, their second in Se- and affirmed my desire to be a physician,”
Medicine (UWSOM) seemed a good place attle and two more years at clinical sites Lowe says. “I took the course during
to start. “The School of Medicine consis- throughout the region. my sophomore year of high school and
tently ranks as the number one primary patrolled for the next eight years until

16 wyoming medicine August 2010


around wyoming WM

medical school.” shadows her ambiguity over which path state-sponsored telepsychiatry pilot project
Lowe says patrolling the slopes will to take toward her MD. “While I greatly from Sheridan. This fall, she begins her
continue to be a passion for her; she plans appreciate my experiences in emergency second year of medical school in Seattle.
to return after she earns her MD. She is medicine, my focus has gradually shifted
appreciative of the exposure to medicine more to public health. I have not decided Tyler Quest
the work offered her. “Patrolling opened on a specialty yet, but I am interested Tyler Quest, like Lowe, has long been
doors to me,” she says, including a chance in infectious disease, epidemiology and attracted to medicine. “I attended the Uni-
to shadow docs in the ER and riding in system-wide solutions to common medical versity of Wyoming for my undergraduate
n ambulances on occasion. problems.” studies and basically wanted to attend
medical school for most of my life (with a
Those ride-alongs propelled Lowe into her Regardless of which specialty she chooses, few other thoughts from time to time).”
next medical foray. “I loved emergency because of her shared medical and out-
medicine and got my EMT license as soon doors interests, WWAMI has long been “a Quest agrees with Lowe that the variety
as I turned 18,” she says. She has since natural choice for me,” Lowe says. and quality of opportunity in the WWAMI
helped transport psychiatric patients via program was a big factor in his decision to
non-emergent air ambulance, volunteered “The support we get through the program enroll. “What many people don’t know is
at the Missoula County, Mont., Search and is much greater than just the financial that Wyoming actually has first year medi-
Rescue and worked for the Missoula city aspect,” she says. “The small class size cal students being educated at the Univer-
ambulance. There was also the two week allows us to have access to our extremely sity of Wyoming each year.”
period in Honduras, in 2007, where Lowe qualified and motivated faculty. We are
says she was inspired “seeing the large provided with all kinds of resources and “Out of (the WWAMI participating) states,
public health impact of small, well orga- supported in all aspects of our education.” Washington is the only one with a four-
nized programs and infrastructure.” year medical program, and therefore a
Lowe is currently fulfilling the research need was identified to give students from
Lowe’s varied palate of experience fore- requirement of her MD working on a the other four states an opportunity to have

Continued on page 18

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A3009_WY_Medicine.indd 1 7/26/10 2:34 PM


WM
around wyoming
Continued from page 17

a more ‘in-state’ experience.” up as one of its biggest boosters. “I learned about WWAMI at a
Quest, also preparing to begin his second year of medical school lunch meeting former students sponsored during my freshman
this autumn, points out the number of prospects he will have to year of college, and have been amazed by it since.”
choose from in his third and fourth years. “Students spend their
time doing clinical rotations in various fields. (We) have the op- “I believe in the mission of WWAMI, to bring physicians back to
portunity to complete these clinical years both at a large medical the state. This not only reduces health care costs in the state, but
institution such as the University of Washington, as well as at also allows for a happier and healthier population with physicians
several different towns and hospitals out in the five state region.” that have received the finest of training.”

Perhaps auguring his own future plans, Quest continues, “Often Program execution also weighed on Quest’s mind in choosing the
students spend part of their (clinical) years in Seattle, then move WWAMI route. “A first year medical school class of 16 students
to a state like Wyoming and do a rotation, then Alaska, et cetera. allows for a great deal of one-on-one instruction and creates an
extremely close knit group of colleagues that can depend on one
“This allows for students to learn in a large hospital with many another for the rest of their life and career.”
students and physicians, as well as practice in a small, rural town,
which might only have one physician and you.” “Wyoming WWAMI is especially unique in that it allows stu-
dents to be paired with a physician preceptor in a one-on-one
“Many people also do not realize that students are allowed to do setting once a week throughout the year.”
their residency training anywhere in the world before coming
back to work in Wyoming. I greatly look forward to spending With classes set to resume soon, Quest is looking forward to
some time in Seattle and someday returning to practice in Wyo- Seattle and is gracious for his experiences in Laramie. “I had a
ming to help care for its population.” great time my first year and am very thankful for the experiences,
faculty, staff and students.” WM
Quest is not a circumstantial benefactor of WWAMI, but shaping

18 wyoming medicine August 2010


legal WM

Negotiating Reimbursement
In A Payor Contract
Not Mission Impossible, And You Should Choose to Accept It.
James (Jim) Dobbyn Nick Healey, JD
Physician Practice Management Healthcare Services Dray, Thomson & Dyekman, PC

Negotiating or renegotiating a payor con- could (and should) be negotiated does not an “out-of-network” provider, or the payor
tract for your medical practice can be one occur to them. Even if the practice feels it may do a good job of promoting its net-
of the most important steps you can make is not being reimbursed fairly by a particu- work of providers. Therefore, there is usu-
toward improving the practice’s financial lar payor, many physicians would prefer to ally some advantage to being a “preferred
health. In the current healthcare reim- concentrate on improving financial areas of provider” for a particular payor.
bursement environment, physicians may the practice in which they feel comfortable
(justifiably) feel that their medical prac- than renegotiate. Negotiation implies con- The “Preferred Provider”:
tice’s financial viability is being threat- frontation, which is not only uncomfort- What’s the advantage?
ened. Most medical practices are finding a able, it goes against many physician’s basic Many practices want to be “preferred pro-
larger percentage of the fees they receive natures. Conflict is rarely part of the heal- viders” for payors, fearing exclusion pa-
is fixed. There is little (or no) room for fee ing process in which physicians are trained. tient sources if they are not. However, it
flexibility with Medicare and Medicaid, Likewise, negotiation implies haggling to is worth recognizing that agreeing to be a
combined with the ever present threat (and some physicians, which is distasteful and preferred provider means agreeing to the
reality) of cuts to the Medicare Physician clearly not why they got into medicine payor’s reimbursement schedules, and thus
Fee Schedule. As national economic chal- in the first place. Thus, many physicians, giving up some measure of autonomy in
lenges mount, health care providers find whether consciously or unconsciously, al- your practice. In making this decision, you
themselves with a greater percentage of un- low the reimbursement levels in their payor should give thought to the following:
insured, underinsured or “no pay” patients. agreements to stagnate or worse, decline.
Physician practices need to look hard at the However, looking at your practice’s reim- • How many patients in your market
financial areas over which they have some bursement levels is one of the best ways area are covered by this particular
control, and try to maximize those areas. to ensure you have the healthiest practice payor?
One of these areas, whether you feel it or possible. • How many providers in your special-
not, is fee reimbursement. ty area already have preferred provid-
Step One: Deciding To Renegotiate. er contracts with this payor?
Prelude: Physician, Heal Thyself. The first decision is one that is usually tak- • What other health entities (i.e. hospi-
Medical practice reimbursement is a hydra, en as a given by health care providers, but tals, surgical centers, DME compa-
the multi-headed beast of myth. It encom- it is one of the most important: Should your nies) have preferred provider agree-
passes financial issues, community service practice have a preferred provider agree- ments with a particular payor?
issues, and patient access issues. Any of ment with a specific payor? Becoming a • If you decide not to be a preferred
these issues is worth writing an article on. “preferred provider” or “in network” for a provider, are there significant admin-
However, this article focuses on addressing payor means that, in return for agreeing to istrative and billing challenges for
the financial implications of deciding to, the reimbursement rates offered by a pay- your practice if you treat patients that
and following through on, renegotiating a or, the payor agrees to give you access to see you “out-of-network”?
commercial payor contract. patients that you may not otherwise have. • Do you have the capacity in your
Patients, by and large, will usually go to a practice, in terms of volume, to han-
Reimbursement is an area that many phy- “preferred provider” for their payor over dle the additional patients that may
sicians overlook when determining how to an “out of network” provider. There can come with being a preferred provider,
improve their practice’s financial health. be many reasons for this; the payor may and if the answer is “maybe”, do the
Reimbursement rates are often taken as a require the patient to pay more of the cost reimbursement rates you will receive
“given” by physicians. That those rates of treatment out-of-pocket if provided by justify the added cost of treating
Continued on page 20
August 2010 wyoming medicine 19
WM
legal
Continued from page 19
Step Two: Review The Payor provision to see if you can terminate the payors will propose a percentage multiple of
Agreement. agreement prior to its expiration. Most pay- the Medicare fee for a particular service. In
If you’ve decided that your practice should or agreements have some type of “without theory, it may sound good to receive 130%
be a “preferred provider” with a particular cause” termination provision, meaning that or 140% of Medicare’s fee schedule; how-
payor, the next step is to review and under- either party can simply terminate the agree- ever, no physician needs reminding that
stand the terms of that relationship, includ- ment without either party having done any- Medicare’s fee schedule is under constant as-
ing the reimbursement levels. These are thing wrong. Many such agreements require sault from Congress, and that Medicare rates
set out in the provider agreement that you that you give written notice (such as 90 days) are typically lower than many commercial
(should) have with the payor. With an exist- before terminating the agreement, although payers. The best option for many practices,
ing payor relationship, pull out your current the timing and notice requirements may be therefore, is to negotiate to be reimbursed at
agreement and make sure you understand complicated and the termination option may a multiple of your own fee schedule. This
the terms you have in place. If you are es- only be able to be exercised at specific times. gives you more control over your fees. Re-
tablishing a new “preferred provider” rela- You should consult with your legal advisor view your own existing fee schedule and
tionship with the payor, ask for a copy of the before terminating the agreement, as there make adjustments before meeting with the
payor’s standard plan agreement. This may are potential downsides to termination that payor.
or may not include a proposed fee schedule, should be considered. However, if you have
but will give you the standard “boiler plate” gone through the analysis above with respect Once you have determined the best pay-
from which to start. to whether you need to be a “preferred pro- ment methodology for your practice, you
vider”, then you will be in a good position need to determine what you will accept for
How long is it, and can I get out? to know whether the potential benefits are reimbursement. Typically, the basis for re-
If you have a current agreement, start with worth the potential downsides. imbursement will be a specific fee for each
determining the “term and termination” current procedural terminology (CPT) code.
provisions of the contract. This will control Step Three: Make Contact Make sure you use the same CPT codes
how long the contract is in effect and when With the Payor used by Medicare (resource based relative
(and if) you can renegotiate. Some contracts Once you understand the various terms of value scale (RBRVS)), which is the stan-
can be very restrictive as to your time frame the existing contract or standard contract, it dard with most medical practices. There are
for re-negotiating. Typically, the “term and is time to meet with the payor’s representa- other companies who attach different rela-
termination” provisions are viewed as “boil- tive. tive value scale (RVS) values to CPT codes,
erplate” and thus either unimportant or not such as Ingenix, which is favored by some
able to be changed anyway, and so not worth At the initial meeting with the payor repre- payors. However, using different RVS scales
being concerned with. However, ignore the sentative, be prepared to discuss the changes will make the process of comparing data
“boilerplate” at your peril! Some of the in the terms of the agreement you are look- with the payor extremely difficult, and you
most important parts of the contract can be ing for. These should include: will probably come out worse off compared
“boilerplate”. This does not mean, though, to the payor.
that they are (a) not important or (b) unable 1. How the practice will be reimbursed
to be changed. for services rendered; Step 4: The Cost of a Pound
2. How much the practice will be reim- of Flesh
The contract language probably does not al- bursed for services; Generally, the fees you request should be rea-
low you to renegotiate reimbursement levels 3. Opportunities for periodic review of sonable for the services you provide. Your
whenever you want. However, it may allow the reimbursement levels; fee schedule, by CPT code, should reflect
you to renegotiate at specific intervals (ie. an- 4. What services are covered; the maximum fee level you charge patients
nually). If the agreement does not give you 5. The term of the agreement and the for specific services. Those fees should be
any reasonable options for renegotiation, termination clauses; determined by examining the market, your
you may have to go to the payor and ask to 6. Possible “special project” arrange- position in the market, the demand for your
discuss renegotiation. Some payors will be ments you may like to see with the services, and the cost of services you pro-
cooperative and work with you on renegoti- payor. vide. As discussed above, practices are re-
ating reimbursement levels. After all, it does ceiving more and more pressure from fixed
not help payors to have networks full of How the practice is reimbursed for services revenue sources in reimbursement. When
physicians that harbor a grudge against the can be as important as how much. Some working with payors, you should examine the
payor. Other payors may be more restric- payors like to use fee schedules that they’ve entire mix of fees you receive and how that
tive. If so, check to see when the agreement developed, and may try to insist on using impacts the overall practice reimbursement,
expires. If it does not expire soon, and you those in the agreement. While this may and remember that payors are competitors
want to renegotiate, you may be forced to seem like a small issue, using the payor’s fee that should be competing with each other.
move into the termination process to rene- schedule takes control away from you on ad- Therefore, one strategy is to look at trying
gotiate. Check the agreement’s termination justing fees and gives it to the payor. Other to develop parity between payors in terms of

20 wyoming medicine August 2010


legal WM

what you are reimbursed for the same CPT ture, the next step is to consider what level potential clients, and just like the providers,
codes. of reimbursement you will accept from a payors have motivations other than simply
payor under that fee schedule. Although the the fee schedule. Most payors are willing to
Legal Note: ultimate goal may be to receive full (100%) work with a practice if the practice is reason-
Don’t seek reimbursement information from reimbursement of your fee schedule, that’s able in its requests.
physicians in your community to determine probably unlikely. The proportion you ac-
what you should charge. cept is ultimately up to you; however, 90% While this article has focused on preparing
of your fee schedule, if it is reasonable and to negotiate payor agreements, the payor’s
When trying to determine what is reason- you have taken care to prepare it according response, and the course and conduct of
able to accept as reimbursement, you may to the steps outlined above, is not unreason- negotiations with the payor once that prepa-
be tempted to simply call colleagues at other able. ration and initial meeting have happened, is
medical practices in your community and ask unpredictable. However, if you have pre-
what arrangements they have with the par- Also, payors may have different levels of pared as set out above, and considered all the
ticular payor you’re negotiating with. After flexibility on different CPT codes, so be issues discussed above, you should be much
all, they are likely your friends and colleagues, aware of the volume of your business that is better prepared than you would otherwise be
and the payor has the information in any being generated by specific CPT codes. It is to handle whatever surprises come your way.
case, since it contracts with all of you. RE- not uncommon for 80% of a practice’s vol-
SIST THE TEMPTATION! Other phy- ume to be concentrated in 20% of the total Conclusion: It’s In Your Hands!
sicians may be your friends and colleagues, number of CPT codes used in the practice. As you can tell, negotiating or re-negotiating
but they are also, from a legal perspective, For instance, a primary care practice prob- a payor agreement can be very challenging
your competitors. Sharing price informa- ably generates a significant amount of its and requires a strong understanding of your
tion between competitors can be viewed as volume and income from CPT codes 99213, practice’s economics, your marketplace, the
the first step to price-fixing among competi- 99214, 99203, and 99204. In a surgical prac- contract language and how it achieves the
tors, which is unlawful under both state and tice, most of the volume and income is con- practice’s goals. However, the best advice
federal anti-trust law. Moreover, the Federal centrated with 10 to 15 CPT codes. If you that can be given, at this point, is that you
Trade Commission, responsible for enforc- are unable to obtain the target percentage of are not powerless in your relationship with a
ing the federal anti-trust laws, has actively your fee schedule that you hoped for with the payor. Nor do you have to be a bully, shout
enforced those laws in the Rocky Moun- payor, consider focusing on the CPT codes or scream in order to be able to negotiate ef-
tain Region in recent years among physician you use the most. Although most plans try fectively. Think about your practice’s goals,
groups sharing pricing information and at- to keep the formulas for reimbursement sim- how those can be achieved and be willing to
tempting to negotiate reimbursement rates ple, and would prefer not to negotiate differ- request specific language and commitments
as a group. In two recent examples, the ent reimbursement percentages for different in payor agreements. You are entering a
FTC entered into consent decrees (essen- CPT codes, it is an option to suggest in ne- partnership of sorts with the payor, and the
tially official settlement agreements) with gotiations. Again, the factors above need to best partnerships are founded on expecta-
two Colorado independent practice associa- be examined in determining what to suggest. tions and commitments that are fair, clearly
tions (IPA’s) the Boulder Valley Independent You should also require contractual language stated and understood by both sides. You
Practice Association (IPA), in 2008, and the that gives you flexibility in adjusting your fee therefore want as much clarity as possible
Roaring Fork Valley Physicians IPA in 2010, schedule from time to time, such as every six in the relationship, which is documented in
to stop those physician groups from shar- months or annually. The payor may want to your payor agreement. The payor also wants
ing pricing information among independent cap the percentage by which fees can be ad- (and probably needs you) as a provider to un-
physician practices and engaging in collective justed in this time period, or may want con- derstand the relationship and wants the least
negotiations with payors. Also, don’t assume tractual language locking you in to the term amount of confusion about your respective
that the FTC will not set its sights on Wyo- of the contract. However, your goal should roles and responsibilities possible. The end-
ming. While the Boulder Valley IPA oper- be obtaining the greatest flexibility for fee game of this process is for you, as a provider,
ated in Boulder, a fairly major metropolitan adjustment. The ideal situation is to be fairly to be compensated fairly for the services you
area, the Roaring Fork Valley IPA operated reimbursed for your services without mak- provide and not to have payor contractual is-
in Glenwood Springs, Colorado, which is not ing you an outlier compared to other simi- sues interfere with the patient/physician re-
so different from many towns and cities in lar practices. Remember, in most cases, the lationship. Although that is a simple goal, it
Wyoming. Therefore, it is clearly better to payor has the same (or even greater options) is not an easy one to accomplish. However,
avoid sharing such information, or seeking it to terminate the relationship, with or without with the preparation and forethought set out
from others. The better course of action is cause, as you have. It is not advisable to be above, it is possible, and you’ll be the better
to obtain such information from national or on a payor’s radar screen because your reim- off for having done it. WM
regional surveys, if possible. bursement levels are unreasonable. Payors
want to have preferred providers in their net-
Once you have established your fee struc- works, which makes them more attractive to

August 2010 wyoming medicine 21


recognition WM

Nick Morris, MD of Powell was selected In addition to dedicating efforts toward the care of Powell patients,
by the Wyoming Medical Society as the Dr. Morris has committed countless hours to the citizens of the
recipient of the 2010 Community Service Powell area through his work with the Heart Mountain Volunteer
Award. This award is presented each year Medical Clinic, a free clinic in Powell that will celebrate its 2nd
to Wyoming’s top physician in recogni- anniversary in early July. He has clearly always gone the extra
tion of their contributions to Wyoming mile to provide quality services to the citizens of Powell. “Nick
communities, honoring the physician for Morris, MD is a tireless advocate for his patients and his com-
time and personal sacrifice for the benefit munity. The Powell medical community is fortunate to include
of the community. him in our ranks,” said Robert L. Chandler, MD of Dr. Morris.
Students at many levels of education have been encouraged by Dr.
Dr. Morris is a beloved member Morris to play a role in the opera-
of the Powell community and tion of the clinic. High school
has been nothing but a beacon and college students alike have
of honesty and integrity. In a learned by shadowing. A Pow-
letter of support for Dr. Mor- ell High School graduate who
ris’ nomination, Powell physi- is pursuing her advanced prac-
cian, Michael Tracy, MD wrote, tice nursing degree spent sev-
“Dr. Morris is incredibly em- eral weeks at the clinic. Bryn
pathic and is truly the epitome Parker, a third year medical
of a ‘small-town’ surgeon. He student in the WWAMI pro-
has a deep commitment to his gram, spent every Tuesday
patients, and he responds with night of her five month rotation
grace in all situations from trau- in Powell volunteering at the
ma calls to being asked a ques- clinic. Dr. Morris has created
tion in the check-out line in the an atmosphere that will shape
grocery store.” He has served Left to right: Nick Morris, MD, Bryn Parker, Mike Tracy, MD, Mark Wurzel, MD the future of healthcare in a
the community in many positive fashion.
leadership roles, including serving as the Chief of Staff at Powell
Hospital, Past Hospital Board Member, and Board member of a Dr. Morris has practiced medicine in Wyoming since 1991. He
local philanthropic foundation. received his undergraduate degree from Pennsylvania State Uni-
versity and later completed his medical school training at Temple
He is well respected by his patients and peers across the Bighorn University Medical School in Philadelphia, PA. Dr. Morris com-
Basin and the referral hospitals in Billings. Dr. Morris has consis- pleted his internship at
tently received positive feedback as a teacher of medical students Dartmouth Affiliated Hospi-
through the WWAMI program. tals in Hanover, NH and finished his medical training with a gen-
eral surgery residency at Episcopal Hospital (Temple University
Former students have commented on how they benefited from his affiliate). Dr. Morris shares his joys with his wife Madelyn and
knowledge base, professional demeanor, and work ethic years af- their four children Trish, Sherry, Chris and Matt. He has a new
ter their rotations with Dr. Morris. A former WWAMI student kayak and plans to do more fishing and paddling out of reach of
from Wyoming, Dr. Nathan Rieb, has moved to Powell to be the his cell phone. WM
community’s general surgeon starting in September 2010. Dr.
Morris will remain in the area in a mentorship role as he retires
and Dr. Rieb begins his career in Powell.

August 2010 wyoming medicine 23


WM
cover story
Continued from page 11

interview skills. “Four years ago we care (and number two in research funding) make convincing argu-
barely had 10 qualified applicants. ments for continued legislative support for WWAMI, Dr. Hillman
This year, we had 16, plus 11 on said.
the alternate list who were just as
good,” Dr. Hillman said. In fact, he He said the WICHE program had just 4-5 students a year, with
said, the Wyoming only a 23 percent return rate.
Legislature will be asked to expand
Paul Johnson, MD ~ WWAMI Graduate funding to 20 students. Wyoming also tried a contract program to send a handful of stu-
dents each year to medical school at the University of Utah and to
The WWAMI arrangement depends on the continued good will of Creighton University in Omaha. That did have a payback provi-
the Legislature. “Of all the things I’ve seen the Legislature do for sion, but it lacked the rural orientation, and the return rate was
30 years, there’s been more bang for the buck with WWAMI than about 45 percent, Dr. Hillman said.
with anything else I’ve seen,” Dr. Hillman said. “This is much
more cost effective than $20 million to start a medical school.” For a brief time in 1999, a proposal by New York millionaire Rob-
ert Ross to build a campus in Casper for a Carribbean-based unac-
In fact, the Legislature did consider a proposal by the University credited for-profit medical school had support from the governor
of Wyoming in 1978 to fund a medical school, to respond to the and several lawmakers in Wyoming.
chronic shortage of rural health care. Fifteen state senators con-
cluded the state lacked the money and population to support a The shortage of physicians in Wyoming is chronic. Scott, Hillman
medical school, and they effectively blocked the funding. The idea and others point to the peculiar nature of rural practice, the pe-
died with that session. culiar Medicare reimbursement formula that short-changes rural
providers and the failure of medical liability insurance reform as
Soon after, the Legislature created the UW Family Practice Resi- possible contributors to the shortage. Meanwhile, the average age
dency Program clinics in Cheyenne and Casper, with the aim of of physicians in Wyoming is 51, and about 20 percent plan to retire
attracting newly graduated family physicians to a residency pro- within the next five years.
gram and then to practice in Wyoming. In the 1980s, as Wyoming
headed into its own recession, some legislators argued for the clin- Back in the early 1990s, the alarm over the shortage seemed to
ics’ demise because they didn’t make economic sense. But they get renewed attention in Wyoming. It was the dean of the newly-
survived, largely on the merit of providing health care to an under- formed College of Health Sciences at the University of Wyoming
served, poor population in the two cities. who took the first steps toward WWAMI, Curran recalled. Dean
Martha Williams assembled the healthcare stakeholders in Wyo-
State Sen. Charles Scott of Casper, who has served in the Leg- ming, and together they looked at the University of Washington
islature since 1979 and is chair of the Senate Labor, Health and and the program as it was working with Alaska, Montana and Ida-
Social Services Committee, remembers those legislative fights as ho – making it WAMI (with one “W”). “Of course they all raved
being motivated at least somewhat by regional rivalries. Sen. Scott about how wonderful it was.”
considers the family practice centers an important piece of Wyo-
ming’s effort to attract primary care physicians – wherever they The Wyoming Medical Society and UW drafted an agreement
are grown. and built support among legislators, hospitals and policy-makers
around the state to join the program. The Wyoming Legislature ap-
WWAMI has begun using the UW Family Practice center in Chey- proved the funding in 1996. Wyoming began the program with 10
enne for clerkships in family practice, and students who serve their students in 1997, later expanding to 16.
post-graduate residencies there have their repayment obligation re-
duced from three to two years. The UW Family Practice center in Dr. Hillman said WWAMI administrators and faculty are con-
Casper is an essential part of primary care for the state’s second- stantly reviewing
largest city, Scott said, and now it operates jointly with the feder- the curriculum and
ally funded community health center. working on im-
provements, includ-
The Legislature previously used the Western Interstate Commis- ing increasing the
sion for Higher Education program (WICHE) to help Wyoming class size from 16
students attend medical school. Lawmakers continue to help pay to 20. “We’re try-
tuition for other health care programs, but state funding for physi- ing to develop the
cians is focused on WWAMI. The high rate of success for bringing program so it em-
Wyoming doctors back to Wyoming and the ranking of the Uni- phasizes the needs
versity of Washington’s medical school as number one for primary of Wyoming,” he
Jackson Sullivan ~ Future medical student... or pilot

24 wyoming medicine August 2010


cover story WM

said. One push is to make a seamless program for primary care “Our goal is to prepare quality physicians from Wyoming who
and family medicine, so a student would start out at the University want to come back to Wyoming in every specialty, family medi-
of Wyoming and perhaps get early admission to a family medicine cine through neurosurgery, because we need all of those.” WM
residency in Wyoming. Another push is to increase graduate medi-
cal education -- residencies – in Wyoming, which is difficult with
such a small population.

The Beginning of Wyoming’s


Medical School Story
By: Marguerite Herman

In 1978, as now, Wyoming struggled with the floor. Sen. Rex Arney, a Sheridan at- opposed to a medical school, we feel it is
the lack of doctors, and the Wyoming Leg- torney, was in the chair for Committee of critical that we inform you and members
islature seemed to like the idea of the Uni- the Whole that day and didn’t vote. A 15-15 of the House that we will not support any
versity of Wyoming creating its own com- stalemate defeated every attempt to restore compromise resulting from this special ses-
prehensive medical school and facilities. the funding or keep $690,000 for medical sion that will leave the door ajar, thus post-
At least the House of Representatives liked school staff and planners for one year. “We poning a decision on behalf of the people
it and included it in a section of the state couldn’t get off the 15-15 vote,” Sadler of Wyoming for another year. Specifically,
budget bill that funded UW, but that’s as said. we will not vote for an additional year’s
far as it got. funding to retain medical school staff and
Arney remembers three House-Senate con- planners. We take this opportunity to for-
The Senate Appropriations Committee de- ference committees that met without suc- ward to you this statement, and the realities
leted medical school funding, and that’s cess, and the Legislature adjourned with no of the situation with sincere hopes we can
how the bill came to the floor for debate. budget for the University of Wyoming for avoid an unfortunate re-enactment of the
the next two years. Ninety days later, Gov. deadlock of the House and Senate as was
In the 30-member Senate, 15 lawmak- Ed Herschler, who had supported the med- experienced in the recent budget session.
ers were resolutely against the idea. They ical school idea, called the lawmakers back Regards,
feared the cost of a medical school in poor for a special session to pass a UW budget. (Signed by each of the 15)
economic times (which occurred 10 years The medical school funding was gone from
later). “I think it would have broken the the bill. That was that.
state,” says Dick Sadler of Casper, 81, who
was one of two Democrats who voted with Sadler said the 15 opponents never formed Sadler thinks at least some supporters were
13 Republicans to oppose funding. They an official block, but for this special session acting out of loyalty to UW. Meanwhile,
also doubted the students in such a sparse- they issued a joint statement, addressed to he said, “I didn’t think we could afford it,
ly-populated state would get experience House Speaker Nels Smith, to make sure and I wasn’t about to change my mind.” He
with the number and variety of diseases everyone understood the score: does recall feeling bad, however, when he
necessary for a good medical education. got up to speak against the medical school
Because of a rumor that a new medical proposal, with his family physician being
Those 15 approved removal of funding, school proposal would be acceptable to the “doctor of the day” and present in the
and they outvoted the other 14 senators on one or more members of the 15 senators Senate chambers. WM

August 2010 wyoming medicine 25


WM
national perspectives
Continued from page 12

3. Integration and consolidation of ser- all its incumbent efficiencies. The federal tients and the general public in making
vices were accelerating well in ad- policy engineers demonstrably don’t intend health care decisions as to what ser-
vance of the federal law as a means of for every physician to be retrofitted into a vices and procedures are more or less
economic survival. Physicians are mi- Mayo, Kaiser, or Geisinger system. In ad- ‘comparatively effective’:
grating into integrated systems, more dition to substantial financial incentives • Such findings may not include
often than not as employees, hospitals for primary care services, medical homes, practice guidelines, coverage
are buying up physicians and smaller and restoring that pipeline, the law contem- recommendations, or payment or
hospitals, especially the now capped plates the semi-organized consolidation of policy recommendations. There
physician investor hospitals, at fire smaller practices in Accountable Care Or- is no requirement that the find-
sale prices, and the plans continue to ganizations. Whether they are the firewall ings communicated to the public
eye each other as prospective owners. to protect that endangered species of small be consistent with U.S. Food and
Market share is acquired, not won and solo group practice or yet another rein- Drug Administration approved la-
through vigorous competition. vention of the clinic-without-walls, ACOs beling of regulated products.
4. EHRs are still due by 2015, and the have the full force of federal law behind • Federal payers are not prohibited
meaningful use criteria have been of- them. It enjoys considerable grassroots in- from using research findings to in-
ficially modified and adopted. Under terest (Colorado is rolling Medicaid ACOs form payment, coverage and treat-
most scenarios, growing adoption will over the next 18 months) but is still an un- ment decisions. However, com-
facilitate the other structural require- tested model outside a few settings other parative research findings alone
ments in reimbursement and account- than the large networks, like the unique may not be used to deny coverage.
ability (code for ‘recovery audits’) community-wide collaboration in Grand 3. Center for Medicaid/Medicare In-
5. Congressional makeover notwith- Junction that includes the community hos- novation is mandated to :
standing, most analysts see the Re- pital and a highly regarded non profit HMO • “test innovative payment and ser-
publican pushback, however substan- vice delivery models to reduce
tial, as sub- threshold-- not enough Thesis III: Executive Branch Triple program expenditures under the
votes to overcome a veto. That renders Threat or Play? applicable titles (Medicare and
some reversible aspects problematic, In what outgoing CBO director Peter Orsag Medicaid) while preserving or
as timelines outrun congressional of- called ‘the largest yielding of sovereignty enhancing the quality of care fur-
fice terms. The polling trends also from the Congress since the creation of the nished to individuals under such
suggest the emergence of a political Federal Reserve’, the Congress handed off titles.”[7]
center as more categories of voters to the executive branch three federal sub- • The enabling law instructs the
understand the personal benefits, fire- agencies real time authority to alter every HHS Secretary, in selecting pay-
walling in some districts a partisan day practice: The Independent Payment ment and service delivery models,
surge. The legal challenges are consid- Advisory Board (IPAB) , the Patient Cen- to “give preference to models that
ered long shots by many constitutional tered Outcome Research Institute (PCO- also improve the coordination,
experts, who note an unbroken string RI), and the Center for Medicaid/Medicare quality and efficiency” of care for
of Supreme Court decisions sustaining Innovation (CMI). Here’s a cocktail nap- Medicare beneficiaries, Medicaid
the Congress’ authority to regulate ac- kin sketch of their powers. It ‘aint rocket beneficiaries, and dual eligibles.
tivities that have a substantial effect on surgery’ as a colleague is fond of saying, [8] The law also allows the Sec-
interstate commerce, including medi- to contemplate how these three change the retary to test models within geo-
cal care, and like Social Security taxes, entire game. graphic areas.
Congress can require the purchase of 1. IPAB: Beginning in January 2014,
health insurance then tax those who do each year that Medicare’s per capita Thesis IV: Physicians Coming off the
not in order to cover those costs. costs exceed a certain threshold, the Bench?
IPAB will develop and propose poli- Organized physician influence on the
Thesis II: Service Integration and its cies for reducing this inflation. The congressional effort has to this point been
Iterations: secretary of HHS must institute the marginal or at best symbolic for the most
The incubating payment realignments are policies unless Congress enacts alter- common of political circumstances: They
by design intended to encourage if not native policies leading to equivalent are sharply divided within their ranks.
compel the integration and subsequent savings. When not just lying low to avoid friendly
coordination of services, since the incen- 2. PCORI: will publish research find- fire, Physician organizations have been
tive payments only accrue in those settings ings and any limitations, as well as vocal, if not visceral in their opinions on
that can prove up evidence based, coordi- what further research may be needed, pivotal elements of the Act(s) , and thus
nated care, demonstrable outcomes, and in a manner useful to clinicians, pa- incapable of supporting the legislation

26 wyoming medicine August 2010


national perspectives WM

with any politically relevant unity. Con- record reviews, and by law can extrapolate and develop new fraud prevention tools.”
sequently, physicians in the form of orga- from random audits their findings across all
nized medicine are perceived on the Hill claims in any given year. The penalties are Sic transit Gloria the presumption of inno-
as also incapable of enforcing hostile stiff, and have the additional leverage of cence. In my experience, the government
votes drawn from the lengthy and conten- threatening criminal prosecution. investigators won’t leave your home with-
tious congressional debate. To be fair, even out a scalp, and the rules heavily favor their
a unified front, which is usually limited to HHS estimates, citing CBO figures, that position. It is a target rich environment,
galvanizing issues like malpractice reform the return on investment by Congress in and they are well equipped to go hunt-
or managed care disputes, would have to anti-fraud efforts is 17:1. Secretary Sebe- ing—loaded for bear, as my father would
overcome the extreme partisan pressures on lius announced in her report to Congress say. WM
their respective congressional delegations, this winter a federal task force, Health-
notwithstanding the fact those delegations care Fraud Prevention and Action Team,
typically enjoy close if not always cordial or HEAT, which says it all while bending
relations with their state medical societ- the rules of federal health care acronyms:
ies. With the laws on the books and now “HEAT is an unprecedented partnership
in the byzantine maze of federal and state that brings together high-level leaders from
agencies, the rules of engagement are very both departments so that we can share in-
different. One former high ranking federal formation, spot trends, coordinate strategy,
official (and now with a prominent DC
law firm) observed recently, ‘the docs
weren’t really in the game because
larger forces were at work… and other
than the AMA and AAFP endorsements,
most of them were wrapped around spe-
cific sub-issues…now is the time they
should come off the bench and work
with their delegations on the hundreds
of insider plays developing at the agen-
cy level.’ His point was, whether the
substance is fecal matter or liquid gold,
it all flows downhill to the states for
implementation, and the state medical
organizations would be well suited to
fully engage their members, given their
local standing and influence within their
local and political communities.’

Thesis V: Getting RAC’d.


Political veterans of health care budget
wars all understand that the first place
the government looks for ‘savings’ in
the system is fraud. Long before health
system issues were a gleam in Speaker
Pelosi’s eye, The (2003) congress au-
thorized as part of the Medicare Mod-
ernization Act the creation of Recovery
Audit Contractors, with, for once, a
fitting acronym, RAC. RACs use pro-
prietary software programs to identify
potential payment errors in such areas
as duplicate payments, fiscal intermedi-
aries’ mistakes, medical necessity and
coding. RACs also conduct medical
WM
national perspectives
Health Reform: Now What?
Some wild guesses and irresponsible speculation:
By: Kimble Ross

As Yogi Berra famously said, ‘the future ain’t what it used to be.’ Here’s a dozen- plus less than scientific guesses
at scenarios that follow from these factors, drawn from ongoing conversations with analysts, think tankers, health
lawyers of considerable experience, economists, politicians, medical society leaders and advocates, and the usual
arm chair opinion suspects.

1. Tighter networks enforced by commercial plans to control costs, since other means of offsetting through risk
aversion and underwriting have been barred. Plans’ payment methodologies will more closely track, even mirror
Medicare policies.

2. Collusion between some plans and some hospitals to control those networks; the term ‘bilateral oligopoly’ will
be googled by more health writers and physicians, who will also be able to distinguish between a monopoly and a
monopsony.

3. Legislation by litigation—the disenfranchised will seek relief from the courts, and the support of their medical or-
ganizations— which will also generate legislative scrutiny of current anti trust laws, state and federal, and in some
jurisdictions realign some plaintiff attorney, physicians-as-plaintiff relationships.

4. Increased friction in some hospital-medical staff settings as administrators control bundled payments, employ more
physicians, and cut deals with payors to maintain networks.

5. More migration of marginal practices into employed settings.

6. More divisions and internal pressures on organized medicine; strange alliances emerge as employed physicians
seek advocates, some plans collaborate with integrated groups, some hospitals do the same.

7. Softening of corporate practice or related restrictions on the hiring and firing of physicians. Full employment for
labor lawyers with enough health policy savvy.

8. ACOs growth, incentives notwithstanding, will run hot and cold. Most significant variable is the presence or ab-
sence of physician leadership in those communities.

9. Increased pressure by RNPs, PAs, other professions to expand scope of practice, which in turn raises militancy
of primary care phyisician organizations; FPs will press medical educators to fill more slots and generate internal
conflicts among the specialties on campus.

10. As more comparative effectiveness research comes on line, along with other payor ‘evidence-based payment poli-
cies, more litigation will arise over standard of care, and increasingly pit manufacturer and physician prescriber
defendants against each other.

11. The CER movement may also draw manufacturers and prescribers closer; formulary gaming or manipulating
by a payer or PBM may draw, for example the PhRMAs and physicians closer on clinical questions of medical
necessity versus cost cutting efficiency, especially when the liability for therapeutic failure or toxicity falls on the
prescribing physician.

12. Fee for service as currently configured joins unaligned solo and small group practices in a slow spiral into obscurity
(or concierge/cash practice).

13. With many more voters covered, political tensions may realign less along insured/uninsured class warfare lines and
more toward age discrimination fronts—Medicare beneficiaries versus Medicaid/SCHIP versus commercial sector-
-the young invincibles mandated to buy coverage or pay a penalty, versus the boomers now acquiring chronic
conditions.
28 wyoming medicine August 2010
a note from our readers...
Dear Editor,

My heartiest congratulations to
Dr. Rob Monger, Editor, and to
Ms. Sheila Bush, WMS Executive
Director, on the publication of the
new WMS magazine.

It is a beautiful publication, with


articles of interest for all Wyoming Services Available 
doctors, and the general population  Support/promote Wyoming Health Centers 
also.  Support the expansion of affordable health care services 
across Wyoming 
This achievement has come about  Improve access to medical, dental and mental health     
only after long hours of thought, services 
consideration, and hard work.  Provide training and technical assistance on rural health 
issues 
 Provide grant writing assistance 
Thank you for your efforts, and
congratulations on this new Wyoming Primary Care Association 
endeavor. I wish you and the WMS For assistance, please contact Kristy Hazelton: 
Magazine a long and successful run. 2005 Warren Avenue ∙ Cheyenne, WY 82001 
(307) 632‐5743 ext. 10 ∙ Fax: (307) 638‐6103 
~Reed Shafer, MD kristy@wypca.org ∙ www.wypca.org 
WMS Past President

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to your health

CHILDHOOD AND ADOLESCENT OBESITY


FACING REALITY AND MEETING THE CHALLENGES
Col. W. Joseph Horam, MD, FAAP

The incidence of childhood obesity in the longer thought to primarily manifest as American Academy of Pediatrics advocates
United States was 5% in 1963 and has risen adult disease. Type 2 diabetes mellitus has fasting lipid screening for all children over
to 17% in 2004 with some studies estimating increased tenfold over the past two decades. 2 years of age with a positive family history
as high as 33% of all youth with either Hepatic steatatosis with nonalcoholic fatty of early heart disease, dyslipidemia or risk
overweight or obese status. This represents liver changes was unrecognized before factors to include obesity, hypertension and
an epidemic of grand proportions. (1,6) 1980 and can be found in 1:3 obese youth. type 2 DM.(6,7,8,9,10)
In general, overweight and obese children The psycho emotional toll has contributed
will worsen as adults. Obesity threatens to escalating problems with depression,
the health of today’s children to such an anxiety, impaired body image and eating ClINICAl eVAluATION
extent that for the first time in over the past disorders. Metabolic syndrome with The evaluation begins with an office based
century of United States history the current hyperglycemia, hypertension, dyslipidemia approach that provides an annual screen for
generation may have a shorter lifespan than and increased risk factors for cardiovascular BMI measurement after 2 years of age. It
previous generations. (2) Societal values disease now exists. is important to recognize risk factors for
and behaviors have created an environment weight problems. Family history of first
of sedentary activity, energy dense foods, degree relatives and genetic predisposition
reliance on sugar-sweetened beverages,
increasing devotion to television/ “For the first time in is highly predictive of a child’s risk for
subsequent development of overweight
computers/video games, larger food over the past century of or obesity problems. Genetic studies with
portions and dependence on motor vehicle
transportation all leading to an imbalance United States history separated identical twins clearly favors
genetics (70%) over environmental factors
of energy consumption for our youth. the current generation (30%) as the major influences for weight
may have a shorter profiles in the absence of medical disease
states. Infrequently diagnosis of primary
The measurement of body mass index lifespan than previous medical conditions may cause obesity.
(BMI) from the calculation of weight in
kg divided by height in meters squared generations.” These include Cushing’s syndrome,
psuedotumor cerebri, hypothalamic
provides an accurate quantitative value
disturbance, pharmaceuticals such as
for total body fat. The Centers for Disease
atypical antipsychotics, polycystic ovary
Control has the broadest population studies Obese children have three times the
disease, pseudohypoparathyroidism and
to develop percentile graphs for BMIs incidence of hypertension. Children
genetic syndromes such as Prader-Willi
for the span of 2 years through adulthood with obesity have a greater incidence
Syndrome. Disorders of hypothyroidism
located at www.cdc.gov/growthcharts. of obstructive sleep apnea syndrome.
are actually an uncommon cause of obesity,
Accepted definitions for overweight Other considerations include polycystic
but are frequently attributed as a cause of
persons are a BMI range of 85%tile to ovary disease, pseudotumor cerebri,
weight disturbance. A child with normal
94%tile and obesity of 95%tile and above. cholelithiasis, musculoskeletal joint
height growth would not be a candidate
Super obesity is defined at the 99%tile disease and dermatologic conditions.
for hypothyroidism. A comprehensive
threshold. (3, 4, 5) The BMI may be Recent studies following accidental deaths
history also includes dietary habits,
overestimated for high weight muscular have documented greater atherosclerotic
physical activities, review of systems,
individuals and underestimates risk for vascular disease in youngsters with known
social history including family activities,
Asians. elevated serum lipid levels. Standards
peer relations and activities, school status
now exist for elevated cholesterol and
COMOrBIDITy triglyceride levels over 2 years of age with
and a comprehensive exam. The history
The impact on the general health and and physical should incorporate the above
recommendations for treatment including
welfare for children and adolescents with mentioned comorbidity concerns. (1, 3, 5)
dietary modifications and medications to
weight pathology is significant and no include the use of bile resins and statins. The

30 wyoming medicine August 2010


to your health WM

lABOrATOry AND TesTING


Basic recommendations include a fasting • Avoid all sugar sweetened Stage 4 Tertiary Care:
lipid panel, fasting glucose with chemistry beverages Academic medical center with consultant
panel and an AST/ALT. Additional tests • Limit juice to less than 6 oz under 6 team of specialists and research capability
depending on clinical concern includes years and 12 oz over 6 years that incorporates treatment protocols for
a chromosome analysis, fasting insulin severe obesity over 95-99%tile. Includes
level, 2 hour glucose tolerance test, • TV/computer/video games screen
time less than 2 hrs per day use of medications and bariatric surgery.
thyroid function, serum amylase and
GGT. Pulmonary function tests and sleep • No TV in bedroom In principle, improvements not seen within
polysomnograpy studies may be considered 3-6 months in any given stage of treatment
• Physical activity over one hour per should move up to the next stage. A
for sleep or respiratory symptoms. An ECG day
is indicated for hypertension. Endocrine reasonable goal is 1 pound weight loss per
and genetic consults are beneficial • Increase home meals month under 11 years and up to 2 pounds per
referrals for special testing requirements. week over 11 years. Caloric restricted diets
• Fast food no more than once per
Radiologic evaluations of the hips and require dietician and provider supervision.
week
knees for slipped capital femoral epiphysis, Diets should be rich in calcium, low in
• Do not skip breakfast saturated fat and limit energy dense foods.
Legg-Perthes disease and Blount’s disease
are advisable when clinically indicated.(1, • Assess the family culture and Recommendations for children under 2
4, 5) motivation to change years of age incorporates exclusive breast
feeding to 6 months of age, use of low fat
milk after one year of age and avoid excess
TreATMeNT AND PreVeNTION Stage 2 Structured Weight Management fruit juice. (2, 4, 5,7,11)

Randomized and controlled studies simply • Dietician consult with planned meals/
do not exist for evidence based treatment snacks and balanced macronutrients
(fat/carbohydrate/protein)
PAyMeNT FOr MeDICAl serVICes
for the management of overweight and
obese children. An Expert Committee The American Academy of Pediatrics has
• TV screen time less than one hour
comprised of the AMA, Health Resources issued fact sheets for obesity coding at
• supervised physical activity www.aap.org/healthtopics/overweight.cfm
and Service Administration and CDC have
made a careful analysis of existing data • monitor compliance with a logbook A complete discussion of this topic is the
to merit their collective support of the subject of “Paying for Obesity: A Changing
following 4 stages of treatment/prevention Landscape” per reference 12. WM
Stage 3 Comprehensive Multidisciplinary (Original Article published in the Kosovo Medical
recommendations:
Includes above stages and team with a Newsletter, US Army Camp Bondsteel Medical
Stage 1 Prevention Plus provider, dietician, counselor and exercise Falcon Task Force, October 2009. Dr. Horam is a
Pediatrician with the Cheyenne Children’s Clinic at
• Eat a minimum of 5 servings of trainer. Increase behavior modification and
Cheyenne Regional Medical Center and serves as a
fruits and vegetables per day visits with a school, hospital or community military physician with the Wyoming Army National
based program. Guard.)

References
1. Barlow EB: Expert Committee Recommendations for Obesity. Pediatrics 2007; 120: S164-S192
2. Davis MM: Recommendations for Prevention of Childhood Obesity. Pediatrics 2007; 120: S229-253
3. Klish WJ: Clinical Evaluation of the Obese Child and Adolescent. Up To Date 2009; Online 17.2
4. Krebs NF: Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S193-S228
5. Schneider MB: Obesity in Children and Adolescents. Pediatrics in Review 2005; 26: 155-162
6. Ludwig DS: Childhood Obesity-The Shape of Things to Come. NEJM 2007; 357: 2325-2327
7. Daniels SR: Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008; 122: 198-2008
8. Ferranti S: Storm over Statins-The Controversy Surrounding Pharmacologic Treatment of Children. NEJM 2008; 359: 1309-1312
9. Cowell KM: Type 2 Diabetes Mellitus. Pediatrics in Review 2008; 29: 289-292
10. Klish WJ: Comorbidities and Complications of Obesity in Children and Adolescents. Up To Date 2009; Online 17.2
11. Spear BA: Recommendations for Treatment of Childhood and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S254-S288
12. Simpson LA: Paying for Obesity: A Changing Landscape. Pediatrics 2009; 123: S301-S307
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Afton, WY Ronald D. Iverson MD Janet Anderson-Ray MD William Ketcham MD Jeffrey Storey MD
David Bender MD John Paul Jones III MD Anthony Aron MD Muhammad Khan MD Rex Stout MD
Kitchener Head MD Thomas A Kopitnik MD John Babson MD David Kilpatrick MD Robert Stuart Jr. MD
Noel Stibor MD Phillip Krmpotich MD Jean Denise Basta MD Donald Kougl MD Sandra Surbrugg MD
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32 wyoming medicine August 2010


* Indicates a leadership role on the WMS Board of Trustees 2010-2011
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Robert Neuwirth MD James Brubaker MD Aaron Jagelski MD Michael Sutphin MD M. Todd Berry MD
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August 2010 wyoming medicine 33


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