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A study in gratitude: Former patient helps out at free dental clinic

A free dental clinic last weekend in Perry treated more than 2,000 patients.

A free dental clinic last weekend in Perry treated more than 2,000 patients. Photos courtesy of the Georgia Dental Association.

Doug Taffe of Fort Lauderdale, Fla., traveled hundreds of miles north to central Georgia over the weekend to work as a volunteer at a free dental clinic.

His volunteer stint at the event in Perry was a form of repayment.

Two years ago, Taffe was in a motorcycle accident and sustained severe damage to his teeth. He couldn’t afford the extensive repairs. He heard about a Georgia Dental Association free clinic in Norcross, and traveled to the Atlanta suburb to see if he could get some work done.

“I looked like a homeless person,’’ he told GHN. “I couldn’t smile, had difficulty eating.”

GDADentists at the clinic pulled about a dozen of his teeth and gave him a denture.

So, out of gratitude, Taffe joined the volunteers in Perry delivering dental care to more than 2,000 people Friday and Saturday.

The Georgia Mission of Mercy is an outreach program of the Georgia Dental Association and its Foundation for Oral Health. It’s held every two years.

This was the first time the clinic was held in Perry. Previous ones were in metro Atlanta.

“We’re trying to move it around the state’’ to reach more people, said Frank Capaldo, executive director of the Dental Association. One big plus for Perry is that it’s near the geographic center of Georgia.


A lack of dental coverage


The services provided at the temporary clinic included cleanings, fillings and extractions. More than 600 dentists volunteered, along with 1,200 health care providers and community volunteers, including dental hygienists, lab technicians, pharmacists and local residents. And there were more than 100 dental chairs in use.

Each patient got a basic health check-up before being moved into one of the chairs.


Taffe’s volunteer work consisted of briefing and advising the patients who were getting partial dentures. “I explain to patients how to care for dentures, what you can and can’t do,” he said Saturday.

Chris Harris, a 40-year-old man from coastal Georgia, had to have 11 teeth pulled and was fitted Friday with a temporary, partial denture, the Macon Telegraph reported.

When he looked at his reflection and his new smile, Harris said, it almost brought tears to his eyes, according to the Telegraph.

Roughly 20 percent of Georgians have no health insurance at all. But a much higher percentage, including those who do have some insurance, lack dental coverage. It’s increasingly common for health insurance coverage not to include dental care.

Frank Capaldo

Frank Capaldo

Oral health, however, is not just a medical side issue. Many people who skip the dental work they need will eventually wind up in a hospital emergency room.

In 2007, there were about 60,000 visits to Georgia emergency rooms for “non-traumatic” dental problems — oral health issues not caused by injuries. That cost more than $23 million.

The problem is not a lack of capacity in the system. Capaldo emphasized that most dentists in Georgia have the ability to see more patients in their regular practices.

Barriers to patients getting needed work, he said,  include lack of money, lack of transportation, an inability to get time off from work, and the Medicaid program not covering regular dental care for adults.

“We have people calling in, asking for free care,’’ he said. “We’re trying to get that messaging out.”

“The need for a dental home [for more patients] is great — no question about it.”

The Georgia Dental Association has a toll-free number for patients to call, 1-800-432-4357. GDA also provides a list of charitable clinics offering care: charitable-clinics.html

Patients can also inquire here to find a dentist: a-dentist.




Will dental ruling send ripples through health care industry?

Georgia's 9,500 nurse practitioners include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University's Nell Hodgson Woodruff School of Nursing.

Georgia’s 9,500 APRNs include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University’s Nell Hodgson Woodruff School of Nursing. Photo credit: Bryan Meltz with Emory Photo/Video

A recent U.S. Supreme Court ruling about teeth-whitening services may have long-term implications for health care professionals and their practices across the country.

The dispute involves the right of dental hygienists to perform such services in North Carolina. The Federal Trade Commission brought a major anti-competition case on the matter. The high court did not settle the case, but rejected the state dental board’s claim that its actions were immune from FTC scrutiny.

“In this case, the North Carolina dental board’s members, primarily dentists, were drawn from the very occupation they regulate. They barred non-dentists [in this specific case, dental hygienists] from offering competing teeth-whitening services to consumers,” said FTC Chairwoman Edith Ramirez in a press release.

The American Nurses Association says the dental board case may have “far-reaching implications beyond dentistry.”

In Georgia, the experts are divided on how, or if, the case could affect professional practice laws.

What doctors and nurses say

Debbie Bartlett, CEO of the Georgia Nurses Association, says her organization “will utilize the Supreme Court’s ruling to help inform Georgia legislators about the need to support federal antitrust laws [as well as] avoid unduly suppressing pro-consumer competition.”

Georgia state practice and licensure law restrict the ability of nurse practitioners — nurses trained to perform many tasks often left up to doctors — to engage in at least one element of practice. Georgia nurse practitioners, also known as advanced practice registered nurses (APRNs), cannot write prescriptions for Schedule II medications. And their ability to order specific diagnostic tests is also limited.

The state requires supervision, delegation or team management by licensed physicians in Georgia in order for any nurse practitioner to provide patient care.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, sees little reason for concern about the high court ruling, because the kind of situation cited in North Carolina does not exist here.

“The North Carolina case is drastically different than the way the licensing boards work in Georgia.” says Palmisano. Here, a board’s proposed actions are reviewed by the state attorney general’s office and released for public comment, he notes.

“The ruling in North Carolina never rose to the level where the Medical Association needed to contact the Georgia Nurses Association,” Palmisano says.

“The two organizations [in Georgia] have a fairly strong relationship. I don’t foresee [a big impact from the Supreme Court ruling] here,” he adds.

Atlanta nurse practitioner Mary Perloe agrees. “I actually think nurse practitioner collaborative agreements with physicians and using evidenced-based protocols make sense,” she says.

“I also believe that the nurse practitioners should bear responsibility for their practice. As NPs gain more authority, accountability needs to follow, and physicians need to be relieved of this liability,” says Perloe.

Rebecca Wheeler, the GNA past president, suggests the ruling may be a mixed blessing for those in the nursing profession.

“I think the decision is great for APRNs, but I am a little worried about what this means in order to protect our own RN scope of practice from medical technician or nursing assistant roles,” Wheeler says. “I feel like this is a bit of a double-edged sword for nursing.

“I’m not saying it’s necessarily a bad thing [referring to the Supreme Court decision]. We probably need to be prepared to ‘give a little’ if we want APRNs to be able to practice to the full extent of their training in Georgia.”


The issue of dentistry


The American Dental Association (ADA) said it was “extremely disappointed” at the U.S. Supreme Court decision.

The group said the decision “constitutes a dramatic departure from the Supreme Court’s established law, and throws into question the regulatory, licensing and disciplinary authority of thousands of professional boards across the county.”

“The ruling creates a quandary for professional boards . . . with no explanation as to what level of ‘active supervision’ is necessary to invoke immunity for each board,” ADA stated.

The association said it is planning to work with other organizations to provide some kind of guidance in view of the Supreme Court’s decision.

But among Georgia dentists, as among physicians in general, there seems to be less alarm about the ruling. Frank J. Capaldo, the Georgia Dental Association’s executive director, says there are a number of important distinctions between the dental licensing boards in Georgia and North Carolina.

“In Georgia, members are appointed to the Board of Dentistry by the governor, but in North Carolina they are elected to the board by other licensed dentists,” Capaldo says. “This difference in and of itself shows significant state oversight in Georgia.”


Some see more opportunities


Scope of practice limitations for nurses exist alongside a shortage of health care providers in Georgia, especially in rural areas.

The consumer group Georgia Watch recently reported that the number of licensed APRNs in Georgia has reached more than 9,500. With the physician shortage in the state, which is expected to get worse, APRNs could help fill this primary care gap, the group’s report says.

NP Photo with manA total of 129 of Georgia’s 159 counties have a shortage of health care professionals. In fact, about 80 percent of Georgia’s counties contain substantial populations without a consistent source for primary care, according to the Georgia Watch report.

Georgia Watch and others continue to urge state policymakers to consider using more advanced practice nurses and physician assistants in health care shortage areas.

Many Georgia physicians, however, traditionally support the restrictions on the duties of nurse practitioners. They’re concerned about whether people who are not doctors — working on their own — have the training to safely diagnose and treat patients, refer them to specialists, admit them to hospitals and prescribe medications for them. These doctors think the NPs should continue to work under the oversight of physicians.

The right of Georgia nurse practitioners to prescribe medications didn’t come until 2006. Georgia was the 50th state to grant NPs prescribing ability.

Many health care experts say that with the influx of thousands of Georgians into the health care system under the Affordable Care Act, the time may be right for the state to review its scope of practice laws, especially in rural areas.

“There are, after all, cost realities here. We just need to be prepared,” says Wheeler, referring to NP restrictions.

“This [Supreme Court] ruling seems to open up the door for everyone, including medical technicians or nursing assistants, as much as it does for APRNs,” she says.


Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.


Health education helping refugees live and thrive in Georgia

Jubilee Partners in Comer helps refugees from many countries get medical care locally.

Jubilee Partners in Comer helps refugees from many countries get medical care locally.

Pa Saw Paw and Eh Kaw Htoo arrived in the United States seven years ago, bringing with them two children.

They’re originally from the Southeast Asian nation of Myanmar, also known as Burma, but they lived in a refugee camp in neighboring Thailand for 20 years. Their ethnic group, a Christian minority known as the Karen, have been frequent targets of war and persecution in Myanmar for decades.

The family’s first two months in America were spent living in a cabin at Jubilee Partners, a self-described Christian service community in Comer, in Madison County.

Georgia has become home to many refugees, from many different countries. That’s especially true in the melting pot of metro Atlanta, but some have settled in small towns and rural areas.

For recently arrived refugees, there’s much that’s new about life in the Peach State. The Karen, for instance, had not seen in-house thermostats in their remote tropical homeland.

But American ideas about health and nutrition, and the complexities of the U.S. health care system, are often equally unfamiliar to refugees. The clipboard questionnaires at doctors’ offices and the elaborate check-in procedures at hospitals — which Americans take in stride — can seem bewildering to a newcomer.


Learning the essentials


For 36 years, Jubilee Partners has been giving newly arrived refugees a safe place to live, teaching them basic English skills, and helping them learn to deal with strange new gadgets and practices.

Jubilee’s basic training for new arrivals lasts for two months and involves spending up to 18 hours a week in English classes. The refugees learn how to set a thermostat, how to cook on a gas stove and many other life skills.

YouTube Preview ImageBecause there’s not much work in Madison County, many refugees complete the training and then head for Atlanta’s growing Karen community.

But city life can be hard, and the promise of a good job does not always pan out. Some Karen bounce back to the Comer area, where others had already chosen to remain after resettlement.

One of Jubilee’s founders, Don Mosley, estimates that more than 10 percent of Comer’s population are people who arrived as refugees.

Jubilee Partners helps refugees get preventive care and medical treatment, which often means sending a translator to help families enroll in Medicaid, obtain care or fill prescriptions.

Jennifer Drago, refugee health coordinator for Jubilee Partners, is a key resource for each group of refugees passing through Jubilee. She acts as a link between refugees and the health care system.

Pa Saw Paw knows from experience that navigating the American health care system can be intimidating for people from her culture. She worked with Jubilee Partners as a translator for about three and a half years, and much of her work was in health care settings.  She now works part time at a school in Madison County and lives with her family in Comer.

“Here it’s hard, I think, hard for my people. That’s why they ask me to go along with them to clinic,” she says. “Some people, even though they speak a little bit of English, they don’t have a high education like that and so they don’t know how to fill out the form.”

In addition to difficulties with deciphering insurance, medical history, and intake forms, refugees face other health-related challenges upon their arrival in the United States.


More choices — good and bad


Many of the Karen people who have been granted asylum were previously on the move for years, or living in resettlement camps where conditions were challenging. The maintenance of a really healthy lifestyle was often a luxury they couldn’t afford.

Upon arrival, they need to get blood work done to test for a variety of toxic environmental exposures. They also need to be tested for tuberculosis.

Jennifer Drago of Jubilee Partners

Jennifer Drago of Jubilee Partners

Drago can assist with family planning, connecting people with mental health resources, understanding and managing chronic conditions such as hypertension, explaining how to take medications, and a variety of other needs.

Karen refugees also struggle with proper nutrition. “They’ve come from a place where they’ve lived on rationed food, mostly two meals a day of rice,” says Drago.

The United States, where food is much more abundant, but not necessarily healthful, can be a dangerous new world. “They come here and are bombarded with food but not understanding how food can be bad for you,” she says.

Karen people continue to keep their traditions alive in Comer. They gather together for major celebrations, but also work to be a part of the local community, despite the challenges they face when they get here.

“[It’s] hard stuff but I’m often amazed at the ones who can make it,” Drago says.


Lauren Schumacker is pursuing her master’s in health and medical journalism at the University of Georgia. She also holds a certificate in culinary arts and enjoys writing about all things food-related.


Will your hospital change hands? Partnerships, purchases on the rise

West Georgia Health in LaGrange is seeking a buyer or partner.

West Georgia Health in LaGrange is seeking a buyer or partner.

The hospital partnership dance continues in Georgia. Given the pressures of the health care economy, nobody apparently wants to be a wallflower.

Last week, St. Mary’s Health Care System in Athens said it is talking with financially ailing Ty Cobb Regional Medical Center about a possible acquisition of the Lavonia hospital.

That announcement reverberated in northeast Georgia, but it was overshadowed by news of a much bigger potential merger in metro Atlanta, between mega-systems WellStar and Emory Healthcare.

This week, West Georgia Health in LaGrange said it hopes to announce a possible partner or buyer soon.

A special panel has narrowed the candidate list for such a deal to two organizations, Jan Nichols, marketing director for the LaGrange health system, said Wednesday.

But sometimes there are fears that the dance is moving a little too fast. A former state lawmaker is concerned about a lack of transparency in the West Georgia situation.

Jeff Brown

Jeff Brown

“When you hire J.P. Morgan [to help explore potential deals], you’ve made a decision to sell or to merge,’’ Jeff Brown, former chairman of the House Health Appropriations panel, told Georgia Health News this week.

He said if West Georgia Health chooses the wrong partner, it could devastate Troup County taxpayers, who are guarantors of a $46 million bond.

Meanwhile, St. Francis Hospital in Columbus, rocked by an accounting misstep that left it financially less secure than it had believed, is talking with Atlanta-based Piedmont Healthcare about a possible alliance. And Tenet Health, a chain based in Texas,  is looking for a partner or buyer for its five metro Atlanta hospitals.


A rapidly changing landscape


The moves are coming fast as the whole U.S. health care system undergoes a transformation, at least partly because of the Affordable Care Act.

Hospitals are being squeezed financially by changes in the way they are reimbursed,  and by federal cuts and penalties.

Health insurers and Medicare are moving more toward paying for bundling of medical services, rather than paying for individual procedures or tests separately. The goal is to end the dominance of  fee-for-service medicine, in which hospitals and doctors are reimbursed based on the amount — not the quality — of care they deliver.

In addition, federal money for hospitals that deliver a “disproportionate share’’ of care for the poor and uninsured is being cut. Georgia hospitals will lose hundreds of millions of dollars.

Ty Cobb Regional Medical Center

Ty Cobb Regional Medical Center

It was the intent of the ACA that states would expand Medicaid to make up for these eliminated funds. But the U.S. Supreme Court ruled that states didn’t have to do that. Georgia is one that has declined to expand Medicaid, saying it would cost too much. Meanwhile, some already vulnerable hospitals are facing a further revenue crunch. (Here’s an article on how  Medicaid expansion has worked out in Kentucky.)

The hospital consolidation drive is moving forward rapidly, in Georgia and nationally. Hospitals of every size, in cities, suburbs and rural areas, have been affected.

Some of the hospitals in the mix are clearly struggling financially. Ty Cobb Regional, a 56-bed rural hospital, is relying on Franklin County to make its bond payments, according to the Independent Mail newspaper.

“Smaller community hospitals are having a real hard time,’’ said Greg Charleston of the consulting firm Conway MacKenzie in Atlanta. “Hospitals are struggling, they don’t know what to do, and they look for a buyer.’’

Part of the consolidation wave, he said, comes from a sense that “it’s the thing to do.  Sometimes it makes sense, sometimes it doesn’t.”

“If you’re a small community hospital, you probably need to team up with someone,” he said.

Larger health systems get patient referrals for their specialist services and solidify their territorial reach through such deals, which can yield economies of scale, eliminate duplication of services, and reduce overall costs, Charleston added.


Problems can add up


In LaGrange, West Georgia Health has been working on a potential deal for months.

A recent LaGrange Daily News article noted that from 2010 to 2013, West Georgia Health’s Medical Center listed revenue deficits each year, with the highest being $6.2 million dollars as in 2013.

Gerald Fulks

Gerald Fulks

Meanwhile, in fiscal 2012, West Georgia CEO Gerald Fulks received what is listed on an IRS 990 form as a $1.6 million “payout.”

Fulks told the Daily News that the payout was accumulated retirement benefits over a 10-year period. His total compensation in fiscal year 2012 was just over $2 million, IRS data show.

Nichols of West Georgia told GHN that the overall compensation package, including Fulks’ retirement benefits, was developed by a compensation committee of the WGH Board of Trustees. “It is based on a number of factors, including comparative health system CEO compensation and health system performance goals,” she said.

When asked why a merger is being considered, Fulks told the Daily News: “Because with the changes that are coming down from the Affordable Care Act, we are simply not big enough to take on the risk of bundled payments from patients, taking the risk of an entire population.

“We don’t have the information technology that is necessary to manage population health and we believe that we can lower our operating costs by participating in the overhead of a larger provider organization, and still provide the kind of care and support that our community expects.”

West Georgia says the hospital is currently operating in the black. Its current cash on hand of $55 million is 121 days, an amount it says is twice the figure required by its current bond covenants of 60 days.

Yet over the past five years, West Georgia Health has faced a rising bad debt and charity care burden, which has jumped from $39.5 million in fiscal 2010 to $64.4 million in fiscal 2014.

Brown, the former state legislator, said that beyond his concerns about the dealmaking process, he believes the LaGrange community will still have a medical facility after the dust settles. “They’ve been here for 75 years,’’ he said.

The hospital is the only one in Troup County, home of the massive Kia automotive plant, one of the economic showplaces of the state.


Medicaid physicians back in same spot after long-awaited raise expires

Dr. Jaquelin Gotlieb examines a new patient, Jada Smith, 5, at her Stone Mountain office

Dr. Jaquelin Gotlieb, shown examining a patient, says that the Medicaid pay bump is a matter of valuing children.

Dr. Michelle Zeanah is getting a big pay cut this month.

It’s not that the Statesboro pediatrician is seeing fewer patients. Just the opposite.

The 12 rural counties surrounding Bulloch County, where Statesboro is located, have no pediatrician. So Zeanah is very much in demand.

Forty percent of her patients have driving distances of 45 minutes or more. A few come from more than 50 miles away.

Dr. Michelle Zeanah

Dr. Michelle Zeanah

Her pay cut involves the Medicaid program. Reimbursements to primary care doctors under Medicaid just went down in Georgia and many other states.

The Affordable Care Act had awarded primary care doctors treating Medicaid patients a two-year pay increase. It was funded entirely with federal money, and pushed their Medicaid pay to the level of Medicare reimbursement.

But that additional Medicaid reimbursement, which went to family physicians, pediatricians and internists, ended Jan. 1. And doctors will be missing it.

“It allowed us to hire more staff so we could serve more patients,’’ Zeanah says. Without it, she adds, “I will have to work 70 hours a week’’ instead of the current 60.

About 70 percent of her patients are covered by Medicaid or PeachCare (the Georgia version of the child health insurance program).

Medicaid, the federal/state program for the poor and disabled, serves more than 1.5 million Georgians. Most are children.

Before the increase, Georgia primary care doctors had gone more than a dozen years since the last Medicaid pay hike.

A few states, including Alabama and Mississippi, have continued giving their primary care doctors the pay hike by using state dollars to fund it.

But Georgia political leaders, on the eve of the 2015 General Assembly, have shown no signs they’ll appropriate money to reinstate the pay hike. The money that would be needed – an estimated $62 million for a year – is not in the Department of Community Health budget being proposed to Gov. Nathan Deal.

Sasha Dlugolenski, a spokeswoman for the governor, said in an email to GHN in September that Deal was aware of the issue. She called the pay hike expiration “one of the early, blatantly obvious examples of Obamacare unloading costs onto the states. This was a short-term Band-Aid to a long-term problem, and now the states are left holding the bag.”

The federal health law required that the raise be paid for two years, 2013 and 2014. The money actually did not arrive till 2014, but when it did, eligible doctors received the pay hike retroactively to Jan. 1, 2013.

Such delays in the payments occurred in many states, including Georgia, that use managed care in their Medicaid programs.

Practices feel the pinch

The end of the federally funded raise means that Medicaid fees in Georgia will now be reduced by 34.8 percent, according to a recent Urban Institute study.

Some pediatricians describe the pay bump as a children’s health issue. They say children on Medicaid generally have greater health and social needs.

“It’s a matter of valuing children as the future of the state,’’ says Dr. Jaquelin Gotlieb, who practices along with her pediatrician husband, Edward Gotlieb.

“I believe primary care doctors feel a significant responsibility to their patients,” adds Jaquelin Gotlieb, who is 68 and has practiced in Stone Mountain for almost four decades. “That’s why we have hung in there.”

If the pay isn’t restored, she says, “This is going to take some of them and push them over the edge.’’

Dr. Eugene Cindea

Dr. Eugene Cindea

Roughly two-thirds of the Gotliebs’ patients are covered by Medicaid or PeachCare, she says.

Dr. Eugene Cindea, a pediatrician at the Longstreet Clinic in Gainesville, says the extra money “allowed us to expand offerings to patients.”

“It felt good for physicians who were seeing a considerable number of Medicaid patients,” he says.

The goal of the pay hike, Cindea notes, was to increase the number of physicians who accept Medicaid patients.

Without the money, he says, it’s more difficult to devote staff to manage the chronic diseases of children. “It decreases the likelihood that we’ll expand in an underserved area,” he adds.

OB/Gyns were not eligible for the two-year federal pay bump that just ended. Pat Cota, of the Georgia Obstetrical and Gynecological Society, says her organization is asking the state to revive the pay increase and expand it to include OB/Gyns.

The majority of children born in Georgia are covered by Medicaid.




An incentive for doctors

In Alabama, physician participation in Medicaid is a concern. The state says about 22 percent of enrolled primary care physicians now receive 90 percent of all claims payments. The other problem is that Alabama has shortages of health professionals in 62 of its 67 counties.

Niko Corley of the Alabama Medical Association says that “for Medicaid to be as efficient as possible, you’ve got to have physicians managing that care.”

The federal pay hike was supposed to increase doctor participation in Medicaid. But Kaiser Health News has reported that most states say they’ve seen no evidence that it did so — mostly because it was a temporary measure.

“The Medicaid pay boost was never meant to be a silver bullet,” Leonardo Cuello, director of health policy at the National Health Law Program, an advocacy group for low-income Americans, told KHN. Still, he worries about the provider fee cuts. “It won’t sink the ship but . . . I’m concerned it will contribute to access problems.”

Statesboro pediatrician Zeanah notes that many physicians have limited their numbers of Medicaid patients. That’s why her pediatric practice continues to see more patients.

Having the pay hike meant that the practice stopped losing money on delivering vaccines to kids on Medicaid. “We made a tiny profit,’’ Zeanah says.

Not having the pay hike, though, means more hours and less reimbursement. It means Zeanah and her pediatrician partners can’t build an office building to accommodate the growing practice.

Medicaid patients require more work, and are more often late or no-shows due to reasons such as lack of transportation, she says. “We have no social worker available to us. I am the social worker.”

Georgia desperately wants to recruit new physicians, Zeanah notes. “When you don’t have Medicaid payment parity, it makes it hard.”


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