MDAdvisor Spring 2017 by MDAdvantage Insurance Company of New Jersey

Chantal Brazeau, MD, & Maria Soto-Greene, MD, MS-HPEd

PROMOTING THE VITALITY OF FACULTY TO COMBAT BURNOUT

Commissioner Cathleen D. Bennett

NEW JERSEY’S OPIOID ADDICTION HEALTH CRISIS

Paula Toynton, MEd, & Kathy Ahearn O’Brien

ENDING THE HIV EPIDEMIC WITH THE HELP OF BIOMEDICAL PREVENTION INTERVENTIONS

CME PERSPECTIVES ON HEALTHCARE FROM THE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE HONOREES

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VOLUME 10 • ISSUE 2 • SPRING 2017

Celebrating 10 Years of Publishing Excellence

HONORING EXCELLENCE CONGRATULATIONS TO THIS YEAR’S EDWARD J. ILL EXCELLENCE IN MEDICINE ® AWARDS RECIPIENTS

MDADVISOR: A JOURNAL FOR THE HEALTHCARE COMMUNITY.

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2018 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS

HONOR YOUR PROFESSION BY HONORING YOUR PEERS. Nominations Now Being Accepted. OUTSTANDING MEDICAL EDUCATOR AWARD OUTSTANDING HEALTHCARE EXECUTIVE AWARD EDWARD J. ILL PHYSICIAN’S AWARD® VERICE M. MASON COMMUNITY SERVICE LEADER AWARD PETER W. RODINO, JR., CITIZEN’S AWARD® OUTSTANDING SCIENTIST AWARD

& Written nominations will be accepted through August 18, 2017. Nominations are open to all New Jersey physicians, healthcare professionals and community leaders. For additional information about the event, and to view the 2018 Guidelines for Nominations, visit www.EJIawards.org or call us at 609-803-2350.

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TE N A ar’s OST C is ye . h t ing me IA A ulat r so t o C a f r I g R 15, ized con age PAT ogn e in p c m e n r F n in ng o urring i ll jo eing KO tarti u wi eb c S s r c o a s E y e. o n D ope who lum dem very i h a , o E l I s c c e . e a r r d TH iso ore rds thei y to are M hon Adv awa om lthc ustr r D e f a d d r O h e M n a e t i g Aw in h FR e of ate n se htin ince issu priv ents hlig u ca re s icine

ed hig w. ring hca s to s yo cem orro t by in M care. A ealt van cian e Sp i a h d m h s e h t a y o t n c ei lth len rse of t 18. e to e is e ph hea ers r 20 xcel mad dive ctic com hop d o o E l n f a t a d y e l r e l e s n I n l p W J. ry a s be tion atio nd m rs and ate ard t ha e, a min dina priv e tribu r a g o d n h o i e n m t l o Edw v a i c fro ga pro priv extr ress zing ittin are ging rog da me ing c n m n p o h a ama s a t b r l e cern su or th ea es n r are n l h u l o e o e a n c e d r h e nsi an the e th ons ight of v is) 9 is spir ill co dati ighl ety ylax 3 n i n i h w h r 9 e a p 1 o u o t av mm pro le t d in e yo ble reco rg. sure g a b estowe hop t be a o o n . I s i l nton p l s , e i e r x B a w rd b -e lat Toy e a t e e y s r e a w r l w t i h p a ef Pau EJI nex ing ces, on t e 7, wer ww. ors van ses clud d to h w d t u n a pag i t a c ( u i e n o s a s e h i f o s n a v s e e o th V. A ssu ion, note hink enti of f HI his i ion mat terv ou t t o t r n y a r i end o n f s d o n f o n e n i A i o t h i u e i t l t e uis tic en ht S Fo mor es acq E ar prev AID roug l d M For b a h clud n t C c i n a n i e r i d v u n c o e a a o s O i Hy e al es h biom nsmiss at f the issu anc v a e of o s omb r i s d t c n h u a e e T i o l e r t h th ica O’B ch.” ce t egy ner med trat edu r rea earn s g u h e n ssio i o i A v to r i k n y s m a i h n e Kat with Com ehe dbr and lth mic mpr roun a e o g e d c i H ’s nt se S ep rsey from mporta “the n . A I D New Je i o S i . U ict er n re the oth add hca te o t e d a l n a d m a e p h so se an u ack abu re n t with r u d g edb i c n e o i f o e l p o h o t, a rd t g t net rwa erin o v f o Ben c look les t. I n artic e m rs. i ro n ade e env r r ou from Sinc

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MDADVISOR

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Michael Cacoilo Rutgers New Jersey Medical School (2017) Kathryn Eckert Rowan University School of Osteopathic Medicine (2018) Devin Walford Godwin Rutgers School of Health Professions (2017) Sydney Hyder Rutgers Robert Wood Johnson Medical School (2017) Timothy Lopez Seton Hall University School of Health and Medical Sciences (2018) Mark McShane Cooper Medical School of Rowan University (2019) Mary Thompson Rutgers School of Dental Medicine (2017) The Advisory Committee advises the Publishing Staff and Editorial Board on topics, themes and invited papers for future issues of MDAdvisor that address the issues impacting young healthcare providers. Look for columns from Advisory Committee members that provide insights into their experiences throughout their education and training in upcoming issues.

MDADVISOR A Journal for the Healthcare Community

NEWS & ACKNOWLEDGMENTS

ANNOUNCING THE NEWEST MEMBERS OF OUR EMERGING MEDICAL LEADERS ADVISORY COMMITTEE:

WHAT’S HAPPENING IN HEALTHCARE? Governor Christie Named Chair of Opioid Task Force Governor Christie has been selected to chair the President’s Commission on Combatting Drug Addiction and the Opioid Crisis, a national task force to address the growing opioid epidemic. Gov. Christie has made New Jersey’s battle to reduce addiction his signature issue for 2017. In February, he signed a law with the nation’s strictest opioid prescription limit, which also ensured patients with state-regulated insurance plans can get up to six months of addiction coverage. NJ Department of Health Partners with New Jersey Hospital Association to Announce Electronic POLST The electronic POLST (Practitioner Orders for Life-Sustaining Treatment) form, called emPOLST, was created to integrate with electronic medical records and ensure seamless access. The emPOLST form will be pilot tested in select sites and eventually rolled out statewide.

PUBLISHER PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company JANET S. PURO Vice President MDAdvantage Insurance Company THERESA FOY DIGERONIMO Copy Editor ERIC R. ORTIZ O2 Advertising EDITORIAL BOARD PAUL J. HIRSCH, MD, Editor-in-Chief HON. PAUL W. ARMSTRONG, JSC (Ret.) STEVE ADUBATO, PHD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DEBARI, PHD JEREMY S. HIRSCH, MPAP WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, ESQ. ALAN J. LIPPMAN, MD JUDITH M. PERSICHILLI, RN, BSN, MA EMERGING MEDICAL LEADERS ADVISORY COMMITTEE MICHAEL CACOILO KATHRYN ECKERT DEVIN WALFORD GODWIN SYDNEY HYDER

TIMOTHY LOPEZ MARK MCSHANE MARY THOMPSON

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE.

Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company and any affiliated companies (all as “MDAdvantage®”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage®, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage®. If MDAdvantage® ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage Insurance Company. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2017 by MDAdvantage®. POSTMASTER: Send address changes to MDAdvantage, 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104. For advertising opportunities, please contact MDAdvantage at 888-355-5551.

MDADVISOR | SPRING 2017

SPRING 2017 – CONTENTS

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Center: Chantal Brazeau, MD Second Row left to right: Nancy D. Connell, PhD; Maria Soto-Greene, MD, MS-HPEd Back Row left to right: Alfred F. Tallia, MD, MPH; Alexander J. Hatala, FACHE; John W. Sensakovic, MD, PhD; Larry Hirsch, MD

1 5 7

LETTER FROM MDADVANTAGE® CHAIRMAN & CEO PATRICIA A. COSTANTE NEW JERSEY’S OPIOID ADDICTION HEALTH CRISIS | By Commissioner Cathleen D. Bennett

CME

ENDING THE HIV EPIDEMIC WITH THE HELP OF BIOMEDICAL PREVENTION INTERVENTIONS | By Paula Toynton, MEd, and Kathy Ahearn O’Brien

PERSPECTIVES ON HEALTHCARE FROM THE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE HONOREES | Edited by Janet S. Puro, MPH, MBA

SPRING LEGISLATIVE UPDATE | By Michael C. Schweder

FREDERICK DOUGLASS MEMORIAL HOSPITAL AND TRAINING SCHOOL: A HISTORICAL PERSPECTIVE | By Dennis Cornfield, MD

PROMOTING THE VITALITY OF FACULTY TO COMBAT BURNOUT | By Chantal Brazeau, MD, and Maria Soto-Greene, MD, MS-HPEd

IGNITING PASSION IN YOUR PEOPLE | By Steve Adubato, PhD

THE VALUE OF MENTORSHIP | By Kathryn Eckert, Emerging Medical Leaders Advisory Committee Member ONLINE ARTICLES – VISIT OUR WEBSITE FOR FULL ARTICLES AT: WWW.MDADVANTAGEONLINE.COM/MDADVISOR

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BUNDLED PAYMENT FOR PHYSICIAN GROUP PRACTICES AND ORGANIZED DELIVERY SYSTEMS | By Barry Liss, Esq.

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New Jersey’s Opioid Addiction Health Crisis By Commissioner Cathleen D. Bennett

New Jersey, like much of the nation, is battling a serious opioid epidemic. Recognizing the urgency of this challenge, Governor Christie has declared that the abuse of and addiction to opioid drugs is a public health crisis in New Jersey.1 As a state, we are focused on developing and executing a comprehensive strategy that removes barriers and obstacles to combat opioid abuse and addiction, which is having a devastating toll on our residents. By the Numbers Opioid addiction does not discriminate. Residents from all walks of life have been impacted. Some of the greatest increases have occurred in demographic groups with historically low rates of heroin use: women, the privately insured and people with higher incomes. Heroin use more than doubled among young adults ages 18–25 in the past decade.2 Although all of our state has been affected, certain areas have been harder hit. In 2015, there were nearly 1,600 drugrelated deaths, which is three times the number of people killed in car accidents in the same year. Of those deaths, 1,173 were related to opioids. While all areas of the state have been impacted, Camden, Essex, Ocean and Monmouth counties have seen the most opioid-related deaths.3 In 2015, heroin was the leading cause of all drug-related deaths in the state, accounting for more than 900 of the deaths.3 Changing Initiation Factors The factors leading to the initiation of heroin use have changed over time. Today, abuse of prescription opioids is a gateway to heroin for a majority of addicts. In the 1960s, more than 80 percent of individuals who entered treatment began with heroin addiction. By 2008 and 2009, 86 percent had used opioid pain relievers nonmedically before using heroin.3 Individuals who are addicted to prescription opioids are 40 times more likely than those who are not to become addicted to heroin.4 Among new heroin users, approximately three out of four report abusing prescription opioids before using heroin.4 In addition, many individuals struggling with addiction have a co-occurring mental health problem. Approximately

7.9 million U.S. adults have mental health and substance use disorders.5 These co-occurring conditions greatly impact the healthcare system, especially when an individual is in crisis. One in eight emergency department visits in the United States involves behavioral health and substance use disorders.6 In New Jersey, emergency department visits increased by 117,000 between 2014 and 2015, and nearly 54,000 of those cases included a mental health or substance use disorder diagnosis, according to the New Jersey Hospital Association.7 Call to Expand Inpatient Acute Psychiatric Beds In February 2017, the New Jersey Department of Health issued a call to expand the number of inpatient acute psychiatric and co-occurring mental health and substance use disorder beds by approximately 864.8 Governor Christie has also signed legislation that would require health insurers to pay without prior authorization for up to six months of inpatient treatment.8 The Department’s call to expand inpatient acute psychiatric and co-occurring mental health and substance use disorder beds recognizes that nearly 750,000 New Jersey adults are receiving mental health treatment and that more than 957,000 New Jersey adults are getting substance abuse treatment.8 This call recognizes that a well-functioning mental health and co-occurring disorder system provides a continuum of care, including acute care, for individuals. This call for expansion reflects that there are individuals who require more intensive hospital care than can be provided in other healthcare settings. The expansion also requires coordination with outpatient services because the Department understands that this is an important approach to helping patients manage their behavioral health conditions. This call provides the mechanism for the coordination of a range of treatment options for those in need. The beds can be added to existing acute care or psychiatric hospitals licensed by the Department, or any healthcare provider can apply to open a new inpatient psychiatric facility or create an inpatient psychiatric wing in an existing healthcare facility. The proposal, representing a nearly 40 percent increase in the adult psychiatric beds currently licensed by the Department, is the first of its kind in nearly 20 years. It is part MDADVISOR

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of a comprehensive strategy that Governor Christie outlined in his State of the State message to create the most aggressive response in the country to the opioid crisis. Available Resources Healthcare providers are key to prevention and treatment of drug abuse. As we have seen the epidemic explode across the state, it is likely that patients treated every day in healthcare settings are affected either directly or indirectly through the impact on individuals, family and friends, therefore linking patients to care is critical. Hospital staff and emergency room physicians are rethinking their emergency protocols for opioid prescriptions. Governor Christie and I recently visited St. Joseph’s Regional Medical Center in Paterson to applaud its Alternatives to Opioids Program (ALTO). After its first year, the ALTO program has reduced opioid prescriptions in the emergency department by nearly 60 percent while still providing patients with needed pain relief. Its success in using nonaddictive drugs to treat migraines, broken hips, kidney stones and 9 other painful conditions has garnered national attention. Everyone in the healthcare community can help fight the opioid epidemic by informing our residents about helpful resources. To ensure all residents are able to connect to care, the Governor also launched a “Help Is Within Reach” public awareness campaign and a 24/7 helpline at 1-844-ReachNJ for instant drug addiction–related help. Through this campaign, the state is working to ensure that those affected by addiction can find the types of resources they need for recovery. Campaign materials are available at nj.gov/governor/reachnj/. The Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA) offer tools that can be helpful in educating patients and evaluating which patients are at risk of addiction. The CDC offers a checklist for primary care providers treating adults (18+) with chronic pain, which is available on the CDC website at www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf. The AMA Task Force to Reduce Prescription Opioid Abuse recommends that physicians register and use state prescription drug monitoring programs and educate themselves on managing pain and promoting safe and responsible opioid prescribing.10 New Jersey has a Prescription Monitoring Program, through the State Division of Consumer Affairs, that collects prescription data on controlled dangerous substances (CDS) and human growth hormone (HGH) dispensed in outpatient settings in New Jersey and by out-of-state pharmacies dispensing into New Jersey. To find more information on how to register, visit the website of NJ Consumer Affairs at www.njconsumeraffairs.gov/pmp/Pages/default.aspx.

MDADVISOR | SPRING 2017

All providers are critical partners in fighting the battle against addiction and in reducing stigma. Patients and families rely on their physicians and other medical providers to be trusted resources for information and counseling. Please partner with the State of New Jersey to raise awareness of the dangers of opioids and to share information with patients on how to get help. Only by working together will we be able to protect our residents from the devastating disease of addiction. Cathleen D. Bennett is the Commissioner of the New Jersey Department of Health. 1

Christie, C. (2017, January 17). Executive order No. 219. http://nj.gov/infobank/circular/eocc219.pdf.

Centers for Disease Control and Prevention. (2015, July 7 [updated]). Today’s heroin epidemic. Vital Signs. www.cdc.gov/vitalsigns/heroin/index.html.

New Jersey Office of the State Medical Examiner. (2016, December 6). Drug related deaths, 2015. www.nj.gov/oag/library/NJ-OSME-2015-Drug%20DeathsChart-by-County.pdf.

National Institute on Drug Abuse. (2015, December 15 [updated]). Prescription opioids and heroin. www.drugabuse.gov/publications/research-reports/relationshipbetween-prescription-drug-heroin-abuse/prescription-opioid -use-risk-factor-heroin-use.

Federal Substance Abuse and Mental Health Services Administration. (2016, March 8). Mental and substance use disorders. www.samhsa.gov/disorders.

Weiss, A., Barrett, M. L., Heslin, K. C., & Stocks, C. (2016, December). Trends in emergency department visits involving mental and substance use disorders, 2006–2013. Healthcare Cost and Utilization Project statistical brief #216. www.hcupus.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-UseDisorder-ED-Visit-Trends.pdf.

New Jersey Hospital Association. (2016, October 18). Report: Mental health and substance use accounts for nearly half of growth in hospital ER volume. www.njha.com/pressroom/2016-press-releases/oct-18-2016report-mental-health-and-substance-use-accounts-for-nearlyhalf-of-growth-in-hospital-er-volume.

Bennett, C. (2017, February 3 [revised]). Notice of rescheduling of certificate of need call for applications for adult acute care psychiatric beds pursuant to N.J.A.C. 8:33-4.1(a)(2). http://nj.gov/health/legal/documents/cn_call_adult_acute_ca re_psych_beds.pdf.

Layton, M. (2017, March 2). U.S. attorney warns of growing opioid epidemic. NorthJersey.com. www.northjersey.com/story/news/2017/03/02/us-attorneywarns-growing-epidemic-addiction/98607538/.

American Medical Association. (n.d.). Prescription drug misuse, overdose & death. www.ama-assn.org/deliveringcare/prescription-drug-misuse-overdose-death.

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In order to obtain AMA PRA Category 1 credit™, participants are required to:

Ending the

1) Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully. 2) The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form. 3) Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete. 4) Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or Fax to: 978-367-9148 5) Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again. 6) Mail the Registration and Evaluation Form on or before the deadline, which is May 1, 2018. Forms received after that date will not be processed.

Epidemic with the Help of Biomedical Prevention Interventions By Paula Toynton, MEd, & Kathy Ahearn O’Brien

Learning Objectives

Authors: Paul Toynton, MEd (Senior Director of Education and Research, Hyacinth AIDS Foundation); Kathy Ahearn O’Brien (Executive Director, Hyacinth AIDS Foundation)

At the conclusion of this activity, participants will be able to do the following:

Joint Providership Accreditation: This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of The State of New York (MSSNY) through the joint providership of Kern Augustine, P.C. and MDAdvantage Insurance Company. KA is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. Kern Augustine, P.C. designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Explain current HIV epidemiological trends in the United States

Articulate the four strategic areas of focus outlined in the National HIV/AIDS Strategy 2020

List the three biomedical prevention interventions available to reduce the transmission and acquisition of HIV

Describe the prescription and monitoring of HIV Preexposure Prophylaxis (PrEP)

Disclosure: Kern Augustine, P.C. relies upon planners, moderators, reviewers, authors and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with MSSNY and ACCME guidelines, all planners, moderators, reviewers, authors and faculty participants must disclose relevant financial relationships with commercial interests whose products, devices or services may be discussed in the CME content or may be perceived as a real or apparent conflict of interest. Any discussion of investigational or unlabeled use of a product will be identified. The planners, moderators, reviewers, authors and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. No commercial funding has been accepted for the activity.

The medical science that has happened in the wake of the HIV epidemic has been nothing short of historic. Today, a person diagnosed with HIV at age 20 and taking current HIV medicines can live to age 70.1 Early treatment for HIV not only improves health outcomes but can also reduce the risk of onward transmission by 96 percent.2 Furthermore, we can biomedically prevent the acquisition of HIV among those at high risk by 92 percent.3 These groundbreaking medical advances have brought the end of the U.S. AIDS epidemic within our reach.

CME

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The HIV Epidemic Today After remaining stable for nearly two decades, the estimated number of annual HIV infections in the U.S. fell by almost 20 percent between 2008 and 2014, from 45,700 to 37,600 (see Figure 1). This drop coincides with advances in HIV treatment and biomedical approaches to HIV prevention. However, this progress is uneven. While rates of new infections have fallen dramatically for people who inject drugs and for heterosexuals (56 percent and 36 percent, respectively), annual infections remained stable for gay and bisexual men, at about 26,000 a year. As in the beginning of the epidemic, gay and bisexual men continue 4 to represent those most affected by HIV.

and at high risk for HIV are not benefiting from the healthcare, treatment and prevention resources available today. Nationally, among people living with HIV (PLWH), 14 percent remain undiagnosed, only 40 percent are engaged 5 in care and a mere 30 percent achieve viral suppression. (See Figures 2 and 3.) Figure 2.

Figure 1.

Figure 3.

According to the Centers for Disease Control and Prevention (CDC), more than 1.2 million people in the U.S. are living with HIV, with most of the ongoing epidemic located in the Northeast and Southern United States.1 In these regions, among highly impacted populations, new infections are driven by high rates of undiagnosed and unsuppressed HIV infections. Although we have made significant advances in our efforts to end the epidemic, many people with HIV

MDADVISOR | SPRING 2017

Social factors play a critical role in the ongoing epidemic. People remain undiagnosed and out of care due to stigma, homophobia, transphobia, racism, comorbid mental health issues and addictions stemming from chronic stress and trauma. Poverty, poor access to healthcare, low health literacy and low self-efficacy also drive new infections and poor health outcomes. These social determinants of health have resulted in high community viral prevalence in small social networks of marginalized populations. For these communities, any risky behavior is 6 high risk for HIV infection. An integrated approach that includes biomedical and behavioral prevention, routine testing and early diagnosis and essential support services for full engagement in care and achievement of viral suppression is needed. Our national plan to end the epidemic hinges on two strategies: 1) to increase to 80 percent the proportion diagnosed who achieve viral load suppression by increasing the percentage of PLWH who are aware of their HIV status to 90 percent and the proportion linked to care to increase to 85 percent and 2) to deliver pre-exposure

CME

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prophylaxis (PrEP) to people at risk for HIV. In a model developed by the CDC, full implementation of these strategies and achievement of these goals could avert 6 185,160 new infections over the next five years. To that end, the National HIV/AIDS Strategy (NHAS) 2020 outlines four key strategic areas of critical focus: 1) widespread testing and linkage to care, enabling people living with HIV to access treatment early, 2) broad support for people living with HIV to remain engaged in comprehensive care, including support for treatment adherence, 3) universal viral suppression among people living with HIV and 4) full access to comprehensive PrEP services for those whom it is appropriate and desired, with 7 support for medication adherence for those using PrEP. While there is not yet a cure or a vaccine for HIV, the HIV prevention toolbox has grown. We now have behavioral, structural and biomedical interventions that have averted more than 350,000 infections and saved more than $125 billion in direct medical costs.8 Proven strategies include testing and linkage to care; rapid antiretroviral therapy (ART) for everyone diagnosed with HIV; access to condoms and sterile syringes; behavioral change interventions for PLWH, their partners and those at high risk of HIV infection; substance abuse treatment and screening; and treatment for other sexually transmitted infections.

Biomedical Prevention Interventions Less known are three biomedical prevention interventions: 1) treatment as prevention (TasP), 2) non-occupational post-exposure prophylaxis (nPEP) and 3) preexposure prophylaxis (PrEP).7 Treatment as Prevention (TasP): The U.S. Department of Health and Human Services recommends ART for all HIV-infected individuals, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection. Early treatment of infected persons arrests disease progression and substantially reduces their risk of transmitting HIV to others.9 In 2011, the HIV Prevention Trials Network (HPTN) 052 study demonstrated that early HIV treatment has a profound prevention benefit. Study results showed that the risk of transmitting HIV to an uninfected partner was reduced by 96 percent.2 The 2016 PARTNER (Partners of People on ART—A New Evaluation of the Risks) study provided additional evidence of the efficacy of treatment as prevention. Among 1,166 HIV-serodifferent couples

(HIV-positive partner taking suppressive ART) who reported condomless vaginal and/or anal sex, no phylogenetically linked transmissions occurred during follow-up. The 10 within-couple rate of HIV transmission was zero. These landmark studies establish TasP as a core prevention strategy. We know with certainty that antiretroviral treatment of HIV-infected persons improves their health and reduces the risk of onward transmission.11 Non-Occupational Post-Exposure Prophylaxis (nPEP): Healthcare providers are familiar with the use of post-exposure prophylaxis (PEP) for occupational exposures. PEP refers to taking antiretroviral medicines (ART) ≤ 72 hours after being potentially exposed to HIV to prevent becoming infected. We now also have guidelines for non-occupational PEP (nPEP). nPEP is recommended when care is sought ≤ 72 hours after a potential non-occupational exposure, i.e., unprotected sexual activity, that presents a substantial risk for HIV acquisition. Assessment for nPEP includes a determination of the patient’s current HIV status. If rapid HIV blood test results are unavailable, and nPEP is otherwise indicated, nPEP should be initiated without delay. HIVpositive patients should be rapidly moved onto ART. All HIV-negative patients who report behaviors or situations that place them at high risk for HIV infection exposure or who have received nPEP more than once within the past year should be provided risk-reduction services, including consideration of pre-exposure prophylaxis.12 Pre-Exposure Prophylaxis (PrEP): Pre-exposure prophylaxis (PrEP) is the newest tool in our prevention toolbox. PrEP is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that have been used in combination with other medicines to treat HIV since 2004. PrEP prevents HIV from making new virus as it enters the body. PrEP medicines can help keep the virus from establishing a permanent infection.13 Taking medicine to prevent infection is not new. Individuals travelling to an area where malaria is common are advised to take malaria medication before and during travel to prevent infection if they are bitten by a mosquito carrying the malaria parasite. We now have strong research evidence that HIV PrEP, when used consistently, is safe and effective for reducing the risk of acquiring HIV infection

CME

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among adults at very high risk for HIV infection through sex, including men who have sex with men and heterosexually active men and women.14 When taken consistently, PrEP has been shown to reduce the risk of HIV infection by up to 100 percent in people who are at high risk. However, PrEP is much less effective if it is not taken consistently. Combined with condoms and other prevention methods, PrEP is a powerful HIV prevention tool that can provide even greater protection to people at high risk of acquiring HIV. People who use PrEP must commit to taking the drug every day and to seeing their 15 healthcare provider for follow-up every three months. Ongoing engagement in care for PrEP ensures routine HIV testing, early diagnosis and linkage to care if HIV is acquired. PrEP care provided along with integrated social services is also an opportunity to address the mental, behavioral and whole health needs of the patient. In this way, PrEP can be a gateway to improved patient health outcomes, can reduce risk behaviors and can positively impact community health. The only medication regimen approved by the Food and Drug Administration (FDA) and recommended for PrEP is daily TDF 300 mg co-formulated with FTC 200 mg (brand name Truvada), taken in a single pill daily for HIV prevention.16 This combination pill was approved by the FDA for use as an HIV treatment in 2004 and was approved as PrEP in July 2012. In 2014, the U.S. Public Health Service published Preexposure Prophylaxis for the Prevention of HIV Infection in the United States.16 These clinical practice guidelines are supported by several study findings that provided evidence that PrEP is safe and effective in the prevention of sexual HIV acquisition. PrEP Research Among Men Who Have Sex with Men: The iPrEx study was a randomized, double-blind, placebocontrolled, multinational, clinical study evaluating tenofovir/emtricitabine versus placebo in HIV-seronegative men or transgender women who have sex with men and with evidence of high-risk behavior for HIV-1 infection. The primary outcome measure for the study was the incidence of documented HIV seroconversion. Of the 2,499 participants enrolled, 1,251 received tenofovir/emtricitabine, and 1,248 received placebo. All participants (drug and placebo groups) were seen every four weeks for an interview, HIV testing, counseling about risk reduction and adherence to PrEP medication doses, pill count and dispensing of pills and condoms.3 Study results showed participants on tenofovir/emtricitabine had a 42 percent risk reduction for acquiring HIV-

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1 infection versus the placebo group. The level of protection was significantly greater among those who adhered well to the daily dosing regimen. Among men who have sex with men (MSM) with detectable levels of the medication in their blood, the risk of HIV acquisition was reduced by more than 90 percent. The study showed that treatment was well tolerated, although nausea in the first month was more common among participants taking medication than among those taking placebo (9 percent versus 5 percent). No differences in severe (grade 3) or life-threatening (grade 4) adverse laboratory events were observed between the active and placebo groups, and no drug-resistant virus was 3 found in the 100 participants infected after enrollment. As a follow-up, researchers conducted the iPrEx OpenLabel Extension (OLE). This study looked at HIV incidence and risk reduction by detectable drug levels. iPrEx OLE allowed participants to join the study but elect to start PrEP at any time within the first 48 weeks. They could also stop taking PrEP whenever they liked. Participants were followed up for 72 weeks regardless of whether they were taking PrEP or not. The study found that PrEP had no significant efficacy in people who took fewer than two doses a week. However, the efficacy of PrEP was 84 percent in people who took two to three doses a week, and no infections at all were seen in people who took at least four doses a week.15 (See Figure 4.) Figure 4.

Note. From â&#x20AC;&#x153;Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: A cohort studyâ&#x20AC;? by R. M. Grant, P. L. Anderson, V. McMahan, A. Liu, K. Rivet Amico, M. Mehrotra, S. Hosek, . . . D. V. Glidden, 2014, The Lancet: Infectious Diseases, 14(9), p. 824. Reprinted with permission.

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PrEP Research Among Heterosexually Active Men and Women: In July 2011, researchers announced the results of two PrEP studies and found strong evidence that PrEP is effective and safe among heterosexually active men and women. In both groups, the primary outcome measure was the incidence of documented HIV seroconversion.16 The TDF2 study found that a once-daily tablet of tenofovir/emtricitabine reduced the risk of acquiring HIV infection by roughly 62 percent overall in the study population of uninfected heterosexually active men and women.16 The PARTNERS PrEP study showed that that daily doses of tenofovir/emtricitabine reduced HIV transmission among heterosexual serodiscordant couples by 75 percent. These trials found that PrEP was equally effective among men and women.10 As with the iPrEx and iPrEx OLE studies, the level of protection offered by PrEP is strongly related to the level of adherence to the daily medication doses.10 Guidelines for PrEP Use: The first step in assessing if PrEP is appropriate for a patient is to determine if the patient is at risk for HIV acquisition.16 This requires a brief sexual history and effective strategies to help normalize this process. Begin with a non-judgmental approach and acknowledge any awkwardness or discomfort the conversation may bring up. Explain that taking a brief sexual history is routine practice and that the information is necessary to the provision of individually appropriate sexual healthcare. Reaffirm the confidentiality of patient information. It is critical that assumptions are not made about a patient’s sexual history and that patients are not made to feel uncomfortable as they share their history. Use the Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014 Clinical Practice Guideline to guide your PrEP assessment. Federal guidelines for healthcare providers recommend that PrEP be considered for people who are HIV-negative and at substantial risk for HIV infection.16 For sexual transmission, “at substantial risk” includes anyone who is in an ongoing relationship with an HIV-

positive partner. It also includes anyone who 1) is not in a mutually monogamous relationship with a partner who recently tested HIV-negative and 2) is a gay or bisexual man who has had anal sex without a condom or has been diagnosed with a sexually transmitted infection (STI) within the past six months or is a heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status who are at substantial risk of HIV infection (e.g., people who inject drugs or have bisex16 ual male partners). For people who inject drugs, “at substantial risk” includes those who have injected illicit drugs within the past six months and who have shared injection equipment or been in drug treatment for injection drug use within the past six months. Healthcare providers should also discuss PrEP with heterosexual couples when one partner is HIV-positive and the other is HIV-negative as one of several options to protect the partner who is HIV-negative during conception and pregnancy.16 Patients are clinically eligible for PrEP if they have a documented negative HIV test before they are prescribed PrEP, exhibit no signs/symptoms of acute HIV infection, have normal renal function, have no contraindicated medications and have documented hepatitis B virus infection and vaccination status.16 PrEP is prescribed in supplies for ≤ 90 days. Monitoring PrEP requires follow-up visits at least every three months to provide an HIV test, medication adherence counseling, behavioral risk reduction support, side effect assessment and STI symptom assessment. At three months and every six months after, follow-up visits are required to assess renal function; every six months, tests for bacterial STIs should be performed. Patients on PrEP should be encouraged to use all appropriate prevention resources. These include behavioral counseling, use of condoms and/or sterile syringes, risk reduction strategies that encourage less risky behaviors (i.e., oral sex versus vaginal or anal sex), couple’s HIV counseling and testing.16

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Final Word Healthcare providers are an essential part of the NHAS, ensuring full implementation of HIV testing, rapid linkage to care and the prescription of ART for people who are HIV-positive and the prescription and monitoring of PrEP for those at high risk of HIV infection. However, no prevention strategy—behavioral, structural or biomedical—is 100 percent effective for people at high risk for HIV infection. While medical advances to treat and prevent HIV infection have been remarkable and significant, we cannot treat our way out of this epidemic. Integrated systems of health and social services are essential to achieving patient and community health. Needs such as food insecurity, housing instability, intimate partner violence, mental health issues, substance abuse and other unmet or unaddressed co-morbid/syndemic conditions decrease a patient’s ability to adhere to treatment and prevention 6 behaviors. Whether within a clinic or in partnership with community-based organizations, healthcare should be integrated with supportive social services to ensure the best patient health outcomes and greater community health. Together, we can make history. We can end AIDS. Paula Toynton, MEd, is Senior Director of Education and Research, Hyacinth AIDS Foundation. Kathy Ahearn O’Brien is Executive Director, Hyacinth AIDS Foundation. 1

Centers for Disease Control and Prevention. (2014). HIV care saves lives. www.cdc.gov/vitalsigns/hiv-aids-medical-care.

The HIV Prevention Trials Network. (n.d.). HTPN 052. www.hptn.org/research/studies/33.

Marcus, J. L., Glidden, D. V., Mayer, K. H., Liu, A. Y., Buchbinder, S. P., Amico, K. R., McMahan, V., . . . Grant, R. M. (2013). No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS ONE, 8(12), e8199. [Available at http://journals.plos.org/plosone/article?id=10.1371/journal.po ne.0081997]

Centers for Disease Control and Prevention. (2017, February). HIV incidence: Estimated annual infections in the U.S., 2008– 2014 overall and by transmission route. CDC fact sheet. www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-incidence-fact-sheet_508.pdf.

Centers for Disease Control and Prevention. (2016, June). HIV in the United States: At a glance. www.cdc.gov/hiv/statistics/overview/ataglance.html.

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CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (2010). Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States. An NCHHSTP White Paper on Social Determinants of Health. www.cdc.gov/socialdeterminants/docs/SDH-White-Paper-2010.pdf.

White House Office of National AIDS Policy. (2015, July). National HIV/AIDS strategy for the United States: Updated to 2020. www.aids.gov/federal-resources/national-hiv-aidsstrategy/nhas-update.pdf.

CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (2011, August). HIV prevention in the United States high impact prevention: Saving lives and money. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1. 258.5010&rep=rep1&type=pdf.

Department of Health and Human Services. (2016, January 28). Clinical guidelines portal. AIDSinfo. https://aidsinfo.nih.gov/guidelines.

Murnane, P. M., Celum, C., Mugo, N., Campbell, J. D., Donnell, D., Bukusi, E., . . . Baeten, J. M. (2013). Efficacy of pre-exposure prophylaxis for HIV-1 prevention among high risk heterosexuals: Subgroup analyses from the Partners PrEP Study. www.ncbi.nlm.nih.gov/pmc/articles/PMC3882910.

Centers for Disease Control and Prevention. (2016, May). Proven HIV prevention methods. www.cdc.gov/nchhstp/newsroom/docs/factsheets/methods508.pdf.

Centers for Disease Control and Prevention. (2016, April). Updated guidelines for antiretroviral post-exposure prophylaxis after sexual, injection drug use, or other non-occupational exposure to HIV—United States, 2016. https://stacks.cdc.gov/view/cdc/38856.

Centers for Disease Control and Prevention. (2012, August). PrEP: A new tool for HIV prevention. www.cdc.gov/hiv/pdf/prevention_prep_factsheet.pdf.

CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (n.d.). PrEP information sheet. www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_prep_english.pdf.

Grant, R. M., Anderson, P. L., McMahan, V., Liu, A., Rivet Amico, K., Mehrotra, M., Hosek, S., . . . Glidden, D. V. (2014, September). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: A cohort study. The Lancet: Infectious Diseases, 14(9), 820–829. [Available at http://thelancet.com/journals/laninf/article/PIIS14733099(14)70847-3/abstract]

Centers for Disease Control and Prevention. (2014). Preexposure prophylaxis for the prevention of HIV infection in the United States – 2014 clinical practice guideline. www.cdc.gov/hiv/pdf/prepguidelines2014.pdf.

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Ending the HIV Epidemic with the Help of Biomedical Prevention Interventions

CME Examination (Deadline May 1, 2018) 1) After remaining stable for nearly two decades, the estimated number of annual HIV infections in the U.S. _____________ by almost 20 percent between 2008 and 2014. a) Increased b) Decreased 2) According to the Centers for Disease Control and Prevention (CDC), most of the ongoing HIV epidemic is located: a) in the Northeast and Southern United States. b) in the Northwest and Central United States. c) in the Southwest and Western United States. 3) Three biomedical prevention interventions include TasP, nPEP and PrEP. a) True b) False 4) It is known with certainty that HIV-infected persons treated with antiretroviral treatment have the following outcome(s): a) Improvement of health b) Reduction in the risk of onward transmission c) Both a and b d) Neither a nor b 5) In 2011, the HIV Prevention Trials Network (HPTN) 052 study demonstrated that early HIV treatment has a profound prevention benefit. Study results showed that the risk of transmitting HIV to an uninfected partner was reduced by: a) 10 percent. b) 50 percent. c) 96 percent. 6) nPEP is recommended when care is sought _____ after a potential non-occupational exposure to HIV. a) < 24 hours b) < 36 hours c) < 48 hours d) ≤ 72 hours

7) PrEP prescribes one pill every day: a) to prevent HIV infection. b) to treat HIV-positive patients. c) to reduce the likelihood of passing on HIV in utero. 8) Among high-risk patients, when taken consistently, PrEp is effective in ______ percent of cases: a) 50 b) 75 c) 100 9) The iPrEx Open-Label Extension (OLE) study looked at HIV incidence and risk reduction by detectable drug levels among men who have sex with men and found ____ percent efficacy in people who took at least four doses a week. a) 0 b) 84 c) 100 10. For sexual transmission of HIV, “at substantial risk” includes anyone who: a) is in an ongoing relationship with an HIV-positive partner. b) is in mutually monogamous relationship with a partner who recently tested HIV-negative. c) is a gay or bisexual man who has had anal sex without a condom or has been diagnosed with a sexually transmitted infection (STI) within the past six months. d) is a heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status who are at substantial risk of HIV infection. e) has injected illicit drugs within the past six months and has shared injection equipment or been in drug treatment for injection drug use within the past six months. f ) all of the above

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REGISTRATION AND EVALUATION FORM (Must be completed in order for your CME Quiz to be scored)

Ending the HIV Epidemic with the Help of Biomedical Prevention Interventions Deadline for Response: May 1, 2018 REGISTRATION FORM First Name

Middle Initial

Last Name

City

State

ZIP

Phone

E-mail Address

Specialty

Degree

Address

ANSWER SHEET Circle the correct answer. 1) A B

2) A B C

3) T F

4) A B C D

6) A B C D

7) A B C

8) A B C

9) A B C

5) A B C 10) A B C D E F

Number of hours spent on this activity _______ (reading article and completing quiz) I attest that I have read the article “Ending the HIV Epidemic with the Help of Biomedical Prevention Interventions” and am claiming 1.0 AMA PRA Category 1 Credit.™ Signature EVALUATION 1. 2. 3. 4.

The The The The

Date Completed by

❑

Physician

content of the article was: authors’ writing style was: graphics included in the article were: stated objectives of this program were:

❑

Non-Physician

Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Exceeded____ Met____ Not met_____

Was this article free of commercial bias? Yes _________ No _________ If not, why not _____________________________________________________________________________________ Please share your name and contact information so that we may investigate further. Participant Name _____________________________________ Telephone/E-mail: ____________________________ 5. Will the knowledge learned today affect your practice? Very Much____ Moderately____ Minimally____ None____ 6. Based on your participation in the CME activity, describe ways in which you will change the way you practice medicine. __Yes Describe ___________________________________________________________________________________ __No Why not ___________________________________________________________________________________ __N/A Were you the wrong audience for this activity? _________________________________________________ 7. Did this CME activity change what you know about: • Current HIV epidemiological trends in the United States. Yes ❑ No ❑ • The four strategic areas of focus outlined in the National HIV/AIDS Strategy 2020. Yes ❑ No ❑ • The three biomedical prevention interventions available to reduce the transmission and acquisition of HIV. • The prescription and monitoring of HIV Preexposure Prophylaxis (PrEP). Yes ❑ No ❑

Yes ❑ No ❑

8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:_________________________________________________________________________________

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PERSPECTIVES ON HEALTHCARE FROM THE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE HONOREES Edited by Janet S. Puro, MPH, MBA The 2017 Edward J. Ill Excellence in Medicine honorees are distinguished professionals who are making a significant impact on healthcare during a time of rapid change and uncertainty. They stand out as leaders who have earned the admiration and respect of their peers for their commitment to providing quality care to patients, while making improvements to the healthcare delivery system itself. We asked all honorees to discuss the greatest challenges they face in their professions. Their answers give us a unique opportunity to better understand the work, as well as the concerns and the hopes, of these honorable leaders in healthcare who have made such significant contributions in their respective fields.

OUTSTANDING MEDICAL EDUCATOR AWARD

John W. Sensakovic, MD, PhD Infectious disease specialist; Associate Dean for Residencies and Fellowships, Seton Hall University School of Health and Medical Sciences/Seton Hall University-Hackensack Meridian School of Medicine; and Director of Infection Control and Continuing Medical Education, JFK Medical Center

Looking back on a long career of practicing and teaching internal medicine and infectious diseases, an appreciation of the privilege and satisfaction, as well as the necessary dedication and responsibility, becomes abundantly evident. Certainly, a career in medicine begins with dedication to education and learning. Role-model teachers enhance that process. Having been blessed with great role models in my training, I have tried to provide the same for my students. Sharing and instilling qualities of excellence in medical care and compassion for patients remain the heart and soul of medical education. Residents, fellows, medical students and allied health students work and study very hard to attain these qualities. Our major responsibility in medical

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practice and teaching is to exemplify, instill and encourage these qualities, which can then be demonstrated by our students in their care of literally hundreds, if not thousands, of patients—obviously, a lot more patients than we can see ourselves on even the busiest of office days! Excellence in medical care also requires continued learning and improvement. Just consider the continuing advances made in medicine, such as in treating AIDS, cancer and cardiac disease, and in gene therapy and PCR diagnostics. Teaching and self-learning are at the core of making these advances available to our patients. One of the most noticeable recent changes in medical care—computerized medicine—has had a major impact on medical education and medical care. Computer access to medical literature can instantaneously bring the practitioner to the latest information on the most common, as well as the rarest, of diseases. Additionally, computer access in medicine makes accurate medical information concerning our patients readily available, including past historical information, medications, laboratory values and the like, all of which can contribute to an improved level of healthcare. As we go through these developments and changes in the delivery of medical care, we must be ever-more focused on maintaining and demonstrating compassion for our patients. The need to maintain focus on compassion in healthcare is never more evident than is seen in the downside of computers in medicine. In any hospital today, it is not unusual to see physicians, nurses and other healthcare providers at the computer station longer than they are at the patient’s bedside or speaking directly to the patient and the patient’s family. From the patient’s viewpoint, this is often taken as an absence of classic compassionate medical care, bedside manner and the caring physician–patient interpersonal relationship. One basic principle of medical practice that I have always shared with my students, verbally and, hopefully, also by example, is intended to instill the importance of compassion in medical care. The potential of computers in medicine to detract from this compassionate relationship make this principle ever-more important. This basic principle is one I hope my students never forget and always live up to in their practices. You cannot cure every patient, but you can make every patient feel a little better by demonstrating compassionate care.

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OUTSTANDING HEALTHCARE EXECUTIVE AWARD

Alexander J. Hatala, FACHE President and Chief Executive Officer, Lourdes Health System Right now, we are in the middle of profound changes in our healthcare system. I am reminded of the famous Volvo ad in which Jean-Claude Van Damme deftly remains aloft as he straddles two trucks, each foot poised on a truck that moves in tandem with the other. In the same way, balancing the mix of danger and agility is what’s required of healthcare providers to manage the “epic split” that is occurring before our eyes. Like all providers, Lourdes Health System has been challenged to shift from a traditional volume-based system to a value-based system that focuses on population health management and community health and wellbeing. This change is built on the expectation that inpatient care will become a much smaller focus of healthcare services. However, payment systems remain rooted in volumebased care, with insufficient reward for population health and prevention strategies. At the same time, healthcare innovations and treatment options evolve, with insufficient resources to support their acquisition. How do we move forward and continue to deliver the quality healthcare that we are known for? Despite the challenges, our vision for population health positions us well to fulfill our mission and to improve health and access in the communities we serve. Through our accountable care organization and other innovative programs, such as LIFE at Lourdes (a program for the all-inclusive care of the elderly), we continue to identify and address community health needs. As we restructure the clinical delivery system for healthcare to meet the triple aim (better health, better care, lower cost), Lourdes has created a clinically integrated network

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that is transforming healthcare. Lourdes has developed one of the largest primary care medical homes groups with almost 200 primary care providers, high-risk clinics and care navigation through the entire continuum of care serving 85,000 lives. Lourdes’ philosophy has always been that partnerships are the best way to meet the needs of the community. After acquiring two of the area’s largest cardiology groups and implementing a cardiology co-management model, we are achieving quality goals that set Lourdes among the top hospitals in the nation for cardiovascular care. We have consistently been recognized by respected organizations such as Healthgrades, Truven Analytics and Becker’s Hospital Review. Lourdes is a partner with Centennial Surgery Center, Acuity Healthcare, DaVita Dialysis, Deborah Heart & Lung Hospital, Walgreens and South Jersey Vascular Institute. Most recently, Lourdes has partnered with the Drexel Neuroscience Institute to introduce new services that were previously unavailable in southern New Jersey. With our new hybrid operating room, Lourdes now offers minimally invasive neurosurgical procedures for stroke, brain aneurysms, tumors and other related conditions. There is no doubt these are uncertain times in healthcare, but I am positive that if we remain committed to our triple aim (better care, better health, lower cost), stay focused on our mission and remain flexible, we are headed in the right direction.

EDWARD J. ILL PHYSICIAN’S AWARD®

Maria Soto-Greene, MD, MS-HPEd Vice Dean and Professor of Medicine and Director, Hispanic Center of Excellence, Rutgers New Jersey Medical School Today, the challenges faced by physicians and educators are many. In the midst of these challenges, how do we remain true to our profession? The answer to this question places the patient at the very core of why we do what we do. Unfortunately, the time allowed for each patient encounter and, if admitted to the hospital, adherence to length-of-stay guidelines have placed a strain on our social responsibilities. Certainly, those of us in academic health centers remain committed to value-based care, yet we are at a crossroads in not being fully able to meet this expectation. When caring for disadvantaged populations, the solution to the problems of quality patient care does not lie only in providing excellent care. These patients lack other daily life resources that often compete with their desire and need to make health a priority. Thus, the more complex question is: How can our health system continue this rapid pace of change and still meet the healthcare needs of underserved communities? To address this question, we add observation units,

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hospitalists and innovative training methods for our residents and fellows. We are charged with safe, effective care and, as such, designing and implementing systems of care that do the very best for our patients. This is a historic time when we must also keep pace with the changing demographics of our nation and the populations we serve. At the same time, we are learning and training environments. All is not lost. As leaders in academic medicine, we recognize our responsibility for being the mentors and role models of the generations that follow. As a physician and educator, it is inspiring to be with likeminded colleagues committed to being at the forefront of innovation through our service, education, research and clinical care. Without question, medicine is truly a noble profession, and I am happy to have been blessed by being a part of it and doing what I can to make a difference in this world.

VERICE M. MASON COMMUNITY SERVICE LEADER AWARD

Chantal Brazeau, MD on behalf of the Rutgers New Jersey Medical School Student Family Health Care Center Professor and Interim Chair of Family Medicine and Assistant Dean for Faculty Vitality, Rutgers New Jersey Medical School The number of uninsured people in our country is a matter of great concern for the healthcare profession. This was not an issue for me growing up and going to medical school in Canada, and as a result, I was not familiar with the concept of student-run free clinics. Since joining the faculty at Rutgers New Jersey Medical School (RNJMS), I have been inspired by the medical students who take up the challenge of caring for people who do not have health insurance or who are underserved. It has been an honor for me to be a faculty mentor and to contribute to the growth of the

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RNJMS student-run free clinic, the Student Family Health Care Center (SFHCC). RNJMS students started planning SFHCC after the 1967 Newark riots to serve the needs of uninsured people in the Greater Newark area. The clinic is celebrating its 50th anniversary in 2017 and is the oldest continually running clinic of its kind in the nation. It has evolved into an active clinic that is open two evenings per week. SFHCC also reaches out to two homeless shelters in the community. Students, along with their faculty supervisors, approach each patient comprehensively. They provide preventive, chronic and acute primary care; they also help patients navigate the healthcare system, register for healthcare insurance or obtain charity care, referrals and low-cost medications. In this hands-on teaching model, students and patients benefit. Medical students learn about the logistics of administering a practice, reaching out to patients for appointments and follow-up. They learn how to function in teams and to work with students from other professions, such as nutrition and dental students. They are taught to monitor the quality of care through formal chart review assessments and to improve the care processes at the clinic. Most importantly, through this service experience, they learn about the needs and life challenges of underserved people and experience the privilege of advocating for those in need. Students reflect about their SFHCC experiences during regular, small-group reflection sessions; I am consistently impressed by the depth of studentsâ&#x20AC;&#x2122; comments as they discuss how a particular patient has touched them, inspired them or helped them to grow as healthcare professionals. Students also share feelings they experience while treating patients who appear not to follow directions, and they learn to appreciate the many reasons and barriers why a patient of limited means may not be able to follow directions. Service experiences such as the SFHCC have been linked to increased medical student empathy, a heightened understanding and appreciation of community agencies and of how to partner with these agencies to advocate for patients. I hope that this experience will prepare our students after they graduate from medical school to take care of underserved people and to continue to be strong advocates of their patients throughout their careers.

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OUTSTANDING SCIENTIST AWARD

Nancy D. Connell, PhD Professor and Director of Research and Director, Center for BioDefense, Center for Emerging and Re-emerging Pathogens, Rutgers New Jersey Medical School In recent years, genome editing has entered a period of rapid acceleration. A collection of methods, which are often referred to loosely as CRISPR (from the technique called “clustered regularly interspaced short palindromic repeats”), has increased accessibility to inexpensive and standardized methods of editing the expression and heredity of genes in animals, plants and insects, as well as in microorganisms. The method provides an exquisitely precise way to target, excise and replace pieces of DNA. CRISPR technology has been used successfully to engineer mosquitoes incapable of harboring the malaria parasite, and the relevant mutation can be introduced into the mosquito population in the wild by a “gene drive.” A number of human trials using CRISPR-based gene editing have been launched in the U.S. and China. These applications of gene editing technology presumably are intended for good—prevention of infectious diseases, novel efficient organ supplies etc. But other kinds of gene editing can give rise to significant ethical dilemmas. The new gene-editing tools can be used to alter plants, animals and insects, as well as somatic (noninherited) and germ-line (inherited) or embryonic cells, including those in humans. What kind of foreign policy implications does this new technology have? In a recent intelligence report, James Clapper, former Director of National Intelligence, stated that the technology makes

possible “creation of potentially harmful agents or products … in countries with different regulatory or ethical standards.” So, how can misuse of gene editing and drives be prevented? One mechanism in place to restrict the development of novel biological weapons is the Biological and Toxin Weapons Convention. The challenge of monitoring these developments is universal. What are scientists’ and physicians’ responsibilities in the successful regulation of these powerful new methodologies? They must be aware of and promote the work and the findings of the international agencies that have begun the necessary complex discussions. Global cooperation among scientists and physicians—including emphasis on the responsible conduct of science—will go a long way toward developing a global standard of bio-risk management. Combining biosafety, biosecurity and bioethics will help lead to an international “web of prevention.”

OUTSTANDING SCIENTIST AWARD

Larry Hirsch, MD Worldwide Vice President, Medical Affairs, Diabetes Care, BD I chose to work in industry after several years in clinical academic medicine, attracted by the opportunity to impact millions of patients—not only in New Jersey but also globally—through product development, innovation and patient and healthcare professional education. Trained as an endocrinologist specializing in diabetes (having taken insulin > 59 years), I felt the cards had aligned in 2006, when I joined the Diabetes Care business at BD. As we contemplated developing the world’s first 4 mm, 32gauge pen needle, we asked a basic question: What is the thickness of skin and subcutaneous adipose tissue at commonly used insulin injection sites? Amazingly, no one had measured this. Published in 2010, this study provided the anatomic rationale for the “shift-to-short” needles, away from legacy 8 mm and 12.7 mm (half-inch), 29-gauge needles. Simultaneously, we proved the new pen needle controlled blood glucose as well as longer needles but with less pain MDADVISOR

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and less anxiety and was strongly preferred by patients. Since then, our work has been replicated globally, and we know that about 50 percent of needles used today are 4 or 5 mm, a remarkable change in 5–6 years. These findings mean much more comfort for insulin-injecting patients. BD Diabetes Care is also known as “the injection experts” in the diabetes community: We published an unprecedented three primary papers in a single issue of the prestigious Mayo Clinic Proceedings in 2016, providing a wealth of practical information and guidance to improve therapy. We continue to innovate, recently bringing to market the world’s first sideported insulin infusion set for pumps and are hard at work on other novel insulin delivery technologies and systems. Before BD, I spent about 18 years at Merck, overseeing completion of the “4S” trial with simvastatin (Zocor)—which changed modern medical practice—and may be considered the father of all statin trials. Additionally, I lead the team that developed alendronate (Fosamax), the first non-hormonal treatment approved by U.S. Food and Drug Administration (FDA) to treat osteoporosis. My experience has validated my decision to join industry, and I am fortunate to have worked (and continue to) with diverse groups of incredibly talented colleagues. Having been diagnosed with type 1 diabetes as a young child, at a time when it was considered a “severe disability,” I try to encourage others with diabetes to believe, “Yes, I can.”

PETER W. RODINO, JR., CITIZEN’S AWARD®

Alfred F. Tallia, MD, MPH Professor and Chair, Department of Family Medicine and Community Health and Founding Executive Director/CEO, Robert Wood Johnson Partners, Rutgers Robert Wood Johnson Medical School and the RWJBarnabas Health System As American healthcare reorganizes around systems of care, improving the value of the care we provide to patients needs to be at the center of all our considerations. Learning

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how to mobilize the right resources that promote health and empower better decision making by patients, families and caregivers is fundamental to improving care. This requires cooperation and coordination among clinicians and hospital systems to a degree we have not seen before. Integrated delivery systems, such as Robert Wood Johnson Partners, are designed to provide environments where collaboration among health professionals and hospitals can effectively and efficiently attend to patient needs in a supportive, coordinated way. We are fortunate in New Jersey to have many stakeholders interested in improving care. However, we don’t have all the answers about what works best under different circumstances and in different populations, which is why research partnerships with academic institutions, such as Rutgers, become so important. Whether those partnerships try new ways of providing care or seek to improve existing care, fostering collaborative, productive work relationships among professionals and hospitals is key to building new patient-centered systems of care. Researchers in my department at Rutgers have identified seven key work relationship characteristics in healthcare organizations that have achieved excellent patient outcomes: trust, diversity, mindfulness, interrelatedness, respect, varied interactions and effective communication. Trust, respect and diversity mean encouraging and valuing different opinions about improving care. Mindful systems do not function on autopilot, but encourage all stakeholders to express their ideas and learn from them. Interrelatedness means knowing how my work relates to the work of others in achieving better overall patient care. Varied interactions in healthcare organizations promote cohesion and better decision making, and a mixture of rich and lean communication styles helps bond employees to the organization’s mission. Are we there yet in achieving effective, collaborative work relationships? Patients say we still have a way to go. But I have no doubt that in partnership with academic institutions, clinicians and managers alike will learn how to better attain this goal in the emerging new systems of care. Our patients expect and deserve no less. Janet S. Puro, MPH, MBA, is Vice President of Business Development and Corporate Communications at MDAdvantage Insurance Company.

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Spring Legislative Update

By Michael C. Schweder Governor Chris Christie has presented his eighth and final budget address to the New Jersey State Legislature in Trenton. The Governor’s budget stands as the largest ever proposed, with the total amount just a bit more than $35.5 billion. New Jersey is currently in its budget season, a time when the Legislature holds open public meetings and hearings with each state department to help give a better understanding of the State’s fiscal status. This process grants the Legislature an opportunity to change certain aspects of the Governor’s budget, but ultimately the Governor can use his veto powers to determine the final state budget. By law, a signed and balanced budget must be enacted prior to July 1, the start of the new budget year. While the FY 2018 proposed budget would be the State’s largest total ever, there are still many cutbacks that leave businesses and industries very concerned, particularly hospitals. The biggest issue for hospitals arises from the $50 million cut to charity care.1 The President and CEO of the New Jersey Hospital Association (NJHA), Betsy Ryan, has stated that “hospitals lean on charity-care funding to provide services for uninsured and underinsured patients.”2 Year after year, charity care has been facing ongoing cuts.2

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State officials have credited the reduction in charity care to the expansion of the Affordable Care Act’s (ACA) Medicaid system, which has insured an additional 550,000 New Jersey residents.3 However, it is unknown what will happen to this system in the coming years. Governor Christie has allocated an additional $30 million to the Graduate Medical Education (GME) program for hospitals, equaling $218 million to be shared among 43 hospitals.4 The increase in the GME will not offset the losses from charity care to New Jersey hospitals, but it can support the effort to prepare new doctors, which the State desperately needs. In total, Governor Christie’s FY 2018 budget proposal would include more than $700 million in state and local dollars for New Jersey’s healthcare system, including support for charity care, medical education and quality improvement.5

Legislative Bill Targeting Healthcare Assembly Bill No. 3404/Senate Bill No. 913: Assemblyman John Burzichelli (D-3) and Assemblyman Craig Coughlin (D-19) sponsored this bill that “permits hospitals

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to establish a system for making performance-based incentive payments to physicians.” The bill has passed through both houses and is awaiting the Governor’s signa6 ture, allowing it to become law. Assemblyman Burzichelli stated that this bill will allow hospitals and physicians to “enter into arrangements to improve the overall health of an individual patient by tracking him or her through the healthcare delivery system.…Physicians will have an additional incentive to go above and beyond 7 to improve outcomes for their patients.” Assemblyman Coughlin concluded that this bill will “create an additional incentive for physicians and hospitals to work collaboratively and efficiently to strive for excellence.…While doctors will receive incentives, it’s ultimately the patients who will win through superior levels of care.”7

Package of Mental Health Bills Assemblyman Gary Schaer (D-36), Assemblywoman Valerie Vainieri Huttle (D-37), Assemblywoman Shavonda Sumter (D-35), Assemblywoman Pamela Lampitt (D-6) and Assemblyman Troy Singleton (D-7) have recently introduced a package of legislation aimed at improving access to critical behavioral health services in New Jersey. The bills include the following: Assembly Bill No. 4468: This bill “concerns Early Intervention Support Services Program in DHS and expansion of program to all counties.”8 Assembly Bill No. 4469: This bill “concerns expansion of services provided by DHS mental health screening services.”9 Assembly Bill No. 4523: This bill “requires DOH to permit certain healthcare facilities to use shared clinical space when providing primary health care and behavioral health care for mild to moderate behavioral health conditions.”10 Assemblyman Schaer (D-36) noted that “early intervention and support is paramount when it comes to behavioral healthcare. With these bills, we will be taking common sense steps to improve and modernize our services, benefiting patients and their families.”11 Assemblyman Singleton (D-7) has expressed his belief that…the bill will help facilitate the integration of primary and behavioral healthcare services while reducing the stigma often associated with behavioral healthcare.”11 All three of these bills were approved and passed out of the Assembly Human Services Committee and have been referred to the Assembly Appropriations Committee.

Michael C. Schweder is the Director of Government Affairs at CLB Partners, LLC, in Trenton, New Jersey. 1

Khemlani, A. (2017, March 9). Which hospitals gain, lose most state funding in N.J.'s proposal? NJBiz.com. www.njbiz.com/article/20170309/NJBIZ01/170309796/whichhospitals-gain-lose-most-state-funding-in-njs-proposal.

Leonard, N. (2017, March 14). N.J. charity care gets slashed (again) amid worry over future health uninsured rates. The Press of Atlantic City. www.pressofatlanticcity.com/news/n-j-charity-care-getsslashed-again-amid-worry-over/article_a9ab71f6-9f4e-5ce4813d-25fec2958cb3.html.

Stainton, L. H. (2017, March 13). ACA Medicaid expansion helped NJ save millions in charity care. NJSpotlight. www.njspotlight.com/stories/17/03/12/aca-medicaid-expansion-helped-nj-save-millions-in-charity-care/.

Stainton, L. H. (2017, March 20). State continues to funnel funds into graduate medical education. NJ Spotlight. www.njspotlight.com/stories/17/03/19/state-continues-to-funnel-funds-into-graduate-medical-education/.

Budget invests $705M in health care. (2016, March 16). The Advertiser News. www.advertisernewssouth.com/article/20170316/NEWS01/170319949/Budget-invests-$705Min-health-care.

Cody, R. J., Vitale, J. F., Burzichelli, J. J., Coughlin, C. J., Schaer, G. S., & Singleton, T. (2016, February 4). Senate No. 913; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/S1000/913_R1.HTM.

Assembly Democrats. (2017, March 16). Burzichelli & Coughlin bill providing incentives to improve hospital care heads to gov’s desk. http://assemblydems.com/Article.asp?ArticleID=12354.

Schaer, G. S., Vainieri Huttle, V., & Sumter, S. E. (2017, January 10). Assembly No. 4468; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A4500/4468_I1.HTM.

Schaer, G. S., Vainieri Huttle, V., Lampitt, P. R., & Sumter, S. E. (2017, January 10). Assembly No. 4469; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A4500/4469_R1.HTM.

Schaer, G. S., Singleton, T., & Vainieri Huttle, V. (2017, January 23). Assembly No. 4523; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A5000/4523_I1.HTM.

Assembly Democrats. (2017, March 20). Schaer, Vainieri Huttle, Sumter, Lampitt & Singleton bill package to improve access to critical behavioral health services in NJ gains Assembly panel approval. www.assemblydems.com/Article.asp?ArticleID=12385.

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Frederick Douglass Memorial Hospital and Training School: A Historical Perspective By Dennis Cornfield, MD

In 1890, black medical school graduates were excluded from every internship in the city of Philadelphia and throughout the Commonwealth of Pennsylvania. Young black women desiring a career in nursing were, likewise, excluded from every nurse training program in Philadelphia, except that of Philadelphia General Hospital (named Philadelphia Hospital at the time), and black physicians practicing in Philadelphia were denied staff privileges at all existing hospitals. One person who was extremely offended by this state of affairs was Nathan Francis Mossell (see Figure 1), the first African American to graduate from the University of Pennsylvania School of Medicine (1882). Mossell was the fourth of six children born to a fairly successful brickmaker who served as a role model for his family by virtue of his strength of character, work ethic and religiosity. Although young Nathan was frequently saddened by the necessity to miss school when he was needed in his father’s brick yard, in his autobiography written at the end of his life, he proudly asserted: “The only man for whom I ever worked was father. I had no opportunity to become a white man’s ‘boy’.”1 In school, he appears to have gotten along well with his classmates, in part due to his large size (6 feet 2 inches,

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approximately 200 pounds) and athletic ability. He engaged in his share of physical fights, not because he enjoyed fighting but because he resented being referred to as a coward. He followed his older brother Charles to Lincoln University in Pennsylvania, where he matriculated in three years and won the Bradley Medal for excellence in the physical sciences. Mathematics was his real strong point, and he seriously considered a career in civil engineering, but the high cost of pursuing an engineering degree ultimately dissuaded him. He did not recall exactly why he chose to pursue a medical career, but once the choice was made, he was determined to attend a medical school with a superior reputation. The University of Pennsylvania fit the bill very well, as his lady friend of two years’ duration, Gertrude Bustill, lived in Philadelphia. Mossell’s first day in medical school resembled Jackie Robinson’s first day in the major leagues. Race relations were such that he felt compelled to carry a hidden revolver. When he took his seat at the first lecture after refusing to sit behind a screen, no one sat within 10 to 15 feet of him, and some students started yelling, “Put the damned nigger out.”1 Other students came to his aid, and soon, the shouting subsided, and the lecture pro-

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ceeded. Mossell was not a person to be tampered with. He had a prickly, probably abrasive personality, and, in later years, he was described by the editor of a black newspaper as a mule who kicks in every direction when provoked. He eventually graduated in the top 25 percent of his medical school class, having received perfect scores in Pediatrics and in Obstetrics and Gynecology. At his graduation ceremony, he received a thunderous ova1 tion from his classmates. After graduating medical school, Mossell worked for two years as an assistant in the surgical clinic of the Hospital of the University of Pennsylvania, a job he secured through the intervention of his old mentor in surgery, Dr. Hayes Agnew. He then opened an office at 924 Lombard Street in Philadelphia for the practice of gynecology. In 1888, he became the first African American to achieve membership in the Philadelphia County Medical Society. Two unpleasant racially related incidents are often mentioned in biographies of Mossell. A local prostitute named Ella Brown sued him for abortion, but he was exonerated with the help of several white physicians at Philadelphia Hospital, who testified that he was totally and justifiably unaware of the patient’s pregnancy. Mossell felt the lawsuit would never have been permitted had he been white. In a second incident, he referred a white female patient of his to the University Hospital for elective surgery, as he did not have hospital admitting privileges. The surgeon who examined her appeared to be dumbfounded that a white person would have gone to a Negro physician in the first place, an exchange that the woman subsequently 2 relayed to Mossell.

Figure 1. Dapper Young Nathan Francis Mossell Nathan Francis Mossell c.1890. Reprinted with permission from the University of Pennsylvania Archives.

Frederick Douglass Memorial Hospital and Training School With incidents like these undoubtedly in mind, and in light of the extremely restricted opportunities for African Americans that prevailed in the 1890s, Mossell eventually realized that he would be better off having an institution he could call his own. He wanted a place where he and his black colleagues could admit and care for their own patients, where qualified young black women could be well-trained in nursing and where young black doctors could hone their medical skills in a good internship. In June 1895, four months after the death of Frederick Douglass, Mossell convened a small group of like-minded people to start making plans for a nurse training school and a hospital that would be open to people of all races and colors, regardless of their financial status. On October 31, 1895, the Frederick Douglass Memorial Hospital and Training School (Douglass Hospital) opened its doors at 1512 Lombard Street in what was then considered South Philadelphia. Douglass Hospital was the second hospital in the United States to be owned and operated by African Americans, the first being Provident Hospital in Chicago, founded in 1891 by the eminent surgeon Daniel Hale Williams. The building that Douglass Hospital occupied was a newly constructed, three-story brick structure (see Figure 2) that the hospital rented for the first two years. It housed offices, an operating room with modern equipment, male and female wards, a maternity ward, a pediatric ward, an emergency room and numerous outpatient clinics. (The clinics were inconveniently located down steep steps in a poorly lit, poorly ventilated 3 basement, a location thoroughly disliked by many patients.) In the first year of operation, the nursing school trained six new students. The ability to accept only high school graduates was an ongoing source of pride for the Douglass nursing school. The hospital had a women’s auxiliary that was responsible not only for providing much of the food and linens for the inpatients but also for the endless fundraising efforts needed to keep the hospital going day to day. The auxiliary was headed by Mossell’s wife, Gertrude Bustill Mossell, a very accomplished woman in her own right. At different times, she was a journalist, author, teacher and suffragette. Her family traced its roots in the United States to 1608. Her great-grandfather was a baker in George Washington’s Continental Army. Her sister’s son was Paul Robeson, the famed actor and singer.1

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Figure 2. The Original Douglass Hospital at 1512 Lombard Street

1895

2015

The building’s exterior in 2015 is virtually unchanged from 1895. This 1895 photo is reprinted with permission from the Special Collections Research Center. Temple University Libraries. Philadelphia, PA.

The first annual report of the Board of Managers shows that there were 987 outpatients and 61 inpatients at Douglass Hospital during the 1895–1896 period, with diseases ranging from alcoholism to whooping cough.4 Ten years later, the report from 1904 to 1906 mentions approximately 10,600 outpatients and 400 inpatients, underscoring the need for a larger hospital.5 In the first year, 31 surgical operations were performed, 21 by Nathan Mossell and 10 divided among five other surgeons. This lopsided activity was apparently sanctioned by the following phrase that appeared in the first annual report and then in numerous subsequent reports: “we permit all physicians to place their patients in the Hospital and attend them while there, except in operative cases, [when] the Hospital reserves the right to use discretion as to the operator.”4 Since Mossell was the hospital’s Medical Director, Superintendent, Chief of Surgery and Chief of Staff, he undoubtedly either wrote this phrase or strongly influenced its writing. In Mossell’s view, the hospital could not afford to permit many types of surgery to be performed by inexperienced hands. An alternate interpretation might be that Mossell wanted the lion’s share of the surgery for himself. The other staff surgeons apparently preferred the latter interpretation. They formed the nidus of an opposition group that steadily grew as the years passed.

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Opposition from Integrationists The Douglass Hospital had its detractors, as well as supporters, in the black community from the very start. Two opposing forces were always present in the black hospital movement. The integrationists wanted African Americans integrated into every aspect of white society, the sooner the better. They regarded Douglass Hospital 6 as “a concession to race prejudice.” The separatists, on the other hand, felt that African Americans needed their own businesses and institutions, like churches and hospitals, at least in the short-tointermediate term before integration could take hold. Although the founding of Douglass Hospital was clearly a separatist effort, Nathan Mossell appears to have been an integrationist at heart, as evidenced by his lifelong, ceaseless efforts to achieve equality of opportunity for African Americans. At the 1896 dedication ceremony for Douglass Hospital, Mossell stated the following: With all, we wish it had not been necessary to establish the Douglass Hospital. We deprecate the present trend in the dominant public mind to create, in many sections of the country, hospitals and medical schools especially for colored people—it means extravagance, inefficiency, duplication of effort, and is undemocratic in that it establishes caste.7 A number of local black newspapers were vehemently opposed to Mossell and the Douglass Hospital. The Philadelphia Tribune was particularly virulent, using numerous opportunities to attack Mossell on a professional and personal level. In 1905, the dissidents within Douglass Hospital were organized into a group of 15 of Philadelphia’s 24 practicing African American physicians. They protested what they felt was the autocratic and dictatorial way the hospital was run. Their leader was Dr. Edwin C. Howard, a Harvard Medical School graduate, who stated: the present hospital has assumed the character of a privately managed, narrow, unprogressive institution, and has failed to meet the objectives for which it was organized—that is, giving opportunities to Negro doctors to get incalculable benefits from hospital practice.8 Late in 1905, the dissidents temporarily succeeded in installing Howard as the new Medical Director, but Nathan Mossell quickly took advantage of a technicality (the newest members of the Board of Directors had not been informed of the meeting to vote on a Medical

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Director),8 had himself reinstated as Medical Director and did not relinquish that post for the next 28 years. In 1907, the dissidents left Douglass Hospital and established Mercy Hospital, just four-and-a-half blocks away at 17th and Fitzwater streets. Mercy Hospital opened on Lincoln’s birthday in 1907 and remained at the same site until 1919, when it moved to a much larger facility (the former Episcopal Divinity School) at 50th Street and Woodland Avenue in West Philadelphia. The hospital fared somewhat better financially than Douglass Hospital over the years but eventually was forced to merge with Douglass in 1948 to assure the survival of both institutions. Mercy-Douglass Hospital eventually closed its doors in 1973, a victim of the same complex social and economic forces that led to the demise of essentially all hospitals of the black hospital movement by the end of the 20th century.

Financial Difficulties In 1909, a new Douglass Hospital was erected a half block west of the original location. It was a much larger and more stately structure than the first hospital and was the pride of the black medical community. The hospital was modern in every respect, from its operating room to its two kitchens to its sun porch (see Figure 3). However, its financial status was always tenuous. It was reasonably successful in raising capital for its building ventures, but it had great difficulty meeting dayto-day operating expenses despite ongoing, Herculean fundraising efforts by mostly the women’s auxiliary. The hospital barely averted a sheriff’s sale in 1910.

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Figure 3. Images of the Newer Douglass Hospital

Legislature’s Appropriations Committee and was informed that $22,000/year had been appropriated for Douglass Hospital but would be available only if Mossell agreed to the rotation by black students. After continued refusals by Mossell and Douglass Hospital, the Legislature eventually withheld the yearly $22,000 for a period of two years but finally relented, probably out of 8,9 embarrassment over its untenable position.

The End of Douglass Hospital

The newer Douglass Hospital at 1530-34 Lombard Street (a), state-of-the-art operating room (b), modern kitchens (c) and a sun porch (d). Photo (a) reprinted with permission from the Philadelphia County Medical Society. Photos (b, c and d) reprinted with permission from the Special Collections Research Center. Temple University Libraries. Philadelphia, PA.

In 1916, Mossell was visited by Dr. William Pepper III, Dean of the University of Pennsylvania School of Medicine. Pepper asked if black medical students at the University could do their obstetrics rotation at Douglass Hospital, the only black hospital in Pennsylvania with facilities and staffing adequate for such a rotation. White maternity patients at the University hospital had complained about being examined by black students. Mossell rejected Pepper’s suggestion on the spot. He claimed that he would have been favorably inclined if the plan for the rotation had included white and black medical students. In his words, “Douglass Hospital was organized to protest racial segregation, not to encourage it.”8 In addition, Mossell was likely irritated by the idea of a medical school using his hospital as a dumping ground while its teaching hospital barely permitted a black physician through its portals. Mossell was soon contacted by a representative of the University, who offered to make him the biggest (i.e., richest) Negro in Philadelphia if he went along with Pepper’s suggestion. Mossell again refused. He then was contacted by a member of the State

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The 1920s were unkind to Douglass Hospital. Early in the decade, the hospital lost the approval of Philadelphia’s Chamber of Commerce and Federation of Charities, and in 1927, the nursing school lost its accreditation, largely because it did not have an adequate facility to house its students (ironically, in the same year, a major building effort got under way for a nurses’ residence). In 1929, Douglass received only conditional approval from the American College of Surgeons (ACS), the major hospital accrediting organization. In a separate, comprehensive study of Philadelphia hospitals the same year, Douglass got poor reviews. The study mentioned the need for repairs, hospital supplies and improved staff morale and pointed out that, in the five years under investigation, bed occupancy had ranged from 27 to 37 percent.10 In the 1930s, very little money was available to Douglass Hospital, due in large part to the Great Depression. Douglass started a tuberculosis treatment program and received some state funding. Toward the end of the decade, murmurings of a possible merger with Mercy Hospital were first heard. In the early 1940s, Douglass Hospital was reendorsed by the ACS. Joint chiefships in some departments were established with Mercy Hospital. However, in the first formal vote put to the Mercy staff in 1941, a merger with Douglass was rejected. In 1942, Douglass’ intern training program was not approved by the state Board of Medical Examiners, a blow from which the

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program and the hospital never recovered. The same year, Douglass Hospital received its first annual grant from the Community Chest of Philadelphia, which was probably sending a message that it approved of the promerger sympathies of the Douglass staff. In 1946, Nathan Mossell died at age 90, having made a house call on a sick neighbor eight hours earlier. In 1947, an independent study by the firm of Ford, Bacon and Davis found the Douglass and Mercy hos3 pitals were on very thin ice financially. A joint hospital committee urged an immediate merger, and in March 1948, Mercy-Douglass Hospital was formed, with all operations located at the 50th Street and Woodland Avenue site. Several months later, Douglass Hospital closed its doors, never to reopen again. It was demolished in the latter half of the 20th century. Several office buildings now occupy the 1530-32-34 Lombard Street site. The original 1895 hospital structure at 1512 Lombard Street is still standing (see Figure 2) and houses three apartment units, with no interior or exterior feature to suggest that it was once a hospital. As Philadelphia’s first (and the nation’s second) hospital owned and operated by African Americans, Douglass Hospital was a pioneer in the emerging black hospital movement. The hospital cared for a population that would, otherwise, have had very limited or no access to healthcare, and it also provided employment for the community and training for doctors, nurses, hospital administrators and other paramedical personnel. Although the founder, Dr. Nathan Mossell, has been accused of excessive selfinterest and autocratic behavior, if history were to judge him, it is likely that his civil rights activism, his accomplishments in black organized medicine and his unceasing efforts to keep Douglass Hospital afloat through difficult times would far outweigh the accusations of his detractors. Dennis Cornfield, MD, is a hematopathologist in the Department of Pathology at Health Network Laboratories/Lehigh Valley Health Network in Allentown, PA.

Mossell, N. F. (1946). Autobiography. Unpublished manuscript, University of Pennsylvania Archives and Records Center, Philadelphia, PA. [Available at www.archives.upenn.edu/primdocs/upf/upf1_9ar/mo ssell_nf/mossell_nf_autobio.pdf]

Heilbrunn, E. (2014, Nov-Dec). A principled man. The Pennsylvania Gazette. http://thepenngazette.com/a-principled-man.

Rudwick, E. M. (1951, Winter). A brief history of Mercy-Douglass Hospital in Philadelphia. The Journal of Negro Education, 20(1), 50–66.

Board of Managers Frederick Douglass Memorial Hospital and Training School. (1896). First annual report. Special Collections Research Center. Temple University Libraries, Philadelphia, PA.

Board of Managers of the Frederick Douglass Memorial Hospital and Training School. (1906). Tenth and eleventh annual report. Special Collections Research Center. Temple University Libraries, Philadelphia, PA.

Gamble, V. N. (1995). Making a place for ourselves: The black hospital movement, 1920-1945. New York: Oxford University Press.

Gordon, F. (1930). Frederick Douglass Memorial Hospital and Training School. Philadelphia: World’s medical centre. University of Pennsylvania Archives and Records Center, Philadelphia, PA. [Available at www.archives.upenn.edu/primdocs/upf/upf1_9ar/mo ssell_nf/douglass_hosp_by_gordon.pdf]

Cobb, W. M. (1954, March). Nathan Francis Mossell, M.D. 1856-1946. Journal of the National Medical Association, 46(2), 118–130.

Note: In his writings, Mossell often alluded to this series of events as illustrative of the righteousness of his cause and that of Douglass Hospital. The interview with William Pepper III was the focal point of Sylvia James’ 1947 play “Within Our Gates.”

Emerson, H., Pincus, S., Phillips, A., Gadsden, P. H., Philadelphia Hospital and Health Survey Committee, & Philadelphia Chamber of Commerce. (1930). Philadelphia hospital and health survey 1929. Philadelphia, PA. [Available at www.worldcat.org/title/philadelphia-hospital-andhealth-survey-1929-conducted-under-the-auspicesof-a-citizens-survey-committee/oclc/301164626?ht= edition&referer=di]

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Promoting THE VITALITY OF FACULTY to Combat Burnout By Chantal Brazeau, MD, and Maria Soto-Greene, MD, MS-HPEd Medical schools across the country have important responsibilities: to educate our nation’s physician workforce, to be at the forefront of medical research, to deliver service and clinical care to diverse individuals and local communities and to provide clinical expertise on a national and international level. This is a tall order that we fully embrace at Rutgers New Jersey Medical School (NJMS), as an academic, biomedical research and healthcare enterprise whose mission is to meet the needs of the local and global community through outstanding education, pioneering research, cutting-edge clinical care and public service. Meeting these aspirations and responsibilities requires a strong and diverse faculty of physicians and scientists. In today’s healthcare climate, creating that type of faculty requires an intentional and proactive commitment to programs that promote faculty vitality.

Burnout in Healthcare Unfortunately, a large number of our nation’s physicians are experiencing burnout—feelings of emotional exhaustion, depersonalization (cynicism) and a reduced sense of personal accomplishment. The rate of physicians who experience

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symptoms of burnout has increased from an average of 46 percent in 2011 to 54 percent in 2014.1 In addition, about 25 percent of physicians and scientists in academic medical centers across the country are thinking about leaving academic medicine.2 Physicians are working in an ever-more complex and regulated healthcare system that requires time-consuming documentation in electronic health records and other venues. This encroaches on time with patients and on the most meaningful and rewarding aspects of caring for people.3 Scientists are faced with fewer grant opportunities and increasing competition for research dollars; they spend increased time applying for grants to conduct the research about which they are passionate. Without question, these are demanding times for healthcare and academic medical centers; along with the demands comes a call for action. At NJMS, this call has been answered by designating the 2016–2017 academic year as “the year of the faculty.” A team, whose members include the authors, along with Dr. Carol Newlon, Associate Director of Faculty Mentoring and Advancement, and Dr. Sangeeta Lamba, Associate Dean for Education, are working to develop a multi-

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pronged approach to enhance faculty well-being and incorporate this important concept into the culture and fabric of NJMS.

Leadership Involvement Specific leadership attributes of faculty’s direct supervisors have been linked to lower burnout scores in 4 faculty. Thus, NJMS is supporting workshops for chairs of clinical and basic sciences departments that address faculty well-being and faculty retention. These workshops include a presentation of data from a survey focused on faculty well-being (led by Dr. Chantal Brazeau with the assistance of NJMS colleagues Dr. Ping-Hsin Chen, Associate Professor of Family Medicine, and Dr. Steven Keller, Professor of Family Medicine and Psychiatry, for survey and project planning). Workshops also include information about burnout, individual and systems approaches to faculty vitality and candid discussions about challenges faced by NJMS faculty. Most importantly, chairs share and discuss support strategies they utilize for their faculty, a topic not typically discussed in routine meetings. To preserve the potential impact of these important discussions, we are collating the shared strategies to create a toolbox of resources that chairs can use to support their faculty. We have started similar workshops for departmental division chiefs, who also have direct supervisory responsibilities for faculty. Faculty well-being is now a regular agenda item in school leadership and chair’s meetings as a constant reminder that we need a healthy and strong faculty to accomplish our mission.

Mentoring Program A second element of our approach to tackling burnout involves a strengthening of our mentoring program. A strong mentor can make a huge difference in the career trajectory, as well as in the success and well-being, of a faculty member. Effective mentoring provides encouragement and strategic planning to help the mentee pursue research and patient-care aspirations; it also offers the opportunity for encouragement and advice when inevitable challenges occur. To this end, NJMS is offering workshops for senior faculty based on resources from the National Research

Mentoring Network5 to increase the number of formally trained mentors in the school who understand a diverse faculty. This presents to even our most seasoned faculty an opportunity to engage in and reflect on their mentoring strategies. These workshops include case-based discussions of challenges typically faced by research faculty and their mentors. The program is continually developing new cases to make the discussions more specific to problems faced by non-research clinical faculty. Through this structured mentoring program, we are developing a robust cadre of faculty mentors who can assist their colleagues and help propel junior faculty toward their goals.

Group Support While challenges, whether local or national, affect all faculty, we recognize that various groups of faculty may be affected differently and may require different support and interventions. The American Association of Medical Colleges (AAMC), the national organization for academic medical centers, has designated a Group on Women in Medicine and Science (GWIMS) that includes support for women faculty recruitment and advancement.6 Dr. Lamba, as the GWIMS representative at NJMS, is developing mentoring and group activities to support women faculty and promote their vitality and well-being. NJMS is also supportive of its rich diversity at all levels and is a strong advocate for underrepresented faculty who are crucial to diverse patient populations, research, education and service. A Hispanic Center of Excellence (HCOE) was developed at NJMS 25 years ago and is still vibrant and active to this day. This kind of program enables the school to provide individualized mentoring and numerous educational programs, thus empowering countless underrepresented faculty to develop their medical careers to the fullest. In addition to these activities, we are developing a robust orientation program for new faculty to introduce them early on to the resources that the school offers. Collectively, this programming provides the environment for our new and existing faculty to advance their careers. In sum, the faculty members at our nation’s medical schools are vital to the successful attainment of each school’s mission and goals. Thus, it is essential that we

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direct time, energy and resources to maintain their wellbeing. Programs such as those in NJMS’s “year of the faculty” are examples of how our medical schools can support faculty vitality going forward. Chantal Brazeau, MD, is Professor and Interim Chair of Family Medicine and Assistant Dean for Faculty Vitality at Rutgers New Jersey Medical School. Maria Soto-Greene, MD, MS-HPEd, is Vice Dean and Professor of Medicine and Director, Hispanic Center of Excellence, at Rutgers NJMS.

Shanafelt, T. D., Hasan, O., Dyrbye, L., Sinsky, C., Satele, D., Sloan, J., & West, C. (2015). Changes in burnout and satisfaction with work-life balance in physicians and in the general U.S. working population between 2011 and 2014. Mayo Clinic Proceedings, 9(12), 1600–1613.

Pololi, L. H., Krupat, E., Civian, J. T., Ash, A. S., & Brennan, R. (2012). Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools. Academic Medicine, 87(7), 859–869.

Sinsky, C., Colligan, L., Li, L., Prgomet, M., Reynolds, S., Goeders, L., . . . Blike, G. (2016). Allocation of physician time in ambulatory practice: A time motion study in 4 specialties. Annals of Internal Medicine, 165(11), 753–760.

Shanafelt, T., Gorringe, G., Menaker, R., Storz, K., Reeves, D., Buskirk, S. J., . . . Swensen, S. (2015). Impact of organization leadership on physician burnout and satisfaction. Mayo Clinic Proceedings, 90(4), 432–440.

National Institute of General Medical Sciences. (2016 [reviewed]). National research mentoring network. www.nigms.nih.gov/training/dpc/Pages/nrmn.aspx.

Association of American Medical Colleges. (2017). About GWIMS. www.aamc.org/members/gwims/about/.

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With Kern Augustine, you will always know where your lawyer stands on your side. That is because when it comes to healthcare we represent physicians not hospitals, not malpractice plaintiffs, not insurance companies, and not managed care companies. Do not take chances. For loyalty and legal experience you can depend on, call Kern Augustine today.

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Igniting Passion in Your People by Steve Adubato, PhD

I recently published my fifth book, Lessons in Leadership, that profiles powerful case studies, spotlighting dozens of leaders and offering lasting leadership strategies for leaders of all stripes. I have spent almost two decades writing about leadership, and I have coached CEOs, managers, executives and physician leaders on what it truly means to be a more self-aware, empathetic and effective leader. At almost every gathering of leaders, I am asked this question: â&#x20AC;&#x153;What is the secret to motivating and engaging team members?â&#x20AC;? Doing this is particularly challenging for physician leaders, who are juggling patient care while overseeing a team of physicians, nurses, office staff and others. Add to the equation the fact that the healthcare landscape is constantly changing, and you have a possible prescription for team members feeling uninspired, overwhelmed, unappreciated or, worse, unmotivated. Fortunately, regardless of the industry, there are some very specific leadership tips and tools that can help you to pump up your people.

Motivate & Engage Give employees challenging responsibilities that test their leadership potential. Expect more from your people than they expect from themselves. Great leaders

push their people. They constantly come up with new, creative projects and assignments that may make team members a little uneasy but at the same time drive them to get outside their comfort zone and achieve great things. This approach will definitely keep them engaged. Lead interactive and goal-oriented meetings that force active employee participation. When physician leaders do this, team members get caught up in the spirit of accomplishing organizational goals, and they can truly connect with the passion and enthusiasm of the meeting leader. Participation is contagious in a positive way. The opposite approach will cause team members to become disengaged and unmotivated. Assign team members to lead certain meetings with clear goals and outcomes. Before those meetings, give other team members specific assignments that they must complete and come prepared to discuss. Smart leaders know they must give up the reins every once in a while to talented team members. As a result, these employees will become motivated to work harder and contribute more to the organization. Create a mentoring and coaching culture. Assign team members less experienced employees to develop into future leaders in the organization and hold them

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accountable over time. By doing this, team players will feel responsible, not only for their own performance but also for the performance of others. Nothing motivates us more than helping colleagues develop their potential. It is exciting and exhilarating, but it doesn’t happen by osmosis. It has to be organized and structured. The great leaders know this. Encourage team members to make presentations. Presenting before internal and external groups on important topics that they know well may make some team members uncomfortable (especially those who say public speaking is nerve-wracking and anxiety-producing). But with the proper coaching and training, these same employees can make great improvements in their communication skills. Experiencing this improvement is extremely motivating, which will cause these same employees to want to get better by working even harder in this area. Conversely, keeping your people in their seats and within their comfort zone guarantees they will become stagnant and bored. Take team members to high-level meetings or conferences outside the office. This will expose them to challenging situations and important stakeholders. Then, be sure to debrief afterward to find out what they took away from the experience. Involving team members in important meetings will help them feel a part of something special, something bigger. The stakes will be higher, and they will feel like they are important to the organization. This will cause them to be more motivated and engaged. Continue to show an ongoing interest in teaching, coaching and mentoring, which is the pinnacle of employee development. Showing you care about an employee may be the ultimate motivator.

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Check for Leadership Mistakes What if you have invested the time, energy and resources to engage and motivate your employees, and you still have a few team members who aren’t as engaged as you would like them to be? As a leader, you are responsible for pressing pause at that point and seeing where you may have missed the leadership goal line. Despite our best efforts, even the best leaders can

(and do!) make some very common leadership mistakes. Following are a few that we can all learn from. Being too “hands off.” Of course we want to delegate specific tasks and functions. But some leaders become so removed from their teams’ operations that they lose touch. These leaders have little idea about the productivity or effectiveness of team members and, therefore, are in no position to provide coaching or feedback about how these employees can improve. Great leaders recognize there is a difference between delegating to empower your people and handing off responsibility without any guidance or coaching. Micromanaging. No, this is not a contradiction of the previous leadership mistake because a leader who does not delegate any tasks or responsibilities runs the obvious risk of filling his or her plate with so much minutiae that it becomes impossible to motivate or engage other team members. Further, by not effectively delegating and creating other leaders on the team, these micromanaging leaders communicate the message that they don’t trust other team members, which results in unmotivated employees, thus reducing productivity, effectiveness and morale.

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Surrounding yourself with “yes” players. A major leadership mistake is to create a culture where those around you tell you that you are right, even if you propose a terrible idea or initiative. Weak leaders communicate the message that team members are “disloyal” or “out of bounds” when they challenge or ask questions of the team leader. When this happens, organizations plow ahead in the wrong direction, taking the whole mission

as a physician leader who is truly “engaged with your team, you must take the time to provide constructive feedback to help your team continue to grow.

”

off course, just because no one was willing or able to challenge the leader’s poor judgment or decision making skills.

Let’s take it a step further. I noticed that you didn’t go into great detail on what you think our options are. Next time, make concrete recommendations that evaluate the costs and the risks.” The key is to give people information that they can do something with. Certainly, it’s okay to a point to say, “Way to go on the Jones report, Mary.” But sooner or later, Mary needs to know exactly what she needs to do to improve. Give feedback face-to-face. Sure, e-mail and phone messages can complement your coaching efforts, but the most powerful and effective feedback is usually in person. This allows leaders to read body language and attempt to interpret the other person’s reaction to feedback being given. It’s hard to do that when you are interacting via technology. In any case, the coaching I do via phone or video conference is effective only once a face-to-face personal connection is well established. Give feedback quickly. Leaders sometimes wait too long to talk to an employee about something they are concerned about. When that happens, the power of feedback is often lost. This is particularly true when giving positive feedback—recognize people’s efforts immediately. Keep a positive attitude. If someone on your team is falling behind or has missed a deadline ask, “What obstacles or issues are keeping you from meeting the goals we agreed on?” The key is to frame your questions in a positive fashion as opposed to assigning blame or fault. After all, the objective of a leader when confronting problems with an employee is not simply to chastise that individual but, rather, to help him or her improve and develop.

Give Feedback Finally, as a physician leader who is truly engaged with your team, you must take the time to provide constructive feedback to help your team continue to grow. The following tips and tools will help you give critical feedback—even when it is hard for your team members to hear it. Be as specific as possible. Employees need to know exactly what they need to do to improve their performance and contribute to the team in a more productive fashion. For example, this quick comment is the type that an employee can do something with to improve: “Mary, you did a great job on the Jones report.

Steve Adubato, PhD, is a four-time Emmy Awardwinning anchor for Thirteen/WNET (PBS) and NJTV (PBS) and has appeared on the TODAY Show, CNN and FOX as a media and communication expert. Steve currently anchors three television series produced by the Caucus Educational Corporation (CEC) — Caucus: New Jersey with Steve Adubato; State of Affairs, a weekly program covering New Jersey’s most pressing policy issues; and One-on-One with Steve Adubato. Log on to www.SteveAdubato.org to learn more.

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THE VALUE OF

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By Kathryn Eckert, Emerging Medical Leaders Advisory Committee Member When I started medical school, I knew I was signing up for a lifetime of nights short on sleep and days short on time. I knew my feet would hurt from running around the hospital, my upper back would throb from hunching over textbooks and my hands would cramp from writing endless notes. I knew I would regretfully miss family events and forget friends’ birthdays, but I knew it would all be worth the satisfaction I would gain from seeing just one patient get well under my care. Though I thought I was prepared for these rigors of medical school, I quickly realized that the reality was much more challenging than I had anticipated. Within the first few months, I found myself losing motivation and feeling fatigued. Weeks progressed to months of 12-hour study days without reprieve. When I sought advice from a secondyear student, he said, “You’ve hit the wall; you’re burning out.” Impossible, I thought to myself. I was finally doing what I loved. How could I be burning out so soon? A few days passed, and I reflected on what my peer had said to me. I decided to seek out the wisdom of someone who had been there before me—a practicing physician. He listened, let me complain and finally said, “I’ve been there, and I know how you’re feeling.” It wasn’t anything prophetic or words I hadn’t heard before, but this simple phrase was cathartic and just the bit of shared understanding I needed to move forward. Every time since this instance when I’ve found myself drowning in study materials and verging on panic, I have

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sought solace in the wisdom of those who have been there before me. Knowing that someone I emulate once struggled through my situation gives me a sense of solidarity. For me, mentorship adds a personal touch to the often impersonal process of becoming a physician. The importance of mentorship in educating medical students cannot be underestimated. In an era of medicine when physician burnout is well documented, medical students need mentors to help them maintain focus and motivation during the trying times in their careers. I am fortunate to come from a community at the Rowan University School of Osteopathic Medicine (Rowan SOM) where faculty members are intimately involved in nurturing student growth. Each incoming, first-year student has the opportunity to be paired with a practicing physician and a more senior student at the school. These relationships positively influence students, not only in their study habits and day-to-day activities but also in the careers they choose after graduation. I hope that the value of mentorship continues to be at the forefront of conversations in medical education at Rowan SOM and at all other training programs across the country. Kathryn Eckert is a medical student at Rowan University School of Osteopathic Medicine, Class of 2018, and a 2017 Edward J. Ill Excellence in Medicine Scholarship Recipient.

Bundled Payment for Physician Group Practices and Organized Delivery Systems By Barry Liss, Esq.

The U.S. healthcare industry, spurred by 1) actions taken by the federal government and 2) widespread opinion that the current rate of increase in healthcare expenditures is unsustainable,1 has turned towards value-based purchasing as an aid to control costs and retain quality of care. One type of value-based purchasing, bundled payment reimbursement, involves having the payor of healthcare services pay a fixed amount to be distributed among all providers involved in the treatment of an individual (e.g., hospital, physician, rehabilitation facility, physical therapist, home health agency, laboratory, etc.) for a specified episode of care (e.g., joint replacement, cancer treatment, coronary artery bypass graft). Bundled payment models

typically include the potential for bonus payments to providers, i.e., distributions of shared savings. Theoretically, bundled payment programs lead to enhanced clinical integration, oversight and conformity with best clinical practices among participating providers, which in turn, theoretically, lead to: 1) as good or better quality of care2 and 2) better cost control. Indeed, bundled payment models have, in fact, been shown to be effective in controlling costs without diminishing quality.3 Therefore, the adoption of bundled payment arrangements by commercial carriers, selffunded health plans and government-sponsored health plans is accelerating.

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KEY STRUCTURAL COMPONENTS OF BUNDLED PAYMENT ARRANGEMENTS Bundled payment arrangements must include certain fundamental components and must navigate a complex web of 4 legal issues including the following five factors.

Temporal Defining the time period to which the bundled payment applies is one of several fundamental components. Determining when it begins (e.g., at the time of hospital admission? on the date a lab test is confirmed?) and when it ends (e.g., three months after hospital discharge? six months?) requires a sophisticated actuarial assessment that providers and payors must agree upon.

Inclusion and Exclusion of Bundled Cases Precise and clear operational definitions of which cases will be included and excluded are essential. Inclusion criteria can be based upon diagnostic and/or procedure codes and the case must be tied to the payor involved in the arrangement. Circumstances that could trigger exclusion might be those in which unintended high utilization costs would result, e.g., from co-morbidities, trauma, acute conditions, or chronic conditions unrelated to the bundle. Inclusion of prescription drugs should also be carefully weighed.

Early Termination Situations will arise that require a case to be terminated before the completion of the bundled payment period, for example, loss of coverage, patient expires or admission to a hospital that is not included in the bundled payment arrangement.

Financial Operations Although the term suggests that a lump sum is paid prospectively when a case is identified, in fact, the payment can be made either prospectively or retrospectively. If the latter, the payor and provider entity perform a reconciliation of actual expenditures that occurred during the bundle period and make an adjustment depending on whether the actual expenditures were above or below a target amount.

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The target amount could be established by a comparison group of patients or an agreed upon benchmark. Another aspect of bundled payment arrangements involves distributions of shared savings (if any) among providers and the payor involved. The potential for these distributions typically arises if the bundled cases are managed less expensively than they were previously managed by a matched comparison group or if the total cost of managing the bundled cases is lower than a previously agreed upon benchmark, provided quality of care has not been compromised.

Legal Compliance There is a veritable laundry list of legal issues that can arise in bundled payment arrangements. So much so, that the federal government has issued waivers to many of them with respect to federal alternative payment models such as bundled payment.5 In the words of a joint statement on these waivers from the Office of Inspector General (OIG) and the Centers for Medicare and Medicare Services (CMS): “The Secretary has determined that the arrangements covered under these waivers are necessary to carry out the testing of the CJR model”6 [emphasis added by author]. (The CJR Model is a bundled payment model that was launched by CMS and applies bundled payments reimbursement methodologies to major joint replacement surgery such as hip and knee replacements.) So, the question arises: What to do about commercial bundled payment models? Indeed, the jointly issued federal waivers apply only to the specific federal program for which they are designed. Bundled payment arrangements involving commercial and self-funded payors are not protected by these waivers and must, therefore, take into account numerous legal issues. Antitrust. Pricing agreements between and among physician practices that compete in the same “relevant geographic area” are generally illegal per se under antitrust laws. Therefore, when competing physician practices agree to accept a certain rate under a bundled payment program, antitrust laws are implicated. However, if those practices are “clinically integrated” or “financially integrated,” the pricing agreements may be permissible. Bundled payment models typically require adherence to some degree of clinical uniformity, which can help establish the fact that the practices meet the test for clinical integration. Fortunately, the U.S. Justice

Department and Federal Trade Commission, which jointly enforce federal antitrust laws, have published numerous materials that can be used to guide the structure of a bundled payment arrangement. Stark. The Stark Law generally prohibits referrals for federally funded healthcare services (e.g., payable by Medicare) by physicians to entities in which they have a 7 “financial interest.” Since bundled payment models may involve physicians who have financial relationships with entities to which they may refer within the bundled model (e.g., employment agreements with a hospital, interests in an ambulatory care facility, interests in an imaging center, etc.) the legal structure must be carefully designed to comply with Stark. That is, all referrals generally prohibited by Stark must be structured to fit within an available Stark exception.8 (As noted earlier in this article, federal waivers pertaining to the Stark Law may apply to certain federal bundled payment arrangements.) Anti-Kickback. The Anti-Kickback Statute prohibits any person, whether a physician or not, from offering or receiving anything of value for the purpose of inducing a referral that results in the submission of a claim for payment by the federal government.9 Unlike the Stark Law, which is a “strict liability” statute, the Anti-Kickback Statute is triggered only if the individual intended to induce the referral with his or her action. As noted above, certain waivers of the anti-kickback law may apply with respect to federally sponsored bundled payment arrangements, such as CJR. Prudence dictates that commercial and self-funded bundled payment arrangements should be structured to fit with all applicable “safe harbors” that pertain to the Anti-Kickback Statute, to the extent possible.10 Civil Monetary Penalty. The Civil Monetary Penalty law, which applies to federally funded healthcare programs, prohibits, among other things, hospitals from paying physicians to reduce medically necessary services.11 As noted above, waivers to these laws may be available for certain federally sponsored bundled payment programs. Professional Regulation: The Board of Medical Examiners. Bundled payment programs must also comply with local laws governing professional practices (e.g., physicians, physical therapists, etc.). These laws, which vary from state-tostate, may prohibit the “corporate

practice of medicine” and, therefore, would not permit a lay person or an entity owned by lay persons to provide professional services or bill for them on its own behalf. In both New Jersey and New York, the corporate practice of medicine is prohibited. Unless a rather narrow exception applies, professional practices must be owned by licensees, and physicians cannot cede their professional judgment to non-licensed individuals. That is, pursuant to the prohibition of the corporation practice of medicine, a lay business entity cannot direct physicians to make, or not make, treatment decisions (e.g., intended to reduce actual expenditures and, thus, increase the entity’s and/or a participating provider’s share of revenue derived from the bundled payment). Bundled payment models—which can blur the lines that otherwise distinguish the discrete roles of physicians, hospitals, payors, and other healthcare providers—must, therefore, be carefully structured to comply with these types of local laws. Insurance Laws. Bundled payment models could involve risk assumption or otherwise be structured in a way that requires compliance with state insurance laws. For example, if an entity involved in the arrangement meets the definition of an organized delivery system (as discussed in the “Large Group Practices and Bundled Payments” section of this article) but fails to become certified or licensed (whichever applies) by the New Jersey Department of Banking and Insurance (DOBI), the arrangement could be in legal jeopardy. The Employee Retirement Income Security Act (ERISA). Bundled payment models involving employersponsored health plans and which also provide for distributions of shared savings can trigger legal issues under ERISA. ERISA imposes strict rules governing the use of 12 employee “plan assets.” Having the ability to exercise discretion with respect to the use of plan assets (which must be held for the exclusive benefit of plan beneficiaries) triggers fiduciary obligations. Depending upon how a bundled payment program is structured, the source of funds from which shared savings are based, and the way in which shared savings payments may be characterized, ERISA’s fiduciary requirements may be implicated. Therefore, architects of bundled payment arrangements that involve employeesponsored health plans must pay close attention to ERISA laws and related guidance issued by the U.S. Department of Labor (i.e., the federal agency that enforces ERISA).

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PHYSICIAN GROUP PRACTICES AND BUNDLED PAYMENTS

ORGANIZED DELIVERY SYSTEMS (ODS) AND BUNDLED PAYMENTS

Physician group practices can participate in bundled payment arrangements provided the arrangement does not violate or conflict with the legal structure of the group. Partnership agreements, stockholder agreements, employee contracts, bylaws, operating agreements and the like must be carefully examined to determine whether the bundled payment arrangement, which could impose treatment guidelines and incorporate specific compensation terms, would be permitted under the group’s existing legal instruments. Employment agreements typically set forth detailed compensation provisions, often based upon formulas that have been subject to exhaustive internal discussion and negotiation within the group. Bundled payment models may require a different approach to compensation. Accordingly, existing employment contracts (and any other legal instrument that governs compensation) must be carefully reviewed and amended if necessary to avoid a challenge from a member of the physician group that the bundled payment arrangement is unenforceable. For example, if a patient’s medical expenses exceed the bundled payment, future physician payments might be used to offset the deficit. If physicians have not agreed to that type of offset, they could argue that the offset provision is unenforceable because the underlying employment agreement was not lawfully amended. Accordingly, the offset could be void and the bundled payment model could be in jeopardy. Bundled payment models may incorporate treatment guidelines or best practices requirements that may not be addressed in the group’s existing legal instruments. Indeed, such instruments may affirmatively reject the ability of the group to impose specific treatment guidelines on any of its members. An inventory of the group’s legal instruments (e.g., bylaws, operating agreement, stock holder agreement, formally adopted policies and procedures, employment agreement, etc.) should be taken to ensure that the bundled payment arrangement does not violate any of them. It may be advisable to amend existing legal instruments to express an affirmative recognition and permission by the members of the group to have the group enter into the bundled payment arrangement.

When contemplating the organizational structure of a bundled payment program in New Jersey, a fundamental question is whether any entity involved is an organized delivery system.13 For example, a corporation or limited liability company that contracts on behalf of a network of healthcare providers could be an organized delivery system, depending upon the purpose and scope of its con14 tracts and the manner in which it is organized. Today, if the ODS assumes “financial risk” it may require a license.15 (Organized delivery systems that do not assume financial risk obtain “certification” rather than “licensure.”16)

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What is Financial Risk? “Financial risk” means exposure to financial loss that is attributable to the liability of an organized delivery system for the payment of claims or other losses arising from covered benefits for treatment or healthcare services other than those performed directly by the person or organized delivery system liable for payment, including a loss-sharing arrangement. A payment method wherein a provider accepts reimbursement in the form of a capitation payment for which it undertakes to provide healthcare services on a prepayment basis shall not per se be considered financial risk. A financial risk shall exist if, under an agreement between the organized delivery system and the carrier, the financial obligations of the organized delivery system for payment of benefits or for providing treatment or healthcare services does or potentially may exceed any payments that may be received from the carrier. Financial obligation shall include the attendant administrative costs related to providing the treatment or services. (N.J.A.C. 11:22-4.2.)

Indeed, the New Jersey ODS statute and regulations specify when, for example, an entity that may appear to meet the definition of an ODS (e.g., a traditional IPA) is 17 not required to obtain ODS certification. If a new ODS must be formed, New Jersey regulations set forth the application requirements that vary depending upon the functions the entity will perform, e.g., network management, utilization review design, 18 appeals, credentialing, etc. Operating an ODS, whether licensed or certified, involves the creation and adoption of numerous internal policies and the submission of numerous documents and reports to the DOBI. The types of policies required by the DOBI depends upon the ODS’s activities. If the ODS will accept risk, it must comply with financial deposit and reserve requirements.19 Licensed ODSs are also subject to inspection and examinations by the DOBI.20 ODS applications for certification and licensure can be found on the New Jersey Department of Banking and Insurance website www.state.nj.us/dobi/division_insurance/managedcare/mcods.htm.

RISK ASSUMPTION AND RISK MITIGATION The assumption of financial risk—to some degree— is inherent in bundled payment arrangements. Arguably, that is the point, and that is why it can be an effective cost control strategy. In some instances, a physician’s risk may be limited to “upside risk” only, whereby the only financial risk would be the loss of a bonus payment. In other instances, the physician could be exposed to limited downside risk, such has having to accept a discount on rates in the event performance targets are not met. But in other instances, a physician or group may be at risk for high-cost episodes of care incurred by patients included in the model. Understanding the degree to which financial risk is transferred to individual physicians and physician groups is critical and can vary widely under different bundled payment models. If the arrangement could potentially shift financial risk to the physician for expenses arising from extremely high-cost cases, that risk could be mitigated by stop-loss insurance, in which case, the stop-loss coverage could be triggered if costs exceed a certain fixed dollar or other appropriate threshold (e.g., upon exceeding “X” standard deviations from the average cost per patient).

CONCLUSION The ripple effects of federal and local efforts to transform the U.S. healthcare delivery system from a volume-based to a value-based system include, among them, the proliferation of bundled payment arrangements, the consolidation of similarly situated stakeholders in the healthcare system and the convergence of historically antithetical healthcare enterprises. These effects are further complicated by state laws, such as the ODS laws in New Jersey, which arose in the wake of the failure of a large New Jersey HMO. Survival strategies for many physicians and physician groups require extremely close attention to trends set by the federal and local government and the agility to effectively respond to those trends. Bundled payment is one such trend, and it has been wholly embraced by the federal government, i.e., CMS, which arguably shapes the healthcare delivery system more than any other single stakeholder. These trends create additional ripple effects such as blurring historical boundaries among providers, insurers, professional licensees and lay businesses—boundaries that have been reinforced by a complex array of existing laws. Successful navigation of these laws and an understanding of how these historic boundaries are shifting have become more complicated but are, nevertheless, an imperative for those practitioners wishing to embrace these trends.

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CMS Bundled Payment Initiatives The Affordable Care Act, colloquially referred to as Obamacare, created, within the Centers for Medicare and Medicare Services (CMS), another center referred to as the Center for Medicare & Medicaid Innovation (CMMI or the Innovation Center). CMS, through the Innovation Center, has launched numerous, far-reaching bundled payment initiatives that involve hundreds of hospital, hundreds of physician groups and tens of thousands of patients. A few examples include the following: Bundled Payments for Care Improvement Initiative (BPCI) was evaluated by the Lewin Group, which based its 1 results on more than 58,000 episodes of care. These 58,000 patient episodes involved a national group of providers who voluntarily participated in the BPIC, including 385 acute care hospitals, 283 physician group practices, 681 skilled nursing facilities and others.2 Oncology Care Model is a national bundled payment model involving 195 physician practices and 16 participating payors.3 Comprehensive Joint Replacement Care (CJR) is a mandatory bundled payment model imposed upon approximately 800 hospitals in 67 metropolitan statistical areas (MSAs). 4 Bundled Payment Model for Cardiology Care has recently been proposed by the Innovation Center, applying payment rules to hospitals located in 98 randomly selected metropolitan statistical areas. 5 1

The Lewin Group. (2016, August). CMS bundled payments for care improvement initiative models: 2-4, year 2 evaluation & monitoring annual report. https://downloads.cms.gov/files/cmmi/bpci-models2-4-yr2rptappendices.pdf.

Barry Liss is a Director and Healthcare Team Leader at Gibbons P.C. in Newark, New Jersey. 1

See, e.g., Chustecka, Z. (2015, June 1). New immunotherapy costing $1 million a year. www.medscape.com/viewarticle/845707.

See, e.g., American Hospital Association. (2014, March). The value of provider integration. Trendwatch. www.aha.org/content/14/14mar-provintegration.pdf; Claffey, T. F., Agostini, J. V., Collet, E. N., Reisman, L., & Krakaur, R. (2012). Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage Plan. Health Affairs, 31(9), 2074–2083.

The JAMA Network. (2016, September 19). Hospital participation in Medicare bundled payment initiative results in reduction in payments for joint replacement. http://media.jamanetwork.com/news-item/hospital-participation-in-medicare-bundled-payment-initiative-results-inreduction-in-payments-for-joint-replacement/; RAND Corporation. (2010). Analysis of bundled payment, technical report (TF-562/20). www.rand.org/pubs/technical_reports/TR562z20/analysis-ofbundled-payment.html.

See, e.g., Liss, B. (2016, December 19). Bundled payments gain traction in health care top ten list - Part I. New Jersey Law Journal, 222(50), 50; Liss, B. (2016, December 26). Bundled payments, Part II. New Jersey Law Journal, 222(51), 50.

See, Slavitt, A. M., & Levinson, D. R. (2015, November 16). Notice of waivers of certain fraud and abuse laws in connection with the comprehensive care for joint replacement model. www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Downloads/2015-CJR-Model-Waivers.pdf.

Id., at 4.

42 U.S.C. 1395nn.

42 CFR 411.357.

42 U.S.C. § 1320a-7b.

42 CFR 1001.952.

42 U.S.C. § 1320a-7a(b).

29 USC 1103.

See N.J.S.A. 17:48H-1 et seq.

N.J.S.A. 17:48H-1.

N.J.S.A. 17-48H-11.

N.J.S.A. 17-48H-3.

N.J.A.C. 11:24B-2.1(c).

Centers for Medicare & Medicaid Services. (2016, Oct. 5). Comprehensive care for joint replacement model. https://innovation.cms.gov/initiatives/CJR.

See, Liss, B. (2015, September 1). An idea whose time has come: Organized delivery systems in N.J. New Jersey Law Journal [Health Care Supplement].

Centers for Medicare & Medicaid Services. (2016, July 25). Notice of proposed rulemaking for bundled payment models for high-quality, coordinated cardiac and hip fracture care. www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2016-Fact-sheets-items/2016-07-25.html.

See N.J.S.A. 17:48H-19 [minimum net worth]; N.J.S.A. 17:48H-20 [deposits of cash, securities]; N.J.S.A. 17:48H-21 [maintenance of fidelity bond]; N.J.S.A. 17:48H-22.2 [increase in amount of capital and surplus required of licensed organized delivery system]; N.J.S.A. 17:48H-22.3 [determination of increase, revision or redetermination; factors].

N.J.S.A. 17:48H-17.

Centers for Medicare & Medicaid Services. (2016, April 18). Bundled payment for care improvement initiative (BPCI). www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2016-Fact-sheets-items/2016-04-18.html. Centers for Medicare & Medicaid Services. (2016, Oct. 11). Oncology care model. https://innovation.cms.gov/initiatives/oncology-care/.

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