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M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

Updates in Cardiac Procedures 2012 Healthcare Priorities Lt. Governor Anthony G. Brown PCMH in Maryland Public and Private Models

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JANUARY/FEBRUARY 2012 VOLUME 1: 2: ISSUE 41


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Contents 12

January/February 2012 Volume 2: Issue 1

18

24

F E AT U R E S

12 More Patients Could Benefit from Newer Cardiac Procedures Take Advantage of Growing Evidence of Effectiveness

18 Patient Centered Medical Homes Become A Reality Public and Private Models Are Underway in Maryland D E PA R T M E N T S

Cases

| 7 | Adults with Congenital Heart Disease Need Evaluation

Solutions

| 8 | Practice Exit Strategy – Never Too Early to Start

Medical Beat Compliance Policy

| 10 | News & Notes in the Medical Field

| 23 | It’s Ok To Fire An Employee For TrashingYou On The Internet… Isn’t It?

| 24 | Maryland 2012 Healthcare Priorities andYour Practice

Heritage

| 29 | MedChi Offers Systems of Support for Maryland Physicians

Good Deeds

| 30 | Hopkins “Heart Hype” Promotes Early Detection of Cardiac Disease inYoung Athletes

On the Cover: Paul Massimiano, M.D., program director for Cardiac Surgery, Washington Adventist Hospital

JANUARY/FEBRUARY 2012

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JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com CONTRIBUTING WRITERS Allison Eatough Tracy Fitzgerald CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com Mark Molesky, Moleskey Photography www.moleskyphotography.com

H

APPY NEW YEAR AND BEST OF LUCK WITH YOUR NEW YEAR’S resolutions far into 2012! Both nationally and statewide, it’s an extremely dynamic political time with a great deal of the political spotlight focused on healthcare. The Maryland General Assembly’s 430th Session begins January 11, 2012 and has 90 days to act on more than 2300 bills including the State's annual budget and legislation impacting the way you practice medicine. In light of that, much of this issue focuses on Maryland’s healthcare policy and policy makers – from the founders of the MedChi (Heritage page 29) to an interview with Lt. Governor Anthony G. Brown (Policy page 24). As publisher/executive editor of Maryland Physician, one the favorite aspects of my job is being on the photo shoots. It’s an opportunity to connect with our editorial subjects with more of a free flowing conversation than a conversation spent trying to capture much of what is discussed with paper and pen (old school – I hear there’s an app which makes that whole process a bunch easier). I had the pleasure of a lengthy conversation with Lt. Governor Brown for this issue with Maryland Physician Managing Editor Linda Harder asking additional questions and taking the notes and the opportunity to capture some of the optimism surrounding progress being made in Maryland’s healthcare policy via conversations with Ben Steffen, acting executive director of Maryland Health Care Commission, and Dr. Niharika Khanna whose practice is enrolled in Maryland’s Primary Care Medical Home (PCMH) model (HIT Feature page 18). There are team based care models now in place in Maryland, both public and private, which are recognizing that there are specific tools you need for you to deliver the type of care that you went to medical school to learn how to deliver. Progress is being made and it needs to be made – according the HCC, Maryland ranks in the bottom quartile in the country for reimbursements. Clinically, in recognition of February as National Heart Health Month we went to some of Maryland’s outstanding cardiologists for updates in cardiac procedures. I remember walking down a hospital hall where my father was chief of pathology and seeing him stunned watching a man walking in his hospital gown with a suture line running almost stem to stern – the same cut my father would make for an autopsy. Those were the early days of open heart surgery. Now, procedures include minimally invasive (MI) with incisions only five to six centimeters in length (Feature page 12) and allow children with congenital heart disease to not only survive but also deliver heart healthy children of their own (Cases page 7). Celebrate February 3 as National Wear Red Day for Women's Heart Health and sport your red! To life!

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Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com WWW.MDPHYSICIANMAG.COM

ADMINISTRATION Ginger Jenkins EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 1663 Millersville, MD 21108 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $42.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any contact is strictly prohibited and protected by copy right laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: KAREN COUSINS-BROWN, D.O. Maryland General Hospital HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS Advanced Pain Management GAUROV DAYAL, M.D. Adventist HealthCare MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.

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Cases

Adults with Congenital Heart Disease Need Evaluation Stacy Fisher, M.D.

CASE: A 34-year-old woman with a history of Tetralogy of Fallot, initially repaired at three years of age, developed increasing dyspnea on exertion that had worsened gradually over two to three years. After graduating from ultrasound school, she worked as a cardiac sonographer, often pushing a large ultrasound machine around the hospital. She began to notice palpitations when she pushed the machine and felt better if she slowed her pace to minimize the intensity of the physical labor. DISCUSSION Advances in medicine have allowed children with congenital heart disease (CHD) to grow into adulthood, where they face a set of unprecedented and unique challenges. In fact, the number of adults with CHD now outnumbers the number of children. Our patient faced some of the typical issues this new and burgeoning population is experiencing. This newly married patient was also trying to conceive a child. After experiencing fertility issues, she underwent fertility treatment and successfully conceived twins. Shortly after conception, she presented for a formal heart evaluation and was found to have a severely dilated right heart with severe pulmonary regurgitation and relatively preserved ventricular function. Like many grown-up congenital heart

patients, she was unaware that she should have had an assessment before pregnancy. If her right heart size had been quantitated before pregnancy, she would have been offered a pulmonary valve replacement before conception. After being treated during pregnancy for atrial arrhythmias and decreased exercise tolerance, she had a near-term caesarean delivery of healthy boys (caesarian due to vertex/ transverse presentations and not maternal distress). Both boys received fetal screening and had normal heart development. After giving birth, she became more breathless with activity over the next year and eventually underwent elective replacement of her pulmonic valve. The surgery resulted in improved cardiac output and associated exercise tolerance. This patient illustrates the challenges that survivors of congenital heart conditions may face as they enter adult life. Patients often present for the first time after college or during pregnancy without knowing their original condition or the nature of their prior surgical repair. Many congenital heart surgeries are palliative, to allow children to grow, with the intent of revising the surgery in adulthood as needed. However, surgeons may have understated the complexity of the initial condition or repair and many adults present with hemodynamic or arrhythmia issues as they outgrow the repair or develop comorbidities. Comorbidities such as hypertension or coronary artery disease alter the balance of heart structure and function and may exacerbate underlying structural heart disease or magnify the impact of a borderline shunt lesion. Referring physicians can improve the health of women with congenital heart disease by referring them for cardiac assessment (and treatment, where indicated) before they become pregnant

or enter the workplace. Family members may also benefit from referrals for cardiogenetic testing and treatment, which is increasingly available. The case presented emphasizes the importance of longitudinal care for individuals with a history of a congenital heart condition, even if that condition was repaired, to prevent potential problems before they arise. As a second case illustrates, heart problems present in many ways. An adolescent referred for an echocardiogram after a new adult general practitioner heard a murmur was found to have a severe aortic coarctation and a bicuspid aortic valve. His blood pressure in the left arm was normal, as the left subclavian artery was involved in the coarctation pathology, while the right arm measurement was severely elevated. He was unaware of longstanding hypertension. He was found to have severe left ventricular hypertrophy at presentation and advised not to participate in a league basketball game the next evening. After receiving a subclavian patch repair, he since has had well-controlled blood pressure on three antihypertensives. He will remain at risk for aortic aneurysm and dissection and will need ongoing follow-up and longterm antihypertensive therapy. Four years after repair he now has mild left ventricular hypertrophy and the function of his bicuspid aortic valve is intact. The advent of advanced cardiovascular surgery has created the first generation of adults with congenital heart disease. These complex patients require evaluation and follow-up for both known and potential risk. Stacy D. Fisher, M.D. is assistant professor of medicine in the Division of Cardiology at the University of Maryland School of Medicine. Her clinical specialties include echocardiography, adult congenital heart disease, heart disease during pregnancy, and pulmonary hypertension.

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Solutions

Practice Exit Strategy – Never Too Early to Start

D

Sharrie Wade, CPA

O YOU HAVE A PRACTICE exit strategy in place? Are you prepared if your partner decides to retire? Are you prepared for an unpredictable situation such as a partner becoming disabled or a partner’s death? Do you have a buy-sell agreement in place? If something were to happen to your partner, would you want to be in business with your partner’s spouse/children? If your answer to any of these questions was no, you have some work to do. Now is the time to plan your exit strategy so that when a partner leaves the practice you already have the details laid out. When in the middle of an “event” emotions are generally high and finances may be tight. To make the transition

limited to death and disability, but could also include involuntary transfers due to bankruptcy, foreclosure and divorce. Entity redemption is the preferable method when the practice consists of many partners. In this type of buy-sell agreement, the sale could be funded through insurance policies owned by the practice or through a cash build-up. The cash build-up can be accomplished by placing money in a fund that requires approval from all partners in the practice before the money can be used for any other purpose. The major disadvantage to these funding methods is that the money/insurance policies are assets of the practice and therefore could be used to satisfy the claims of creditors.

“If you don’t have an exit strategy in place, now is the time to start working on one so that when the unexpected happens you are prepared. “ smoother, establish the guidelines for the agreement now. Regardless of whether or not your partner’s exit from your practice is planned or unplanned, you should have a buy-sell agreement in place. The buy-sell agreement could allow for the shares to be transferred from the outgoing partner through entity redemption, a cross purchase agreement or hybrid of the two types. A variety of factors can influence which type of buysell agreement is best for your practice, the most important factors are the number of partners and how the sale will be funded. In an entity redemption, the practice would have the right to purchase the stock when a trigger event happens. Trigger events would include a planned event, such as retirement, or unplanned events. These unplanned events are not 8 |

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In a practice with fewer than three partners, a cross-purchase agreement is the preferable method. In this type of agreement the remaining partners would purchase the exiting partner’s interest in the practice. A cross-purchase would be funded by each partner owning an insurance policy on the lives of the other partners in the practice. The proceeds from these insurance policies can be used as payment toward the purchase. Both scenarios eliminate the possibility of having to do business with an unintended third party, such as your partner’s spouse/children or a creditor if the unforeseen happens. Regardless of which type of agreement you decide, the funding needs to be in place well in advance so that the money is available to pay for the sales price outlined in the agreement. The sales price can be

calculated by using a formula, an agreed upon value or a third party appraisal. Even though it is important that the buysell agreement is in place, it is equally important that it is reviewed periodically for reasonableness. If a partner’s exit from the practice is planned, the buy-sell agreement can also address the possibility of adding a new partner or partners. When there is a planned exit from the practice and you are seeking new partners, the new and remaining partners should organize its assets, liabilities and discretionary expenses. Discretionary expenses are ones that may be unique to you as a partner rather than needed for operational purposes. This will give a more realistic financial picture and enhance the value of the practice. It is important to keep accurate detailed records as new partners may be interested in statistics about your practice. These benchmarks may include revenue per full-time partner, number of patients seen and percentage of patients that are private pay, insurance, and Medicare. If you don’t have an exit strategy in place, now is the time to start working on one so that when the unexpected happens you are prepared. And if you already have your exit strategy in place, review it to make sure that it reflects up to date information and does not require revision. Financial advisors including your CPA and attorney are an excellent resource for recommendations for your particular situation. A buy-sell agreement is an important key tool for your practices continuation and exit strategy. Sharrie Wade, CPA, is President of Clark & Anderson, P.A. a certified public accounting firm based in Glen Burnie, Maryland. She can be reached at swade@cacpas.net


Medical Beat UM School of Medicine Creates Clinical and Translational Sciences Institute University of Maryland School of Medicine Dean E. Albert Reece, M.D., recently established a new Clinical and Translational Sciences Institute (CTSI) to foster the translation of fundamental science to patient care and community health. The institute is an umbrella organization that creates a multidisciplinary infrastructure to help advance basic science research discoveries into novel therapies to treat and prevent serious chronic conditions and improve human health. The institute’s research and education efforts will target health disparities among underserved populations in Baltimore and beyond. Led by Co-directors Alan R. Shuldiner, M.D., and Stephen Davis, M.B.B.S., the institute will focus on six research areas: diabetes, heart disease, cancer, infectious and inflammatory diseases, schizophrenia and head injury.

MedChi Welcomes New President MedChi named Urologist Harry S. Ajrawat, M.D., its 164th president during its annual fall House of Delegates meeting in September As president, Ajrawat said he hopes to focus on increasing communications efforts among MedChi and its members. Ajrawat received his medical degree from The Guru Nanak University in Amritsar, India. He completed a residency in general surgery and urology at the State University of New York at Buffalo and is board certified in Urology. In 2006, Ajrawat joined several other urologists to form the MidAtlantic Urology Associates, LLC, where he is currently president and CEO. He has served as president of the Prince George’s County Medical Society, The Indian American Medical Society of Greater Washington and The Indian American Urological Association of North America. Urologist Harry S. Ajrawat, M.D., He succeeds David Hexter, M.D. an emergency MedChi’s newest president. physician from Baltimore.

Advanced Pain Management Changes Name Effective January 1, Advanced Pain Management will become KURE Pain Management. The pain management practice, which has offices in Annapolis, Chestertown, Easton, Glen Burnie, Hyattsville, Kent Island, Lanham, Waldorf and Washington D.C., will still provide patients with the same services as before.

Franklin Square’s Stroke Care Program Achieves Top Award

From left, Carolyn Core, Senior Vice President of Corporate Services, Anne Arundel Health System; Lex Birney, CEO of The Brick Companies; Julie Natoli, COO of The Brick Companies; Victoria Bayless, president and CEO, Anne Arundel Health System, stand near the AAMC Environmental Sustainability Exhibit, made possible by The Brick Companies of Edgewater.

The American Heart Association/American Stroke Association recently honored Franklin Square Hospital Center’s stroke care program with its Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award. The award is achieved through a greater than 85 percent compliance with all core measures of stroke care over a 24-month period.

Anne Arundel Medical Center Receives Green Award Anne Arundel Medical Center recently became the first acute care facility in Maryland to receive gold-level LEED® certification through the U.S. Green Building Council. LEED, also known as Leadership in Energy and Environmental Design, is an internationally-recognized green building certification developed by the council in 2000. Gold is the second highest certification available, exceeded only by platinum. In April, AAMC opened a new patient tower, built with environmental sustainability in mind. The LEED certification came as a result of the tower’s green design and construction features, including a 16,700 square-feet living roof, low flow fixtures and native plantings that thrive with little water, a highly efficient HVAC system and LED operating room lights.

M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

Neurological Disorders New Approaches and New Treatments Pain Management Diminishing Pain and Restoring Function Healthcare IT Client Server or Cloud?

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NOVEMBER/DECEMBER 2011 VOLUME 1: ISSUE 4


UM Doctor Receives Medical Equality Award The Association of American Medical Colleges recently awarded Cardiologist Elijah Saunders, M.D., with its 2011 Herbert W. Nickens Award. The award honors individuals who have made outstanding contributions to promote justice in medical education and health care equality. Saunders, a professor of medicine and head of the Section of Hypertension at the University of Maryland School of Medicine, has worked to achieve medical equality and eradicate health care disparities within AfricanAmerican communities for more than 50 years. An international expert on hypertension in African-Americans, Saunders has devoted his career to developing programs that reach patients in non-traditional settings like barber shops, all to educate them about the importance of cardiovascular health. He was the first African-American resident in internal medicine at the University of Maryland in 1960 and the first African-American cardiologist in the state in 1965. Saunders also co-founded several organizations, including the Association of Black Cardiologists and the American Society of Hypertension.

GBMC Names New Division Heads Greater Baltimore Medical Center recently named Joan Lewis Blomquist, M.D., as Division Head of Urogynecology and Abraham Allan Genut, M.D., as Division Head of Neurology. Blomquist, who is board certified in obstetrics and gynecology, has served on GBMC’s medical staff since 1996. She is co-director of DEXA and Osteoporosis Services and associate director of the Johns Hopkins/GBMC Fellowship in Urogynecology and Reconstructive Pelvic Surgery. Genut, who is board certified in psychiatry and neurology, has served on GBMC’s medical staff since 1991. He is a clinical instructor in neurology at Johns Hopkins University Hospital, as well as clinical assistant professor in both neurology and psychiatry at the University of Maryland School of Medicine. Genut succeeds Howard Moses, M.D., who retired in December 2010. Moses served as Chief of Neurology since GBMC was founded in 1965.

Joan Lewis Blomquist, M.D.

Abraham Allan Genut, M.D.

Baltimore Launches Script Your Future Campaign U.S. Surgeon General Regina M. Benjamin, M.D., recently visited Baltimore to launch Script Your Future, a national campaign to educate consumers on the importance of taking medication as directed. The campaign, led by the National Consumers League, brings together more than 100 public and private stakeholders to raise awareness about the growing public health issue of medication non-adherence and provide patients and health care professionals with resources to Maryland Physician Publisher/Executive Editor, Jacquie Roth, prevent it. with U.S. Surgeon General, Regina M. Benjamin, M.D. Non-adherence is responsible for more than one-third of medicinethe number of Americans affected by one or related hospitalizations and nearly 125,000 more chronic conditions requiring medication deaths in the United States each year. Medgrows to a projected 157 million by 2020. ication non-adherence also adds $290 billion To participate in the Script Your Future in avoidable costs to the health care system Baltimore coalition or for more information, annually – a figure that is expected to rise as contact Kerry O’Neill at 410-902-5035.

Clinical Features Maryland Physician focuses on the latest cancer developments. We talk with top Maryland specialists to get their take on the effectiveness of the latest treatments for prostate, breast and blood cancers.

Healthcare IT In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Don’t be left behind – read what Maryland physicians and healthcare IT experts have to say that eases the pain of transition to an electronic world.

In Every Issue and Online

Cases  Solutions  Compliance  Medical Beat  Policy  Heritage  Legacy  Good Deeds Jacquie Roth  Publisher/Executive Editor 443-837-6948  jroth@mdphysicianmag.com www.mdphysicianmag.com

JANUARY/FEBRUARY 2012

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More Patients Could Benefit from

Newer Cardiac Procedures   

Take Advantage of Growing Evidence of Effectiveness BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

When should you refer a patient to avoid subjecting him or her to unnecessary or unproven cardiac procedures? Maryland Physician interviewed three Maryland cardiac specialists to provide the latest information on newer techniques to manage patients with mitral valve damage, chronic total occlusions and atrial fibrillation (A-Fib). Dr. Rami, co-director of the Minimally Invasive Pituitary and Skull Base Center at GBMC


Paul Massimiano, M.D., program director for Cardiac Surgery, Washington Adventist Hospital

Minimally Invasive Valve Repair Proven Effective “The most important trend in heart surgery over the past decade is the transition to a minimally invasive (MI) platform,” says Paul Massimiano, M.D., program director for Cardiac Surgery at Washington Adventist Hospital. “Anything we traditionally did through the front can now be performed less invasively. “In the 1990s,” he continues, “we began paving the way with cannulas in the groin, accessing the femoral artery and vein through those and using smaller incisions to gain access to the heart.” Dr. Massimiano specializes in mitral valve repairs. While MI approaches to this procedure have been performed since the late 1990s, a surprisingly small percentage – only 10 to 15% – of mitral valve procedures in the U.S. are currently performed this way. In addition to being more technically challenging and taking more OR time,

the MI approach has a steep learning curve. “These are some of the reasons it hasn’t taken off more,” says Dr. Massimiano. There are three possible MI techniques – robotic, direct vision, and thoracoscopic. The direct vision approach is used for the majority

become more experienced with MI approaches, we’ve used the robot less with comparable results.” Dr. Massimiano adds, “Most patients are candidates for the MI approach, with the few exceptions including those with markedly reduced heart function or significant peripheral

“If you wait for symptoms or for chamber enlargement, you’ve probably waited too long.” –Paul Massimiano, M.D. of cases because the results are consistently superb. “There’s been a big debate about robotic versus nonrobotic approach,” Dr. Massimiano notes. “Both are good, and both have demonstrated excellent results. As the surgeons in our practice have

vascular disease. There really is no age cut-off now, either – some of our patients are in their 80’s.” After more than a decade of results, numerous studies have shown the MI approach to be safe and to provide results comparable to an open incision. JANUARY/FEBRUARY 2012

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John Wang, M.D., chief, cardiac catheterization lab, Union Memorial Hospital


As is true of many surgical procedures, high volumes and experience are important. “The key to success is proper selection of the patient, as well as the surgeon and center,” notes Dr. Massimiano. Both the techniques and the instruments in valve repair procedures have progressed. The MI incisions are only five to six centimeters in length, thanks to improvements in equipment and techniques. Catheters and cannulas can be inserted percutaneously using thinner, smaller, and more flexible devices. The advantages of the MI approach for patients are clear – most patients go home Day 2 post-op and 20% go home Day 1. The average length of stay is three-and-a-half days versus five to six days for an open incision, but the real benefit to patients is their ability to resume work and most activities within a few weeks instead of months. Dr. Massimiano urges referring physicians to refer patients early. “The data shows the importance of this. The AHA guidelines provide excellent guidance for referring physicians. If you wait for symptoms or for chamber enlargement, you’ve probably waited too long. “

New Techniques Boost CTO Success Rates Angioplasty and stenting have become so successful in treating most coronary blockages that it can be frustrating to manage coronary chronic total occlusions (CTO), which until recently had a far lower success rate than other percutaneous coronary interventions. CTOs involve complete blockages of coronary arteries for more than three months. They are most common in the right coronary artery with the remainder evenly split between the left anterior descending (LAD) and circumflex arteries. These blockages consist of hard plaques made of dense, fibrous tissue and calcification at the proximal and distal ends. Patients often slowly develop small collateral vessels to restore limited blood flow, and may not recognize their symptoms because they slowly adapt to their limitations. In the event a patient develops blockages in the “normal” blood vessel providing the collateral

flow to the CTO, they are at a higher risk for myocardial infarct (MI) and death. “CTOs represent the last frontier for coronary intervention,” says John Wang, M.D., chief, cardiac catheterization laboratory, Union Memorial Hospital. “A conservative estimate of their prevalence is that they represent about 20% of patients in the cath lab.”

other side. For example, in a 100% blocked right coronary artery (RCA) that is collateralized by the LAD, we would wire the septal perforators from the LAD to enter into the distal RCA. We then probe the occlusion from the back side, which typically is much softer and easier to cross.” Physicians are encouraged to refer patients for evaluation of their CTOs. ‘There are many patients who have

“ere are many patients who have CTOs that are being medically managed right now because there were no good options before” –John Wang, M.D. With conventional wire escalation techniques, interventionalists have about a 50/50 chance of opening the blockage with angioplasty. This approach is time consuming and entering into the true lumen is highly challenging. Recent advances in angioplasty techniques for CTOs have dramatically improved the odds for these patients, with success rates approaching 90% when the newer techniques are employed. “We’ve done about 15 of these procedures since August, 2011,” notes Dr. Wang. “Before, we had no hope of getting into some of these blockages. Which approach to start with is case dependent, as every angiogram has specific nuances. With the new ‘antegrade’ technique, we use a “CrossBoss™ CTO Catheter that has a blunt, rounded tip. Instead of going through the true lumen, we go into the wall of the blood vessel and track subintimal, then re-enter the true lumen with a Stingray™ CTO Re-Entry System. It’s like running ductwork to the second floor of your house behind the drywall. Once we enter a softer area, we can make a new channel to put the stent into the true lumen.” Dr. Wang continues, “A second new ‘retrograde’ technique approaches the blocked coronary artery from the

CTOs that are being medically managed right now because there were no good options before” Dr. Wang says. “Once you start looking you realize that there are many patients that would benefit from this technology. To determine if they’re a candidate, we need to see their cath films and speak with them and their referring physician.” With the new CTO techniques, patients typically go home the next day. They can resume normal activities at the same rate as other angioplasty patients. ‘This represents an exciting new option for CTO patients,” Dr. Wang concludes. ‘It’s allowing a whole subset of patients to have options.”

Dispelling Atrial Fibrillation Myths Baran Kilical, M.D., F.A.C.C., cardiac electrophysiologist (EP) at Anne Arundel Health System, spoke to Maryland Physician to dispel some common myths about the best way to manage A-Fib. Dr. Kilical sees numerous patients with this common condition and understands that it can be frustrating to manage.

MYTH #1 Anti-coagulants unnecessary after achieving normal sinus rhythm

“A common misconception among patients is that if you maintain sinus JANUARY/FEBRUARY 2012

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MYTH #4 Ablation reserved for sickest patients

“The truth is,” Dr. Kilical observes, “after one episode of failure after medication, or for those who have side effects from medication, you’re a candidate for ablation. In fact, ablation is less beneficial for the sickest patients; paroxysmal A-Fib patients benefit the most. “ The success of ablation is dependent on:  A-Fib duration  Ejection fraction  Left atrial size  Mitral regurgitation  Sleep apnea

Baran Kilical, M.D., cardiac electrophysiologist, Anne Arundel Health System

rhythm, your risk of stroke decreases and you can stop taking anti-coagulation medications,” Dr. Kilical comments. “That’s a mistake. The American Heart Association guidelines recommend continuing anti-coagulation based on your CHADS score (an acronym of the five key risk factors for stroke following A-Fib - congestive heart failure, hypertension, age, diabetes and stroke or TIA history) regardless of a successful ablation. Catheter ablation is reserved for symptomatic patients to eliminate symptoms and anti-arrhythmic medications, but not to stop anticoagulation.”

MYTH #2 Dabigatran superior to warfarin

Dr. Kilical says, “The reality is that, for all practical purposes, their efficacy is equal. The main advantage of PRADAXA® (dabigatran) is that you don’t have to take dietary precautions or check the international normalized ratio (INR) regularly. The Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial found that the risk of major bleeding with warfarin at the end of two years was 7%, vs. 6% with dabigatran. The risk of a hemorrhagic stroke was 0.75% with warfarin and 0.72% with dabigatran. As 16 |

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a new medication, it is considerably more costly than warfarin, although it doesn’t involve regular blood work.”

MYTH #3 Aspirin appropriate for CHADS Score of 1

EPs have long used the CHADS Score to guide the use of anti-coagulants. Having two or more factors warrants the use of an anti-coagulant, while a score of 0 indicates that no anticoagulants are required. A CHADS score of 6 is associated with an annual risk of stroke of 18.2%, whereas a score of 0 is associated with only a 0.5% risk of stroke. The controversy arises when patients have a score of 1. “The AHA guidelines say you can use either aspirin or warfarin for this group,” says Dr. Kilical. “I tend to use blood thinners for these patients, because bleeding can be controlled, but a stroke is a devastating event. Most of the studies, except for the Stroke Prevention in Atrial Fibrillation (SPAF) trial, concluded that aspirin was of little or no benefit. Most EPs say that taking aspirin is treating the doctor, not the patient.” However, he notes that he sometimes prescribes aspirin when a patient is opposed to using warfarin.

Catheter ablation success rates have increased in recent years, thanks to a better understanding of the disease, new techniques and technology, and more experience. Early ablation success rates were 60% or more for paroxysmal A-Fib and 30% or less for persistent A-Fib. Dr. Kilical notes, “Now, some 80% of patients undergoing ablation are successful, meaning they are free from A-Fib for at least 12 months without taking medications. Ablation used to involve a long, difficult procedure. However, with new catheters that can deliver circular lesions, improved 3-D mapping, and a growing arsenal of new tools, the procedure is faster, safer and more successful.” The new ablation procedures can involve FDA-approved radiofrequency (RF) energy to destroy tissue through resistive and conductive heating, or cryoablation, which effectively destroys tissue by freezing. Dr. Kilical reminds physicians, “Keep in mind, A-Fib begets A-Fib. I prefer to perform ablation before A-Fib becomes permanent. A-Fib is progressive, with increased frequency and duration secondary to the inflammation and scarring in the myocardium. It’s best to refer patients while their A-Fib is still paroxysmal and can be more readily treated.”

Paul Massimiano, M.D., program director for cardiac surgery, Washington Adventist Hospital. John Wang, M.D., chief, cardiac catheterization lab, Union Memorial Hospital Baran Kilical, M.D., cardiac electrophysiologist, Anne Arundel Health System.


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Healthcare IT

Patient Centered Medical Homes BECOME A REALITY Public Multi-Payer and Private Models are Underway in Maryland BY LI N DA H A RDER • PHOTOGRAPHY BY MARK MOLESKY

T

WO PATIENT CENTERED Medical Home (PCMH) programs are currently underway in Maryland. The 2010 legislative session established funding for the Maryland Multi-Payer PCMH program (MMPP) pilot program, which launched April 2011 for 53 practices and about 200,000 patients. A few months earlier, CareFirst BlueCross BlueShield launched a PCMH program that covers its insured patients in participating provider panels. Maryland Physician spoke with leaders of both programs plus four participating Maryland physicians to learn about their

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early progress and future challenges. The American Academy of Pediatrics originated the PCMH concept in 1967 and made it policy by 1977, when it established standards to improve the access, planning, management, coordination and tracking of healthcare services, with the primary care provider as the hub. The National Committee for Quality Assurance (NCQA), developed a set of measures for physicians to achieve PCMH recognition that were recently updated to be aligned with CMS Meaningful Use requirements. These promote using


electronic health records to track care, especially for the small fraction of highrisk patients that account for a third of healthcare expenditures. MMPP Pilot Program

The three-year MMPP pilot program, under the aegis of the Maryland Healthcare Commission (MHCC), includes patients insured by Medicaid, Aetna, CareFirst, CIGNA, Coventry, United Healthcare, select self-insured employers, and possibly Medicare. Ben Steffen, acting executive director of the Maryland Health Care Commission and director of Maryland’s PCMH program, says, “Governor Martin O’Malley, Lieutenant Governor Anthony Brown and Secretary of Health

and Mental Hygiene Dr. Joshua Sharfstein are fully behind the PCMH program. The priority this program places on the primary care physician is long overdue.” The enrolled practices are given financial, logistical and educational support to achieve NCQA Level 1 recognition in late 2011 and Level 2 recognition by late 2012. Overseeing that support is the Maryland Learning Collaborative, a partnership between the University of Maryland, Johns Hopkins Community Physicians and the MHCC that started in March, 2011. Niharika Khanna, M.D., program director, Maryland Learning Collaborative and Associate Professor Family and Community Medicine at

University of Maryland School of Medicine, explains, “MHCC selected us to be their partners in program administration. We announced the multi-payer program on April 14th. Fifty-three practices comprised of over 339 primary care providers signed up. Our practices are very diverse and include 15 practices that have 20% or greater Medicaid patients. “The legislature approved the program and innovative payment model reforms totaling about $ 3.5 million were developed for prepared practices to ensure that payments go directly to the practices in two parts: 1) care management payments of about $3 to $7 per member per month (PMPM) and 2) a year-end share of any cost savings from reduced hospitalizations, readmissions, ER visits and the like. Additional state support was designated to establish the Maryland Learning Collaborative and the external evaluation team.” She reflects, “Collaboration is the key strength of our model. We conducted a series of webinars on each NCQA standard and the practices decided which data they needed to identify high-risk patients. We offer multi-media, skills development and training workshops to practices to support a team-based care management model where a variety of healthcare personnel can learn to perform the functions of embedded care management. While not required, 51 of the practices have EHRs and most will interchange with CRISP’s Health Information Exchange (HIE). Patient advocates drawn from our practices have guided us at every step.” Provider Experience

Howard Haft, M.D., MMM, FACPE, medical director of Maryland Healthcare and Shah Associates, a multi-specialty group practice in Southern Maryland with multiple locations, notes that some of their locations are participating with the state model while others are in the CareFirst program. He is optimistic about the potential for the PCMH model to transform patient care. Ben Steffen

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Healthcare IT “It’s a lot of work but it has its rewards,” he notes. “It provides better care. Before we started this, we relied on our patients to tell us when they were in a hospital or to return for follow-up appointments. Now, our care managers help us make the connections and ensure that they’re seen back in our practice within 72 hours of discharge. “I really like it and patients like it,” Dr. Haft adds. “PCPs used to rely on a wing and a prayer that the patients would see the specialist when referred and that we’d get information back. Only 30 to 40% of diabetics, for

Niharika Khanna, M.D.

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example, were getting regular eye exams documented. Now, our staff gets a list of patients referred so that we can track their progress, with clinical information in that referral. It provides more integrated care.”

on patients who need more help in between visits and prevent a chronic problem from becoming a disaster.” “We’re not trying to make more money but to build a better healthcare system. We’re newborns at this. It will

It’s a lot of work but it has its rewards. It provides better care.” –Howard Haft, M.D. Dr. Haft agrees that care management is key. “Care managers are embedded at all of our sites,” he says. “I can’t tell you how valuable that is for us and our patients. They focus

be a journey, but at least this time the path on that journey is lit.” Seth Eaton, M.D., an internist and pediatrician with MedPeds, participated in the BC Collaborative pilot program as well as the current state multi-payer model. He notes, “We chose the state pilot because it involves so many more of our patients. Additionally, as a practice that has had an EHR since 2004, we didn’t want to duplicate our existing documentation processes. With the state model, we can integrate the care coordination into our existing workflow.” Dr. Eaton describes some of the changes that PCMH has brought. “We’re in the process of hiring an additional LPN to serve as the care manager for all eight of the MAs in our practice and one of our other nurses is working to reach out to 50 of our sickest patients. We’re starting up holiday and Sunday hours in 2012 and will be part of the CRISP HIE so that we can mine hospitalization and ER data to better coordinate care. To share in year-end savings, we have to hit both process measures, such as making sure we’ve measured hemoglobin A1C in diabetics, and outcome measures,” he adds. In a short time, the vast majority of MMPP practices met the October 28, 2011 submission deadline to meet Level I NCQA. Notes Dr. Khanna, “It’s mind boggling that they completed them in time. We think we’ll be ready for Wave 2 of NCQA recognition by July 2012. It’s hard to know yet if the dollars provided will be adequate until we have the cost data.” What can interested PCPs do to join? Dr. Khanna advises, “Write a letter to us or the MHCC. We’re seeing a lot of interest throughout the state.”


CareFirst PCMH Program

CareFirst’s PCMH program builds on the lessons of its three-year pilot program that concluded in 2010. The current program, according to Chet Burrell, president and CEO of CareFirst, has signed up about 2,900 physicians and 300 nurse practitioners in Maryland, DC and Virginia, making it the largest in the country. “In our program, the PCP cannot join as a solo practitioner,” says Mr. Burrell. “They need to be part of a virtual panel or small group of five to 15 providers. The average panel size is 10 providers and about 3,000 members, in line with early predictions that this size would generate sufficient patient volumes to spread risk without being unwieldy.” Mr. Burrell adds, “What doctors

need most are the ability to see their roster of patients, make a care plan for high-risk patients, have a longitudinal record of care and have powerful analytics and support. We supply all of those things.” Provider Experience

George Lowe, M.D, vice president, Mercy Health Services, Medical Director of Lutherville Personal Physicians, a unit of Maryland Family Care Inc., a group of 75 PCPs, participated in both the pilot and current CareFirst PCMH programs. He observes, “Most of the practices in the pilot successfully achieved NCQA Level 3 recognition. The current model adds in a case management component for at-risk patients and promises to share in cost savings based on outcomes and patient satisfaction.”

MARYLAND’S PCMH MODELS AT A GLANCE MD Multi-Payer PCMH

CareFirst BCBS PCMH

Launch date

Mid April 2011

January 2011

Payers

Aetna, CareFirst, Cigna, Coventry, United, Medicaid, select self-insured employers

CareFirst only

Number of Enrolled Physicians/Practices

339+/53

2900 MDs/nearly 200 panels; also 300 NPs Must be in panel of 5 to 15

Timeframe

3 year pilot

2011 launch with ongoing registration

Support

MD Learning Collaborative – webinars & other support, coaches, etc.

Care managers paid for by CareFirst, web apps, etc.

Features

Each practice can create its own care management model within NCQA guidelines

Common web-based model for all participating panels

Not required but most have EHR

Encouraged, not required

$3-7 PMPM; up to $55,000 per MD per year Shared savings end of year

12% fee schedule increase $200 per care plans; $100 to maintain plan Shared savings end of year

EHR Requirement Payments

Chet Burrell

Patricia Czapp, M.D., medical director for eight practices and 20 physicians in Anne Arundel, and also a participant in both CareFirst programs, is enthusiastic about the changes PCMH has wrought. “It has transformed our practice, and the patient really is the focus. Before, we felt we couldn’t afford to hire more staff; PCMH forces you to build an effective internal team and redesign care delivery so that doctors perform fewer clerical tasks and go home earlier, while seeing more patients during their work day. “We used to have one or one-half medical assistants per physician; now we have two,” she continues. “We train them to comprehensively review each patient’s needs beyond that visit’s particular focus, such as scheduling an overdue mammogram, updating immunizations, refilling chronic medications and periodic specialty referrals. Most of the keyboard work has been done by the time the physician sees the patient, so the doc gets more “face” time with each patient. The staff find it more rewarding, too – like the docs, they now get cookies and fruit baskets from grateful patients!”

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Healthcare IT

Patricia Czapp, M.D.

Care Managers, Care Plans and Medical Health Records

Mr. Burrell comments, “We give providers the data to determine who in their patient roster might benefit from a care plan.” Providers are paid $200 to develop a care plan for higher risk patients and $100 to maintain these plans. More than 1,000 care plans were initiated in 2011. To better manage high-risk patients, CareFirst employs regional care coordinators, each of which oversees

broadband access, and that’s it.” CareFirst’s other key feature is an online Medical Health Record for each patient that tracks episodes of care, medications, and other key health data.

Remaining Challenges for Programs Reimbursement

Both PCMH models provide immediate increases in physician compensation and share in any savings at the end of the year. Mr. Burrell explains how the CareFirst shared savings works. “We

It has transformed our practice, and the patient really is the focus… PCMH forces you to build an effective internal team and redesign care delivery so that doctors perform fewer clerical tasks and go home earlier… ” –Patricia Czapp, M.D. seven to eight care managers in 18 subregions. The care managers, contracted through a vendor, are local nurses with practice management experience. Mr. Burrell explains, “We weren’t sure if the doctors would accept the nurses into their practices, but by and large, they have. The care managers learn the patient’s history, document what they need and serve as the navigator to ensure that the patient receives necessary services. It’s all conducted on a web-based application. The physicians need a PC and 22 |

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support and the data you need. The program is data-intensive, not anecdotal. Unlike some past models, there is no downside risk for physicians. If you spend more than anticipated, it’s a no lose situation.” Mr. Burrell concludes, “There is more time involved to participate in a PCMH, but it’s enlightened selfinterest. We provide powerful rewards for providing more managed patient care. Even though the shared savings piece is somewhat complex, it’s amazing how many providers readily grasp it. My gut is that about half of the panels will see shared savings.” “I’m optimistic,” exclaims Dr. Lowe. “Primary care physicians have always wanted the ability to help our patients outside the office and to keep them healthy. Thanks to PCMH, that’s becoming a reality. We’ve extended both our practice hours and the ways that patients can contact us, including a patient portal where patients can register, request appoints or referrals, or renew prescriptions.”

set up a Patient Care Account in which we deposit virtual global credits; actual healthcare utilization costs are subtracted from those virtual credits. For example, a panel might accrue $10 million in their account by receiving a $200 to $300 PMPM credit for a panel of 3,000 patients. Health expenses would be debited against those credits. “While each region has a different amount based on historical care experience,” he continues, “your job is to beat the global expected cost of care and we help by giving you the nurse

Mr. Steffen observes that access to data is one of the major challenges facing PCMHs, due in large part to restrictions in state law limiting what information can be shared. “We worked to make it easier for physicians to obtain data without violating the law, but we need to revisit this issue in the future. Practices need to have data on patients that need treatment.” Dr. Khanna concurs. “We need to know which patients to target because we can’t follow everyone. Access to care is a second critical issue. We’re exploring the possibility of group visits, where, for example, diabetic patients might have a group session with a PA or NP to learn how to monitor their disease and when to get preventive care.” A third issue is the continued refinement of the shared savings methodology. “All of the PCMH models have complex methodologies,” Mr. Steffen notes. Despite the issues, all interviewees were optimistic about the potential of the PCMH model. “This is a wonderful opportunity for primary care physicians. It’s what we thought we would do when we set out to practice medicine,” Dr. Khanna concludes.


Compliance

It’s Ok To Fire An Employee For Trashing You On The Internet… Isn’t It? By Stephen Kaufman

Y

OUR PRACTICE HAS CAREfully protected itself and management against employees bad-mouthing them using social media like Facebook, Twitter, blogs or chat rooms. The policy handbook is clear: Employees are prohibited from using the internet to make disparaging comments about the company; offensive language about co-workers is forbidden; and posting pictures depicting the company in any way, including a logo or uniform, is not allowed. Employees are warned that their internet use will be monitored and that they can be fired for violations. Given this, when two low level, administrative employees are caught having a Facebook discussion about the need to improve their supposedly horrible working conditions and, in doing so, describe their supervisor as a mentally-ill dirtbag, firing them would be legal and appropriate, right? Well, no. Not anymore. According to recent interpretations of the federal employment laws by the National Labor Relations Board (NLRB), such a firing is likely illegal. The NLRB is a Great Depression New Deal-era federal agency. Its mission is to protect the rights of private sector employees to join together to improve their wages and working conditions, with or without a union. The NLRB has regional offices nationwide where employees can file complaints, which also can be filed online. The NLRB has the right to investigate complaints and, if necessary, sue employers in administrative courts. Recently, the NLRB Acting General Counsel issued a report explaining that the NLRB considers certain employee conduct on social media legally protected, even if it violates employer policies. According to the General Counsel, social media postings are protected if they amount to “concerted activity,” which is when two or more employees take action

for their mutual aid regarding their work conditions. A single employee can also engage in concerted activity if she brings group complaints to the employer or tries to prepare for, or organize, group action. Unfortunately, there is no definite answer as to whether a particular internet posting is protected. Every case is different. Here are some examples. In one case, in preparation for an upcoming meeting with management, employees tweeted about inadequate staffing and called supervisors incompetent. The NLRB said their firing was improper. In another case, two employees could not be fired for having a Facebook conversation expressing their dissatisfaction with the employer’s tax withholding practices, which they had asked be placed on the agenda for an upcoming management meeting. This was true even though the employees had

with co-workers, and none of them had responded to the posts. Although all cases are different, having a company policy on social media can help an employer manage employee internet communications. However, the policy must be well thought out. Just as it can be illegal to punish an employee for concerted action, it can be illegal to have a policy that is so broad that it restricts the right to concerted action. For

"Unfortunately, there is no definite answer as to whether a particular internet posting is protected. Every case is different." used several expletives in questioning management competence. Despite the crudeness of the critiques, the NLRB concluded that the conversations were protected concerted action. On the other hand, criticism using social media is not protected if it is unrelated to the conditions of employment or does not seek to involve other employees. For example, an employee was properly terminated for making derogatory tweets about his employer’s competitor, in violation of company policy. In another case, the employee made derogatory comments about his employer’s customers and colorfully wished them harm. Although the employee was commenting on his terms of employment, his termination was deemed appropriate, because he had not discussed his postings or complaints

example, prohibitions on talking on the internet about practice management can be improper, because “practice management” can include group discussions about wages or work-place safety. Hospital rules prohibiting employees from using social media in a way that might disregard confidentiality rights, harass or defame hospital employees or damage the hospital’s reputation have been declared improper for the same reason. Thus, the best policies address legitimate practice interests and are just broad enough to protect those interests. Drafting a good policy is worth the effort, as it can help avoid the cost and bad publicity of an NLRB investigation, or worse, a finding of wrongdoing. Stephen Kaufman is Chair of the Health Care Group at the Offit Kurman law firm. He can be reached at skaufman@offitkurman.com.

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Policy

Maryland 2012 Healthcare Priorities and Your Practice An Interview with Lt. Governor Anthony G. Brown LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

that it might include healthcare… He said ‘great, I want you to take on healthcare and for you to work with our Health Secretary and all of the other departments on health and you be the lead for the administration on healthcare.’

Q:

What are some of the most important healthcare issues you have championed since taking office and how are they making Maryland healthy?

A:

Maryland Physician Publisher/Executive Editor Jacquie Roth and Managing Editor Linda Harder recently sat down with Anthony G. Brown, Esq., Lt. Governor, to learn what progress Governor Martin O’Malley’s administration has made to date on healthcare access, care and equity, as well as how its legislative priorities for 2012 may impact physicians.

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Q:

How did you come to spearhead healthcare initiatives for the administration? Why?

A:

The why goes more to my being raised in a home headed by a physician… my father was a doctor. He was first an OB/GYN… then, later in his practice, he became a physiatrist… I saw the difference that he made in the lives of his patients… So, I’m certainly sensitive to issues impacting physicians and their quality of life. When I was elected in the 25th legislative district… I was attracted to economic matters. When I was in the General Assembly, healthcare was in two different committees… Environmental Matters and the Economic Matters Committee, which I was on, that had the health payment system, access to care, reimbursement and things like that… While I was in that committee, I became much more knowledgeable and immersed in issues dealing with the health payment system… When the Governor looked at what my portfolio might be, I suggested to him

We really have done a lot. We’ve done things like the Patient Centered Medical Home pilot program. In 2007, the Governor created the Health Quality and Cost Council (HQCC), which I chair. It brings together a number of stakeholders from… the private and public sector… to look at areas where we can improve quality and reduce the cost of care in Maryland… One of the initiatives that came out of the Council is the Patient Centered Medical Home (PCMH) program… It was in 2010 that we were able to introduce the legislature and we launched the program this year. We have approximately 300 providers – the vast majority are physicians, but there are some nurse practitioners, covering upwards of 200,000 patients… it’s patient centric… to make access to care more accessible. That may mean nontraditional hours, using alternate forms of technology to communicate with patients – emails, even social networking. It requires that they adopt electronic health records and that they focus on wellness and prevention. If they choose to do that, they are eligible for enhanced reimbursement. We believe you do need to incentivize certain behavior in the health delivery system… you have to provide enhanced reimbursement (see related article p. 18). … The model also includes shared


savings… Not only do you have an enhanced reimbursement, not only do you have a monthly stipend per patient, but there’s going to be a shared savings component. You’ll have benefits to patients and to providers. When we speak to providers, they didn’t go to medical school to spend seven minutes with their patients and just scratch the surface… Physicians want to spend time with their patients and get to know them… So I think it improves the quality of practice, which encourages and incentivizes more doctors coming out of medical school to go into primary care because it’s a sustainable practice.

Q:

What are your legislative priorities for healthcare in 2012 that support physicians?

A:

… I know that one of MedChi’s legislative priorities is how we regulate, govern and supervise the physician community. Is our process for discipline fair and open and accurate, is it predictable, is it timely? One of the things we’ll be working with MedChi on… is the Maryland Board of Physicians. It may require restructuring. . We’ll be looking at: how do we have a better process for evaluating and making a

also asked this governing board to come back and answer a lot of questions. Do we regulate [insurance products] inside the exchange the same way we regulate outside the exchange? How do we establish the navigator system? And physicians play an important role in helping us to understand how to set up the exchange and what that means for their practices, so we’ll be working with physicians and non-physician providers as we set up the Health Benefits Exchange… We’re one of a few states actively, aggressively moving forward on the Exchange… The second thing we’re going to work on… is Health Disparities. This is also part of the answer to the question about why I focus on healthcare. There are a number of contradicting or confusing data points in our state. We live in the wealthiest state in the nation, we live in a state where we’re ranked 5th, (which is good because #1 is the best) in the number of children living in poverty, and we rank second for highest per capita primary care providers, yet we’re ranked 41st in infant mortality and 35th for geographic disparities, so something is going wrong. We have great healthcare institutions like Johns Hopkins and University of Maryland…, yet our health quality indicators certainly indicate that

Physicians play an important role in helping us to understand how to set up the Exchange and what that means for their practices, so we’ll be working with [them]… decision on the scope of practice and how do we ensure quality of practice in a way that is fair and open and transparent to physicians? One of the things I learned when I speak with small business owners regardless of the industry they’re in… is that, when they have to interact with government, they want predictability in the process. So we’re going to work with MedChi to enhance the process. Our two biggest healthcare proposals will be the Health Benefits Exchange [note: On April 12, 2011, Governor O’Malley signed into law the Maryland Health Benefit Exchange Act of 2011], which is a critical part of healthcare reform, and you may recall that this past legislative session, we established the framework for a governing board but we

we have a lot of room for improvement. … We’ve established a health disparities workgroup that Dean Reece, [Albert Reece, M.D., dean, University of Maryland School of Medicine] is chairing, and asked them to present a bold proposal to incentivize providers and communities to expand and deliver care in those parts of the state… We can use GIS mapping to map where our disparities exist… We know where the highest incidence and rates are, and we can also map where our physicians are located. You will easily see a correlation between the higher incidence of chronic disease and the lack of primary care physicians. We’re planning to create health enterprise zones… we’re going to create these zones and within them we will accept applications from health care

providers and even community organizations that impact healthcare… Everyone will agree that we need to address disparities, but it isn’t happening. How do we make it happen? Incentivize providers, go into those communities, bring resources, bring the talent, identify the need and make a difference. Then we’ll… give you relief on property tax, income tax, loan assistance and retraining programs… Every tool we have in our toolbox, we will put into that zone to make it the most attractive place for a primary care or other provider to establish their practice.

Q: A:

Are any of these zones identified yet?

Actually, we aren’t going to create the zone – when we create the program, we’re going to say to an applicant, ‘you tell us the zone that you think you can impact’… It’s a lot like Economic Enterprise Zones… We’re going to do the same kind of thing for these health zones. We’ll say, ‘This is the criteria we’re looking at us, you tell us where you can achieve some of the goals we’re trying to accomplish, where you can be most effective, what resources you’re going to bring to bear and we’ll evaluate that and then agree that, yes, that’s a zone… you’ll benefit from whatever incentives we can design.’ That’s the second big proposal we’re sending to the legislature and, as you can tell, the one I’m most excited about.

Q: A:

How will you fund this program?

We’ll probably start by using existing programs… For example, we have the PCMH program and EHR program where we provide enhanced reimbursement… In 2007/08, when we introduced our health reform proposal… some of that was funded by the tobacco tax. Another portion of that, especially the Medicaid side – we did an analysis that, if we provide more people with Medicaid coverage, we can reduce uncompensated care in our emergency rooms by a certain amount… We were able to make an accurate calculation of what that savings would be and… used those savings to pay the cost, in part, of JANUARY/FEBRUARY 2012

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Policy

Maryland Physician Publisher Jacquie Roth and Anthony G. Brown, Esq., Lt. Governor.

that program. We’ve got to do the same thing here. If we are… creating this with the goal of reducing disparities… then we have to be able to make projections on what those cost savings will be. Since a big piece of that is Medicaid… we can calculate those savings for our state… We may take applications and approve, say three enterprise zones, just like we piloted the PCMH program… we pilot it, measure the benefit and then go statewide… we’ll probably do the same thing here.

Q: A:

What do you plan to do about medical malpractice this year?

Maryland undertook reform in the 2004 [special session] and 2005 session. We made sure we had all the stakeholders around the table – the legal community, the provider community, patient advocates – to look at what we can do, because the real issue here is quality of care… The goal really is to reduce unintended outcomes. The approach we took looked at quality measures, insurance reform measures to make sure that the insurance system was fair, balanced and adequate, and we did look at the legal system. … It was a balanced approach… And we made adjustments in all three of those areas so that we could strengthen the protections for patients and protect physicians in their delivery of care… And to make sure the legal system continued to be a necessary backstop for 26 |

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patients who needed protection… If the physician community is asking us to take a look at it again, whatever we do needs to be in a balanced approach. I don’t think there’s one silver bullet answer to medical malpractice. What the governor and I have also been focusing on is how we can enhance reimbursements… Because we hear time and time again that Maryland is a bad state for physician reimbursement. We don’t regulate reimbursements for physician providers like we do for hospitals. Recently, the governor and I did support one physician initiative, which was the Assignment of Benefits. It’s a way in which you better position physicians to get reimbursement from the insurance carriers than currently exists… It was a MedChi priority, we supported it and it passed in the legislature. It’s one small way we’re trying to better position physicians vis a vis carriers in that world of reimbursement. I think that’s the real challenge – how do we better reimburse and compensate our physicians for the hard work that they do…

Q: A:

What changes do you propose to the Maryland Board of Physicians?

That will be a bill before the legislature… I can’t tell you how many physicians I speak with who get a notice from a patient that’s filed a complaint with the Board. And the physician gets a letter from the Board…and you send the

records and then literally, there are cases that five years later, you still haven’t heard back. No one wants that hanging over their head. That is a priority for MedChi, and we’ll be working with them… we’ll probably have the Department of Health and Mental Hygiene take the lead on restructuring, retooling and reorganizing that board. And then we’ll be looking at all of the medical boards to see how they interact. Here’s the issue with scope of practice that we’ll try to address… every year, the different professions… come in and say, we want to be able to do more or another group says we want them to do less. And the truth is that the legislature is not well equipped to adjudicate each of these scope of practice issues… Dr. (Joshua) Sharfstein [Secretary of the Department of Health and Mental Hygiene] goes to the boards and tries to find some compromise and consensus… but they can’t get the boards to cooperate. There’s got to be a better mechanism for us to empower our Health Secretary to resolve those disputes… My personal opinion… on scope of practice is that the best place to resolve them is not in the legislature and not in law. I think that the professions, based on their education, training, background and experience, should be able to make determinations on scope of practice… There’s going to be an overlap in the scope of practice… But the key is, do you have the coordination of professional activity, so that where there is overlap, you don’t have people running afoul… so that the nurse practitioner is working in conjunction with the medical doctor that is coordinating closely with the pharmacist. If the Patient Centered Medical Home was the universal model, you wouldn’t have scope of practice issues. A lot of it comes down to delivering the service within the scope of your education, background, training and experience – number one. And number two, adequate collaboration and supervision throughout the healthcare delivery system… whether quarterbacked by a medical doctor in most cases or someone else, but figure out what that collaboration needs to be and work it out. Lt. Governor Anthony G. Brown was elected alongside Governor Martin O’Malley in 2006 and reelected in 2010. He leads the O’Malley-Brown administration’s work to expand and improve health care as well as many other initiatives.


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Heritage

MedChi Offers Systems of Support for Maryland Physicians By Tracy M. Fitzgerald

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HETHER PRACTICING privately or through affiliation with a hospital or healthcare system, physicians in Maryland can rest assured that each day, there are people out there working hard on their behalf; people advocating for proposed healthcare laws and regulations that will help and support physician practices, and lobbying against those that could add even more challenges to the already complex and challenging dynamics of the patient care environment. The Maryland State Medical Society (MedChi) is committed to making Maryland a better place for physicians to live and practice… and has been, for quite some time. The organization, originally named the Medical and Chirurgical Faculty of the State of Maryland, was established in 1799 with a charter to “prevent the citizens of Maryland from risking their lives in the hands of ignorant practitioners or pretenders to the healing art.” In the 200 years to follow, the organization’s notable accomplishments included the initiation of a Maryland medical college, known today as the University of Maryland School of Medicine, the opening of a state medical library, and the

Local physicians and dignitaries joined in 1909 to commemorate the dedication of the building that MedChi continues to call home today. Prominent medical leaders took part in the event, including G. Milton Linthicum (4th row, far right) and Wm. Osler (1st row, second from right), whose names are remain familiar in Maryland's medical communities.

well as quality of service delivered from medical and social providers. In 1999, the organization officially changed its name to The Maryland State Medical Society (MedChi). “The work of MedChi is literally entwined in the medical history of Maryland,” said Gene Ransom, MedChi CEO. “Today, we are focused on healthcare advocacy in Annapolis and Washington D.C., and continuously educating our members, so that both physicians and the public can be better served.” Known as one of the most progressive medical societies in the country, MedChi’s mission is to serve as the state’s foremost advocate and resource for physicians, their patients and the public health. Their

“Now is not the time to sit back. We need physicians to get out there and have a voice.” –Gene Ransom, CEO of MedChi

establishment of the Baltimore College of Dental Surgery. Leaders rallied and succeeded in the creation of a state board of health and board of medical examiners. To demonstrate its commitment to public wellbeing even further, the Society launched the Center for a Healthy Maryland, designed to improve the overall health status of Marylanders as

mission is fulfilled through the promotion of medical science and knowledge, the enhancement of physician relationships with their patients, the achievement of the highest standards for medical education and ethics and the creation of systems to offer universal access to healthcare. MedChi’s 65 employees support its Law and Advocacy Division, Legislative

Offices, Continuing Medical Education Department and Information Center, providing members resources to present questions and find answers related to all facets of the practice of medicine. “Helping doctors learn so they can make the right decisions for their practice is a big priority for us,” said Ransom. “Many are overwhelmed with the amount of change that is happening in healthcare right now; they are concerned about quality of life issues as well as the viability of their practices. We are fighting for those doctors, investing our time and resources into following policy makers and lobbying to help assure good decisions are made by the government and General Assembly.” According to Ransom, there has never been a better time than now for physicians to take action and get involved with the state’s medical society. “Now is not the time to sit back. We need physicians to get out there and have a voice,” he said. “There are so many opportunities through MedChi to get involved, be educated and work together to fight for the practice of medicine.” Ransom encourages Maryland physicians to contact him directly to discuss opportunities for involvement by emailing him at gransom@medchi.org. JANUARY/FEBRUARY 2012

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Good Deeds

Hopkins “Heart Hype” Promotes Early Detection of Cardiac Disease in Young Athletes

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By Tracy M. Fitzgerald

HEODORE ABRAHAM, M.D., associate professor of Medicine in the Division of Cardiology at Johns Hopkins Hospital, wants to make sure that young athletes realize that being healthy and in good shape does not necessary make them invincible. He wants them to be educated about a heart condition called ventricular hypertrophy, and the fact that it is the most common cause of sudden death among people under the age of 30. And perhaps most importantly, he is volunteering his time each year, to give young athletes an opportunity to be screened. Since 2006, Abraham has coordinated and led the “Johns Hopkins Heart Hype” program, inviting young athletes to be screened for hypertrophy, which causes the walls of a heart’s main pumping chamber to thicken and in some cases, fail. Since its inception, the annual event, typically held at Morgan State University in conjunction with the Maryland State High School Track and Field Championships, has given close to 1,000 young athletes an opportunity to detect a heart condition, or confirm the absence of one, in the most positive cases. “We saw a 17-year-old, two-sport athlete who was in great shape and had

According to Dr. Abraham, Heart Hype is Johns Hopkins’ largest community outreach effort and involves use of more than $2 million in equipment. The program’s impact on the public will expand significantly in 2012, with plans for the screening event to be offered during the National Junior Olympics Track and Field Championships, which will be held July 23 - 29 at Morgan State University’s Hughes Stadium. The event, expected to draw 6,000 to 8,000 high school athletes from across the country, will give Dr. Abraham and his team of volunteers an opportunity to change many lives.

“Our number one goal is to raise awareness and make sure that people know how important it is to be screened regularly, and to act immediately if they ever experience chest pains or other signs of a potential heart condition.” –Theodore Abraham, M.D.

no health issues or complaints, but just decided to participate since we were there,” said Dr. Abraham said. “We detected a significant issue and saw that his heart was functioning at a very low level, leading to treatment that could have saved his life or prevented a serious incident down the road.” 30 |

WWW.MDPHYSICIANMAG.COM

“Athletes are not aware of how prevalent this condition is, and neither are their parents,” said Dr. Abraham. “Our number one goal is to raise awareness and make sure that people know how important it is to be screened regularly, and to act immediately if they ever experience chest pains or other signs

of a potential heart condition.” With preparations already underway for the 2012 screening event, Dr. Abraham is actively searching for volunteers to help support the program and assure that as many young athletes as possible can participate. While clinical experts can help by reviewing EKGs and ultrasound results, additional volunteers can be utilized for registration and management of the overall process flow for each participant. “It’s very fulfilling to see teenagers come in to the event with a sincere desire to find out if they are okay,” said Dr. Abraham. “It is great to be able to give them that confirmation, or to steer them in the right direction for help, if they show early signs of heart disease.” Physicians and other members of the community that would like to support the event through volunteerism are encouraged to call 410-502-7974 for further information. Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us by contacting us via email at gooddeeds@mdphysicianmag.com.


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Maryland Physician Magazine Jan/Feb 2012