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M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

VOLUME 2: ISSUE 6 NOV/DEC 2012

PALLIATIVE MEDICINE & HOSPICE CARE: A BETTER END OF LIFE CAN ACCOUNTABLE CARE WORK FOR YOUR PRACTICE? PHYSICIAN AND CONGRESSMAN ANDY HARRIS

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Contents 16

VOLUME 2: ISSUE 6 NOV/DEC 2012

10

24

F E AT U R E S

10 A Better End of Life Palliative medicine and hospice care the right choice for many

16 Preventing Falls and Medication Complications in Seniors Simple measures in the office reduce risks

20 Accountable Care Organizations Can they work for your practice? D E PA R T M E N T S

Cases | 7 | Supporting Patient Spirituality Compliance | 9 |Healthcare Reform & Compliance with Department of Labor Mandates Living | 24 | Deep Creek Lake: A Winter Weather Lover’s Dream Come True Policy | 26 | Physicians in the Political Process: Congressman Andy Harris, M.D. Solutions | 29 | Essentials of an Accountable Care Organization Heritage | 30 | Dr. Bob’s Place Brings Comfort and Care to Kids with Terminal Illnesses

On the Cover: Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake.

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

I

FIRST BECAME AWARE OF THE POWER OF FACING DEATH AND GRIEF when my mother read Elisabeth Kubler-Ross’ book, On Death and Dying in the early ‘70s. I don’t remember why she was reading it but knowing my mother, it was a must read. My mother had tremendous intellectual curiosity and that time was a time of spiritual awaking and awareness for many. Kubler-Ross’ work revolutionized how providers took care of the terminally ill and our understanding of the grieving process. Her work continued to have a direct impact on my life years later when I grieved the loss of my mother and just a bit later, my sister. Because of the care delivered by incredibly caring hospice providers who personally touched my family with hospice care and grief counseling, I am forever inspired to share with others what hospice entails: a better end of life and a better understanding of the end of life. That now includes a newer concept of care for both the terminally and chronically ill, palliative care. The decision to focus on hospice care and palliative medicine as this issue’s cover story, A Better End of Life (page 10), is part of my personal mission. Hospice of the Chesapeake’s Chief Medical Officer Lou Lukas, M.D., says about palliative and hospice care, “When you give patients control, they usually decide what’s best for them and society.” The same applies to the goals of an Accountable Care Organization (ACO). The ACO model was hotly debated as part of healthcare reform, but many hospitals and doctors have moved to the model to receive financial incentives, achieve quality gains and reduce healthcare spending – all obtainable by engaging and empowering patients in their care and wellness. Maryland Physician Managing Editor Linda Harder presents a thorough review of the birth of ACOs in Maryland and the impact they hope to have on patient care (page 20). Medicine isn’t always about the most cutting-edge treatment or high tech equipment – often, providing simple comfort, common sense and a respect for spirituality can improve outcomes. Simple measures both in your practice and your patients’ homes outlined in our feature on geriatric care can greatly reduce risk of falls and medication complications for the senior members of your patient population. They may even prevent tragic consequences (page 16). Learning and understanding your patients’ most cherished beliefs will impact their care and perhaps even lead to a better understanding of yourself (see Cases page 7). With that message of spirituality and recognition of the holidays ahead, I wish you and yours a joyful and peaceful holiday season.

To life!

Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com 4 | WWW.MDPHYSICIANMAG.COM

EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine – Your Practice. Your Life.™ 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 $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any contact is strictly prohibited and protected by copyright 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 PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management 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

Supporting Patient Spirituality Pat Fosarelli, M.D., D.Min.

CASE: Al, a 56-year-old patient you’ve treated for years, has been diagnosed with advanced lung cancer. He chooses to do nothing about it because “It’s obviously God’s will that I die now.” Lyn, his wife, also your patient, believes that medical personnel and treatments are gifts from God; she wants Al to avail himself of all treatment options for which he qualifies. You are in a quandary, as your belief system does not correspond with either of theirs.

DISCUSSION In the recent past, concerns about spiritual matters rarely were brought to a physician’s attention; such matters were thought to be more properly in the purview of the chaplain or clergyperson. Both the Health Insurance Portability and Accountability Act (HIPAA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) include the need to assess patients’ religious or spiritual resources and their need for spiritual/religious care. We might be tempted to believe this is a responsibility of an institution rather than an individual. Yet, because physicians typically lead the medical teams that address these issues, they

should know what information is useful and how to obtain it, even if another team member actually collects the information. Further, many patients prefer to discuss these matters with their own physicians rather than with medical, nursing, or chaplaincy personnel whom they do not know. Religious beliefs can play a major role in how people live their lives and how they approach illness, dying, and death. For example, one religion holds that a certain procedure must never be done, while another holds that it can (or should) be done. Even people espousing the same religion might see its tenets differently. In this case, Al and Lyn are of the same religion, but Al sees illness as a punishment meted out by God, while Lyn sees medical personnel, procedures, and medications as God’s gifts which are to be used whenever possible. Although a physician’s religious beliefs might come into play if he or she is being asked to do something contrary to one of these beliefs, it is generally the patient’s beliefs that must be elucidated and explored vis-à-vis his or her condition and acceptable treatments. Because the patient is often in a vulnerable state, weakened by illness or mental anguish, insisting on a therapy that is clearly against his or her beliefs is usually counterproductive in getting the best outcome for the patient and family. Several screening tools have been used to sort out religious/spiritual beliefs that are of primary importance to a patient, especially when such beliefs have an impact on what therapies will be accepted. Although no screening tool is perfect, physicians should be aware of the most widely used tools. The American College of Physicians offered the ACP Spiritual History:1  Is faith (religion, spirituality) important to you in this illness?  Has faith been important to you at other times in your life?

 Do you have someone to talk to about spiritual matters?  Would you like to explore religious matters with someone? Puchalski et al developed the FICA Spiritual History: 2  F (faith) - What is your faith tradition?  I (importance) - How important is your faith to you?  C (community) - What is your community of faith?  A (apply) - How do your religious and spiritual beliefs apply to your health?  A (address) - How might we address your spiritual needs? The American Academy of Family Physicians offered the HOPE Spiritual Assessment: 3  H: Sources of hope, meaning, comfort, strength, peace, love, and connection  O: Organized religion  P: Personal spirituality and practices  E: Effects [of beliefs/practices] on medical care and end-of-life issues These questions can start important conversations, even if the physician does not personally provide the spiritual care. Learning about and respecting patients’ most cherished beliefs often has a transformative effect on members of the medical team, especially when patients are better understood. In addition, learning about what gives meaning to another person might bring some clarity as to what brings meaning to oneself. Pat Fosarelli, M.D., D.Min., is the associate dean of The Ecumenical Institute of Theology of St. Mary's Seminary & University in Roland Park. The Ecumenical Institute offers several master’s-level courses that explore the intersection of medicine and religion, spirituality and health. 1

Lo, Quill & Tulsky in Annals of Internal Medicine

130 (1999): 744-49. 2Puchalski & Romer in Journal of Palliative Medicine 3 (2000): 129-37 3

www.aafp.org/afp/2001/0101/p81.html NOVEMBER/DECEMBER 2012

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Compliance

Healthcare Reform & Compliance with Department of Labor Mandates By Jack Weidner, CLTC

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S WE APPROACH THE 2014 health insurance mandate, the principal element of healthcare reform (HCR), there continues to be more questions than answers for the various stakeholders involved. For practice leaders or employers, the next 15 months will provide time to evaluate your health insurance options and define your future liability. The evaluation process also will require paying attention to compliance with the U.S. Department of Labor (DOL) mandates. Employer size does matter in the evaluation process of defining your liability for 2014 and in defining what DOL mandates need to be addressed. Investing the time now to properly evaluate your options will pay off. The Presidential election outcome may bring a repeal of HCR, but the need to comply with DOL mandates will remain. The Law

In March 2010, the HCR bill was passed; implementation began September 23rd of the same year. Regulators intend to hire the equivalent of a military division of new IRS, Employee Benefits Security Administration (EBSA) & DOL auditors to ensure compliance with the new legislation and the dated Employee Retirement Income Security Act (ERISA) laws. That increased capacity to audit employers makes it essential to comply with DOL mandates. The following key compliance elements require attention:

Section 125 plans - if an employer is pre-taxing an employeeâ&#x20AC;&#x2122;s share of the medical insurance contributions, they should have a section 125 premium only plan (POP plan) document in place and the plan should be subjected to discrimination testing annually. Employers of any size are required to

have this document in place, yet most do not have a current document or complete the annual testing. Without a POP plan, the IRS could disallow all prior pretax medical insurance deductions taken. COBRA (20+ employees) or Maryland Continuation of Benefits (under 20 employees) - employers that sponsor health, dental and vision insurance benefits are required to offer terminating employees and their dependents the extension of coverage and may charge 102% of premium. There are strict notification rules and penalties for not complying. Outsourcing this requirement is advised; the cost is not prohibitive. As of September 23, 2012, employers are required to distribute a Summary of Benefits and Coverage (SBC) for most fully insured plans they sponsor to new enrollees and existing employees. The HCR-related mandate is designed to simplify communication materials for employees. The related insurance company is responsible for creating the plan-specific SBC, which must be distributed during the open enrollment period that falls after September 23 for participants and beneficiaries and the effective date of coverage for new enrollees. Employers must adhere to the rules for information distribution. Summary Plan Descriptions for all employer-sponsored plans must be available for employees, for companies of any size. Most insurance companies provide certificates of coverage or contracts of coverage to employers for distribution, but almost all lack the ERISA required elements of information to make them compliant. Providing a complete summary plan description is the responsibility of the employer. It is easy to have a third party create an ERISA â&#x20AC;&#x153;Wrapâ&#x20AC;? document that contains the

missing ERISA information, which satisfies the Summary Plan Description compliance requirement for each employer sponsored benefit plan. If an insurance plan change has been made since the plan has been in effect, the specific plan must have a written Summary of Material Modification (SMM) to document the change. Once the SMM is completed, it must be distributed to plan participants and beneficiaries. Annual reporting 5500 Form Filing for employers with over 100 full time employees, each employer sponsored plan must file a 5500. Filing a 5500 form is required for employer sponsored retirement plans irrespective of employee and plan asset size. Failure to have filed the appropriate 5500 forms could result in significant penalties from the IRS or DOL. Family Medical Leave Act (FMLA) an employer with more than 50 employees is required to comply with FMLA. Integrating payroll with the multiple data elements that require tracking under FMLA requirements has merit. With 15 months remaining to the implementation of healthcare reform and the insurance mandate, it makes sense to map your evaluation process. Take time now to assess your level of compliance with the DOL mandates. Given the increase in government auditing capacity, it is even more critical to audit your own practice or company. With the selfimposed DOL audit completed, you will be well positioned to focus on health plan design, cost and liability in the second half of 2013. Jack Weidner, CLTC, is managing member of Chartwell Benefits Solutions, LLC, a consulting firm specializing in the areas of group & individual health insurance, Medicare supplement, disability income, life & long term care protection.

NOVEMBER/DECEMBER 2012

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BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

A BETTER END OF LIFE PALLIATIVE MEDICINE AND HOSPICE ARE THE RIGHT CHOICE FOR MANY With more than 5000 hospice programs nationwide covering about 1.6 million people, perhaps health professionals should be more comfortable having end-of-life conversations with patients than they are. However, medical training is oriented to aggressive interventions to save patients, not ease their end of life, and these conversations are difficult to initiate. Maryland Physician interviewed hospice and palliative medicine physicians and other experts for some advice. 10 | WWW.MDPHYSICIANMAG.COM


W

e’re not taught how to have these conversations in medical school; in fact, we’re taught the opposite – to do everything we can,” laments Madai Chardon, M.D., associate medical director, Seasons Hospice & Palliative Care of Maryland. The number of people over age 85 has doubled in the last decade,” says Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake. “If we treat them like 60 year olds, we can do more harm than good by over-treating them.”

What is Hospice?

While awareness and understanding about hospice have grown, misconceptions persist. Even physicians may not fully understand what hospice entails – and many don’t understand the newer concept of palliative care (also called palliative medicine). Dr. Chardon notes, “A lot of physicians still have misconceptions about hospice and feel that we’re giving up on the patient. We’re definitely not. Our goal is to shift to more aggressive pain management. Hospice is a philosophical shift in the way we treat people. Frequent communication and understanding the person’s goals is key.” According to Dr. Lukas, “Hospice involves the entire family. We ask, ‘How do we add quality of whatever time this person has left? How do we make this time worth living? What is important to the patient, what are their goals? Then, what treatments will help reach those goals?’” “We’re a team,” says Sharlene Rajapakse, M.D., associate medical director, Seasons Hospice & Palliative Care of Maryland. “We deal with the spiritual, emotional and physical issues patients and their families have.” A superb way to bridge the gap

Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake

between cure-based care and hospice is palliative care (also called palliative medicine.) Don Schumacher, CEO of the National Hospice and Palliative Care Organization (NHPCO), says, “In the last 10 years, palliative care has become more popular. Physicians usually are more comfortable making a referral to this type of program and it can be a great bridge to hospice.”

What is Palliative Medicine?

Palliative medicine is specialized medical care for people with serious illnesses, whatever the diagnosis, to provide relief from symptoms, pain, and stress. In contrast to hospice care, it can be provided along with curative care. Hospice of the Chesapeake launched Chesapeake Palliative Medicine in 2012.

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to get new models of care, not new treatments,” Dr. Lukas adds. “When you give patients control, they usually decide on the treatment that’s best for them and for society. Palliative and hospice care are good for the patient and for the system.” Starting the Conversation with Your Patient

Sharlene Rajapakse, M.D. and Madai Chardon, M.D. associate medical directors, Seasons Hospice & Palliative Care.

“…physicians still have misconceptions about hospice and feel that we’re giving up on the patient.We’re definitely not.” – Madai Chardon, M.D.

12 | WWW.MDPHYSICIANMAG.COM

Sandra Anderson, communications director for Hospice of the Chesapeake, comments, “The choice used to be between care and cure. Palliative care is the bridge between those two.” “Both hospice and palliative care are really about comfort,” contributes Dr. Rajapakse. “Everything we do is to make people feel better.” When Should Palliative Medicine or Hospice Be Considered?

“Doctors are typically afraid of making the referral too early and then tend to overestimate survival by as much as five times, so it isn’t surprising that we tend to get patients very late in their illness when we have less time to be helpful. The best guide to the need for palliative care is what we call the ‘surprise question’ – would I be surprised if this patient died in the next year or two? If you wouldn’t be surprised, it is time to start the conversations!” Dr. Lukas exclaims. Physicians can request a palliative care consultation while the patient is in the hospital, or directly from their primary care practice. “Anytime a patient needs increasing management of their pain and symptoms, it’s time to ask for a palliative care consult,” says Mr. Schumacher. “It’s up to us as doctors, especially as primary care physicians – we need to rise to the occasion and advocate for patients

“Too often, it’s a ‘don’t ask, don’t tell game’ between the doctor and patient,” Dr. Lukas says. “Research has found repeatedly that an honest conversation creates a momentary anxiety but then anxiety diminishes.” Dr. Chardon concurs. “We physicians often don’t realize that the family wants us to be honest with them – most of the time, though, they’re waiting for us to initiate the conversation.” “An earlier conversation is far better,” contributes Mr. Schumacher. “Patients often ask why they weren’t referred earlier.” Our experts recommend that doctors ask the patient and family about their understanding of the patient’s illness. Dr. Lukas advises, “Ask them what they understand about the prognosis. What are their goals? What feelings are they having? Then discuss the options that they have.” Physicians don’t need to fear that hospice means the end of their relationship with the patient. “We don’t take patients from their doctors,” notes Dr. Lukas. “In fact, we love to have them involved because they know the patient better than we do. They can choose to participate or not.” NHPCO’s Caring Connections at www.caringconnections.org offers free, downloadable brochures that can help physicians begin discussions with their patients and families. Not Just for Cancer Patients

While most people think of cancer patients when thinking of hospice, the reality is that only about half of patients in hospice have a cancer diagnosis. The range of other appropriate diagnoses is vast, spanning a number of chronic diseases in their terminal stages, including cardiac and pulmonary diagnoses such as COPD, and medical frailty with or without dementia. “Parkinson’s, Amyotrophic Lateral Sclerosis (ALS) or any chronic disease


can be appropriate for hospice,” Dr. Chardon notes. Dr. Rajapakse agrees. “We forget that many other patients besides those with cancer may benefit from hospice.” Open Access – Controversial

Yet a third option for some patients is Open Access, a concept that is still controversial among those in the field. “Seasons Hospice started this in Chicago more than a decade ago,” says Dr. Rajapakse. “It’s a bridge between aggressive treatment and hospice care. If a blood transfusion offers a better quality of life, it might be performed. Open Access may help to get patients on hospice sooner; it’s tailored to each patient.” Reimbursement

Palliative medicine is reimbursed through Part B Medicare or private

insurance, comparable to billing for other physician services. By contrast, Medicare reimburses hospice agencies on a per diem basis for all non-physician care. The per diem fee covers medications, chaplain and counseling services, nursing, home health aides and much more. Private insurance is more variable, but many insurers model their hospice coverage after Medicare. Selecting a Hospice

Maryland is fortunate to have a wealth of hospice programs to choose from, with more than 20 programs across the state, many of which serve multiple counties. Dr. Chardon comments, “That increases the quality of care. Look for support, availability, and services offered. It’s a similar process to choosing a physician.” Hospice and palliative care play an important role at the end of life, perhaps

most comparable to anticipatory guidance provided for expectant mothers and newborns. Dr. Lukas concludes, “It takes as much planning to make the end of life go well as it does to make the beginning of life go well.”

Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake Madai Chardon, M.D., and Sharlene Rajapakse, M.D., associate medical directors, Seasons Hospice & Palliative Care Don Schumacher, CEO, National Hospice and Palliative Care Organization Sandra Anderson, communications director, Hospice of the Chesapeake Martha O’Herlihy, retired R.N. and founder, Hospice of the Chesapeake

Hospice of the Chesapeake 35 Years of Innovative End-of-Life Care

H

Hospice of the Chesapeake originated in 1977 from the efforts of a small group of volunteers who saw the need to help those who were terminally ill. After hearing Dr. Elisabeth Kubler-Ross speak at Hopkins, the group was empowered to seek to provide hospice care locally. The group met for about a year before their labors paid off, and the first patient was seen in 1979. Martha O’Herlihy, a R.N., and her husband, Hilary O’Herlihy, M.D., were among those founding pioneers. Ms. O’Herlihy recalls, “It was a massive education task. Fran Grauch did all of the administrative work, and she, my husband and I spent hours educating physicians. My husband was instrumental in getting physicians to volunteer on our patient care team. Since doctors were trained to cure, many got upset about their patients dying. One of the wonderful things was that, as volunteers, we were pioneers and could

spend as much time as we wanted with patients and their families.” Ms. O’Herlihy remembers one family where the nine children were fighting over who was spending more time with their dying mother. “Hospice of the Chesapeake intervened to help the family realize that they needed to decrease the tension in the family and accept their mother’s wish to die without more interventions. They finally came to accept her death,” she says. Over the years, Hospice of the Chesapeake grew into a major organization with a host of residential and outpatient services, including the Tate House, Anne Arundel County's first in-patient hospice facility, and the Mandrin Inpatient Care Center. The Life Center (TLC) provides grief counseling, support groups and education for patients and their families. It even operates two weekend camps for grieving children and teens. “Today, we have bereavement teams that include

social workers, volunteers and pastoral care. Someone from the bereavement team may visit before death upon request of the social worker; at the time of death the nurse gives information about TLC,” says Ms. O’Herlihy. The hospice has an even more ambitious future. “We’re at a pivotal point in our history,” notes Sandra Anderson. “We’re launching a new vision that includes research and physician education. We have a group of patients at the end of their life that can help us expand our knowledge of what works best. We can provide a classroom for doctors who want to specialize in this area. We’re also seeking to build a new facility with over 20 beds. It’s more conducive to caring for those at end-oflife than a typical hospital unit.” All of these programs and facilities remain focused on the organization’s original mission. As Ms. O’Herlihy concludes, “Hospice is about living the best life you can until death occurs.”

NOVEMBER/DECEMBER 2012

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PREVENTING FALLS AND MEDICATION COMPLICATIONS IN SENIORS Simple measures in the office reduce risks 16 | WWW.MDPHYSICIANMAG.COM

Colleen Christmas, M.D., geriatrician and associate professor of medicine at Johns Hopkins Bayview Medical Center,


BY LINDA HARDER PHOTOG RAPHY BY TRACEY BROWN

MINIMIZE MEDICATION PROBLEMS

Seniors face myriad health issues, but perhaps one of the worst is that they are often sick from the very medications that are prescribed to get them well. While seniors comprise about 12% of the U.S. population, they consume roughly 35% of prescription drugs and an astonishing 50% of over-the-counter (OTC) products. Given that the elderly are more likely to be taking multiple medications –frequently 6 to 12 – some of which may combine to create adverse reactions, it’s not surprising that they are most prone to disaster. Colleen Christmas, M.D., geriatrician and associate professor of medicine at Johns Hopkins Bayview Medical Center, notes that doctors could do more to address this issue. “Numerous studies show that physicians often neglect to ask the elderly what other medications they’re taking. And lots of providers don’t talk to each other.” She continues, “As a geriatrician, I’ve improved the health of far more people by stopping pills than by starting them. A huge number of people are over-medicated.” Dr. Christmas advises the following actions for primary care physicians to help ameliorate these problems: > Communicate with other providers about what medications they have prescribed.

Communication among providers helps reduce adverse reactions. > Empower patients and their families.

They are the ones who are connecting with all of the providers. “I always print out the full list of medications at the end of the visit and have the patient or family member double check at home to make sure they don’t have other pills beyond this list,” Dr. Christmas states. > Have patients bring all of their pills, including OTC pills, to their visit and take

I’ve improved the health of far more people by stopping pills than by starting them. – Colleen Christmas, M.D.

time to thoughtfully review them.

“I review my patients’ pills every single visit,” notes Dr. Christmas. “I understand the time pressure but we can’t afford not to do it. It has to take priority. It’s fine to use a nurse practitioner or other skilled staff for this purpose, but it should be done.” Patients often take large quantities of OTCs, assuming they’re safe because they don’t need a prescription for them. “Patients sometimes take fistfuls of ibuprofen and other NSAIDs,” Dr. Christmas laments. > Make sure the patient’s chart is up to date with the correct list of medications. > Ensure that any new medication you prescribe does not interact negatively with the patient’s other medications.

Dr. Christmas notes, “Warfarin and other blood thinners send many people to the ER. Antibiotics are perhaps the most frequent class of drugs that adversely interact with these. A patient may start with a cough, then suddenly their INR is 8 and they have a nosebleed.” > Generally avoid prescribing any medication new to the market.

“Newer medications are often not adequately tested, especially in elderly populations who have multiple diseases,” Dr. Christmas observes. “Some 10% of

new drugs are later withdrawn and they are often tested in healthy people with only one disease. New drugs in old people are simply a bad idea.” > Encourage patients to use only one pharmacy.

“At times, I’ve been grateful when a pharmacist called to double check a prescription I wrote,” recalls Dr. Christmas. “They are another set of eyes to review the medications prescribed.” Mail order pharmaceuticals can make that kind of oversight more challenging, but they offer convenience and cost savings for patients. “I’ve found these companies may send notices but they’re not always on target, she adds.” > Employ technology to promote medication safety.

Dr. Christmas comments, “Our EHR flags drug interactions. Most of the time, I was already aware of it, but in a small percentage of cases, it was helpful.” > Exhaust all non-drug methods to improve health, and then start with the lowest possible dose. > Determine if any current medications can be discontinued.

“I always ask myself if there’s a pill I can stop prescribing,” Dr. Christmas declares. > Prescribe the simplest medication regimen possible

“Physicians have to be practical – we can’t prescribe complex regimens,” advises Dr. Christmas. If the best time to take a medication is at night, but the patient can better remember to take it in the morning, determine if that could work. Using pillboxes, including newer ones with alarms that go off if medications aren’t taken, can help. And of course, the best resource of all is another person.” NOVEMBER/DECEMBER 2012

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Vitamin D, PT Prevent Falls

George Hennawi, M.D., geriatrician and director of Geriatrics at MedStar Good Samaritan Hospital.

…everyone over age 65 [should] be asked at least yearly, ‘Have you fallen in the past year?

period had 16% fewer fall-related hip fractures in the year following their surgery. However, this and other studies suggest that the risk of hip fractures may actually increase after one cataract is removed, perhaps due to impaired depth perception or wearing an older glasses prescription.

– George Hennawi, M.D.

Simple Fall Prevention Measures in the Office ASSESSING AND PREVENTING FALLS

The health statistics associated with seniors who fall are appalling. Each year, 30 to 40% of those over 65 who are still in the community fall, while about half of those in an institution fall. After elderly people have fallen, they have a 65% risk of falling again. Some 15% of falls lead to hip fractures, and 40% of those suffering these fractures will die within one year. Once hospitalized with a broken hip, it’s difficult to get patients up and moving again, prevent risks such as blood clots, confusion, pressure ulcers and infectious diseases, and overcome the fear of falling again. Finally, falls are also one of the leading causes of death from injury in this age group. Assessing and preventing falls, therefore, is key to keeping elderly people healthy. Yet the problem is multifactorial; falls can be the result of adverse medication reactions, vision loss, musculoskeletal weakness or arthritis, balance loss or even environmental factors such as poor lighting or loose throw rugs. A large study published August 1, 2012 in the Journal of the American Medical Association found that those who had cataract surgery during the study 18 | WWW.MDPHYSICIANMAG.COM

Even within the limits of the primary care office visit, physicians can prevent many falls with a simple question and test, believes George Hennawi, M.D., geriatrician and director of geriatrics at MedStar Good Samaritan Hospital. “He states, “I recommend that everyone over age 65 be asked at least yearly, ‘Have you fallen in the past year?’ If they fell, ask about the circumstances of the fall, whether they tripped, and if they fell more than once.” ‘Get Up and Go’ Test

Dr. Hennawi also recommends performing a simple ‘Get Up and Go’ test. “Using a stop watch, ask them to get up without using an armrest, walk 10 feet and come back. Evaluate their gait – a shuffling gait could indicate Parkinson’s Disease, limping could be indicative of arthritis, listing to one side could suggest a neurological disease and so on. Less than 10 seconds is the norm; in the frail elderly, 11 to 20 seconds is more usual. Anything longer than 14 seconds indicates a heightened risk of falling. If there is a major gait disturbance, or they have had more than one fall in the past year, they should be referred to a physical therapist (PT) or geriatrician.”

According to the U.S. Preventive Services Task Force, Vitamin D and PT are the only two factors that have been proven to prevent falls. “This group tends to be conservative,” acknowledges Dr. Hennawi. PT can improve balance, endurance, strength and range of motion as needed to reduce the risk of a fall. It has been shown that most falls happen between patients’ beds and their bathrooms. Modifying environmental factors, such as installing nightlights or other easy-to-access lights, limiting the need to climb stairs, installing grab bars and removing throw rugs or anything that can be tripped on are common-sense ways to reduce these falls. The role of primary care physicians in fall prevention may grow, as access to a geriatrician is likely to get more limited as the population ages. Dr. Hennawi says, “Some 16 to 17% of the population is projected to be over age 65 by 2020 – and there aren’t enough geriatric medical training programs to keep up with the demand. “When you realize how much damage a fall causes, you realize the issue warrants more attention than it currently gets,” Dr. Hennawi notes. “Even if there is no fracture, patients are at increased risk for a decline in functional status and a possible institutionalization. They become afraid of falling again so they become less mobile. It sets off a negative sequelae of events. Most at risk are those who have suffered ‘a long lie’ – those who fell down and were unable to get themselves up without assistance. It’s a major predictor of decline.” “I’m starting up a multi-disciplinary falls prevention program involving PTs at both MedStar Good Samaritan and MedStar Union Memorial,” he concludes. “We still don’t know how much PT is necessary, who qualifies, and how often, and for how long. That’s where the future is.”

Colleen Christmas, M.D., associate professor of medicine and program director, Internal Medicine Residency George Hennawi, M.D., director of Geriatrics, MedStar Good Samaritan Hospital; assistant clinical professor, University of Maryland School of Medicine; medical director, Geriatric Unit, MedStar Union Memorial Hospital


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Healthcare IT

ACO ACCOUNTABLE CARE ORGANIZATIONS

 Can they work for your practice? BY LINDA HARDER PHOTOG RAPHY BY TRACEY BROWN

Maryland Physician interviewed physicians and health administrators to understand how ACOs are evolving in Maryland and what impact they hope to have on patient care.

20 | WWW.MDPHYSICIANMAG.COM


An Accountable Care Organization (ACO) is a major undertaking, on first blush appropriate only for those in large groups or health systems in urban areas. However, physicians in small practices and rural areas can also participate in some ACOs. Most ACOs are starting as part of the Medicare Shared Savings Program created under the Affordable Care Act (ACA), yet future models will apply the ACO approach to privately insured patient populations. ACOs are designed to encourage physicians and other healthcare providers to come together to coordinate patient care with shared data and infrastructure, for a fixed cost. Requirements for Medicare ACOs include having a minimum of 5000 Medicare beneficiaries (existing Medicare patients do not opt in or out of the program, but can opt out of sharing their historical data) and reporting on 23 of 33 total quality metrics (other metrics are provided by surveys and other data). Maryland ACOs As Maryland Physician went to press, out of 154 ACOs in 37 states, the Medicare Shared Savings had approved four Maryland ACOs:

Robin Motter, D.O., chairman, Family Practice (GBMC)/ family practitioner (GBMC at Hunt Valley), member of the GBHA Board of Directors

 Greater Baltimore Health Alliance Physicians LLC (GBHAP)  Accountable Care Coalition of Maryland LLC, in Southern Maryland (ACC of MD)  Maryland Accountable Care Organization of Eastern Shore LLC  Maryland Accountable Care Organization of Western MD LLC At least five other Maryland ACOs have filed for approval in January 2013. These ACOs are taking different approaches to their administration and financing. One is financed and administered by an arm of its hospital partner, GBMC. Med Chi assisted the other three ACOs, two of which are smaller, rural ACOs that were approved under the Advanced Payment Model; the third (ACC of MD) partnered with Collaborative Health Systems, a subsidiary of Universal American. Hospital-Affiliated Model: GBHAP GBMC is the first hospital in Maryland to partner with physicians to create an ACO through its affiliate, Greater Baltimore Health Alliance Physicians, LLC (GBHAP). Colin Ward, GBHAP’s executive director, says, “It has taken two

years to go from concept to fruition; one year was spent consulting with lawyers and other consultants to put the structure in place and file for approval.” This ACO has about 10,000 beneficiaries and 100 participating providers, including nurse practitioners (NPs) and some specialists, some of which are employed and others of which are aligned. “An ACO has a similar concept to a Patient Centered Medical Home, (PCMH)” says Robin Motter, D.O., a participating family practitioner and member of GBHAP’s board. “In March 2012, we received Level 3 recognition from NCQA. We participated in Carefirst Blue Cross Blue Shield’s PCMH, which provided a foundation for the ACO because its metrics are very similar.” The first wave of practice changes was launched as part of the PCMH, with care managers and enhanced IT to monitor care. Diabetic care had already become more rigorous, with greater emphasis on patient education and monitoring. Additional changes in the brief months that the ACO has been operating include leaving 30% of the schedule open for same-day appointments to take care of urgent issues. Mr. Ward also notes, “Transition guides are now in place at GBMC to follow congestive heart failure patients and get them back to the physicians.” “My referral patterns to specialists also may change once I see outcomes data,” Dr. Motter adds. Many practices in GBHAP use eClinicalWorks (EHR vendor), though it’s not required. The ACO is a design partner for the vendor, which involves helping the vendor select relevant clinical data for other ACOs as well as their own. They are also in a pilot program with CRISP to provide real-time notification of hospitalization, so that patients discharged from the hospital have the opportunity to be seen in the physician’s office within 48 hours. GBHAP had to submit a list of tax IDs for all participating physicians. That list will likely remain stable over the three years of the pilot to avoid impacting benchmark data. “We’re sending out letters that the practice and their doctors NOVEMBER/DECEMBER 2012

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Healthcare IT are participating in the Medicare Share Savings program,” notes Mr. Ward. “The aggregated claims data of patients of participating physicians is automatically shared, except for any patients who opt out of having their information reported.” GBHAP chose Medicare’s singlesided payment model, which provides fee-for-service payments plus the opportunity to share in a percent of any savings at the end of each year. This model provides the group with less potential upside than the two-sided model, but no downside risk. Advance Payment Model for Small, Rural Practices In November 2011, the CMS Center for Medicare and Medicaid Innovation also created a competitive Advance Payment Model that will allow up to 50 rural ACOs to receive advanced compensation without any downsized risk. The risk-free advance ($250,000 plus $36 times the number of beneficiaries) is paid off from a

management agreement to provide care coordination and other services. Services must be tailored to each ACO due to community differences; in Garrett County, most practices are close to the hospital, whereas in Easton, they are more spread out. On the IT side, we’re currently demoing a number of systems that can provide both the care management system and the interface engine to gather and analyze data. Very few systems are good at both. “Having PCMH experience helps; an ACO is a logical extension of that,” he continues. “We’re using the ACO to pilot exciting new things such as telehealth and after-hours support that rotates among practices. Patients will receive preventive health reminders and coordination across care settings, among other advantages. ACOs provide smart care coordination with secure, real-time data utilization.” “ACOs differ from HMOs in several key ways,” adds Mr. Behm. “First, the

Our goal is to provide care we’d want for a member of our own family. Better managing patient care gives your job the meaning you sought when you went to medical school. – Robin Motter, M.D.

portion of any savings at the end of each of three years. Physicians in this model also receive $8/month/beneficiary to help offset the costs of coordinating care and enhancing data. These ACOs must meet criteria that include having no health system/insurer involvement, having a sufficient number of Medicaid beneficiaries and rural providers, and a quality spend plan. As soon as MedChi saw the regulations, they jumped at the opportunity to assist physicians in this type of practice. Two ACOS affiliated with MedChi Network Services – Maryland Accountable Care Organization of Eastern Shore LLC (15 physicians) and Maryland Accountable Care Organization of Western MD LLC (23 physicians) – were approved in July, and two more hope to receive approval in January 2013. Craig Behm, executive director of MedChi Network Services, explains, “We own the legal entity designated as each ACO and intend to work with the participating practices to enter into a 22 | WWW.MDPHYSICIANMAG.COM

quality metrics are clearly defined. Second, they are physician-led and oriented towards patients. Third, there is no in-network requirement and fourth, there is increased health IT and data capability.” Accountable Care Coalition of MD – Partnering with a National Firm

Accountable Care Coalition of Maryland LLC (ACC of MD) in Hollywood is a partnership between a national ACO administrative company, Collaborative Health Systems (CHS) (operating 16 ACOs in total as of July 2012), and area group practices that include 109 physicians. It will serve more than 11,000 Medicare beneficiaries in St. Mary’s County and Southern Maryland. CHS and the physician group each own half of the new entity, ACC of MD, that contracts with CMS and care providers. It functions like a management services organization. Nayan Shah, M.D., medical director, Shah Associates MD LLC, the large

multi-specialty practice providing much of the ACO’s care, states, “The ACO model appealed to us immensely. It makes providers accountable to patients. Especially the elderly, who have multiple medical problems and get fragmented care from multiple specialists.” “An ACO requires good IT infrastructure,” contributes Vicky Parikh, M.D. MPH, executive director, Reliance Health, “plus good care managers who understand the patient’s social and economic needs. They make sure the patient goes to their primary care physician and specialists as needed and takes their medications. Studies have shown that if the patient is seen within two to three days after discharge, they do much better.” Dr. Shah concludes, “As participants in both the state and Carefirst PCMHs, we already had care management experience, but we didn’t have good IT or financial resources. CHS has helped us achieve our goal.” Jim Korry, senior VP of network operations at CHS, comments, “We have 15 years of experience with Medicare and have operated many Medicare Advantage plans where we were at risk, so we have experience with care coordination, infrastructure and compliance. However, there are major differences, too. We are setting up full partnerships with doctors. Our mantra is that we’re the backbone – we provide the infrastructure, resources and information, so the doctors can provide the best care possible.” He continues, “We promote the use of EHRs for participating practices but it’s not required. Universal American has a relationship with NextGen, which practices can take advantage of if they wish. We’re being approached by a number of consultants and vendors that want to partner with us. In the future, as we track our results, I expect we’ll be in dialogue with specialists and hospitals.” The challenges of launching an ACO, even with a partner, are tremendous. They typically require one to four million dollars of capital investment, to pay for developing a complex IT infrastructure, hiring and managing care managers, etc. However, the physicians participating in the ACO have no financial risk to join. “It takes 14 to 15 months to see any money from CMS,” says Dr. Shah. “And if savings do not occur, you need to invest yet more dollars in the second year.”


The Future: Taking the ACO Concept to the Employer Market Beyond Medicare, a future ACO model also awaits commercially insured patients. Stuart Sutley, chief strategy officer of Allegeant, a mid-Atlantic company focusing on accountable care solutions for employers, says, “Hospitals that have employed us to execute integrated health management programs for their own organization are now asking us to help them take the same concept to the employer market by using ACO fundamentals to develop new revenue opportunities and manage health to better outcomes.” Starting with the premise that more than three quarters of chronic disease is lifestyle-related, Allegeant has worked with hospitals and other employers to improve the health of employees and dependents and reduce healthcare utilization, using strong data analytics and innovative wellness initiatives. “We typically capture daily or monthly claims and pharmacy feeds for self-insured employers. We can, over time, develop a snapshot of the member’s health and deliver it to their doctor if that doctor (or practice) is aligned with our hospital client,” explains Mr. Sutley. “That frees up physicians to use the patient visit for more in-depth health discussions.” Mr. Sutley adds, “We need to start looking at how to treat patients that are still working. We see doctors interested in aligning themselves with employers. Employers are incentivizing their employees to utilize providers that manage health and save costs. What

Stuart Sutley, chief strategy officer of Allegeant, LLC

to build foot traffic and make hospitals a destination of choice versus a destination of need. Joining an ACO It’s not too late for unaffiliated physicians to sign up with an existing ACO, but after January 2013, they can only do so on an annual basis. ACO requirements have become less onerous as CMS responded to provider concerns. “CMS made ACOs more physician and provider friendly since they first issued the regulations,” Dr. Shah says. “Many physicians have a negative idea of ACOs from the old regs, but it’s

An ACO requires good IT infrastructure, plus good care managers who understand the patient’s social and economic needs.

Robin Motter, D.O., chairman, Family Practice (GBMC)/family practitioner (GBMC at Hunt Valley), member of the GBHA Board of Directors Colin Ward, executive director, Greater Baltimore Health Alliance Craig Behm, executive director, MedChi Network Services Nayan Shah, M.D., medical director, Shah Associates MD LLC, and president, Reliance Health Vicky Parikh, M.D. MPH, executive director, Reliance Health Jim Korry, senior VP of network operations at Collaborative Health Systems (CHS), the ACO partner with Shah Associates. Stuart Sutley, chief strategy officer, Allegeant, LLC

– Vicky Parikh, M.D.

doctors like is that they’re getting an incentivized patient who is more likely to comply with their advice.” Patients are then at risk to incur more healthcare insurance costs if they don’t follow the doctor’s recommendation. Allegeant has contracts with several Maryland and out-of-state hospitals to build and launch hospital-branded wellness programs aligned with primary care physicians to take to the community

worth looking at now. Structured properly, they will decrease the burden on the primary care physician. “ Dr. Motter concludes, “Our goal is to provide care we’d want for a member of our own family. Better managing patient care gives your job the meaning you sought when you went to medical school. The system we had was not right and does not work – we have to do something different.” NOVEMBER/DECEMBER 2012

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Living

Deep Creek Lake: A Winter Weather Lover’s Dream Come True GARRETT COUNTY CHAMBER OF COMMERCE: CREDE CALHOUN, VISION QUEST STUDIOS

By Tracy M. Fitzgerald

Wisp Resort is Maryland’s only ski resort, featuring 32 slopes and trails for skiing and snowboarding, as well as designated areas for ice skating, snow tubing, snowmobiling and more.

S

OME PEOPLE FIND THEMselves booking trips to Alaska, Iceland or other frigid destination points around the globe, in search of the most “serious” winter weather escapes and adventures. Each year, an estimated 1.1 million others simply go to Deep Creek Lake. Nestled in Garrett County, Maryland, the four-season resort town has earned its place on the map of “hot spots” that are known to get quite cold. In fact, according to data from the U.S. Census

24 | WWW.MDPHYSICIANMAG.COM

Bureau, daily temperatures in the area are typically 10 to 15 degrees cooler than what are recorded in the surrounding metropolitan areas, and the average annual snowfall of 120 inches is just about double that of what residents and visitors of Fairbanks, Alaska see in a given year. Bottom line: during the winter months, it’s COLD. And with that, comes a wealth of opportunities to see, do and explore a one-of-a-kind winter wonderful that offers something for everyone of all


ages and interests. Best of all, the white fluffy stuff that slows or even closes towns elsewhere, is the very thing that keeps the Deep Creek Lake area alive and thriving. “Nothing stops here when it snows 18 inches,” said Nicole Christian, president and CEO of the Garrett County Chamber of Commerce. “If people can’t drive, they use a snowmobile to get around. It’s one of the few places where ‘winter blues’ don’t happen!” Let there be snow!

Skiers and snowboarders need not look any further for the best place to go than Wisp Resort, featuring 32 slopes and trails across 132 acres of skiable terrain, covered with snow naturally or through use of a snowmaking system that is recognized as one of the most efficient in the world. Those looking for a spot to lace up their skates will find Garrett County’s only ice rink at Wisp, and when it’s time to give those legs a rest, resort visitors are often found meandering toward Bear Claw Snow Tubing Park, featuring two conveyor belts that lug snow lovers to the top of a hill, for their next whirl back down to the bottom of the mountain, in the comfort of their tube. Snowmobiling is another popular attraction at Wisp, with guided tours available on private trails for adults and children. “Adventure enthusiasts who like to be outside when it’s cold will find every activity they could possibly desire here,” said Christian. No white stuff required

No snow? No problem. There are plenty of other activities available to keep you busy and entertained during

Coaster, with tracks that run overtop the ski trails, giving riders a 1,300 foot view of Deep Creek Lake in the distance as their two-seater cart ascends up Wisp Mountain. At the top of the resort, don’t miss the opportunity to visit Adventure Sports Center International, a “white water on demand” facility that features a re-circulating white water course with adjustable levels of difficulty, based on each person’s experience and skill. The less adventurous folks will not feel disappointed at Deep Creek, either, with horse-drawn carriage rides offered for couples and families in search of peaceful and relaxing tours of town, and dogsled rides available for those craving a faster-paced, one-in-a-lifetime kind of experience. Staying in, staying active

Looking for a bit of indoor fitness and activity? Check out Garrett County’s new Community Aquatic and Recreation Center (CARC), open to the public and offering competition and recreational swimming pools, basketball courts, and scuba, kayaking and canoeing learning programs. Families and especially those with little ones in tow will want to make time for a visit to the Deep Creek Lake Discovery Center, an interactive nature center with educational exhibits and activities for all ages. Historical sites to see

While most people visit Deep Creek Lake with a vision to spend a good portion of their time in the great outdoors, others come to tour the town’s museums and historical sites, including the Oakland B&O Railroad Museum and

“Nothing stops here when it snows 18 inches. If people can’t drive, they use a snowmobile to get around. It’s one of the few places where ‘winter blues’ don’t happen!” – Nicole Christian, President and CEO, Garrett County Chamber of Commerce

Deep Creek’s winter months. Sign up for Wisp’s Flying Squirrel Canopy Tour, a challenging zip line course that will teach you how to break, steer and zip along tree-top cable lines. Hop onboard the resort’s famous Mountain

the Garrett County Historical Society Transportation Museum, both featuring various transportation artifacts and displays. Anyone wishing to dig deep into their family’s genealogical history should visit the Friend Family Association’s

Skiing is a favorite activity for many visitors to the Deep Creek Lake area, with downhill trails available at Wisp Resort and cross country options available through many of Garrett County’s 10 state parks and forests.

National Heritage Museum, known for its second-floor library that is packed with ancestral data. The Grantsville Museum, housed in the town’s former library, is a good spot to stop for a peek at the work of renowned photographer Leo Beachy, as well a display of local historical artifacts from Garrett County. Kick back and relax

Deep Creek Lake is known for its cozy accommodations, with bed and breakfasts, cottages, cabins and lodges, and luxury vacation home rentals available to suit every budget and style. Fireplaces are common, making it easy to snuggle up with a good book and cup of hot cocoa after a long, but fun-filled day out in the cold. Looking for some additional pampering? Schedule a massage or spa service in one of the area’s eight salons, go on a wine tasting or tour or just throw on some comfortable clothes and plan to catch a movie at the town theater. Plan your trip

The Garrett County Chamber of Commerce makes planning a visit to Deep Creek Lake easy. Visit www.visitdeepcreek.com for guidance and information on local accommodations, dining, activities and attractions, events and more. NOVEMBER/DECEMBER 2012

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Policy

TRACEY BROWN

Physicians in the Political Process: Maryland Congressman Andy Harris, M.D. advocate in the legislature. But because the legislature has gotten so involved, part of taking care of patients now is making your views heard in the legislature. Along with being involved in specialty societies, take time off to make your views known to the people whose policies will have incredible effects on your practice.

Q:

Have you seen an increase in activism by physicians?

Congressman Andy Harris, M.D.

Maryland Physician Publisher/Executive Editor Jacquie Roth and Managing Editor Linda Harder recently interviewed Congressman Andy Harris, M.D., (R), a practicing anesthesiologist committed to healthcare issues.

Q:

When in your career did you decide to become proactively involved in politics?

I’ve always been interested in politics because my parents are both refugees. My father spent several years in the Soviet Gulag for being anticommunist and experienced a political system out of control, so they understood the importance of being involved. In 1998, I was on the faculty at Hopkins and involved with my state anesthesiology association and realized that an opportunity existed to get into elected office. I ran, and served for 12 years in the Maryland State Senate.

Q:

What are your priorities as a physician in Congress?

As government becomes more involved 26 | WWW.MDPHYSICIANMAG.COM

in the process, we actually have a decline in quality and access to healthcare. As Medicare policy becomes more cumbersome, access is decreasing… because the government’s response to a budget crisis is always to decrease payments to providers. It’s what I call back-door rationing. You can see a physician, but you have to wait in line long enough. We know that Medicaid is in the same situation, that only 42% of specialists will see a Medicaid patient. That’s not a system we ought to promote and progress to.

Q:

What are your suggestions to get Maryland physicians to take a more active role?

They just have to get involved. We don’t go to medical school to learn how to

Overall, nationally, more physicians are ‘getting it’ – that you really do have to be involved. Medical schools now frequently include courses in advocacy. The system is kind of stacked against patients because they don’t have time to go and express their opinions to legislators. Insurers or legislators can’t be their advocates because balancing a budget is almost diametrically opposed to guaranteeing access. When I was in the legislature, every year when the budget was deficient, they would pick a provider class and decrease payments to them. The end result is that, if you have a Medicaid card in Maryland, you almost can’t go to the physician of your choice and you’ll end up in a managed care panel. We should do better.

Q:

How do you stay in touch with physicians and what they need?

I’m still active in the national anesthesiology society and still maintain my license. Ten days a year, I’m in a hospital with my colleagues. I’m also invited to societies around the country to address the issues, so I’m frequently in touch with physicians. Recently, I was in Texas addressing and listening to the concerns of their medical society. They have huge drug shortages that are really beginning to impact care. One of the causes of the shortages is that the regulatory environment is so


unfavorable for drug manufacturers. When the new FDA ratcheted up the regulatory warnings, and there were three to four times as many warnings in its first year, companies decided to stop production. We effectively restrict what companies can charge, through a variety of schemes that include what the federal government will pay. When you make it economically unfavorable to make a drug, usually generic drugs, companies stop making them. Take epinephrine, we have shortages of this very inexpensive drug because companies don’t think they can make enough money on it. As government has gotten more involved, and not being willing to restrict tort, you have the logical conclusion that the company decides to make something else. I think there’s a bright future for biomedical research and pharmaceutical innovation. But we have to be mindful of the fact that when you place a 2% tax on medical technology, you get less medical technology. That’s one of things that the ACA [Affordable Care Act] taxed. It’s an interesting policy judgment.

guaranteed health insurance. You have to go to the Maryland Insurance Commission site. I supported that concept when I was in the state legislature, because insurance fails when someone is uninsurable. I think that 35 states already have high-risk pools; we just need to incentivize the other ones. The other thing is, I think we should require all insurers to offer a policy for children up to age 25. However, I believe

“I believe that, in general, state solutions work better than a centrally imposed federal solution.” that, in general, state solutions work better than a centrally imposed federal solution… If a state is not doing a good job, the federal government can incentivize them to. We can do it through the states without a single, one-size-fits-all mandate. In Massachusetts, for example, they decided they want universal coverage and that’s fine. But to impose their system on another state where people don’t feel quite the same, that’s not the way the country should be set up.

Q:

Q:

The moral question is whether we should do stem cell research with your own cells or with embryonic cells from someone else. Since, in the long run, the solution is going to be using your own cells… are we losing opportunities if we look at [using embryonic cells]? Embryonic cells are totipotent because they can become any organ... We need to get other cells back to the stage where we can turn their genes on and off. I’m convinced we’ll be able to do that. So to me, that’s where the focus should have been because there’s so much controversy the other way... We’re just not smart enough to figure it out how to do it yet.

The problem is that, whenever you put healthcare in the federal government and they have a budget problem, they cut payments to providers. This is what happened with SGR. When they ran out of money, they decided to automatically cut payments to providers and it’s accumulated over time… It’s a real quandary. We will never cut that reimbursement rate and we shouldn’t. Seniors understand what the result of that will be – that their physician will no longer be able to afford to see them. Congress did what it’s famous for – kick the can down the road and the cliff gets steeper and steeper. The 10-year cost of fixing SGR is over $300 billion. We have many competing demands for that money. The best we’re going to get right now is a solution one year at a time. H.R. 5707 proposes to use the savings we get by not spending money in Iraq and Afghanistan… but it’s not real dollars, so this bill doesn’t get to the core of the problem. As a society, we have to decide what level of care we’re going to provide to our seniors and how to make it solvent.

Maryland is actively involved in stem cell research, with support from the 2006 Maryland Stem Cell Research Act. What’s your opinion of this?

Q:

Are there any aspects of the ACA that you support?

I’ve long supported healthcare reform. There are two aspects of the ACA I do support, [though not on a federal level]. One is coverage for people with preexisting conditions – everyone has or will have a pre-existing condition at some point. In Maryland, we’ve solved this. If you have a pre-existing condition, you’re

The current Medicare system is not going to guarantee access for seniors. We have an aging population and we’re not tremendously expanding the number of physicians. 10 to 15 years from now, it’s likely that most primary care will be delivered by mid-level providers. If there’s a push to train more primary care physicians, we’ll have a shortage of specialty physicians. As people age, they require more specialty care, so we

Do you support H.R. 5707 (Medicare Physician Payment Innovation Act of 2102) to repeal the SGR and reform Medicare?

shouldn’t pretend that that shortage is not going to exist. From the government’s view, that shortage controls costs – you end up waiting longer to see a physician. We should have a discussion – do we want to control costs by controlling access?....

Q:

What are your views on tort reform?

I was an obstetric anesthesiologist who finished my training in 1984. At that time, a solo practice obstetrician who was covered every other weekend was treating my wife. When it’s time for my daughters to go to obstetricians, they will be in large groups and if they’re lucky, they might see the same person twice. That’s because obstetricians are worried about getting sued and can’t afford the insurance. The answer? You have to go to systems. In the Maryland legislature, I proposed a bill that took cerebral palsy off the litigation table by forming a fund that would pay for care for that child without assigning blame. But until we can overcome advocacy by the trial bar, the problem will continue. These are bipartisan issues. Neurosurgeons face the same problem. My first idea to solve this is to take litigation off the table for government patients (Medicare or Medicaid). The other thing is we have to put common-sense limits on noneconomic damages. We should probably start with ER, obstetrics and neurosurgery. We have changed the way healthcare is delivered as a result of tort liability, and it’s not been for the good. Andy Harris, M.D., is an anesthesiologist and the Congressman for the 1st Congressional district of Maryland. He previously served as a Maryland State Senator. He serves on the Transportation and Infrastructure, Natural Resources and Science, Space and Technology committees.

NOVEMBER/DECEMBER 2012

| 27


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Solutions

Essentials of an Accountable Care Organization

T

By Cindy Friend, RN, BSN, MSN, MBA/HCA

HE DIRE NEED FOR REFORM OF the current healthcare system has prompted one of the most unprecedented healthcare delivery transformation efforts in U.S. history. Healthcare leaders recognize that a patient-centered medical home (PCMH) integrated, accountable care organization (ACO) that utilizes health information technology (HIT) in a meaningful way and supports health information exchange (HIE) can improve the quality and safety of care, while holding promise to reduce overall costs. Many public and private payersponsored ACO shared-savings programs are emerging to incentivize healthcare providers to establish ACOs. An ACO is composed of groups of healthcare providers – including physicians, hospitals, and specialists – that establish a healthcare delivery organization to coordinate and facilitate high quality care for the patients they serve. ACOs are evaluated on the effectiveness, efficiency, and quality of care provided and must be able to report on the performance of clinical quality indicators. Establishing or participating with an ACO can be beneficial for physician practices. While a feasibility assessment and gap analysis are critical first steps, below are a few additional elements to consider when determining whether to develop or join an ACO:

ACO Structure and Operations An ACO needs to establish a financially sustainable organization with sound business operations. The organization should be stakeholder inclusive and ensure that clinical leadership is highly involved with the ACO activities. The organization may take on a number of shapes but should at least have the following components:  Governance - a Board of Directors comprised of all stakeholders to provide oversight.

 Operations and Business Management - an operations management team including an Executive Director to provide leadership and oversee the day-to-day business management. In addition, a Program Management team is needed to provide program/project management support and implement the recommendations from the Board of Directors and Advisory Groups.  Advisory Groups - engage subject matter experts to participate in advisory groups to guide its business development, policy, technical and clinical areas.

Clinical Practice and Care Delivery All healthcare providers participating with the ACO need to work together to develop a coordinated approach to managing the patients they serve. This includes components such as access, population management, care management, care planning, care transitions, care coordination, and optimal use of health IT. Below are a few key aspects of a robust clinical delivery model:  Patient-Centered Care Model  Integrated Health IT  Clinical Staff Engagement and Training Program  Patient Engagement and Education Strategy  Continuous Quality and Performance Improvement Program Technology Infrastructure and Tools

To provide effective and coordinated care, healthcare providers must have the tools to collect, manage, analyze, and share health information. An ACO should consider including the following technology:  HIE - technology that enables healthcare providers to share health information with other providers that are also caring for the patient.

 HIT - tools allow healthcare providers to collect, manage, and analyze health information. Essential HIT tools include: • Electronic Health Records (EHR) • Computerized Physician Order Entry (CPOE) • Electronic Prescribing (eRx) • Clinical Decision Support (CDS) • Standing Orders • Patient Portal • Data Analytics/Reporting • Care Coordination (CC) • Care Plan (CP) • Self-Care Management While EHRs have come a long way over the past couple of years and manufacturers have integrated more functionality, such as eRx, CPOE, CDS, standing orders, and patient portal; EHRs have a long way to go to adequately support clinical needs such as care coordination, care planning, patient self-care management, and quality improvement tools. An ACO should work closely with its technology partners and explore the marketplace to develop a strategy that meets its organization. Performance Reporting and Quality Measures

An ACO will likely need to report its performance on quality measures externally if participating in a sharedsavings program. It will need to program the requirements and develop the reports for each of the various programs, a complex task since the reporting requirements can vary from payer to payer. Cindy Friend, RN, BSN, MSN, MBA/HCA is the owner and managing director of Trivantage Solutions, LLC, a Maryland-based full service healthcare consulting firm providing clinical, technical, and business services to the healthcare industry and specializing in PCMH and ACO transformation.

NOVEMBER/DECEMBER 2012

| 29


Heritage

Dr. Bob’s Place Brings Comfort and Care to Kids with Terminal Illnesses

D

By Tracy M. Fitzgerald

with their kids,” said Charlotte Hawtin, executive director of Joseph Richey Hospice. “While we are caring for the patient, we are also doing a lot of things to help strengthen the connection between that child and his or her parent. What we do is a God-send for many families.” Upon entering Dr. Bob’s Place, it is immediately clear that the center is designed to comfort and sooth children.

“We can’t change the outcome, but we can change the comfort level and give parents an opportunity to hug and snuggle with their kids.” – Charlotte Hawtin, Executive Director of Joseph Richey Hospice

Ten years after his death, his vision became a reality. Dr. Bob’s Place opened in July 2011, as a project of Joseph Richey Hospice. Dr. Irwin’s memory is preserved by the center that dons his name, as well as the fact that his son, pediatrician John Irwin, M.D., serves as medical director today. The program, offering care for kids from age birth to 18, is recognized as the first in the country to feature an inpatient facility for children, as a licensed hospice provider. The mission at Dr. Bob’s Place is fairly simple: maximize quality of life by managing pain and symptoms, and allow kids who are sick to stay at home, or in a “home-like” setting, for as long as possible. Recognizing that children are unique human beings, with little bodies that require treatment that it is quite different from what an adult would experience, the center practices an interdisciplinary clinical approach, combining medical care with emotional, psychosocial and spiritual support for patients and their families. “We can’t change the outcome, but we can change the comfort level and give parents an opportunity to hug and snuggle 30 | WWW.MDPHYSICIANMAG.COM

Colorful murals, animal-themed furnishings, playrooms and large family gathering areas help welcome patients and their parents, and provide a “home away from home” for those requiring palliative or end-of-life care. Accommodations allow for one parent to live at Dr. Bob’s Place alongside their child. “People have an amazing response to the environment,” said Janet Will,

RNMS, and director of Dr. Bob’s Place. “It doesn’t feel like a hospital and everything you see is child-friendly. It’s very welcoming. In fact, some people don’t want to leave.” Raising the necessary funds to open and operate Dr. Bob’s Place, a three-story, 20,800 square-foot facility, was no small feat. A $4.5 million fundraising endeavor provided enough resources to open the facility, stock it and see it through the start-up phase. Fundraising efforts continue today, with goals to purchase more equipment, continuously recruit more staff, add furnishings and open a sensory room. “Death is a natural part of life and is not something to be afraid of,” said Hawtin. “But we believe strongly that comfort is a right. Everything we do for our patients and their families is geared toward that.” Pediatricians with patients requiring curative and palliative care concurrently can refer patients to Dr. Bob’s Place by calling 410-523-1414. More information is available at www.drbobsplace.org. Pediatrician John Irwin, M.D., leads a team of clinicians and support providers who focus on making children with terminal health conditions as comfortable as possible. Dr. Bob’s Place is a facility specializing in palliative and end-of-life care for patients from birth to age 18.

PHOTOS COURTESY OF DR. BOB’S PLACE

R. BOB’S PLACE IS A Baltimore-based program that provides palliative and hospice care for children with life-limiting conditions, named in honor of the late Robert Irwin, M.D. It was “Dr. Bob” who had the vision, years ago, to open a hospice facility centered around the needs of young patients, in partnership with Joseph Richey Hospice, where he served as a volunteer physician.


Good intentions or bad judgment?

Good intentions or bad judgment? There are times we do crazy, misguided things; feats that shouldn’t be possible, and sometimes aren’t. So when you push yourself past your limits, it’s nice to know there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedures like hip resurfacing – all combined with the latest rehabilitation services. Nice work, knees and hips – the dynamic duo – when we ask too much of you To find an orthopedic specialist near you, call 410-601-WELL (9355).

There are times we do crazy, misguided things; feats that shouldn’t be possible, and sometimes aren’t. So when you push yourself past your limits, it’s nice to know there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedures like hip resurfacing – all combined with the latest rehabilitation services. www.lifebridgehealth.org/RIAO www.lifebridgehealth.org

Nice work knees and hips – the dynamic duo – when we ask too much of you!


Climbing with Confidence After Catheter Ablation at

For priority transfer of your cardiac admissions, call Cardiac One-Call 866-684-8460. To refer a patient for a cardiac surgery consult, call 301-891-6101.

Guillaume Marรงais, 37, Montgomery County, Treated with Heart Ablation for Atrial-Fibrillation


Maryland Physician Magazine Nov/Dec 2012