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M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

NEW HOPE FOR BREAST, PROSTATE AND LUNG CANCER USING 3T MRI AND PET/CT TO FIGHT CANCER HEALTH INFORMATION EXCHANGES BEGIN TO BRIDGE THE GAP

www.mdphysicianmag.com

VOLUME 3: ISSUE 5 SEPT/OCT 2013


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Contents 12

VOLUME 3: ISSUE 5 SEPT/OCT 2013

24 F E AT U R E S

12 New Hope for the Top Three Cancers 18 Harnessing the Power of Imaging to Fight Cancer 26 Health Information Exchanges: The Next Hurdle D E PA R T M E N T S

Cases

| 7 | Lung Cancer Screening Benefits High-Risk Patients

Compliance

| 9 | ACA Impact on Small Private Medical Practices

Policy

| 24 | Maryland Health Connection: A New Insurance Marketplace

Living

| 30 | Rock Hall: Capturing the Treasures of the Chesapeake Bay

Solutions

| 33 | Four Tips to Tax-Efficient Investing

Good Deeds

| 34 | NAMI: Educating, Supporting and Advocating for Local Patients with Mental Health Needs

On the Cover: Christopher Runz, D.O., University of Maryland Shore Regional Health’s Comprehensive Urology office

26


Social and digital media

have become an integral part of our culture, having both a positive and negative impact on our daily lives. They’ve changed the speed of information exchange, powerfully affecting our everyday existence and touching nearly every feature and department in this issue of Maryland Physician. Social media affords you the opportunity to connect with your patients for health and wellness education, disease management and healthcare delivery. Social media raises awareness of risks for and treatments of disease. The news of Angelina Jolie’s preventative double mastectomy (a treatment option in response to a rare genetic mutation for breast cancer) was instantaneously communicated via social media. In our cover story (page 10), we’ve consulted with Maryland experts on treating the three top cancers, so that you’re better informed when your patients ask about aggressive treatments such as the one elected by Ms. Jolie, or developments in radiation therapy for lung cancer or screening for and treating prostate cancer. Digital media delivers real-time data and information that has a positive impact on care delivery and reporting, yielding quality data such as such as readmission rates or ER returns. Maryland is ahead of many states in connecting electronic information from one provider to another; while interoperability presents its challenges, the benefits are clear – see Healthcare IT (page 26). In Policy (page 14), we interviewed Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. Our conversation with Ms. Pearce spotlights the Maryland Health Connection, the health insurance marketplace for Marylanders where patients and small businesses can digitally compare insurance plans and costs. We discuss the impact this marketplace may have on those of you running your own practices, including the potential influx of patients – some of who may be new to the concept of having a primary care physician. Health insurance companies target patients that are less expensive to carry – the young, healthy and those most savvy in managing their chronic diseases – to offset those who are more expensive to insure. These younger and savvier patients are the same ones who have immediate access to information on your reputation as a provider as well as disease and treatment options. Research demonstrates that patients are more likely to trust online information about you than information gathered anywhere else. Do you know what your online reputation is, and how to manage it? In October, Maryland Physician Events launch with “Reputation Management & Social Media Evolution for Medical Practices: Reactive, Proactive and Legal Implications.” Join us to learn how you can best engage with your patients and manage your online reputation, while understanding the legal implications. See page 6 for speakers, dates and locations. Managing a practice may be more stressful than ever. Take a break from it; turn off your smart phone, shut down your computer and head outside this fall. Living (page 30) showcases one of the most beautiful spots on the East Coast found right here in Maryland – Rock Hall. The word is that the waterfront beauty found there is like no other. To life!

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

JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Tracy Fitzgerald PROOFREADER Ellen Kinsella PHOTOGRAPHY Tracey Brown, Papercamera Photography Melissa Grimes-Guy, Location Photography, Inc. Kevin J. Parks, Mercy Medical Center Randy Sager, Randy Sager Photography, Inc. BUSINESS DEVELOPMENT Eileen Nonemaker enonemaker@mdphysicianmag.com 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 949 Annapolis, MD 21404 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 content 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: 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 CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center 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. Printed on FSC certified, 100% PCW, chlorine free paper


EVENT Reputation Management & Social Media Evolution for Medical Practices: REACTIVE, PROACTIVE AND LEGAL IMPLICATIONS Educate and empower Maryland physicians to promote health education, health literacy and healthcare delivery AND to protect their online reputation

FEATURED SPEAKERS: Ed Bennett

James F. Doherty, Jr.

Brenda Brouillette, RN, BS

Brian W. Flynn, Ed.D.

Director of Web & Communications Technology at the University of Maryland Medical System and is responsible for all aspects of their web programs. Mr. Bennett led the UMMS online initiatives designed to educate and attract new patients. He’s pioneered search engines optimization techniques that are now standard for hospital websites. Mr. Bennett sits on the external advisory board of the Mayo Clinic Center for Social Media.

Principal in the Maryland law firm of Pecore & Doherty, LLC, representing health systems and individual, group and institutional healthcare providers and suppliers. Mr. Doherty maintains faculty appointments at the Johns Hopkins Bloomberg School of Public Health and the University of Maryland Francis King Carey School of Law.

President and Founder of Savvy Marketing Solution, LLC. With a combination of a clinical background with healthcare leadership roles, Ms. Brouillette delivers an astute understanding and expertise in healthcare social media. Savvy provides physician practice and healthcare entities with strategic marketing and business development services.

(Anne Arundel County Event Only): Associate Director of the Center for the study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of Health Services. Dr. Flynn specializes in how stress alters cognitive processes and offers clinical interventions to support patients and their families by adapting communication strategies for high stress situations instantaneously communicated via social and digital media.

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Cases

Lung Cancer Screening Benefits High-Risk Patients By Stephen Cattaneo, M.D.

CASE: In 2012, a 65-year-old female, current smoker with a 58-pack year smoking history (the equivalent of one pack per day for 58 years) underwent a chest X-ray as part of her preoperative workup prior to left shoulder arthroscopic surgery. Her radiograph identified an incidental left lung lesion. Subsequent diagnostic chest CT scan revealed a 2-cm, spiculated lesion in the lateral basilar segment of the left lower lobe approximating the major fissure. PET/CT demonstrated significant hypermetabolic activity within the left lower lobe lesion, but without abnormal uptake in her hilar or mediastinal lymph nodes or other distant sites. Since she had excellent performance status and adequate pulmonary function, she elected to undergo surgical management of her lesion that consisted of a thoracoscopic (VATS) therapeutic wedge excision of the nodule followed by completion lower lobectomy and lymphadenectomy. Final pathology confirmed an invasive adenocarcinoma extending to the visceral pleural surface with all lymph nodes negative. She has been undergoing routine oncologic surveillance for her stage 1B lung cancer for the past 18 months with no signs of recurrence.

DISCUSSION: Until recently, efforts at screening for lung cancer, including sputum analysis and chest X-ray, have failed to demonstrate a survival benefit, even for higher-risk patients. However, in the summer of 2011, the New England Journal of Medicine published the results of the NCI-funded National Lung Screening Trial (NLST), which demonstrated a mortality benefit of screening high-risk persons for lung cancer by yearly low-dose CT scan.

consumption, lung cancer remains the leading cause of cancer deaths in the United States, claiming the lives of approximately 160,000 Americans annually. In Maryland residents, the yearly incidence of lung cancer is approximately 3,700, accounting for about 2,800 deaths annually. Unfortunately, in its early stages, lung cancer is rarely symptomatic. As a result, it can go unnoticed for months or years. Most people are diagnosed

In Maryland residents, the yearly incidence of lung cancer is approximately 3,700, accounting for about 2,800 deaths annually. Since these landmark results were made public, numerous medical societies, including the American Cancer Society, the American College of Chest Physicians and the American Society of Clinical Oncology, have provided recommendations for annual screening that closely parallel the criteria utilized by the NLST. Following review of the NLST results and other ongoing related trials, the U.S. Preventive Services Task Force (USPSTF) recently proposed annual lung cancer screening of long-time smokers by low-dose CT scan. Those eligible for screening are: z 55-79 years of age z Current smokers or those who have quit in the past 15 years z Those who have smoked a minimum of 30-pack years This draft recommendation from the USPSTF is currently available for public comment, and is expected to be formally adopted in the next few months. The USPSTF recommendation has tremendous implications. Despite generally declining rates of cigarette

with advanced-stage disease, with nearly 90% ultimately dying from their cancer. Our patient was fortunate to have a chest X-ray prior to shoulder surgery that led to the incidental discovery of her early-stage lung cancer. Clearly, she would have greatly benefitted from screening, as she fits the criteria proposed for lung cancer screening. Once the USPSTF issues a final recommendation, it will be imperative that all practitioners, and ultimately patients, are educated about the role and value of lung cancer screening. Smoking cessation remains the most important means of preventing lung cancer, but we finally have an evidencebased screening method to identify people at the highest risk. This proposed recommendation should greatly reduce or eliminate the need for incidental discovery of early lung cancers, as occurred in this patient, and will ultimately provide an increased chance for earlier detection, treatment and cure for this devastating disease. Stephen Cattaneo, M.D., is Anne Arundel Medical Center’s medical director, Thoracic Oncology Division, and director, Surgical Oncology.

SEPTEMBER/OCTOBER 2013

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Compliance

ACA Impact on Small Private Medical Practices

O

By Chris Rutzebeck

N MARCH 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA), which aims to eliminate inefficiencies in our current healthcare system and extend coverage by providing affordable care to uninsured Americans. Small private medical practices (less than 50 employees) are planning ahead for the effects these changes will have on their practices. Since federal agencies are continuing to develop new rules and guidance, practices should consult with legal counsel for a comprehensive explanation of the ACA and how various regulations will apply to them. As the owner of a small private medical practice, you should know which provisions taking effect January 1, 2014, may affect the health insurance plan currently offered to your staff, including:

- Prevention, wellness, and chronic disease management services - Outpatient or ambulatory care ACA Premium Rating Methodology

Small private medical practice rates in Maryland are currently based on the average age of the employees enrolled in the plan. Going forward, group rates will be the sum of individual rates for each enrolled individual based on their age. Rating will no longer be based on enrollment tiers of Employee, Employee + Spouse, Employee and Child, and Family. ACA-compliant plan premiums will be calculated based on the age of the employee, his/her spouse and each dependent (when applicable). For family plans, rates will include the employee, his/her spouse, the oldest three children under age 21 and all adult children ages 21 to 26.

Employer Mandate

Small private medical practices (1–49 employees) are NOT subject to the employer mandate or financial penalties. Essential Health Benefits

Any plans sold or renewed in the small group market (except grandfathered plans that are renewed by December 1, 2013) will include new benefit requirements known as Essential Health Benefits (EHBs). Many existing medical plans currently include these benefits, but annual and lifetime dollar limits have been removed. The EHBs are: - Emergency services - Hospitalization - Laboratory services - Maternity and newborn care - Mental and behavioral health and substance use disorder services - Prescription drug coverage - Rehabilitative and habilitative services and devices - Pediatric dental and vision coverage

Premium Increases

The ACA also introduced new fees, taxes and assessments that may add to the cost of health insurance plans, including: z Federally Facilitated or State Exchange User Fees – in Maryland, state funding will cover this fee in 2014. z Transitional Reinsurance Program – All plans in Maryland will be charged a $5.25 PMPM (per member per month) fee. z Patient-Centered Outcomes Research Institute Fee – Commercial health insurers and employer-sponsored health plans will be assessed an annual fee to fund patient-centered outcomes research. This fee, which will be imposed for a limited number of years, is: z $1 per covered life for the plan and policy years ending after September 30, 2012, and before October 1, 2014 z $2 per covered life for the plan and

policy years ending after September 30, 2013 and before October 1, 2014 z Risk Adjustment Fee – All nongrandfathered small group plans will be charged this fee, estimated at $1 for each covered life per year. Additional fees will be applied, but the amounts have not yet been determined by the federal government: z Health Insurer Fee – All plans in Maryland will be charged this fee, estimated at 2% to 3% of the premium. z QHP Certification Fees for Small Business Health Option Program (SHOP) – All plans in Maryland will be charged this fee if purchasing a plan on the SHOP Exchange. Medicare Payroll Tax for HigherCompensated Staff

Currently, all employees pay a 2.9% Medicare tax. According to the IRS: z An employer must withhold an additional Medicare hospital insurance tax (0.9%) from wages it pays to an individual in excess of $200,000 in a calendar year without regard to the individual’s filing status or wages paid by another employer. z An individual is liable for additional Medicare taxes if the wages, compensation or self-employment income exceed the threshold amount for the individual’s filing status: - Married filing jointly threshold — $250,000 - Single threshold — $200,000 Take action now to ensure that you are prepared for the health insurance changes coming in January 2014. Christopher M. Rutzebeck is the benefits manager at Human Resources inc. He can be reached at chris@hri-online.com.

SEPTEMBER/OCTOBER 2013

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Profile

SPONSORED CONTENT

ACOs: Returning Joy to the Practice of Medicine GBMC HealthCare was the first Maryland hospital to partner with physicians to create an Accountable Care Organization (ACO) through its affiliate, Greater Baltimore Health Alliance (GBHA). After two years of planning and initial setup, the ACO was launched in 2012. Colin Ward, GBHA’s executive director, says, “We were very deliberate in our developmental years, creating a physician-led board of directors and aligning with like-minded providers.” What is an ACO? An ACO is an organizing entity that allows providers to work in concert to provide more coordinated patient care. Ward provides an interesting analogy: “We consider patients to be a movie, not a snapshot,” he says. “The ACO can look at the gaps in patient care and reach out, actively engaging patients who have multiple chronic conditions between visits. The ACO itself is physician driven. We assimilate clinical information and claims data from the physicians, then give it back to them to foster shared decision-making.”

ACO Benefits The true value of the ACO lies in its ability to get real-time and retrospective 10 |

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information about its patients so that doctors can intervene quickly to prevent minor issues from spiraling into major health crises. Ward observes, “It’s a mindset shift that, if done right, provides clear benefits to both physicians and their patients. Colin Ward, GBHA’s executive director An ACO can return Participating physicians use electronic joy to the practice health record systems to share clinical of medicine because physicians can information among providers. The ACO see meaningful changes in the care of provides technical assistance to optimize their patients. the system, or assist practices in “Our ACO can give participating implementing a system from scratch. physicians data revealing such To participate in the Medicare ACO information as which of their program, GBHA had to submit hypertensive patients are not under good a list of tax IDs for all participating control, or which of their patients have physicians to determine the population of A1C levels that are too high,” Ward patients attributed to GBHA. As part of continues. “We can provide the clinical the program, CMS shares claims files that data tied to specific patient names to help the ACO understand patient needs, shine a light on places where the and close gaps in care. Notes Ward, physician’s attention is needed.” “Both Medicare and Cigna are providing us with information that is vital to properly engaging patients and caring for GBHA ACO Today, the GBHA ACO has slightly more them in a more proactive manner.” GBHA chose Medicare’s single-sided than a year of experience under its belt. It has nearly 14,000 combined beneficiaries payment model, which provides fee-forservice payments, plus the opportunity to in the Shared Savings Program share in a percentage of any savings at the established by Medicare and the Cigna end of each year. This model provides the Collaborative Accountable Care group with less potential upside than the Program. There are 100 participating two-sided model, but no downside risk. primary care providers, including nurse practitioners (NPs) and physician assistants (PAs), plus some specialists. Building on the PCMH Model Some providers are employed and others The GBHA ACO builds upon the Patient are aligned with the ACO. The entity has Centered Medical Home (PCMH) four care managers and is hiring two concept. Robin Motter-Mast, D.O., a additional ones. It also employs three participating family practitioner in Hunt care coordinators for managing nonValley, and member of GBHA’s board, clinical issues. recalls, “In March 2012, our practice


received Level 3 recognition from NCQA. We participated in CareFirst BlueCross BlueShield’s PCMH, which provided a foundation for the ACO because its metrics are similar.” The ACO now has four NCQA-recognized PCMH practices, and another three under consideration. As a PCMH, the Hunt Valley practice had already hired care managers and enhanced its IT capabilities to better monitor patient care. The approaches they were beginning to use as a PCMH, such as greater education and monitoring of diabetic patients, provided an excellent basis for the ACO. When they transitioned to the ACO, they also added new services, such as leaving 30% of the daily schedule open for same-day appointments to take care of urgent issues and ensuring extended office hours. Virtually all of these open slots are filled each day. The ACO entails changes on the hospital side as well. Ward notes, “For example, transition guides are now in place at GBMC to follow congestive heart failure patients and get them back to the primary care physicians after discharge.”

From Reactive to Proactive Data “As a pilot program with CRISP, which runs the state’s Health Information Exchange, the Encounter Notification Service (ENS) has been critical to help us better coordinate patient care,” Ward remarks. “We get real-time notification of hospitalizations and ED visits, so that patients discharged from the hospital have the opportunity to be seen in the physician’s office within 48 hours. “Thanks to the statewide database, we can see if a patient has visited several EDs in the state, for example, and can intervene to address their medical problem and often prevent future visits or hospitalizations. Or, we can tell that, while on vacation at the beach, one of our patients had chest pain and went to the ED in that area.”

“We’re moving from reactive to concurrent and eventually proactive data,” comments Ward. “That’s meaningful to patients and doctors alike. We can do something to prevent an emergency visit if we see that patients aren’t controlling their Robin Motter-Mast, DO, GBHA diabetes or other participating family practitioner. chronic conditions contracts that require them to know how well. Our care managers can contact a their patients are doing and to intervene patient who was seen in the ED and ask quickly if necessary. Being aligned with an if they need help with prescriptions or ACO allows them to do that.” home health. Or, they can arrange for inHe concludes, “The key is that we home PIC line placement after a patient is discharged, instead of having that done help reorganize and re-engineer with small, smart and focused changes that in the ED or hospital.” give physicians more joy and that keep Ward notes that the data also helps patients healthier. Physicians are no to shift patient thinking and behavior. “With the ENS, we can view the patient’s longer going it alone. They get peer-topeer interaction and learning, plus chief complaint. When we contact the information about their practice that patient and tell them that we could have they can compare to other practices. handled their problem in the physician’s They can handle activities that need office, not in the ED, they are often physician intervention while the ACO pleasantly surprised. It’s an opportunity handles non-provider tasks.” to educate them.” Physicians interested in learning more Specialists can participate in multiple about GBHA can contact Garret Morris ACOs and are not formally named as by calling 443.849.4242 or by emailing participants with GBHA. ACO referral gbhaquestions@gbmc.org. Information guidelines set milestones for specialty about the Medicare Shared Savings care, so that both the referring and Program is available at receiving physician agree on the plan www.cms.gov/sharedsavingsprogram. of care. Once the agreed-upon clinical milestone is achieved, patients can be returned back to the primary care office. *www.innovation.cms.gov/initiatives/ACO/ “It frees up a specialist’s schedule so that new patients needing initial consultations can be seen more quickly,” Ward notes. “One of the biggest challenges we hear Is an ACO Right for You? from patients and providers is the delay Providers should have or be willing to get in scheduling an appointment to see a the following to participate in an ACO specialist, and this can alleviate that.” As reimbursement becomes increasingly z Implement and use an EHR tied to outcomes, Ward advises, z Share clinical data for quality “Physicians will have pay-for-performance reporting z Use evidence-based practices where appropriate

CMS Description of an ACO ACOs are groups of doctors, hospitals and other healthcare providers, who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. *

z Offer some extended hours (evenings, early mornings, weekend coverage) z Leave 20–30% of schedule open for same-day appointments z Interact with care managers for patients needing additional support

SEPTEMBER/OCTOBER 2013

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NEW HOPE FOR THE

TOP 3 CANCERS BREAST, LUNG AND PROSTATE

LINDA HAR DE R • P HOTOGRAPHY BY TRACEY BROWN

Maryland Physician recently consulted with experts in breast, lung and prostate cancer to learn the latest about appropriate screening and treatment for these common cancers. PROPHYLACTIC MASTECTOMIES AND GENETIC MUTATIONS Given that one in eight women are now at risk for breast cancer in their lifetime, Dr. Kristen Fernandez, breast surgeon and director of the Breast Center at MedStar Franklin Square Medical Center, says, “I often tell my new patients that the two big risk factors for getting breast cancer are being a woman and getting older.” Media coverage of Angelina Jolie’s prophylactic bilateral mastectomy at age 37 heightened awareness of the role of genetic mutations in breast cancer and raised questions about the best course of action in these cases. Jolie, who carries a mutation of the BRCA1 gene and whose mother died of breast cancer at age 56, has stated that her physicians determined her risk of breast cancer was 87% and her risk of ovarian cancer was 50%. Genetic mutations greatly increase the risk of incurring breast cancer. However, Dr. Fernandez corrects some of the misconceptions about 12 | WWW.MDPHYSICIANMAG.COM

genetic variants, noting, “Only 5 to 10% of breast cancers can currently be tracked to gene mutation. People come to my office worried about their family history, but we look at whether there’s really a clear pattern and we look at both the maternal and paternal family history. Even many physicians don’t realize that the father’s side of the family is equally important in assessing genetic risk.”

Determining Genetic Testing Appropriateness Dr. Fernandez continues, “The best person to refer for BRCA testing is a living relative who’s already had pre-menopausal or bilateral breast cancer, or breast and ovarian cancer, not the unaffected woman who may or may not be at risk. If the relative with cancer tests negative for a mutation, there’s no need to test the patient who’s worried about their risk. “BRCA testing is easy to perform and typically covered by insurance, but it’s often not appropriate,” she adds. “If the patient is


to 87%, compared to about 12% for the average woman, and breast cancer occurs at a younger age in these women compared to sporadic breast cancers in the general population. An oophorectomy decreases breast cancer risk by about half.” When advising women at high risk about the best course of action to take, Dr. Fernandez listens to what is important to them. “I try not to make assumptions about what they will want. Prophylactic oophorectomy may be a good first surgery from a clinical standpoint, but if the woman is not ready to go through early menopause, but does want a mastectomy, that may change our treatment plan. Similarly, the decision about using autologous tissue from belly fat in breast reconstruction is a personal one – it involves a second incision and more pain, but it gives the woman a ‘tummy tuck’ at the same time.” She continues, “And for many women, surgery is not the best choice. Prophylactic mastectomy and oophorectomy are the best risk reduction tools that we have for women with a BRCA gene mutation, but that does not mean that every woman with a gene mutation has to have surgery. The decision to have surgery such as this is a very personal one and should not be made without a detailed discussion of risks, alternatives and expectations. I use our genetic counselor extensively in these cases. And often my patients will go with their siblings or parents so that several family members can have the opportunity to hear the explanations and ask questions of the genetic counselor.”

Dr. Kristen Fernandez, breast surgeon and director of the Breast Center at MedStar Franklin Square Medical Center

Breast Cancer Detection and Prevention

negative for BRCA1 or 2 gene mutations but has a significant family history, you don’t know what that means. We suspect that about half of all genetically-related breast cancers are caused by BRCA1 and 2, but there are likely hundreds of genetic mutations that we haven’t yet identified, and those could put the patient at risk.” Dr. Fernandez advises that women with the following personal or family histories should be counseled about their increased risk: z Breast and ovarian cancer history within the same side of the family

z Multiple cases of premenopausal breast cancer in the same side of the family z Male breast cancer z Bilateral breast cancer z Those of Ashkenazi (Eastern European) Jewish descent with breast or ovary cancer “The BRCA1 and BRCA2 mutations increase the risk of ovarian as well as breast cancer, and the former is far harder to detect at an earlier stage,” she notes. “The lifetime risk for breast cancer through age 70 with BRCA1 and 2 is 50

Dr. Fernandez stresses that monthly breast self-exam is still a critical component of breast health. “Every month, I see several women who found a lump despite a negative mammogram. Women with genetic mutations should get a yearly breast MRI and a baseline mammography, followed by a mammogram every two to three years until age 40, to minimize ionizing radiation. Breast ultrasound is best when there is a palpable lump or the MRI and mammogram results disagree.” The U.S. Preventive Services Task Force (USPSTF) and other medical groups now recommend chemoprevention with tamoxifen and raloxifene for many women at highest SEPTEMBER/OCTOBER 2013

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risk for breast cancer – those 40 to 70 years of age with a family history of breast cancer, without signs or symptoms of breast cancer, and never diagnosed with breast cancer or ductal carcinoma in situ. Women with a history of blood clots, including deep vein thrombosis, pulmonary emboli, strokes or transient ischemic attacks, should not be prescribed these agents.

Amar Rewari, M.D., MBA, radiation oncologist at Shady Grove Adventist

RADIATION THERAPY ADVANCES IN LUNG CANCER The top risk factor for lung cancer continues to be smoking; smokers are at a twenty-fold greater risk of incurring lung cancer than non-smokers, and those who quit after having smoked can halve their risk. “Counseling on smoking cessation remains critical because lung cancer is still the primary cause of cancer mortality for both men and women,” says Amar Rewari, M.D., MBA, radiation oncologist at Shady Grove Adventist. Dr. Rewari is excited about two newer developments in radiation therapy for treating non-operable, early stage lung cancer: low-dose rate brachytherapy with mesh implant and stereotactic body radiation therapy (SBRT).

Mesh Brachytherapy While the gold standard for treating lung cancer is a full lobectomy, many patients aren’t good candidates for surgery. Until lately, a wedge resection had an 18% risk of recurrence – three times that of a lobectomy. External beam radiation therapy suffers from the difficulty in limiting radiation to just the suture line, where recurrences are most likely to develop.

which is laid down directly on the suture line, contains seeds with a half-life of several days to several weeks, delivering high dose radiation to a focused area while sparing normal lung tissue.” He continues, “Studies have shown this brachytherapy procedure, which has been used in academic centers but was not available in community hospitals until recently, to be very safe, without long-term complications. It makes the results more comparable to a lobectomy for patients who can’t tolerate major surgery.”

SBRT The second development is Stereotactic Body Radiation Therapy (SBRT). This approach, appropriate for patients with inoperable early stage cancer, involves immobilizing the body and using imageguided radiation therapy. SBRT can be used only on Stage 1 lung cancer with tumors up to 5 cm in diameter.

Prophylactic mastectomy and oophorectomy are the best risk reduction tools that we have for women with a BRCA gene mutation, but that does not mean that every woman with a gene mutation has to have surgery. – Kristen Fernandez, M.D. However, using low-dose rate brachytherapy during a wedge resection for patients with Stage I non-small cell lung cancer greatly reduces that risk of recurrence. Dr. Rewari explains, “In this procedure, after the tumor is removed, the radiation oncologist gives the surgeon a mesh sheet containing iodine or cesium to place in the chest cavity. The sheet, 14 | WWW.MDPHYSICIANMAG.COM

Dr. Rewari describes this procedure. “Stereotactic radiation therapy was originally created for the brain, where physicians used a coordinate system to give high doses of radiation with millimeter level accuracy. The challenge in the lungs was finding a way to precisely focus the radiation on a moving target. The patient is set up with full

body immobilization and an abdominal compression device to make each breath more consistent, while a 4D CT takes CT scans over 10 phases of the breathing cycle to assess for tumor motion. For the image guided radiation therapy we take a mini CT scan of the lungs to pinpoint the tumor prior to each treatment.” He adds, “If the tumor is not close to critical structures, we can achieve an 85 to 95% prevention of recurrence with just three treatments, typically given about twice a week. Tumors close to critical structures such as the heart and vessels may require five treatments with a smaller daily dose.”

Concurrent Therapy for Advanced Cancer For advanced stage lung cancers, radiation therapy is combined with chemotherapy. “If patients are good surgical candidates then chemotherapy and radiation is given before surgery,” says Dr. Rewari. “With radiation alone, the median survival is 10 months; with chemotherapy and radiation given sequentially, median survival rates increase to 14 months, and with concurrent therapy, to 17 months. Recent studies show that adding surgery could reduce the chance of the cancer recurring, may prevent having to treat lymph nodes that were previously treated electively, and reduce radiation doses, resulting in less toxicity.”

PSAS AND ACTIVE SURVEILLANCE: JUDGMENT IS KEY Excluding non-melanoma skin cancers, prostate cancer is the most common male


cancer and the second highest cause of male cancer deaths. About 240,000 men were newly diagnosed with prostate cancer in 2012, and about 28,000 died of the disease that year. While death rates fell significantly in the early 1990s, they have leveled off in recent years. African American men and those with a family history of prostate cancer including fathers, brothers, sons, uncles and grandfathers, are at higher risk for prostate cancer. Screening for prostate cancer has come under intense scrutiny in the past few years. Christopher Runz, D.O., a urologist at University of Maryland Shore Regional Health’s Comprehensive Urology office, comments, “Until a few months ago, the standard was to perform a yearly digital rectal exam (DRE) and

fit all and that’s where medical judgment comes in.” Dr. Runz continues, “At this year’s American Urological Association (AUA) annual meeting, new prostate cancer screening guidelines were announced that call for a more individualized approach. Physicians need to talk to their patients about the benefits and risks of these screening tests and give them options. Generally speaking, we have tended to over-treat prostate cancer in the United States, especially in men over age 70, as some of these men have slow growing indolent prostate cancer. However, we do not want to miss a higher-grade prostate cancer in a man with a 15 to 20+ year life expectancy. The AUA recommends that all men age 50 to 69 talk with their doctor to determine if prostate cancer

Studies have shown this brachytherapy procedure… to be very safe, without long-term complications. It makes the results more comparable to a lobectomy for patients who can’t tolerate major surgery. – Amar Rewari, M.D., MBA

their healthcare provider to determine appropriate steps. z Men aged 55 to 69 have the greatest benefit of routine screening. They should talk to their healthcare provider about the risks and benefits of prostate cancer screening to determine what is best for them. z In men who wish to be screened for prostate cancer, the AUA now recommends a PSA and DRE every two years. “Asymptomatic men aged 55 to 69 and worried or at-risk men under 55 derive the greatest benefit from being screened,” advises Dr. Runz. “I recommend that primary care physicians discuss the benefits and risks with their patients, understanding that these tests may detect prostate cancer earlier, help them live longer and avoid problems from the cancer. However, testing also can involve false negatives and positives, or diagnose a slow growing indolent cancer that may never cause a problem for the patient yet whose treatment could entail side effects.”

Active Surveillance Guidelines prostate specific antigen (PSA) test on men from age 50 to 75 or 80, depending on their overall health and life expectancy. Last year, the U.S. Preventive Services Task Force (USPSTF) recommended that PSAs shouldn’t be performed as community or employerbased screenings, but one size doesn’t

screening is right for them.” General screening guidelines recommended by Dr. Runz include: z Men aged 40 to 54 years old should not get routine PSA screenings, but those who are having urinary changes or other concerns should talk with

Christopher Runz, D.O., University of Maryland Shore Regional Health’s Comprehensive Urology office

New studies support active surveillance as an appropriate approach for a select population. Dr. Runz notes, “A patient with a normal digital rectal exam (DRE) plus a Gleason Score of 6 or less is typically appropriate for this approach. I also consider the patient’s life expectancy and comorbid conditions. The first conversation we have is whether we need to treat the prostate cancer. I tell many of these patients with low-grade, low-volume prostate cancer that it’s not a short-term threat and may not be a long-term threat to them. I’ve found that providing articles, books and online videos also helps to educate my patients about low-risk prostate cancer and make thoughtful, shared decisions.” A Johns Hopkins study published online in the Journal of Clinical Oncology on June 17, 2013, found that African American men were at higher risk of upgraded cancer than white men when undergoing surgery after active surveillance, suggesting that active surveillance could be riskier for this population. Guidelines for active surveillance call for PSA/DRE exams every three months for the first year, followed by a second biopsy. At the end of that first SEPTEMBER/OCTOBER 2013

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year of surveillance until about age 80, exams should be performed as needed, with follow-up biopsies every three to five years. “About 25% of our active surveillance

Oncotype DX Genomic Prostate Score (GPS) as a new genetic test. “It’s a good option for men on active surveillance,” remarks Dr. Runz. “We send a specimen from the biopsy to a specialized lab.

Asymptomatic men aged 55 to 69 and worried or at-risk men under 55 derive the greatest benefit from being screened. – Christopher Runz, D.O. patients eventually go on to have treatment if their repeat biopsy shows a change in their prostate cancer,” Dr. Runz says. “We readdress curative treatment options with them if they have a grade or stage migration after a repeat biopsy and they’re appropriate candidates. This may mean continuing active surveillance or surgery or radiation therapy. It is important to ensure that this is a shared decision-making process with the patient and family so they fully understand the risks and benefits of each option, including understanding the natural history of their particular prostate cancer.” In May 2013, the FDA approved

GPS is a measure of the activity of 17 genes within the tumor and can help to predict the aggressiveness of the patient’s prostate cancer. This test is only meant for low to intermediate grade prostate cancers, so it’s a good option for men who are on or considering active surveillance. This test can help those patients without high-grade-disease personalize their treatment based on their cancer genetics.”

New Treatment for Advanced Prostate Cancer Men under age 65 with metastatic, castration-resistant prostate cancer who have failed radiation therapy or

surgery often are referred for androgen deprivation therapy (ADT). This hormonal therapy typically halts the cancer progression for 18 to 24 months, but is not a cure. Until recently, the only other therapeutic option was docetaxel based chemotherapy. However, two new drugs – Xtandi (enzalutamide) and Zytiga (abiraterone) can block testosterone receptors and stop testosterone production earlier in the cascade, providing promise for men with prostate cancer resistant to hormonal therapy.

Amar Rewari, M.D., MBA, radiation oncologist at Shady Grove Adventist Radiation Oncology Center Kristen Fernandez, M.D., breast surgeon and director of the Breast Center, MedStar Franklin Square Medical Center Christopher Runz, D.O., urologist at University of Maryland Shore Regional Health, Comprehensive Urology

Building Healthy Practices in today’s dynamic healthcare environment

Clinical Features Maryland Physician spotlights the latest innovations in clinical care and treatment delivered by your Maryland peers and colleagues as well as advances in medical training which facilitate achieving the highest standards of quality care and practice management solutions.

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 healthAs a leader in the field of medical practice management, SHR Associates, Inc. delivers consulting and practice management services to physicians and healthcare organizations. We provide the business resources and tools to help physicians prosper in today’s dynamic healthcare Proudly serving the physician community for over 30 years!

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SURVIVE & THRIVE

in a Patient-Centered Medical Home model

B est Doctors provides virtual medical consultations

and second opinions to physicians and their patients. Dr. Lewis M. Levy, Vice President of Corporate Medical Quality at Best Doctors, explains how the company’s innovative service is an incredibly valuable resource for physicians in a patient-centered medical home or accountable care organization. Q: Why is Best Doctors a valuable resource for practices using PCMH payment models? A: Our services enable the physician to regain more control of the consultation process and may help the practice earn more payment incentives. In brief, our service is designed to:

✓ Increase the patient’s access to specialist care ✓ Improve dialog amongst physicians ✓ Optimize the efficient use of specialty resources ✓ Enhance primary care physicians’ capacity to care for chronic or complex cases

Q: How does Best Doctors support the patient-centered medical home (PCMH)? A: When a physician faces a challenging case, he or she can contact Best Doctors and receive a well-researched, evidence-based second opinion from a nationally-recognized specialist. This isn’t a utilization review. It is a superb and timely resource for doctors and a powerful way to improve patient outcomes and satisfaction.

Q: Who are the Best Doctors expert specialists? A: Our specialists are chosen via an impartial, nationwide poll of physicians that asks doctors who they would see for their own care. Specialists are practicing physicians and often affiliated with leading centers of excellence. Our polling process is Gallup reviewed and certified.

Q&A with Lew M. Levy, MD

Q: How can Best Doctors improve upon the professional network doctors have already established? A: The Best Doctors service provides an expert second opinion, typically in much less time than it takes to schedule an appointment at a specialty or teaching hospital. In addition, Best Doctors often provides treating physicians with a complete and comprehensive medical history of their patient.

Q: Why does Best Doctors work to support physicians in this way? A: Our service is financed by large employers and health plans as a part of their employee/member benefits offerings. Therefore, our objective is to support physicians in finding the right diagnosis and treatment for these patients.

About the Interviewee Dr. Lewis Levy is Vice President of Corporate Medical Quality at Best Doctors. The mission of Best Doctors is to provide the right diagnosis and right treatment to patients. The company provides medical consultations by connecting patients’ physicians to the best expert specialists in the world. Dr. Levy provides medical leadership to the clinical operations team. He has over twenty years of clinical experience as an internist at Harvard Vanguard Medical Associates in Boston and is also as an Instructor at Harvard Medical School. He earned his medical degree from the University of Rochester School of Medicine and Dentistry and completed his residency in Internal Medicine at the Graduate Hospital of the University of Pennsylvania.

LEARN MORE AT: www.BestDoctors.com/MarylandMD1


Harnessing the

POWER of Imaging to Fight Cancer Imaging modalities play an important role in the early detection and monitoring of cancer. Maryland radiologists describe how advances in 3T MRI and PET/CT are improving oncologic imaging. By Linda Harder

NOPR DEMONSTRATES VALUE OF ONCOLOGIC PET/CT The value of PET with F-18 fluorodeoxyglucose (FDG-PET) in oncologic diagnosis and treatment planning was demonstrated resoundingly in the National Oncologic PET Registry (NOPR), which began in 2006. After the initial NOPR data was analyzed, in 2009 the Centers for Medicare and Medicaid Services (CMS) expanded coverage for FDG-PET scanning for Medicare beneficiaries diagnosed with cancer. The NOPR continued to collect data for many remaining cancer indications. The 2009 CMS ruling provided reimbursement for PET scans used in the initial evaluation of patients with most types of solid tumors, and allowed for PET in subsequent evaluations for an expanded number of cancer types. Ethan Spiegler, M.D., chief of Nuclear Medicine at Advanced Radiology and chair of Nuclear Medicine at Saint Agnes 18 | WWW.MDPHYSICIANMAG.COM

Hospital, notes, “Since 2006, almost all solid tumors have been approved for initial diagnosis with PET.” In 2011, based on a February 2010 National Coverage Decision, the NOPR began collecting data on Medicare patients undergoing PET with sodium fluoride-18 (NaF-PET) to evaluate bony metastatic disease. Dr. Spiegler comments, “While FDG-PET has proven to be an excellent tool for soft tissue information, the registry is still used to compare sodium fluoride bone scans to NaF-PET. I think the results are likely to show that PET is useful for bone metastasis, common in prostate cancer.” Beginning in early 2013, CMS allowed physicians to order up to three FDG-PET scans after the completion of initial therapy without having to submit data to NOPR. Local Medicare contractors must determine whether subsequent scans will be covered. The CMS decision was applauded by PET advocates, including the Society of Nuclear

Medicine and Molecular Imaging and the Medical Imaging & Technology Alliance (MITA). Dr. Spiegler notes, “Referring physicians no longer need to complete NOPR paperwork to refer patients for PET/CT. While not perfect, NOPR is considered a successful model that is likely to be replicated in the future. It gathered evidence from more than 100,000 scans to show that PET positively affects patient management. In the scheme of things, even though it’s an expensive technology, it was found to save dollars and lives.” CMS also added prostate cancer as a clinical indication for PET this year. Dr. Spiegler cautions, however, “In prostate exams, PET/CT is not appropriate for the initial diagnosis, although it has a strong role to play in guiding the management of advanced prostate cancer.” He adds, “Myeloma also just got coverage approval this year. And we are


now researching whether using FDG and NaF during the same PET/CT scan can be used in place of a bone scan plus other modalities. The only added cost of this approach would be the second isotope.”

NEWER RADIOISOTOPES SHOW PROMISE In September 2012, the FDA approved the production and use of C-11 choline in PET as a result of its effectiveness in detecting recurrent prostate cancer. It is appropriate for patients previously treated for prostate cancer who have elevated prostate-specific antigen (PSA) levels. New isotopes for determining whether or not prostate cancer is confined to the gland are also in the research and development stage. According to Dr. Spiegler, “No modality does that well yet. It’s not clinically available today, but studies look promising.” A Johns Hopkins study published recently in the Journal of Nuclear Medicine gives preliminary hope that a new small molecule radiotracer (18FDCFBC) can be used in PET scans to visualize metastatic prostate tumors. Rather than using an analogue of glucose labeled with 18F-fluorine, the study attached 18F-fluorine to DCFBC, the small-molecule compound they manufactured that can target the prostate-specific membrane antigen (PSMA) found in prostate cancer, and vasculature found in other types of solid tumors. Because 18F-DCFBC targets PSMA as it protrudes from the cellular membrane of the tumor, it highlights cancerous soft tissue, such as that in lymph nodes. And its ability to directly target the tumor site appears to enable it to pick up lesions not seen on conventional bone or CT scans because they haven’t yet resulted in local bone destruction.

ONCOLOGIC 3T MRI “A very important contribution 3T MRI has had in oncologic imaging is the enhancement of MR spectroscopy,” says Elias Melhem, M.D., John Dennis chairman of the Department of Diagnostic Radiology and Nuclear Medicine at the University of Maryland Medical System. “The enhanced signal-to-noise ratio of 3T helps because it can detect metabolites despite their low concentration. 3T also provides better spectral resolution that

allows us to tease out the metabolites that are significant in cancer.” 3T spectroscopy not only distinguishes cancer cells from benign tissue, but it can also determine how aggressive the tumor will be. Another advantage of 3T in oncologic imaging entails Susceptibility Weighted Imaging (SWI). SWI has developed into a powerful clinical tool used to visualize venous structures and blood products in the brain and to study a range of pathologic conditions. It provides complementary information to that offered by spin density, T1 and T2. Dr. Melhem explains, “SWI is implemented much better at 3T. We can detect metastatic breast cancer at a much earlier stage, for example.”

3T MRI FOR PROSTATE CANCER 3T MRI is used in conjunction with ultrasound in staging prostate cancer, to determine if the cancer has extended beyond the capsule. It can also be used in computer-assisted 3D MRI/Ultrasound Fusion Biopsy to create a more targeted biopsy in men who have had a negative biopsy but a rising Prostate-Specific Antigen (PSA), or men diagnosed with prostate cancer who are undergoing active surveillance. Radiologists and urologists combine efforts to fuse an

it requires that a smaller 5T magnet be available in a room adjacent to the 3T magnet. “The C-13 is cooled to nearly zero degrees Kelvin,” Dr. Melhem notes. “The 5T magnet is used polarize the contrast agent. As soon as it’s polarized, it is brought into the room with the 3T magnet and the patient, and then injected. When using C-13 in humans, it must be sterile, which makes the technique expensive.”

TREATING BRAIN TUMORS WITH 3T 3T MRI is also starting to be used in conjunction with focused ultrasound to treat brain tumors. “We will be the first in Maryland to use MRI-guided focused ultrasound to detect changes in brain tissue temperature,” states Dr. Melhem. “We will use MRI to localize the tumor, then use the ultrasound to heat and destroy cancerous tissue. It’s useful with primary tumors or metastastic disease, as well as epilepsy. We will be involved in Phase III trials of essential tremors. We would heat up an affected area, watch that the tremors improved, and know that we had targeted the right tissues.” Dr. Melhem predicts that in the next year or two, 3T MRI will be able to target tissue in the breast and prostate using much the same approach. He

…NOPR is considered a successful model that is likely to be replicated in the future. It gathered evidence from more than 100,000 scans to show that PET positively affects patient management. – Ethan Spiegler, M.D.

MRI image onto a live 3D ultrasound image to create a Doppler ‘map’ that pinpoints the location of potential tumors and replaces the current random template biopsy. The near future of 3T MRI holds even more excitement. “The future is in MR Imaging with Carbon 13 labeled 3pyruvate, and UMMC will be one of the first to get it,” enthuses Dr. Melhem. “We will be part of a multi-center trial led by University of California San Francisco that will observe metabolic activity in prostate cancer to determine who is appropriate for watchful waiting and who is not. The challenge has been how to accurately classify patients.” The new approach may be limited to academic centers with deep pockets, as

concludes, “PET/CT and 3T MRI play complementary roles in detecting metastatic disease. MRI is most useful in peering into the brain to find evidence of metabolites, while PET/CT is excellent throughout the body. Together, they provide nearly complete surveillance.”

Elias Melhem, M.D., the John Dennis chairman of the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical System Ethan Spiegler, M.D., chief of Nuclear Medicine, Advanced Radiology and chair of Nuclear Medicine, Saint Agnes Hospital

SEPTEMBER/OCTOBER 2013

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Profile

SPONSORED CONTENT

Lessening the Pain of an EHR Upgrade or Purchase

W

HY IS AN EHR purchase or upgrade so often painful – and for so long after its initial purchase? And does it have to be? James Milligan, CEO of Medical Mastermind, who has seen many physicians that are still putting in long hours, long after their EHR implementation, believes it should not be so painful. He says, “We’ve seen some doctors that were still carrying both paper and electronic charts around for months. They were disenchanted because the EHR had not delivered on the paradigm it had promised – that it would be easier and better than paper and that they could see more patients. It was true that staff no longer hunted for records and that pharmacy orders could be delivered electronically, but otherwise it was more, not less, painful.” While it’s also painful to abandon the many hundreds of hours and thousands of dollars invested in an existing EHR, the failure to deliver on promised efficiencies is one of the reasons that many physicians are now looking to change their EHR system. “Some of the newer systems are delivering on their promises,” Milligan says. “They are focusing on work flow, ease of use, being intuitive, decreasing 20 |

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James Milligan, CEO of Medical Mastermind

the number of clicks and being available on mobile devices such as an iPad. These products are finally delivering on the paradigm that was promised.” Suggested questions to ask when evaluating a new EHR purchase or an upgrade follow. Is It Designed With Physician Input?

The desire to have an integrated system based on the way physicians actually practice motivated Software Unlimited Inc. to merge with Integrated Health Care Solutions (IHCS) in early 2013 and rename the company Medical Mastermind. Milligan explains why IHCS was selected out of 200 practice management companies they had considered. “IHCS was launched when a group of EHR designers got together with five dissatisfied physicians and several programmers to create one of the few EHR systems that meet

physician needs. They worked together to create a system that was easy to use, facilitated physician workflow and reflected the way each of the doctors actually practiced medicine.” “Of course, any EHR represents a big change and involves change management,” Milligan acknowledges. “But it should not make things more difficult, and after the start-up period, it should greatly reduce the time physicians spend charting so that seeing more patients is a natural consequence of using their EHR.” The company, which is headquartered in Pikesville, MD, has more than 1,500 customers in the U.S. and about 250 of those are using the new EHR – we’re the fastest growing EHR vendor in the U.S.,” Milligan comments. “We do all of our implementation on site and our local staff provide service throughout Maryland.”


Does the EHR Specialize in Your Specialty?

One of the questions to ask an EHR vendor is whether their system can accommodate the needs of your medical specialty. “Medical Mastermind can be used by all specialties, but we have seven that we do exceptionally well, including primary care, pediatrics, orthopaedics, otolaryngology, podiatry, urgent care and chiropractic,” Milligan states. Does the EHR Accommodate Variations in Practice Style?

One of the greatest challenges EHRs face is accommodating variations in the way physicians practice – even within the same group. Jody Harbour, Medical Mastermind’s chief designer and VP of Product Development, recalls, “One of our practices has seven surgeons; while they’re all in the same location, they practice medicine in seven different ways. Our system was the only one they found that allowed them to keep practicing individually. For example, one physician wanted a templated (a pre-defined tool to capture and organize clinical data within the system) approach, while another preferred the narrative approach. We found a way to incorporate the narrative approach while still maintaining compliance. We spent a long time learning from the physicians and then applying what we learned to our system.” Mark Brown, M.D., FACS, was initially the most reluctant physician in his ENT practice to convert to an EHR. However, after rejecting a number of EHR systems, he found he was impressed by Medical Mastermind’s willingness to learn from him. “My attraction to the system was that they said, ‘we’re going to make this work the way you practice now,’ not, ‘you have to practice the way we’re going to make this work.’’’ After becoming one of the system’s biggest advocates, Dr. Brown retired and went on to become the medical director for Medical Mastermind. The Medical Mastermind EHR system is easy to adapt to the needs of a given physician because it has a series of ‘switches’ that can be turned on and off. That makes it flexible without requiring an expensive or labor-intensive custom solution. Mastermind EHR arrives fully integrated with PM and Billing, and uses a permissions-based system to allow

access to various functions depending on the user. For example, to enable the complete Practice Management suite, settings are changed by Medical Mastermind once the licenses are purchased, eliminating the need for additional software installation or integration.

PM are appropriate for the solo practitioner, but easily scalable to a practice with 50 practitioners or more in multiple locations. “We have experience with both solo physicians and larger groups, whereas legacy products usually become too complicated when you try to scale them down,” Milligan notes.

Does the EHR Offer Integrated Practice Management?

Does the EHR Offer a Robust Patient Portal?

Another reason to replace an EHR includes needing a system with integrated practice management (PM), rather than one that was retrofitted, or two separate software programs attempting to share data. According to Milligan, “Many vendor companies focused solely on their EHRs, but that created inefficiencies when they tried to integrate the system with practice management. Without a single, integrated database, you lose information on scheduling, patient data, billing and so on.”

Meaningful Use Stage 2 will make patient access to their data and communication between providers and patients more critical. Patient portals have proven to be an effective way of achieving some of the Stage 2 milestones as well as a time-saver for physicians and patients. Satisfied user Darmesh Bhakta, DPM, comments, “The patient portal is a huge benefit for us. It saves time, especially if patients can fill out their medications and dosages at home. We get a more complete picture of the entire patient that

….any EHR represents a big change... But it should not make things more difficult, and after the start-up period, it should greatly reduce the time physicians spend charting so that seeing more patients is a natural consequence of using their EHR. – James Milligan, CEO Peter Whitehead, M.D., a pediatrician whose group uses Medical Mastermind, notes, “They have helped us, from a physician practice standpoint and an operational standpoint, to manage our monies going in and out, manage our visits in, manage our patients to optimize healthcare and to optimize revenue for the practice.” Can You Choose Between Client Server and Cloud-Based Systems?

As discussed in the Nov/Dec 2011 issue of Maryland Physician (Should You Store EHR Data Onsite or Offsite?), physicians have to determine whether a server-based or cloud-based EHR approach makes the most sense for their practice. Milligan notes, “A big part of our acquisition of IHCS was that it enabled us to offer physicians the choice of either approach. Also, if the doctor wants us to handle his or her billing, we can offer that as part of our services.” Mastermind EHR and Mastermind

way. The patient portal helps us to be more complete. Now we feel like we have triple-checked their data. The patient checks it, our medical assistant and I check it, and we have an entire history – and it’s correct.”

Medical Mastermind, established in 1984, provides Electronic Medical Record and Practice Management solutions to thousands of physicians from all specialties. Its award-winning software (including its recent award as the 2013 Black Book award for #1 Top Rated EHR for Otolaryngologists, and inclusion in Capterra’s 2013 list of the Top 20 EHRs in the country) is designed by doctors, nurses, billing administrators, and other medical personnel to provide the ideal solutions for any size practice and every specialty. For more information, visit www.medicalmastermind.com.

SEPTEMBER/OCTOBER 2013

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Policy

Maryland Health Connection: A New Insurance Marketplace As this issue went to print, the date to launch enrollment for families and individuals in Maryland Health Connection was looming for Executive Director Rebecca Pearce and her staff. Ms. Pearce talks about how this new service will change healthcare coverage for many, as well as its potential impact on physicians.

Q:

What is Maryland Health Connection? The Health Connection

is a new health insurance marketplace designed to make it easier for Marylanders to shop for, compare and purchase quality health coverage. We’re not federal health insurance; we’re the conduit – the “store” – for carriers to put their products on our shelves. A single, streamlined application determines eligibility for Medicaid or private insurance. Consumer assistance will also be available through our call center or in person throughout the state in local health departments, departments of social services and a network of consumer assistance organizations known as “Connector Entities.” 24 | WWW.MDPHYSICIANMAG.COM

TRACEY BROWN

An Interview with Rebecca Pearce, Executive Director, Maryland Health Benefit Exchange

Q:

What was one of your greatest challenges? Even though Maryland

started early compared to many states, we had lots of policy decisions to make. And, we had to set up an entire organizational structure – we started with just me. Today, our state agency has grown to more than 50 people.

Q:

Who do you expect will purchase insurance in the Health Connection? The first year, we expect

about 250,000 newly eligible people to enroll, which includes about 100,000 people who will be newly eligible for Medicaid when it expands from 116% to 138% of the federal poverty level. Maryland Health Connection will determine if a person qualifies for Medicaid or commercial insurance. At the end of 2015, we expect that all of the 1.2 million people on medical assistance will use the marketplace.

In Phase 2, our long-term goal is to have the non income-based Medicaid population go through it as well – that is, long-term care, disability and also social services. We’ve done 12 focus groups around the state. There’s a misnomer that people don’t want health insurance. We found that people want to have health insurance and want to know that they can see a physician when needed. When we presented them with a price and the value of the insurance they would get through Maryland Health Connection, and what the federal subsidies might be, they were willing to give up amenities like their cable television to get health insurance.

Q:

Which insurers are participating in Maryland Health Connection?

Currently, we are working with CareFirst BlueCross BlueShield, Kaiser


Permanente, United HealthCare and Evergreen Health Cooperative. The 2011 legislation requires that insurers making a certain dollar level outside of the exchange must participate in Maryland Health Connection. We’re also hoping to see MCOs [Medicaid Managed Care Organizations] starting in 2015; they’ll need to obtain a license first.

Q:

Discuss the rates that will be charged under the Health Connection.

Maryland’s rates are among the lowest of the 12 states with approved or proposed rates – on a dollar-to-dollar basis, they’re lower than all but one plan in New Mexico. New York, for example, decreased their rates 50% but they are still higher than ours. And three out of four Marylanders are expected to qualify for federal tax credits. You can’t do an apples-to-apples comparison to rates in the past year because this is the first year that we will be offering essential health benefits under the new marketplace due to the ACA. Because of self-selection, the individual market has historically had a lean set of benefits. It’s like comparing buying a hatchback to buying a sedan. Everyone is hoping the marketplace will attract younger people. They are often overlooked as the people who will get subsidies through the marketplace, but because many of them are not making large salaries, they will benefit. The federal subsidies apply to individuals making up to $44,000 a year. Someone making the federal poverty level of about $22,000 will pay a maximum of 6.5% of their income, or about $114 per month, out of pocket for insurance because the federal government is giving subsidies. We don’t control the fee schedules that carriers pay providers, but they should be similar to other fee schedules.

Q:

For physicians who run small businesses, what are the options and requirements? The Small Business

Health Options Program (SHOP) will open in January 2014 and provide small businesses a choice of quality insurance plans and carriers. Companies with up to 50 employees are eligible, but not required, to purchase insurance through

Maryland Health Connection. There is no penalty for employers of this size. And the federal government just said that there is no penalty for any size employer in year one. Employers can only access federal tax credits if they purchase coverage through SHOP beginning in 2014. Our website includes a Small Business Tax Credit Calculator to help them determine if they qualify for a tax credit for providing insurance for employees.

Q:

Will those using Maryland Health Connection be able to see their doctor? In fact, we created the ability to

search online for a list of participating health plans by doctor. You can bring up all of the plans that include your doctor. We’re the only place you can do that.

Q:

How will providers be affected?

We would love to partner with the physician community; we recognize that they’re going to be touching the people we’re bringing in. We want to understand from them what they are seeing. They may see an influx of people who may not be used to using primary care. So there may need to be some education on their part – for example, they may see a 40-year-old who has used ERs, not a

Q:

How will you educate and enroll the 180,000 people that you anticipate?

We have multiple ways to enroll people. The first way is through insurance brokers. About 1,500 insurance brokers in the state have provided notice of their intent to use our Health Connection. They have to be licensed by the Maryland Insurance Administration to participate, and authorized by us to sell through Maryland Health Connection. With about 180,000 newly insured people, it’s a growth opportunity for brokers. We’ve been partnering with them since 2011 – we want to supplement them, not replace them. We also are establishing a customer support center with a toll-free number, and we awarded grants to six consumer assistance organizations (Connector Entities) statewide to provide individual enrollment assistance. They will reach the underserved and hard-to-reach populations, including those with disabilities. We’re hiring a total of 300 people to provide in-person assistance; 150 of whom are navigators who provide education and outreach, as well as enrollment in both Medicaid and qualified health plans. The remaining 150 people are known as assisters; these individuals also conduct education and

The Small Business Health Options Program (SHOP) will open in January 2014 and provide small businesses a choice of quality insurance plans and carriers. – Rebecca Pearce primary care physician, to date. We are working directly with FQHCs [Federally Qualified Health Centers] and community providers, and especially the mental health providers to let them know that, as people get insured, they need to contract with the carriers in Maryland Health Connection, and here’s what you need to do to change your business model. And we’re talking to the carriers as well. We’ve been trying to bridge that gap between those two sets of providers. And the governor’s office is working to address provider shortages.

outreach. They can also enroll people in Medicaid, but not private insurance. We are also working with the Department of Health and Mental Hygiene and Department of Human Resources to train the caseworkers and eligibility workers in the local health departments and departments of social services statewide. These 2,500 people, who currently enroll people in Medicaid, will receive in-depth training on the use of Maryland Health Connection and enrollment. (continued on page 29) SEPTEMBER/OCTOBER 2013

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Healthcare IT

H e a lt H i n f o r m at i o n e xc H a n g e s :

THE NEXT HURDLE EHR adoption has skyrocketed, but can disparate systems talk to each other? Health information exchanges (HIEs) are beginning to bridge the gap; Maryland is ahead of many states and stands to weather the loss of HITECH Act funds beyond 2013 better than most programs.

LINDA HARDER • PHOTOGRAPHY BY TRACE Y BROWN

T

HE HEALTH INFORMATION Technology for Economic and Clinical Health (HITECH) Act made electronic health records (EHRs) nearly ubiquitous. According to a 2012 survey by the Centers for Disease Control and Prevention, the percent of physicians using an advanced EHR system climbed from 17% in 2008 to more than 50% by 2012, and over half had received an incentive payment for meeting Stage 1 of Meaningful Use. Similarly, the survey found that hospital adoption of EHRs grew from 9% in 2008 to 80% by 2012. But as Meaningful Use Stage 2 looms on the

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horizon starting in 2014, providers need to begin contemplating the next major hurdle – connecting electronic information among disparate EHRs and hospital systems to begin better coordinating care. CRISP: Maryland’s HIE

To encourage electronic sharing of patient information, the State HIE Cooperative Agreement Program has helped fund state and regional efforts. With funds from this national program, as well as state funding, Maryland formed a statewide HIE called the Chesapeake Regional Information


System for our Patients (CRISP), a notfor-profit membership organization that became operational in September 2010. CRISP is in a better financial position than many HIEs, with a combination of state, federal and hospital funding. “We have less than one year left of federal funding,” David Horrocks, CRISP CEO, comments. “But they are only about 15% of our HIE budget. I’m confident that we have a revenue model that will allow us to continue our work.” A 2013 status report from the Robert Wood Johnson Foundation, Health Information Technology in the United States, found that, in contrast to Maryland, where all acute care hospitals participate in CRISP, nationally only 30% of community hospitals participated in HIE during 2012. And only 10% of operational HIEs supported six Stage 1 Meaningful Use measures for information exchange. Not surprisingly, the use of HIE by physician practices was much lower, with 10% reporting participation in 2012 compared with 3% in 2010. Adam Weinstein, M.D., nephrologist and medical director of the Eastern Shore ACO, says, “In Maryland, the information is centrally controlled, which gives us better control and standards than in states such as Utah, which has an Intermountain Health HIE that is not statewide. The goal of sharing data is the Holy Grail.” Now that all hospitals and a number of key radiology and laboratory providers have had ample time to contribute data, the next step in the arduous process of achieving interoperability is to provide more electronic information about hospital admissions, discharges and emergency visits to physicians, so that they can follow up with outpatient care as appropriate. Horrocks says, “We have three services – Query Portal, Encounter Notification Service (ENS), and Reporting for Quality Initiatives. We’re happy to help physicians start on a process to use the ENS or Query Portal.” Query Portal Service

Comments Horrocks, “The Query

Portal currently receives about 15,000 queries a month and that number is doubling roughly every six months. The typical user is an ER physician or other physician in the hospital setting, but physicians in ambulatory settings can also take advantage of this service once they are credentialed.” The portal allows clinicians to enter a patient name and view prior medical records (chiefly from prior hospitalizations) and also a growing amount of lab and imaging data. “In the last month, we’ve added several new feeds from hospitals, such as new lab results. Our goal is to have more than 90% of all possible feeds by this fall,” Horrocks notes. Craig Behm, executive director, MedChi Network Services, explains, ���The doctor can query the hospital where his patient was discharged for lab values and other data, as available. It’s a work in progress, though Maryland

opiod use data into physicians’ hands, to support the Prescription Drug Monitoring Program.” CRISP is seeking to deploy single-signon between hospitals and practice EHRs and the Query Portal, so that credentialed doctors can quickly access patient information. Today, the patient’s name and address must be entered manually, taking up valuable time, and adding the risk of human error. Encounter Notification Service

A newer CRISP service that went live in August 2012 is the Encounter Notification Service (ENS), which provides messages to participating physicians when their patient visits the emergency department (ED), or is admitted or discharged to a hospital. Physicians can select the services for which they want to receive notification. Behm observes, “Any physician practice can participate in ENS. The

David Horrocks, CRISP CEO

is at or near the top of connectivity compared to other states.” “The Query Portal is used primarily when the doctor is in a treatment encounter, to help him or her make the best decision,” says Horrocks. “And we’re now partnering with the Department of Health and Mental Hygiene to get pharmacy data on prior

physician panel sends a list of patients to CRISP, and CRISP assigns those patients to a doctor. That doctor can select what data he or she wants to get. It involves an open source, secure message platform through a web portal. All of the data is free.” “About 700 physicians have signed on, mostly primary care physicians,”

SEPTEMBER/OCTOBER 2013

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Healthcare IT Secure Messaging to Connect Providers

CRISP also offers DIRECT Messaging, a secure and encrypted email service that supports electronic communication between physicians, nurse practitioners, physician assistants and other healthcare providers. This service continues the goal of securely sharing a patient's clinical information among their treating providers in Maryland. Currently, DIRECT Messaging is free for the first year. However, secure messaging is not yet widely used. Dr. Weinstein notes that electronic communication between primary care physicians and specialists has a long way to go. “The challenge is to make the data HIPAA compliant. It’s far from the panacea envisioned, so most doctors are still faxing information. The staff has to print out the faxed data; I manually sign it and send it back.” Craig Behm, executive director, MedChi Network Services

says Horrocks. In large practices, the notification may go to the care coordinator, who channels information to the appropriate physician. The data can also be downloaded in a spreadsheet, so that information can be sorted. Practices can choose to receive one summary email early each morning to provide information on all patients that can be incorporated into their daily routine. “It’s a good fit for physicians in a Patient Centered Medical Home or Accountable Care Organization (ACO),” Horrocks adds. “And Medicare has new CPT codes that reimburse physicians for timely follow-up care, so this service potentially enhances a physician’s revenue stream.” Quality Initiative Reporting

Quality initiative reporting is the newest aspect of CRISP’s data, operational since January 2013. It provides inter-hospital readmission reporting, so that a patient discharged from one hospital and readmitted elsewhere within 30 days can be tracked. The ER Bounce-Back report is being rolled out this fall, so that hospitals can track when discharged patients return to the ER within 72 hours. 28 | WWW.MDPHYSICIANMAG.COM

Getting Data to the ‘Last Mile’

As a provider trying to take the data available from CRISP and put it to work for an ACO comprised of many individual practices, Dr. Weinstein has a unique perspective. “At the moment, we’re simply reporting the data, but our ACO is about to get CRISP data. We’ll

clearer about what data we need. We’re focusing on things we think will impact our cost and reporting on them. Our ACOs are a microcosm of the industry. It comes back to how you get different EHR vendors to talk to each other.” Behm contributes, “MedChi would like to see Maryland have almost a state utility model for interoperability. CRISP has made incredible progress in setting up the pipeline. However, at this time, some hospitals can send a summary within 48 hours, while some can’t send any summary yet.” The lack of compensation is another barrier to coordinated care. Dr. Weinstein notes, “I do a lot of home monitoring now, but it’s not reimbursed. The ACO gives us hope that we’ll be incentivized in the long run. All of us want to see basic issues tackled but we don’t have a reimbursement system to do that.” Dr. Weinstein explains, “The question is, ‘What is the critical data coming out of an outpatient encounter?’ It’s easy to say that someone with congestive heart failure should be seen often and receive a special diet, but if that patient can’t get up and down the steps to come to the office, we may not be able to give them the care they need.”

"We’re trying to address the ‘last mile’ of connectivity – the provider." – Adam Weinstein, M.D.

know that one of our patients was just discharged and focus on care transitions as points of potential intervention.” He is focused on getting the data, whether electronic or not, to ‘the last mile.’ He explains, “We’re trying to address the ‘last mile’ of connectivity – the provider. CRISP sends the data to us and we get it to each doctor, whether it has to be via fax or whatever other process the doctor can use. Each practice has its own IT system, so we have to be flexible. Starting this summer, we’re putting the technology pieces in place. You need an extra staff person to handle the data.” He adds, “Practices are figuring out what their relationship is to aggregate data. But we’re getting a better sense of what it means to be an ACO, and we’re

Behm acknowledges, “In some cases, we’re using 21st-century technology but 20th-century processes. It’s easy to get frustrated, but in two years we’ve seen great progress. We’re no longer talking to doctors about what Meaningful Use is, but about how they get there. We need to take the risk to lean forward.”

Craig Behm, executive director, MedChi Network Services David Horrocks, CEO, Chesapeake Regional Information System for Our Patients (CRISP) Adam Weinstein, M.D., nephrologist and medical director of the Eastern Shore ACO


Maryland Health Connection: A New Insurance Marketplace

benefits would provide the best solution for a group’s employees.

(continued from page 25)

Q:

We just received our final funding, and contracts started July 1, 2013. In August we’re training staff, then they’ll hit the street around September, and about the same time we’ll be rolling out a statewide advertising multi-media campaign. We’re also receiving requests to speak at hospitals and medical societies.

Q:

How has your experience on the insurance side been helpful? Having

knowledge of insurance programs has been hugely helpful in my current role. I understand how people purchase insurance and what’s important to them. At Kaiser Permanente, I spent lots of time negotiating and facilitating the communication between employers, insurers and doctors, and getting all of the stakeholders to agree upon what

How has being a woman affected your career? I discovered early

on that you have to make decisions based on facts, not feelings. I realized that people make decisions in business based on data. I’m often the only woman in the room, and I’m leading meetings with male CEOs, many of whom head multi-million-dollar companies. There have been weeks on end when I haven’t been home in time to put my daughter to bed. I couldn’t do this job without having an understanding husband and family.

Q:

Will you be able to relax a bit once enrollment begins? I tell people

that we’re racing to the start, not the finish. Open enrollment runs for six months. After October 1, we need to be focused on how to make what we put in place for the start better, and make sure we have as many Marylanders enrolled by March 31 as possible. Visit www.MarylandHealthConnection. gov to learn more, or visit Facebook: www.facebook.com/MarylandConnect; Twitter: @MarylandConnect and YouTube, www.youtube. com/marylandconnect

We’re not federal health insurance; we’re the conduit – the “store” – for carriers to put their products on our shelves. – Rebecca Pearce

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Living

Rock Hall: Capturing the Treasures of the Chesapeake Bay

A

S THE WEATHER BEGINS to cool and the fall foliage begins to paint communities across Maryland in shades of orange, red and brown, the town of Rock Hall braces with excitement for its biggest event of the year. Thousands of tourists flock to the small waterfront community in Kent County to take part in “FallFest,” recognized as one of the best celebrations of music, dancing and oyster shucking that can be found along the East Coast. Held at The Mainstay, a historical building in town that has served as the venue for hundreds of concerts and musical performances of all genres since its opening in 1997, the 16th annual FallFest will feature a full lineup of family-style entertainment and fun on Saturday, October 12, 2013. “FallFest originally started as another way to draw people into town for a fun

By Tracy M. Fitzgerald • Photography by Jacquie Cohen Roth

FallFest, held annually in Rock Hall, is recognized as one of the best celebrations of music, dancing, and oyster chucking found along the East Coast.

to northern ports in Pennsylvania and New York, and southern ports along the Virginia coast. Production and distribution of commercial seafood was a town priority in the early days, with more than 80 percent of Rock Hall’s residents making a living that revolved around the “fruits” of the Chesapeake

Sometimes you can look out on the Chesapeake Bay and you will see hundreds of boats anchored. It’s this kind of scenery that people come to Rock Hall for.”—Ron Fithian, Rock Hall town manager weekend,” said Ron Fithian, who serves as town manager for Rock Hall. “The weekend centers around music, crafts and family-friendly activities, and last year we brought in the oyster theme, which went over very well; in fact, we shucked over 13 bushels of oysters! Every year, the event gets bigger and better.” Rock Hall has long been recognized as a seafood town that offers easy access to the wide open spaces of the Chesapeake Bay. Originally called Rock Hall Crossroads, the town was positioned as a connection point for shipments of tobacco, seafood and other agricultural products transported along the Eastern Seaboard, from Baltimore and Annapolis 30 | WWW.MDPHYSICIANMAG.COM

Bay. Today, the town is best known as a scenic sailing community, offering a peaceful place to kick back and relax. “We actually have more boat slips within the town limits than we do full-time residents,” said Fithian. “Sometimes you can look out on the Chesapeake Bay and you will see hundreds of boats anchored. It’s this kind of scenery that people come to Rock Hall for.” Visitors of Rock Hall have found that getting out on the water for the day is actually quite easy. Novices, experienced sailors, and even those wishing to charter a boat for a day of fishing or relaxing on the water will find a wealth

of options, as Rock Hall has six fullservice marinas, plus a handful of smaller ones, in operation. And for couples or crowds who prefer to unwind on the water over dinner and a glass of wine, a number of special sunset sailing packages are available. On the entertainment front, Rock Hall strives to please locals and tourists alike throughout the year. In addition to FallFest, the town puts on a series of annual events and festivals, including a “Pirates and Wenches Tour” that draws thousands of people for a few days of reenactments and summertime fun every August. There are also three museums open year-round that spotlight and celebrate the history of Rock Hall and its people, and its notable contributions to the seafood and sailing industries. Additionally, Bayside Landing Park, positioned alongside the Rock Hall Harbor, offers a public swimming pool and dual public access boat ramps, while Ferry Park – noted as one of the best local beach picnic sites – features a shaded pavilion and breathtaking views of the Chesapeake Bay. “People that visit Rock Hall go home and tell others about the waterfront beauty that can be found here, that is like no other,” said Fithian.


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32 | WWW.MDPHYSICIANMAG.COM


Solutions

Four Tips to Tax-Efficient Investing By Keith I. Levitt, CFP®

P

HYSICIANS ARE OFTEN IN HIGHER tax brackets, making the tax implications of their investments especially important. If your portfolio isn’t tailored for tax efficiency, you could be costing yourself tens of thousands of dollars. A recent study charted U.S. investment performance from 1926 to 2011.1 It found the average annual rate of return on the stock market dropped from 9.8 percent to 7.7 percent after accounting for taxes. If you invested $100,000 at 9.8 percent, after 20 years your investment would be worth $700,000 – that’s $235,000 more than the same investment at 7.7 percent. A tax-efficient financial plan takes advantage of specific strategies designed to mitigate the effect of taxes on your investments. Here are four ways taxsmart investing may help you keep more of what you earn. Tax-Managed Mutual Funds. Although mutual funds are generally not known for their tax efficiency, tax-managed mutual funds seek to limit turnover and distributions and use other strategies to minimize tax implications. Separate Accounts. Through separate accounts – that is, managed investments that buy individual securities with

pooled money – a manager can avoid pre-existing gains/losses and short-term capital gains, strategically harvest losses to offset gains and identify lots for sale. Tax-Deferred Accounts. The table below summarizes considerations of taxable and tax-deferred accounts in seeking to improve your portfolio’s tax-efficiency: Knowing When and How to Sell

Holding investments for more than one year can help you take advantage of the lower long-term capital gains tax rate when you sell, though there may be investment risks to consider. Buying the same security at different times and prices (“lots”) gives you control over any gains/losses you realize. Capital losses can be used to offset gains dollar-for-dollar plus up to $3,000 of ordinary income each year, though realized losses in tax-deferred accounts cannot offset gains in taxable accounts. Losses from wash sales (i.e., when you sell a security at a loss but repurchase the same or similar security within 30 days before or after the sale) cannot offset gains or income in the current tax year – the loss may be deferred until the replacement property is sold or permanently disallowed. One other strategy worth discussing

Taxable Accounts

Tax-Deferred Accounts

Individual stocks you plan to hold for more than one year

Individual stocks you plan to hold for less than one year

Tax-managed stock funds, index funds, taxmanaged funds and low-turnover funds

Actively managed stock funds generating short-term capital gains

Stocks or mutual funds paying qualified dividends

Taxable bond funds; corporate and government bonds producing high-income, zero-coupon bonds; inflation-protected bonds or high-yield bond funds

Municipal bonds

REITs

with your financial advisor is converting 401(k) funds into Roth retirement accounts. Although income contributed to a Roth 401(k) is taxable the year it is earned, it will grow and, in many cases, be distributed tax-free. Because of market fluctuations, your portfolio’s performance may vary. However, tax-smart strategies may help you gain greater control over the taxes you pay and keep more of what you earn. Investors should consider the investment objectives, risk, charges and expenses of mutual funds carefully before investing. This and other information is found in the prospectus or summary prospectus. Please read the prospectus or summary prospectus carefully before investing. There are many differences between separately managed accounts and mutual funds, all of which should be considered very carefully before investing. All investments carry some level of risk and may not be suitable for all investors. Fixed income securities’ value generally declines in a rising-interest-rate environment. High-yield securities may be subject to market, interest rate or credit risk. Dividends are not guaranteed and are subject to change or elimination. Past performance is not a guarantee of future results. Article provided by Robert W. Baird & Co. for Keith Levitt, Senior Investment Consultant and Vice President at the Baltimore office of Robert W. Baird & Co., member SIPC. He can be reached at klevitt@rwbaird.com. Robert W. Baird & Co. does not provide tax advice.

1 Taxes Can Significantly Reduce Returns data, Morningstar, Inc. March 1, 2012.

Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and CFP® in the U.S.

SEPTEMBER/OCTOBER 2013

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Good Deeds

NAMI: Educating, Supporting and Advocating For Local Patients with Mental Health Needs

issues they actually have, like an injury, infection, ache or pain.” NAMI Maryland has formed six education and support-based programs, making tools and resources available for patients, as well as Shown at a recent community event (left to right) is Don Slater, NAMI board president, Brian Hepburn, M.D., executive director of caregivers, relatives and Maryland’s Mental Hygiene Administration, and Kate Farinholt, survivors. Many group executive director of NAMI Maryland. discussions are led and complex cases to a specialist for care,” facilitated by people who once faced Farinholt added. psychological issues themselves, and can According to a report published by speak from personal experience. the U.S. Department of Health and “We partner with the very people Human Services, one in four adults who originally came to us for help,” experience a mental health disorder in explained Farinholt. “We also work to any given year. That same report bring physicians and other specialists confirms that fewer than one-third of together to talk about the issues they those individuals receive care for their are seeing with patients, and how they diagnosable condition; a statistic that We are working hard to build relationships and directly motivates the work of NAMI Maryland and its sister organizations, make new connections, so that doctors can located in each state of the country as adequately address basic mental health issues well as Washington, D.C. in a primary care setting, and will know when “NAMI was created 30 years ago as an advocacy organization, and it was and how to refer more complex cases to a clear pretty quickly that there were specialist for care. –Kate Farinholt, executive director, NAMI Maryland opportunities to fill the gaps and create systems to support patients and families can work together to address them.” services available for patients with who struggle with mental health issues,” Increasing access to mental health mental illness, with a vision to ensure said Farinholt. practitioners for Marylanders is a key that those diagnosed receive the NAMI Maryland has developed a priority for NAMI Maryland. According treatment and support needed to lead brochure outlining available services and to Farinholt, many patients often turn to full and productive lives. support programs. Physicians are their primary care physician as a first “Research shows that people with encouraged to contact the organization step, rather than a specialist, which can severe and chronic mental illness die at 410-884-8691 to request an electronic lead to undiagnosed, untreated or under25 years earlier than the average copy of the brochure. For further treated conditions. American,” said Kate Farinholt, information, visit www.namimd.org. “We are working hard to build executive director of NAMI Maryland. relationships and make new connections, “These are the people who always Maryland Physician would like to so that primary care doctors can answer ‘I am fine’ when their doctor hear about your “Good Deeds.” adequately address basic mental health asks how they are doing, because they Please share your ideas with us at issues in a primary care setting, and will are only focused on getting through news@mdphysicianmag.com. know when and how to refer more the day. They don’t even think about the VERYONE KNOWS THAT mental health issues exist within the patient population, but very few truly understand the prevalence of these medical challenges in communities across Maryland. The fact is that more than 300,000 citizens of the state have been diagnosed with schizophrenia, depression, bipolar disorder or another serious mental illness. And that number continues to grow. Many of the patients who suffer from these conditions face a long line of physical, psychological and emotional challenges that can impact their day-today functionality and capabilities. Thankfully there is an organization committed to providing education, support, outreach and advocacy on their behalf: The National Alliance on Mental Illness (NAMI). The local affiliate, NAMI Maryland, makes a number of

34 | WWW.MDPHYSICIANMAG.COM

PHOTO COURTESY OF NAMI MARYLAND

E

By Tracy M. Fitzgerald



Maryland Physician Magazine Sept/Oct 2013 Issue