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October 2013

Official Publication of The Lancaster City & County Medical Society

Integrative Medicine Taking “Alternatives” Mainstream

Caring for the Long term Insights into Lancaster County Elder Care

The Primary Care Shortage How Severe Will the Shortfall Be? To view this issue online, visit

Periodical

lancastermedicalsociety.org


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A 17543 Lititz B 17538 Landisville C 17601 Lancaster

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Executive Director’s Message

From New Technology to Organic Produce

“Thank physicia you to the manage ns, practice rs, who ext and readers e congratu nded their lati job well ons on a done.”

B

.efore I discuss the topics of this issue, I must say that I’m thrilled by the enthusiastic response the first issue of Lancaster Physician has received, and I’m grateful to those who made it a success:

Thank you to the contributors who took time from their busy schedules to write articles or sit through interviews. Thank you to the physicians, practice managers, and readers who extended their congratulations on a publication well done. Thank you to the patients who asked questions about the stories and information they read. The Lancaster City & County Medical Society will continue to build Lancaster Physician around our mission. We’ll strive to provide value to the medical community and the patient population by offering a unique voice in service to the public health. In this issue, we cover a wide range of topics from Community Supported Agriculture to Physician Quality Reporting System, to communications technologies that enable patients to be more engaged in their care. As we do in every issue of Lancaster Physician, we’ve included segments to keep you in the know about upcoming events, member news, and legislative updates on important issues that affect both practices and patients. We hope you enjoy reading the October issue as much as we continue to enjoy working with the membership and contributors in creating it. Again, thank you for your positive feedback and encouragement!

lancastermedicalsociety.org

As always I want to engage you in the conversation, and we welcome you to suggest topics that will serve the interests of the Lancaster medical community and your patients. Please contact me at klyons@lancastermedicalsociety.org or 717.393.9588.

LANCASTER 4 PHYSICIAN


Contents

2013-2014 BOARD OF DIRECTORS OFFICERS

OCTOBER 2013

Paul N. Casale, MD President The Heart Group of Lancaster General Health

Christopher L. Hager, MD Immediate Past President Lincoln Family Medicine

James M. Kelly, MD President-Elect Lincoln Family Medicine

David J. Simons, DO Vice President Community Anesthesia Associates

C. David Noll, DO Secretary Ephrata Community Hospital

Stephen T. Olin, MD Treasurer Lancaster General Hospital

DIRECTORS John A. King, MD Elected Director Three Years General Internal Medicine of Lancaster

The Primary Care Shortage The health care system is complex and changing, and data can be manipulated. How real is this problem? (p.10)

Laura H. Fisher, MD

Robert K. Aichele, DO Elected Director One Year Aichele & Frey Family Practice Associates

Stacey Denlinger, DO

Shawn F. Phillips, MD

International Medical Graduate Representative Neurology & Stroke Associates

Charles A. Castle, MD Lancaster County Business Group on Health Representative Lancaster General Health

Karen A. Rizzo, MD, FACS PAMED Officer Liason Lancaster Ear, Nose & Throat

Lancaster Physician is a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patient-centered care in an increasingly complex environment.

Featuring Landis Communities in Lititz. Part one of a series focused on the long term care options in Lancaster County. (p.20)

Partial knee resurfacing is an advanced treatment option designed to relieve pain and restore range of motion. (p.14)

Elected Resident Two Years Heart of Lancaster Regional Medical Center Residency Program

Venkatchalam Mangeshkumar, MD

Long Term Care

MAKOplasty® Partial Knee Resurfacing

Elected Director Two Years Lancaster Family Allergy

Elected Resident One Year Lancaster General Hospital Family & Community Medical Residency Program

Part I

Best Practices

In Every Issue

6 Integrative Medicine 9 PALCO 10 PCP Shortage 14 MAKOplasty® Partial Knee Resurfacing 17 Medical Real Estate Trends 18 Online Patient Portals 20 Long Term Care

23 24 27 28 32 34 36

Lancaster Physician is published by Hoffmann Publishing Group, Inc. Reading PA I HoffmannPublishing.com 610.685.0914 I kay@hoffpubs.com

Patient Advocacy Healthy Communities LMS Foundation Updates Restaurant Review News & Announcements Member Spotlight Regulatory Updates

Editor-in-chief: Kelly Lyons, Executive Director, LCCMS Editors: Laura Fisher, MD, Lancaster Family Allergy James Kelly, MD, Lincoln Family Medicine


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pr ctices Integrative Medicine PALCO PCP Shortage...How Severe Will the Shortfall Be? MAKOplasty® Partial Knee Resurfacing Medical Real Estate Trends Long Term Care Tanning Bed Legislation

Taking “Alternatives” Mainstream KEITH WRIGHT, MD, FAAFP, ABIHM

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h by the way Doc, I just wanted you to know that I stopped ‘medication X’ as I kept hearing that it causes problems, and I’ve started taking an herbal supplement instead.” This has not been an uncommon occurrence in my practice over the last 20 years, and it’s usually spoken as I am about to leave the room. A variety of thoughts arise as I hear this. Is the supplement safe? Effective? How does it compare to the traditionally prescribed medicine? What repercussions will I have from the insurance company and LANCASTER

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medical group chart audits because the patient stopped the recommended medicine? Do I have enough time to discuss the pros and cons of this herbal therapy? I would assume that this happened even to Hippocrates, as human nature has sought to find alternative ways to improve health over the centuries. However, Hippocrates


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Alternative medicine

probably didn’t have the same angst that modern physicians feel when they hear these statements. We have the pressures of practice guidelines, reimbursement tied to outcomes, and the lack of time to fully discuss alternative care. Many physicians don’t have much knowledge about complementary care, and even if they do, that knowledge may be limited by a lack of outcome data. So what should we do? One approach commonly used is to strongly advocate for the use of traditional treatments with the attitude that alternative care is, at its best, a good placebo, and at its worst, downright quackery. Another approach is to forgo most traditional medications with the view that “natural” treatments are the best because they are less toxic and provide more complete healing of the total person. Over the years, I have come to the conclusion that healing/health is a complicated process, and the journey toward good health can be influenced by a variety of factors. A blending of both traditional and complementary care seems to be a good moderate approach in my practice. However, being educated in Western medicine in the U.S. 20 years ago, I had no formal education in complementary care. This created internal conflict when faced with patients who had questions about their health which required knowledge beyond the use of traditional pharmaceuticals, physical/ occupational/speech therapies,

basic nutrition and exercise, and basic mental health counseling. I marveled at the occasional patients who achieved a healthier state by a total transformation of their lifestyle, but wasn’t sure how to motivate others to do the same. Patients’ comments about various non-traditional treatments left me mumbling, “I don’t know much about ____, but I guess it is ok to try it.” At times I would be astonished at the results, for example, seeing a patient lower total cholesterol by over 100 points. Was this really the result of the supplement? Was this a placebo effect? Was it due to an increased awareness of lifestyle? A change in the patient’s diet? There were many patients’ anecdotes about how much better they felt after using complementary treatments. Although these were anecdotes, it was apparent that healing also occurred outside the boundaries of traditional pharmaceuticals. To become more effective in my role as a holistic physician, I needed more knowledge about other treatments. Working with the Plain Community (Amish and Mennonite) and the many “English” patients who desire alternative care, I knew there was a desire among some patients to have a physician with some basic knowledge who could discuss these complementary treatment methods. Research into education venues led me to the American Board of Integrative Holistic Medicine, which offers a course focused on a balanced approach to holistic care. Nutrition as medicine, exercise, spiritual well-being, energy medicine, acupuncture, ancient Chinese and Indian treatments, and much more were discussed in their course. Information was presented in an evidence-based manner, as much as the current data would allow. The field of

Integrative Medicine was presented as complementary and synergistic with traditional medicine. It recognizes that true health is not merely the absence of disease, but a holistic state of well-being, with the primary responsibility for that state lying with the patient.

KEITH WRIGHT, MD, FAAFP, ABIHM LEACOCK FAMILY PRACTICE

The integration of complementary care within my practice has been fairly easy. Starting with discussions about proper nutrition and exercise, I have more educated dialogues with patients regarding carbs, gluten-free diets (when appropriate), aerobic activity, and other lifestyle changes that most physicians are comfortable promoting. These are the foundation blocks of any healthful lifestyle, although outcome data on even these basic recommendations may not be adequate. Patients may not be willing to make these changes, as it is easier to “just take a pill” (taking fish oil supplements instead of eating a moderate amount of fatty fish). However, it is quite gratifying when patients become active participants in their health care, making significant lifestyle changes which improve their overall health. Supplements/vitamins/herbs are the most common forms of alternative care that patients want to discuss. Our office encourages patients to bring in their medicines and supplements at their visits, which gives me a better idea of what the patient is truly taking. (Home visits provide me with an excellent opportunity to assess this as well.) I have discovered that if I actively dialogue Continued on page 8

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with the patients about what “natural” medicines they may be using, it often opens a broader discussion about other lifestyle issues. As with other medicines, patients have a variety of beliefs regarding their supplements. I try to artfully discourage those which may cause harm, and reinforce those which may show benefit. Spiritual/social health also is very important in treating a patient holistically. As I see patients over time, the overall picture of their social network and spiritual beliefs start to form. I can then make recommendations based on their belief systems, such as prayer, meditation, and yoga. After the patients realize that I want to have a dialogue about their overall health, and realize that my overall goal is not to prescribe more medications and order tests, they begin to share other treatments they are undergoing. We can then talk about

Alternative medicine

chiropractic, naturopathic, massage, and other treatment modalities. The challenges to practicing integrative holistic medicine are many. The lack of appropriate time to discuss these issues with patients is one of the biggest challenges. The advantage of being a primary care physician is that I establish relationships with patients that last many years. While I can’t address all of these issues at each visit, I may address one component at a time and build upon it when needed. For insured patients, I will often bill based on time with counseling regarding these issues. Also, there is often conflicting data, or lack of rigorous outcome data, on holistic treatments. Just as with traditional pharmaceuticals, recommendations change at times, requiring continual updating of information. The road to providing holistic care is

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long, but rewarding. Careful listening to the patient, asking about what treatments they are using, providing recommendations and guidance, and acquiring more knowledge about complementary care are all components of integrating holistic care within the practice (and are common tools already used by physicians). Printed and online tools will help with up-to-date knowledge about holistic care. While I have just begun the journey of providing more holistic care, I have already seen improved health in a few patients as a result. I believe that future medical practices will blend traditional and complementary methods of healing as we seek to become more well-rounded physicians. Give it a try! Start by incorporating more specific detailed information about diet and lifestyle. Perhaps then patients will start to say, “Oh by the way Doc, I feel much better!”


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Project Access Lancaster County (PALCO) PROJECT ACCESS LANCASTER COUNTY (PALCO) IS A PROGRAM OF THE LANCASTER COUNTY MEDICAL FOUNDATION TO CHAMPION HEALTH INSURANCE COVERAGE

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esources for Human Development (RHD) in a collaborative partnership with Project Access Lancaster County (PALCO) was awarded the largest federal Navigator grant in Pennsylvania to assist the state’s uninsured with health insurance enrollment by targeting those who have struggled to obtain coverage. PALCO will help provide health insurance enrollment assistance in the ten counties in Pennsylvania with the highest rates of uninsured people. The counties–Philadelphia, Montgomery, Bucks, Chester and Delaware, Allegheny, Lancaster, York, Berks and Lehigh –account for 53 percent of uninsured Pennsylvanians. RHD, a national human services nonprofit with corporate headquarters in Philadelphia, is collaborating with

the U.S. Department of Health and Human Services through a cooperative agreement to provide Navigator services in those ten counties. RHD and its collaborating partners are deeply embedded in each of these counties. Together the collaboration will implement a multi-level outreach and communication effort that will reach approximately 576,000 individuals. The grant of $953,176 was awarded to RHD on August 15th, as Health and Human Services Secretary Kathleen Sebelius announced a total of $67 million in awards to 105 Navigator applicants in 34 Federally-facilitated and State Partnership Marketplaces. These Navigator grantees and their staff will serve as an in-person resource for Americans who want additional assistance in shopping for and enrolling in plans in the federally-run Health

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Insurance Marketplace beginning this fall. “Traditional communication tools alone are not effective in reaching large numbers of people,” said RHD corporate assistant director Laura Line. “Yet people continue to participate in and rely on trusted organizations where social connections are made and care is received. These organizations have extensive local networks, and direct access to the people who would most benefit from the federally-facilitated health insurance exchange.” The Health Insurance Navigator Program seeks to utilize these groups with deep roots in communities to access uninsured and under-insured individuals. Many of these groups already provide or advocate for access to health care as one aspect of their work. Navigators will work with and within these groups and their networks, giving presentations and facilitating individual enrollment. Furthermore, community-focused media outlets, social media and technology provide a critical mechanism to reach people effectively. The program will partner with Cárdenas-Grant Communications to extensively use these personalized channels that are often sources for health information to reach potential enrollees as a key part of the communications campaign. “Navigators will be among the many resources available to help consumers understand their coverage options in the Marketplace,” said Secretary Sebelius. “A network of volunteers on the ground in every state–health care providers, business leaders, faith leaders, community groups, advocates, and local elected officials–can help spread the word and encourage their neighbors to get enrolled.” Learn more at

palcolancaster.org


AN NC CA ASSTT EE RR M M EE D D II C CA ALL SS O OC CII EE TT YY..O O RRG G LL A

Best Practices

COVER STORY

THE PRIMARY CARE SHORTAGE...

How severe will the shortfall be? DAVID H. EMMERT, MD

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here are dire predictions about the future of October Lancaster Physician primary care access in America. Population trends and the Affordable Care Act are seen to create a major increase in demand, while little is being done to shore up supply. But the health care system is complex and changing, and data can be manipulated. How real is this problem? The AAMC (Association of American Medical Colleges) has predicted that by 2020, there will be 45,000 too few primary care physicians, in addition to a shortfall of 46,000 specialists.1 Colwill et al2 project a shortage of 44,000 primary care specialists by 2025. Increases in population growth, an estimated 15% from 2010 to 2025, account for the largest boost in demand. The portion of the population over 65 will make up a disproportionate amount of the increase, and a larger, older group of patients needs more care. Insurance expansion will require more physicians on top of that. One estimate predicts a need for 33,000 more primary physicians to meet the needs of a larger population, 10,000 more to meet the needs of an older population, and 8,000 doctors to see the patients brought into the system by the Affordable Care Act.3 The supply is not increasing fast enough to meet this demand. We are adding doctors, but not nearly enough. In 2013, 33 more medical students matched in family practice than in 2012. Headlines from the National Residency Matching Program touted a significant increase in medical students entering primary care, but many of these students committed to internal medicine and pediatrics, residencies from which a large proportion will ultimately subspecialize. In the end, less than 25% of graduating students choose primary care.4

L A NLCAANSC TAE SRT E10 R

10 P H YPSH I CY ISAI C NI A N


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Some reasons for this failure will be familiar: heavy upfront investment in student loans, made worse by shrinking reimbursements and higher overhead. We have been promised new models of reimbursement focused around quality and efficiency, which would seem to favor primary care physicians in the medical landscape, but financial investments in patient-centered medical home (PCMH) have yet to pay off for many of us. Currently we are caught between two reimbursement paradigms, neither of which is sufficient to appeal to medical students tempted by more lucrative specialties. The situation is worse, however, because the doctors we have already trained and convinced to work in primary care may not be as productive as they used to be. Why? Technological requirements have reduced productivity for many of our physicians, who are never going to be as efficient with tools that are built around ease of reporting, not ease of documentation.

Primary care physician shortage

More physicians are employed by hospitals. The American Hospital Association reports that, in 2010, nearly 20% of physicians worked for hospitals, a rise of 34% since 2000. Being employed decreases productivity, sometimes substantially, when compared to owning a practice.5 At the same time, the ACA and meaningful use mandates increase the cost disproportionally for smaller, independent physician practices. And since overhead is increasing, selling their practices is even more appealing. More physicians are practicing parttime. In a survey of 14,366 doctors from 2011,6 22% of males and 44% of females worked less than full time, up from 7% and 29% in their 2005 survey. The most likely doctors to work part-time are older men near the end of their careers, and younger women trying to balance family and work. This trend parallels a change in the overall demographics of physicians: male physicians are aging as a group, and the proportion of women in 2010 was

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32.4%, up from 26.8% in 2000. We may be adding doctors, but on average they are not seeing as many patients. PCMH models might reduce the number of patients that can be seen in a day. One emphasis of PCMH is same-day scheduling, which requires that plenty of appointment slots be kept open for urgent issues. While this is good for overall care and patient satisfaction, there are days when those slotsacgo unfilled, as noted by Green et al.7 This reduces potential productivity for each physician, and increases the number of physicians needed to care for a population.

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Not everyone is convinced, however, , if thatyothe end result of current changes t to the health care system will be fewer primary care doctors. Business professors from Columbia and Wharton bey that primary care shortages could lieve be avoided by using teams of doctors who can see each other’s patients, increasing the use of advanced practice r providers such as nurse practitioners Continued on page 13


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Best Practices

and physician assistants, and utilizing electronic communication. If we combine these techniques, individual doctors ought to be able to increase their panel size to accommodate the swelling patient ranks. However, it is reasonable to question these assumptions, since they depend on multiple (and sometimes controversial) changes to our current system. While cross-coverage on call has a long medical heritage, today’s patients are often quite picky about which doctor they see on a regular basis. There is resistance to the idea of increasing the scope of practice of advanced practice providers. Recent evidence suggests

Primary care physician shortage

that the advanced practice providers we would need for this plan to succeed may not be there; similar to medical students, nurse practitioner and physician assistant students are frequently choosing to subspecialize.8 Finally, many of my colleagues refuse to consider adding another uncompensated task like electronic communication to their to-do list, especially when the barrier to firing off an email seems lower to consumers than fighting through a phone tree to leave a message. Others have summarized the importance of primary care to the quality of life, mortality, and cost of health care for Americans.9 A prospective

shortage of primary care physicians therefore implies the potential for significant harm. And that shortage seems much more fact than fiction, given current population and practice trends. The only uncertain issues are just how severe that shortfall will be, and how best to address it.

DAVID H. EMMERT, MD MANOR FAMILY HEALTH CENTER

References 1.Dill MJ, Salsberg ES. The Complexities of Physician Supply and Demand: Projections Through 2025. Association of American Medical Colleges, 2008. 2. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood).2008;27(3):w232-w241. 3. Patterson SM et al. “Projecting US Primary Care Physician Workforce Needs: 2010-2025.” Ann Fam Med, Nov/Dec 2012, Volume 10, Number 6, pp. 503-509. 4. O’Reilly, Kevin. “Primary Care Shortfall could be worse than predicted.” Amednews.com. July 17, 2013. Accessed August 20, 2013. http://www.amednews.com/article/20130717/profession/130719995/8/. 5. Gottlieb S. “Hospitals Are Going On A Doctor Buying Binge, And It Is Likely To End Badly,” Forbes.com. March 13, 2013. Accessed August 18, 2013. http://www.forbes.com/sites/scottgottlieb/2013/03/15/hospitals-are-going- on-a-doctor-buying-binge-and-it-is-likely-to-end-badly/. 6. Flatt T, “Survey Reveals Physician Shortage Challenges Medical Groups and Increases Demand for Advanced Practitioners,” American Medical Group Association, March 12, 2012. Accessed August 18, 2013. http://www. amga.org/AboutAMGA/News/article_news.asp?k=569. 7. Green LV, Savin S, Lu Y. “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication.” Health Aff January 2013 32:11-19. 8. Gates T, Fogleman C, and O’Hurek D. “A Primary Care Perspective on U.S. Health Care: Part 1: The Good, The Bad, and The Ugly. The Journal of Lancaster General Hospital, Summer 2013. Vol 8, No 2, pp. 37-43. 9. Gates T, Fogleman C, and O’Hurek D. “A Primary Care Perspective on U.S. Health Care: Part 1: The Good, The Bad, and The Ugly. The Journal of Lancaster General Hospital, Summer 2013. Vol 8, No 2, pp. 37-43.

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to experience symptoms that interfere with activities of their daily living. Learn more about

A total knee replacement is the treatment of choice for patients having arthritis in all compartments of the knee. The surgery predictably reduces pain and, in most cases, improves function. Complete recovery from the procedure can range from several months to a year. Longevity of the prosthetic knee can vary, and some younger patients may require revision surgery down the road.

Lancaster Regional Medical Center’s Orthopedic Care Network

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Continued on page 16

Learn more at

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FEMUR

PATELLA

New Knees...New Life

TIBIA

PARTIAL KNEE RESURFACING IS AN ADVANCED TREATMENT OPTION DESIGNED TO RELIEVE PAIN AND RESTORE RANGE OF MOTION SETH D. BAUBLITZ, DO ORTHOPAEDIC SPECIALISTS OF CENTRAL PA

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orldwide, millions of people are living with osteoarthritis, also known as degenerative joint disease. This condition commonly involves the knee joint and is characterized by the breakdown of cartilage and the underlying bone. The degeneration of these tissues and bony overgrowth leads to pain and stiffness in the joint. These symptoms often interfere with quality of life and prompt many to explore treatment alternatives.

At the present time, there is no cure for osteoarthritis. Treatment strategies center on alleviating pain and improving function. Orthopedic surgeons typically initiate a conservative treatment approach which can include a combination of anti-inflammatory medication, intra-articular injections, physical therapy, medications, and bracing. Surgical management is commonly offered to patients that exhaust non-surgical modalities and continue LANCASTER

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The knee is comprised of three compartments. (1) Medial (on the inner side), (2) lateral (on the outer side), and (3) femoro-patellar (under the kneecap or patella). Each compartment can be individually affected by arthritis and there is an implant specially designed for each. If a second compartment then becomes diseased, that too can be fitted with the appropriate unicondylar implant and after that, even a third implant may be fitted. In this way a total knee replacement can be achieved but with limited removal of bone and ligaments.


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New knees...new life

Best Practices

What is MAKOplasty®? MAKOplasty® is a robotic armassisted partial knee resurfacing procedure designed to relieve the pain caused by joint degeneration due to osteoarthritis (OA). By selectively targeting the part of your knee damaged by OA, your surgeon can resurface your knee while sparing the healthy bone and ligaments surrounding it.

MAKOplasty® Partial Knee Resurfacing Can: Enable surgeons to precisely resurface only the arthritic portion of the knee Preserve healthy tissue and bone Facilitate optimal implant positioning to result in a more natural feeling knee following surgery Result in a more rapid recov- ery and shorter hospital stay than traditional total knee replacement surgery

Because the native knee is a complex hinge joint that consists of three individual compartments, a subset of patients feels that a total knee replacement feels “unnatural.” The invasive nature of the surgery requires intensive rehabilitation and a several day hospital stay. A substantial number of patients are living with arthritis that affects a limited area of the knee joint. These individuals may be excellent candidates for a partial knee replacement. Instead of replacing the entire knee, the surgeon removes only the diseased bone and tissue from the involved area. The metal and plastic implants are placed; however, the healthy parts of the knee and native knee ligaments remain intact. Partial knee replacement surgery is often referred to as “minimally invasive” because it typically requires a smaller incision and less bone removal. Other potential advantages include less blood loss, shorter hospital stay, and faster time to functional recovery. Technological advances have resulted in wider adaptation of partial knee replacement surgery. Sophisticated

surgical instrumentation and implant design have helped eliminate many of the pitfalls once associated with the procedure. In fact, robotic-assisted knee surgery has emerged and holds tremendous promise for enhancing patient outcomes. One type of this surgery is called MAKOplasty®–robotic-assisted partial knee replacement and resurfacing. This procedure can also be used for total hip arthroplasty as well. Surgeon experience and appropriate patient selection are crucial to the success of any type of partial knee replacement surgery. Patients who qualify for the procedure can expect good long-term results. Conversion of a partial knee to a total knee replacement is possible and may be required in rare cases. LANCASTER

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Seth Baublitz, DO, is a board certified orthopedic surgeon specializing in sports medicine and arthroscopic surgery. Dr. Baublitz is the only orthopedic surgeon in Lancaster County to perform both MAKOplasty® Partial Knee Resurfacing and Total Hip Arthroplasty. For more information call 717.735.1972 or visit oscpdocs.com.


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Best Practices

services the consumer purchases. Do not disregard the natural security of an office on the second floor of a building, as this creates a natural barrier to entry and sometimes can be leased or purchased at a discount to ground level space.

Five Trends in Medical Real Estate BLAZE L. CAMBRUZZI, MBA, MSFRE CHIEF OPERATING OFFICER, ROCK COMMERCIAL REAL ESTATE, LLC

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hanges in the health care environment have encouraged many independent physicians to reevaluate their real estate ownership strategies. Although they have historically preferred to own their facilities, many physicians now need to redirect capital to support physician recruitment efforts, foster professional development, implement electronic medical records, and keep pace with ever-changing medical equipment and technology needs.

professional brand. I teach in the business program at Millersville University and quite often I will show my students a commercial from the 1960s or 1970s and ask them to compare these commercials with those of today. Without exception the difference in brand messaging always emerges as a critical distinction. You simply cannot ignore branding anywhere in your business model, especially your building which is often the first impression you offer your patients.

Faced with these varied pressures, new health care regulations, and a continually depressed national economy, many practices are looking to recapture value from their properties. Below are five current medical real estate market trends.

SECURITY So many of our medical offices today have superior security provided by expensive cameras and systems yet for those practices who operate in buildings that have residential style windows, you may not realize how quickly a thief can get in and out of your building. Modern commercial facilities feature different types of windows that do not break easily and create tremendous security for one of the most sensitive

SIGNAGE In an era of branding, you cannot ignore the impact your building and exterior signage have on your

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LEASE VS. BUY Many medical professionals choose to follow the ideology that it is best to own real estate. This may be a good idea, however there are cases when this is not. For example, if you have a large amount of capital tied up in equity for your real estate you may want to consider a structural shift and move to a lease arrangement whereby you could extract that equity and use it for other things such as equipment, or to retire other debt. You can structure a lease that will secure your location, offer flexibility, and even achieve improvements that are apportioned to additional rent. In order to achieve this you may consider a sale leaseback situation or a sale and relocation. INTERIOR STYLE If your waiting room looks the same as it did ten years ago, you should really consider what this says about your practice. Presentation counts toward actual and perceived quality. You really want to make your best presentation both inside and outside of your building. TWO BRANCHES ARE BETTER THAN ONE With the growth in backend office management, many medical practices are finding it effective to leverage existing and trained staff to open satellite or branch offices where backend office functions can still be managed at the main office. Some offices are finding this to be effective if the satellite or branch office is only open a few days a week. To learn more, contact Blaze at BCambruzzi@RockRealEstate.net


L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

that provided Medicare or Medicaid had electronic medical records, according to the U.S. Department of Health and Human Services (HHS). By the end of this year, however, 50 percent of physicians and 80 percent of hospitals will have employed electronic records and demonstrated meaningful use.

Learn more at

MYLGHealthSupport@LGHealth.org

Online Portals Powering Patient Engagement INCREASED USE OF SECURE ONLINE TOOLS IS IMPROVING EFFICIENCY AND PATIENT COMMUNICATION SUSAN SHELLY

L

ancaster General Health (LG Health) has seen dramatic increases in enrollment since introducing its online patient portal, myLGHealth.org, at the beginning of 2010. And, the response from both patients and doctors has been enthusiastic. Several months after the initial implementation of the portal, patient enrollment was measured at 1,600. A little more than three years later, enrollment at the end of June was reported at 53,000, according to Kelley Dubbs, Logistics Manager for Consumer Relations.

The portal, which is a piece of LGH’s system-wide electronic medical record system, is a secure website that enables patients to access their medical records and, in some cases, those of family members; request prescription refills; communicate with their doctors; make or cancel appointments; view test results, and more. Implementation of the patient portal is partly in response to President Obama’s 2009 declaration that electronic medical records should be a national imperative for improving the effectiveness of the health care system.

“We’ve done a lot of work to educate patients about the product, and it’s paid off,” Dubbs said. “As patients become more aware of the product and its potential benefits, we’ve seen big increases in enrollment, which is encouraging for everyone.”

“This product will help us to meet certain objectives,” Dubbs said. “With all the government regulations coming down the road, we’re looking to get patients more engaged with their care.” In 2008, only about 17 percent of physicians and 9 percent of hospitals

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“With all the government regulations coming down the road, we’re looking to get patients more engaged with their care.” Engaging patients electronically in their health care, as myLGHealth. org enables patients to do, is a step in demonstrating meaningful use of electronic medical records. Medical care providers that demonstrate meaningful use can qualify for incentive payments. HHS Secretary Kathleen Sebelius said electronic medical records will both improve patient outcomes and reduce health care costs. “We have reached a tipping point in adoption of electronic health records,” Sebelius said. “More than half of eligible professionals and 80 percent of eligible hospitals have adopted these systems, which are critical to modernizing our health care system. Health IT helps providers better coordinate care, which can improve patients’ health and save money at the same time.” Michael Ripchinski, MD, Physician Informatics Liaison at LG Health, said that, in addition to working toward meeting objectives related to the Affordable Care Act, the portal is good for both patients and physicians, greatly improving the chance for effective


october 2013

Best Practices

Online portals

communication and reducing the risk for medical errors.

CAMPUS EYE CENTER

“One of the biggest advantages is that it gives physicians the ability to really engage their patients,” Ripchinski said.

For All Your Eye Care Needs

OUR SERVICES INCLUDE: Primary Eye Care | Routine Vision Services Medical & Surgical Eye Care

The portal enables doctors to communicate test results to patients the same day they were administered, to monitor patient conditions such as blood pressure or cholesterol, and to collaborate online with patients. According to Ripchinski, typically, information conveyed online from patients to their doctors is more complete and reliable than what physicians would get from phone messages or messages conveyed by busy nurses. Some functions, such as scheduling their own appointments or requesting prescription refills online, also save time and cut costs.

Kerry T. Givens, M.D., M.S.

Lee A. Klombers, M.D.

“The benefit of being able to refill prescriptions online is huge,” Ripchinski said.

LANCASTER

• Pediatric and NeuroOphthalmology • Premium Intraocular Lenses (IOL’s) • Strabismus (lazy eye) • Thyroid-related eye problems

Among the specialized surgeries we offer: • State-of-the-art small incision no-stitch cataract surgery with topical anesthesia • Modern laser vision correction techniques, such as LASIK • In-office glaucoma and diabetic laser surgery • Eye muscle surgery for eye misalignments and lazy eye

2108 Harrisburg Pike | Suite 100 | Lancaster, PA 17601 David S. Williams, M.D.

Lancaster General Health’s patient portal, myLGHealth.org, is a secure website that enables patients to:

condition. Ripchinski shared that having direct access to their charts reduces the chance for error and puts patients more in charge of their own care. It also allows parents or children of elderly parents to access and monitor their loved one’s health information. This can help assure that medicines are taken properly and that all family members have the same information regarding care.

• Eye infections • Eye injuries • Eyelid growths • Foreign bodies • Glaucoma • Macular degeneration

Two Convenient Locations: Health Campus: 717.544.3900

While many of the patient-doctor benefits of the portal system are mutual, patients benefit in some other ways, as well. Instead of just hearing a physician inform a patient about a condition, the patient now has the ability to read the diagnosis on his chart, receive patient education information, and keep track of what is being done to treat the

Access medical records Access medical records of family members Communicate with health care team Request prescription refills Request physician referrals View test results View past and future appointments Schedule or cancel appointments Select specific days and times for appointments Receive reminders to schedule routine tests, such as colonoscopies and mammograms View background and educational information about illnesses or conditions

• Astigmatism (Toric Lens) • Blepharitis • Cataracts • Diabetic eye problems • Dry eyes

Lisa J. Kott, O.D.

Willow Lakes: 717.464.4333

222 Willow Valley Lakes Drive | Suite 1800 | Willow Street, PA 17584

Olga A. Womer, O.D.

www.CampusEyeCtr.com

While myLGHealth.org is in place, it is by no means a finished product. Recently, for instance, a feature was added that gives patients the ability to view available appointment dates and times and choose the ones they want. “We’re always integrating new features,” Dubbs said. Meanwhile, patients who use myLGHealth.org are enthusiastic about the product, saying that it has improved their ability to communicate with their physicians. One mother said she encourages her three teenagers to use the portal in order to increase their personal stakes in their health care. LG Health is the only Lancaster County hospital to have a patient portal in place and operating at this time, but at least one other facility is near to providing the service for patients. Ephrata Community Hospital is looking to roll out a portal system at the beginning of 2014, according to Joanne Eshelman, Director of Community Relations. “It’s been a lengthy process, but we’re in the process of getting from here to there,” Eshelman said. “We expect to introduce the patient portal in January.” Heart of Lancaster Regional Medical Center in Lititz does not have a portal in place at this time, according to Amanda Brunish, Marketing Director.

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L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

It’s one of those things people never want to think about until they, or a loved one, need long term care. It is also one of those things that is much easier to talk about and research before you, or a loved one, actually need it. This series will feature long term care options in Lancaster County. It is aimed at providing insight for your patients so that you can be better equipped to guide them through this major change in their families’ lives.

ian Lancaster Physic .. ongoing series .

CARING FOR THE LONG TERMounty

Part I

In Lancaster C

Steeple View Lofts is Landis Communities newest living option. Located in the heart of downtown Lancaster, it contains 36 rental apartments for those 55-plus. The rentals are designed for those wanting to be involved in the vibrant Gallery Row area of the city.

Landis Communities...Not Just a Home Anymore DANA D. MYERS

E

va Bering, Vice President of Operations for Landis Communities (formerly Landis Homes), says, “There has been a complete transformation in the long term care in Lancaster County. Long term care is so much more than just nursing homes, we’re talking about the continuation of care for an adult–it’s a whole continuum of care.” 

“Most people do not want to live in a nursing home,” Bering said. And the long term care industry in Lancaster is responding. “The goal is really to keep people where they want to live for as long and as least expensively as possible. There are more options than ever–and the options are increasing everyday.” Bering said that seniors do not need to be rushed into a nursing home.

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Just because seniors do not know the current date, does not mean they are not mentally sound; it may simply mean that they do not have a real need to know the date. If they take a longer time to answer a question, they may have delays in processing because their brain is aging, but they still may be very intellectually competent. They may have hearing or vision


OCTOBER 2013

Best Practices

Caring for the long term

Landis at Home, a PA licensed home-care agency, provides reliable, cost-effective care to adults who have chosen to remain in their homes on the campus of Landis Homes, or who live within a 15-mile radius.

October Lancaster Physician

senior apartments afford socializa- tion and city life for seniors.

Landis Nursing Home–an envi - ronment that provides the highest level of care for people who are medically frail. Landis Retirement Communi- ty–apartments and cottages for people who choose social interac- tion and who want to have access to care later in life.

Welsh Mountain–A small, 36 unit, freestanding independent personal care home offered at a lower cost to residents. Landis Communities is the sole owner of Welsh Mountain. In addition, a low income, subsidized housing facility was approved in July 2013.

Adult Day Service–allowing caregivers to work and have respite, while seniors have an opportunity for socialization. During Adult Day Service, seniors can receive therapy and have medi- cations administered.

Many retirement communities offer similar arrangements and are seeking additional alternatives because most seniors do not want to live their lives in nursing homes.

deficits, or they may not be able to write. While these conditions are flags that individuals need assistance, they are no flags that individuals must be confined to nursing homes. That is why retirement communities are developing alternative living arrangements and options for seniors to receive the care they need, at a cost they can afford, and at a location that they enjoy. For example, Landis Homes changed to Landis Communities to better represent the different living arrangements available, including:

Eva Bering, Vice President of Operations, Landis Communities

Marcille Crossland, LUTCF, CLTC President of Integrated Business Consultants, Inc

Landis at Home–private care at the client’s location, on a private pay basis. Steeple View Lofts–a restored tobacco warehouse in Lancaster City, which is handicapped accessi- ble, but offers no health care services. (Landis Communi- ties holds the master lease.) The

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Technology, of course, has become a major player in helping to keep patients safer at home. Medication dispensers, medical alarm and protection systems such as Life Alert, even Skyping, all allow seniors to be monitored and to get the help they need, when they need it. “One of our biggest challenges is educating the medical community about exactly when seniors need to be ‘put in a home,’” Bering says. “Families come to us in very tense and stressful situations because their physician or social worker told them they need 24hour care, when in most cases, 24-hour care just does not exist. Realistically, no in-patient facility provides 24-hour Continued on page 22


L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

Caring for the long term

Taking the LEED* in Going Green As Landis Homes, a continuing care village of Landis Communities, embarked on its expansion, management made a commitment to being ‘good stewards of the earth,' and in 2009 the Living Green effort began. “We are situated in the middle of Manheim Township’s agricultural district,” Linford Good, VP of Planning and Marketing, says. “As we grew, we wanted to reduce the negative impact on our environment. We also wanted to differentiate ourselves from other retirement communities. I think we’ve been successful on both fronts.”

For more information landiscommunities.org contact@landiscommunities.org

direct care. At a hospital, a patient may receive 7-9 hours of direct care, at a nursing home it may be 4-5 hours, and in personal care it may actually only be 2 hours of direct care. Another challenge is changing the mindset that ‘once in a home, always in a home.’ Our goal is to get people back to their own home as quickly and safely as possible. If a senior has an episode that requires skilled nursing care, it is not a life-sentence as it used to be. Seniors now can and should move in and out of nursing homes depending on their specific needs at the time.” Unfortunately, much of the long term care decision-making process has to revolve around finances. Marcille Crossland, LUTCF, CLTC, President of Integrated Business Consultants, Inc., long term care and investment advisor, said, “If clients have long term care insurance, the burden on families can be greatly reduced. Insurance can cover home health care, assisted living facilities, adult day care, and nursing home care. Some policies offer straight

cash benefits for services provided. Years ago, policies simply covered nursing homes, but the goal for most people is to remain at home as long as possible. LTC insurance is one way to make that goal a reality.” Of course, the earlier you purchase LTC insurance, the more affordable it is. “The ideal time to purchase LTC insurance is in your 50s, or early 60s, before typical infirmities set in and premiums increase,” Marcille said. “Insurance professionals can evaluate individuals’ goals for their retirement, the actual cost of care right here in Lancaster County, and factor in inflation, to ensure that people can structure a plan to meet those goals.” “We don’t expect physicians to master the changes in the entire long term care industry,” Bering said. “However, sometimes patients look to their physicians for answers. As long as physicians understand that there are options and alternatives, they can begin the process on the right foot.” LANCASTER

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The most recent phase of Living Green is the addition of new cottages and hybrid homes (a cross between cottages and apartments) that meet LEED Gold Certification.* LEED (Leadership in Energy and Environmental Design) certification entails utilizing design components and processes that have less negative environmental impact, including geothermal heating and cooling. The design also preserves open space, reduces surface parking, ensures indoor air quality and uses energy-efficient materials and construction methods. The new residences are set to open in the fall of 2013 and spring of 2014. Landis Homes’ Living Green initiative began with a comprehensive stormwater management process, including restoring a floodplain–which will allow storm water to permeate the ground rather than run off. Also, ten percent of Landis Homes’ electricity is purchased from “green power” generation, which includes renewable energy sources such as solar, wind, geothermal, biomass, and low-impact hydroelectric. “Many of our residents are very interested in the Living Green effort,” Good said. “They are interested in learning about the changes we are making to enhance the environment of Landis Homes and Lancaster County, as well as the environment that we will pass down to their great-grandchildren. It’s been an exciting and a rewarding process.” *Gold LEED Cerification equals between 60 to 79 of 100 possible base points in a suite of rating systems for the design, construction and operation of high performance green buildings.


OCTOBER 2013

Patient Advocacy

Learn more at pamedsoc.org/stories/hero4/tanning

That’s why Bruce Brod, MD, of Dermatology Associates of Lancaster is hopeful and enthusiastic about House Bill 1259 that recently passed the PA House and is now approaching the Senate. The bill, introduced by Rep. Frank Farry (R-Bucks) would prohibit use by minors under the age of seventeen, and requires parental consent for minors ages seventeen and eighteen. “I’m excited about this bill,” Brod said. “A tanning law has never made it through the PA House before, so we think we made it over a big hurdle.”

Kid Tested...Mother Approved? Tanning bed age restriction legislation passes House and moves to Senate. DANA D. MYERS

T

he World Health Organization’s list of Class 1 Carcinogens (known human carcinogens): cigarettes, asbestos, plutonium, and tanning beds.

Yes, tanning beds. So why does Pennsylvania permit anyone, any age, to use tanning salons? Good question. Especially considering Pennsylvania is one of only two states east of the Mississippi (Alabama is the other) and one of only ten states in the country with no tanning salon age restrictions. Over one-third of teen women use or have used tanning salons by age seventeen. Nationwide, 28 million people per year visit tanning salons (approximately one million visits per day). The success of the tanning industry is that it is marketed to teens with great introductory rates. Tanning is addictive, and actually releases endorphins, similar to

running, creating a natural high. Teens get hooked and tan into their twenties, thirties, and beyond. Look at the melanoma statistics. Melanoma has been fairly stable over recent years except for one group: young women. There has been a steady two percent increase in melanoma, and, with the lag time for cancer to actually surface, dermatologists and oncologists are expecting that steady rise to continue. Many organizations, including the American Academy of Pediatrics, the American Academy of Dermatologists, and the Food and Drug Administration, are calling for a ban on indoor tanning, the sale of indoor tanning equipment, or exclusion of minors from tanning...yet no law has ever been passed in Pennsylvania. LANCASTER

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Bruce Brod, MD Dermatology Associates of Lancaster

PAMED encourages physicians to contact their senators and ask for their support when they return to vote on the legislation in the fall. “Melanoma is a disease that affects all of our patients,” Brod says. “This is certainly not limited to dermatology–oncologists, ear/nose/ throat, plastic surgeons–and now, unfortunately, even pediatricians, and countless other specialties are all affected. I urge all of our physicians to call because it makes a big impact when senators hear from physicians. Thankfully, your opinions still carry a lot of weight. They know you are busy, so when you take the time to call, it means even more. I always think of the quote by Thomas Jefferson, ‘We don’t have a government by the majority, we have a government by the majority who participate.’ Now is the time for all of us who understand the ramifications of tanning beds to start participating.”

pasen.gov

To contact your PA State Senator


L A N C A S T E R M E D I C A L S O C I E T Y.O R G

to them. Lancaster County, with its plentiful access to fresh produce and strong commitment to supporting local businesses, has naturally become a part of this trend. In 2004, Lancaster County boasted just one farm that offered a “farm share” program to area residents; today, there are 12 local farms participating.

October Lancaster Physician

In addition to local families, medical professionals have also found value in the CSA “buy local” concept. According to local nutritionist Carol Spicher, besides supporting local agriculture, medical practitioners are focused on incorporating more whole, nutritionally-rich foods into their diets and their patients’ diets.

Eating out of the (CSA) Box COMMUNITY SUPPORTED AGRICULTURE: ACCESS TO LOCALLY-GROWN PRODUCE OPENS OPPORTUNITIES FOR LANCASTER COUNTY RESIDENTS TO MAKE HEALTHFUL CHOICES PHOEBE CANAKIS OWNER AT PHOEBE’S PURE FOOD

W

ith a growing number of people in tune with the taste – and nutritional benefits – of local, freshly picked, in-season fruits and vegetables, Community Supported

Agriculture (a.k.a. CSA) has sparked a lot of interest nationally. CSAs allow local residents and organizations to buy shares of locally-grown produce and either pick it up or have it delivered LANCASTER

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Joining a CSA helps not only support local growers and prevent local farms from disappearing, but it also provides health benefits to participants. Fruits and vegetables that are at their peak freshness taste their best (which means people are more inclined to eat them), and they offer optimal nutritional value, which may help reduce the risk of some diseases. In Lancaster County, CSAs offer an opportunity for more healthful eating to a community that as a whole suffers from diseases directly attributable to poor diet and obesity. Data from the PA Department of Health suggests that 64% of adults in Lancaster County are overweight or obese, and 54% of Lancaster County youth are overweight or obese.


october 2013

Eating out of the (CSA) box

Healthy Communities

Data from the PA Department of Health suggests that 64% of adults in Lancaster County are overweight or obese and 54% of Lancaster County youth are overweight or obese Lighten Up Lancaster Coalition, an initiative to educate people and help them lead healthier lives, has taken the CSA concept one step further. With the support of Lancaster Buy Fresh Buy Local, a successful pilot program was developed to bring CSAs to the workplace. By participating, employers give employees the convenience of getting fresh produce at the office – which facilitates eating well and could ultimately result in better employee health and fewer sick days. “One of the goals of the Lighten Up Lancaster Coalition is to increase access to healthy foods. LULC, in partnership with Lancaster General Health, is a coalition with a mission to increase the number of Lancaster County residents maintaining a healthy weight,” explains Beth Koser-Schwartz, Healthy Weight Management Coordinator at Lancaster General Health Wellness Center.

Dr. Cynthia Kilbourn of Lancaster General Health Family & Maternal Medicine is passionate about incorporating healthy lifestyles into her family’s daily routine and sharing tips with her patients about how they and their families can easily do the same. She encourages families to shop together, find substitutions for “plastic foods,” keep food preparation simple, and substitute processed foods with more nutritious food choices. Kilbourn does not allow patients’ budget challenges to discourage her from inspiring healthy eating habits. If the upfront payment for the convenience of a CSA is prohibitive to patients, she suggests the alternative of shopping at local farm markets, like Lancaster Central Market and Eastern Market. “I really believe that you can eat well on a budget by shopping for the

Koser-Schwartz believes that when a doctor speaks with patients about weight and related health issues, it allows the practitioner to become a living well role model for patients and the community. The cooperation between Lighten Up Lancaster Coalition, Lancaster General Health and Buy Fresh Buy Local facilitates educating patients about nutrition and providing them access to fresh produce.

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right things, and cost shifting from unhealthy items. For example, a lot of families spend money on sugary beverages; drinking water instead frees up funds for healthier options,” says Kilbourn. She also recommends that families consider getting more for their money by reallocating a large portion of their meat budget to buying beans or other grains like protein-rich quinoa. According to Kilbourn, it’s both challenging and rewarding to educate patients and instill a sense of curiosity about whole, healthful foods. Of course, it’s easier after they realize they have convenient access to it– and they can afford it. Continued on page 26


L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Eating out of the (CSA) box

Healthy Communities

Ready to eat fresh? Check out these resources for recipe ideas that inspire healthful eating: Simply in Season Cookbook by Mary Beth Lind & Cathleen Hockman-Wert The Central Market Cookbook Phyllis Pellman Good & Louise Stoltzfus (get your copies at Lan- caster Central Market Vegetables Everyday by Jack Bishop Vegetarian Times or Moosewood Cookbooks, Recipe Apps (Eating Well Healthy in a Hurry) LuminousFoods.com MeatlessMonday.com LightenUpLancaster.org PhoebesPureFood.com Or find a Local “Pot Luck” (find details on LancasterVegetarianSociety.org)

raw4yoga.com–4th Fridays in Lititz phoebespurefood.com 2nd Fridays in Wyomissing Lancaster Raw Food Potluck–3rd Mondays in Kinzers.

Make It a Family Affair!

G

et the family involved and engaged in a healthy lifestyle. Some CSA programs offer programs that will discount the rates of shares if families do some of the work on the farm, or they offer opportunities to pick-your-own fruits and vegetables. Both give families the ability to get outside and work together. Dr. Jim Spicher, General Internal Medicine of Lancaster,

p e r s o n a l

c a r e

is an avid vegetable gardener whose family runs an organic CSA in central PA. He shares that there’s a bonus health benefit to CSA programs that allow you to harvest your food: not only do you know exactly where the food you’re eating is coming from; you’ll also get some fresh air and exercise.

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october 2013

LMS Foundation Updates Learn more at

pamedsoc.org/Practice-Management/ MedicareMedicaid/News

...Leading the Fight for a New Medicare Payment Model LARRY LIGHT VICE PRESIDENT FOR POLITICAL AFFAIRS, PAMED

T

he congressman from the 16th District (portions of Berks, Chester & Lancaster counties) is not just your ordinary “Joe.” He’s a long time public official who has an equally long record of working closely with physicians. In Congress, Joe Pitts is Chair of the Health sub-committee of the House Energy & Commerce Committee, the committee with oversight of Medicare. During the Congressional District “work” period, he made it a point to meet with his physician constituents to get their feedback on H.R. 2810–the bill he is promoting to permanently repeal the Sustainable Growth Rate (SGR) and implement a new payment model for Medicare. Observers of the national health care debate give it a good chance to avoid again kicking the SGR problem down

the road. And as an extra bonus, H.R. 2810 will avoid the catastrophic 24 percent Medicare cuts scheduled to take effect at the end of the year. H.R. 2810, the Medicare Patient Access and Quality Improvement Act of 2013, has serious traction in DC. The Lancaster City and County Medical Society sponsored a round table forum with Congressman Pitts on August 21st. With Congressional staff available to provide the detailed specific answers on the technical aspects of the bill, Pitts emphasized that the bi-partisan nature of his legislation should bode well for getting it enacted. He acknowledged that there is a lot of work to do, but that unanimous votes in both the sub-committee and the full committee were a good start to full House approval, and serious discussions with both parties in the Senate. LANCASTER

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The two dozen physicians and practice administrators meeting with Pitts didn’t hold back with either questions or criticisms. They noted that the planned annual increases of 0.5 percent were minimal and not nearly enough to cover rising practice costs. There was similar concern about the 1 percent bonus to be earned by those who exceed the quality standards and the importance of who or what was setting the quality standards. The mandate for using electronic health records was also discussed. Pitts and his staff were prepared with the answers, or at least the explanations. Higher annual increases would make the legislation too expensive to be seriously considered. This is intended to provide a time of stability and time to develop new models of care and payment. The core of the quality assessment would be the existing specialty defined measures, not bureaucrats at HHS, and conceivably all providers could qualify for the bonus, not just an arbitrary percentage of physicians. The Health sub-committee has already initiated parallel studies of the drug shortages and prices that are problematic to oncologists. And finally, this is bi-partisan so it has a chance, it is a permanent SGR repeal not a postponement of the problem and it avoids the catastrophic end of the year cuts. It is unlikely that any of the physicians left the meeting with any doubts that Joe Pitts listened to their concerns.

LARRY LIGHT VICE PRESIDENT FOR POLITICAL AFFAIRS, PAMED


L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Restaurant Review lccms member reviewed!

Federal TapHouse BY JAMES M. KELLY, MD

B

eing a fan of craft beers, I was excited when I first heard about the Federal Taphouse, which opened this summer at the North Queen and Chestnut Street intersection in downtown Lancaster. With one hundred beers on tap, there is something for everyone’s taste. A good “bar food” menu accompanies the large beer selection, and the location in the heart of downtown Lancaster could not be better. My wife Kim and I tried the Taphouse twice in the first several weeks after its opening. Our initial experience was on a First Friday. The wait for a table was unfortunately over 2 hours, so we decided to have a drink and be on our way. The second venture was with another couple on a Saturday evening in July. After a relatively mild forty-minute wait, we had a table for four without a reservation. The service was

initially a bit slow, but for most newly opening restaurants I find it takes a good three months before proper judgment can be made regarding service and food times. The beer menu is overwhelming. Upon first walking into the bar, the beers are written on a chalkboard in the greeting area. The beers are organized by type– IPA, Porter, Lager–to assist with your decision-making. I must have spent 10 minutes studying the list prior to placing an order. Only after reaching the bar did I see the printed beer menu, which helped me organize my thoughts a little better for the next round. The lower level of the restaurant is one large open room. A bar area with several flat screen TVs flows nicely into the dining room. Full-length windows look out onto Chestnut Street. There is a second level soon to be a cocktail/upscale wine bar that will open later this fall.

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I started with Founder’s All Day IPA from Grand Rapids, Michigan. Kim is a fan of wheat beers and tried a Long Trail BlackBeary Wheat from Bridgewater Corners, VT. Both beers tasted great, and with another couple we split an appetizer of homemade soft pretzels. The pretzels were larger than we expected, salted just right, and perfect for dipping with the accompanying spicy mustard and beer cheese sauces. We added a second appetizer; duck fat fries topped with braised short rib and melted mozzarella cheese. The fries were cooked perfectly, and the shredded pork topping was a unique addition–a surprisingly good combination. We decided next as a group to split a few of the wood-fired pizzas. I have always felt that good wood-fired pizza is hard to come by in Lancaster, but our choices did not disappoint. We tried a BBQ chicken pizza topped with roasted chicken, mozzarella, fontina, and red onion. The crust had a perfect crispness and the BBQ sauce had a great balance of sweetness and tanginess–a very good pizza! Our second choice was a “Polpette” pizza with homemade meatballs, tomato, mozzarella and provolone. This pizza was my wife’s favorite; my only complaint regarding the Polpette was the size of the toppings. The meatballs were fairly large which required me to cut and redistribute on my pizza slice to be sure I had meatball in each bite. We each tried a second beer with our entrée. I ordered Sweet Baby Jesus, a chocolate and peanut butter porter from DuClaw Brewing in BelAir, Md. Our friends thought I was crazy for trying this, but I can honestly say it was one of the better beers I have tasted in a while. The flavors were subtle and not overwhelming; the beer was smooth and not too heavy. Kim tried a Blue Point Toasted Lager, from Patchogue, NY, which had hints of almond–another good choice.


october 2013

There are many additional entrees to order, ranging from ribs to steak to fish and chips. The couple next to us had salmon steaks and gave a rave review. We unfortunately did not order dessert, but I’ll definitely save room for a Nutella Pizza or chocolate stout brownie on our next visit. In the 10 years I have been in Lancaster, I have seen our downtown transform into a vibrant inner city with many excellent yet family-friendly restaurant options. The Federal Taphouse certainly continues in this tradition. The atmosphere, food, and beer selection were great, and I’ll certainly be back this fall to sample their selection of seasonal pumpkin beers.

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L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements

Three County Residents Awarded LCCMS Foundation Scholarships Future physicians look to provide care to underserved The Lancaster Medical Society Foundation, a foundation of the Lancaster City & County Medical Society, is pleased to announce the recipients of the 2013 Foundation Scholarship. These students have earned numerous academic and leadership awards, and they have been involved in research and clinical experiences. CAITLYN R. RIEHL Riehl grew up in Gap and is a 2013 cum laude graduate of Washington College, Chestertown, MD. She received the Eugene B. Casey Medal, which recognizes a senior woman for being an outstanding scholar and student leader. She will begin her medical studies at Penn State College of Medicine this fall.

Gap taught me to value what I had and to understand that many families go without fulfilling their basic needs. The financial state and cultural mindset of my community has a negative impact on many people’s health. This has stimulated my interest in working with those in rural areas.” Mitchell B. Crawford Crawford is a resident of Conestoga. He completed his undergraduate work at Millersville University. This fall, he will begin his third year at

“My older sister and I are the first in our family to receive a post-secondary education,” says Riehl. “Growing up in

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Philadelphia College of Osteopathic Medicine. At PCOM, he participates in the Primary Care Scholars Program for which he was chosen due to his high level of motivation and his interest in a career in primary care working in underserved communities. Crawford is also a member of Sigma Sigma Phi Honor Society. Crawford states, “I was incredibly optimistic about a future in medicine and I wanted to put my academic abilities to use to better the lives of others. It is incredible to me that while serving others, the training demands the best of you and the experiences mold you into a better person. I have also begun to realize that being a physician is not


october 2013

News & Announcements just a profession, but a way of life–a dedication to medicine larger than I could have understood when applying to medical school. On reflection, I truly could not imagine doing anything else.”

LCCMS scholarships

Research Confirms Use of CO2 During Colonoscopies Reduces Pain

Andrew B. Martin A resident of New Holland, Martin graduated magna cum laude from Messiah College. He will begin his medical education at Penn State College of Medicine this fall. Martin says, “I never thought I would desire a life in medicine, but medical experiences in rural Appalachia, Zambia, Bolivia, and Guatemala have allowed me to discover a place where my passion for science and the needs of the world coincide. While knowledge and critical thinking skills may remain paramount in determining the success of a physician, clinical experiences allowed for me to discover another important aspect of medicine: empathy. I recall the Zambian villagers camped outside the hospital for weeks at a time. These people covered great distances to reach the hospital because they believed they could be helped. The simple presence of a capable medical team had given them reason to hope. The desire to practice medicine in underserved areas is not an ignorant attempt to be the savior of the broken; it is simply a genuine effort to give people the hope they deserve.”

The use of CO 2 has been proven to reduce pain and bloating, decrease recovery time and improve patient satisfaction. RGAL is the only gastroenterology practice in Lancaster that uses CO2 (instead of room air) during colonoscopies. CO2 is used at the Oregon Pike and Harrisburg Pike centers.

About LCCMS Scholarships

No additional cost and less pain. Wouldn’t your patients prefer CO2?

Lancaster Medical Society Foundation scholarships are awarded to residents of Lancaster County who are attending allopathic or osteopathic medical schools. Applicants must demonstrate academic achievement, exhibit good character and motivation, and show financial need. The Scholarship Foundation is generously supported by the Lancaster County medical community, including Lancaster General Health, Ephrata Community Hospital, Lancaster Regional Medical Center, and Heart of Lancaster Regional Medical Center. In addition, group practices, individual medical society members, and local businesses support the fund.

Four Convenient Locations • Lancaster Health Campus • Oregon Pike-Brownstown • Women’s Digestive Health Center • Elizabethtown www.RGAL.com • 717.544.3400

To apply for the 2014 Lancaster Medical Foundation Scholarship, visit the Lancaster City & County Medical Society’s website, LancasterMedicalSociety.org, or call 717-393-9588.

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L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements To publ new LC ish photos of physici CMS memb er ans, p digital lease submit klyons copies t @lanca o ster

Welcome New Physicians...

medica lsociety .org

To date, for 2013 dues cycle

Bruce Waskowicz, MD

Susan Bowman

Conestoga Family Practice

Practice Administrator Lancaster Urology Matthew Evans, DO

Patrick Moreno, MD

Cardiac Consultants, PC

East Petersburg Family Medicine Evan Harlor, DO

Otolaryngology Physicians of Lancaster

David Musser, MD. FACS

Keyser & O’ Connor Surgical Associates, Ltd Vu Nguyen, MD

Joel Horning, MD

Orthopedic Associates of Lancaster, Ltd

New Holland Family Medicine Caitlyn Riehl

Student Penn State Medical College

Thomas Ring, MD

Patrick Judson, MD

Orthopedic Associates of Lancaster, Ltd

Lancaster General Medical Group

Colleen Rumsey, MD Dan Johnson

Student Kirksville College of Osteopathic Medicine Michael Katos, MD

LRMC Anesthesia Associates Joshua Luginbuhl

Student Drexel University College of Medicine

Lancaster Emergency Associates Faith Sawyer

Practice Administrator Lancaster Cancer Center, Ltd David Somerman, DO

Hypertension & Kidney Specialists Mary Strickler

Practice Administrator Cardiac Consultants, PC

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Sharon Wolman

Practice Administrator Eye Doctors of Lancaster


OCTOBER 2013

News & Announcements

Frontline Groups Groups with 100% physician membership as of 9.11.13

Aichele & Frey Family Practice Associates Allergy & Asthma Center Argires, Becker, Marotti & Westphal Campus Eye Center Cardiac Consultants PC Cardiothoracic & Vascular Surgeons of Lancaster Child & Adolescent Psychiatric Associates Community Anesthesia Associates Community Services Group Conestoga Pulmonary & Sleep Medicine Dermasurgery Center PC Dermatology Associates of Lancaster Ltd Eastbrook Family Health Center Electrodiagnostic Medicine Group Ltd ENT Head and Neck Surgery of Lancaster Ephrata Behavioral Health Services Eye Associates of Lancaster Ltd Eye Doctors of Lancaster

Eye Health Physicians of Lancaster Eye Physicians of Lancaster PC Family Eye Group Family Medicine of Ephrata General & Vascular Surgery of Lancaster General and Surgical Oncology Specialists of Central PA Glah Medical Group Heritage Surgical Assoc Highlands Family Practice Hospice and Community Care Hyperbaric & Wound Care Internal Medicine Specialists of Lancaster County Jeffrey H Chaby DO & Associates Justin L Cappiello Md Pc Keyser & O’Connor Surgical Associates Ltd Lancaster Arthritis & Rheumatology Care Lancaster Cancer Center Ltd Lancaster Cardiology Group LLC Lancaster County Center for Plastic Surgery Lancaster Ear, Nose and Throat Lancaster Family Allergy Lancaster Physicians For Women Lancaster Plastic Surgery Lancaster Skin Center PC Lancaster Urology Leacock Family Practice

Lincoln Family Medicine Maternal-Fetal Medicine Specialists Nemours Children’s Clinic New Holland Family Medicine OBGYN of Lancaster Orthopaedic Specialists of Central Pa Orthopedic Associates of Lancaster Ltd Pain Medicine & Rehab Specialists Patient First - Lancaster Pennsylvania Counseling Services Lancaster Pennsylvania Specialty Pathology Rehabilitation Medicine Associates of Lancaster Pc Rothsville Family Practice Roy D Brod MD Southeast Lancaster Health Services Inc Southeast Lancaster Health Services-Arch St Southeast Lancaster Health Services-Hershey Ave Stephen G Diamantoni MD & Associates-Leola Surgical Specialists Of Lancaster The EMG Group at The Electrodiagnostic Center of Lancaster Welsh Mountain Health Center

Membership: What’s In It For You? No time to get down into the weeds of health care policy, legislation, and regulations that will affect the way you practice medicine? Most likely not. That’s where the Pennsylvania Medical Society and the Lancaster City & County Medical Society come in. They inform and represent you on the issues so you can stay focused on diagnosing and healing your patients. The Pennsylvania Medical Society and the Lancaster City & County Medical Society advocate on your behalf to address the issues that will impact your practice–and your patients. The Medical Society also provides resources for education, leadership training, practice management, and patient safety–all made possible by your membership dues. Take this important step toward sustaining a thriving practice —renew your membership for 2014!

HOW? Respond to your October renewal letter Go to pamedsoc.org/membership Call 717.393.9588

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L A N C A S T E R M E D I C A L S O C I E T Y.O R G

MEMBER Spotlight

STEPHEN T. OLIN, MD “Collectively, the societies represent a respected voice sought out by legislators and policy makers, locally, regionally, and nationally.”

S

tephen T. Olin, MD, has been practicing medicine since 1973. He completed his residency at Lancaster General Hospital’s Family Practice Residency Program. Throughout his career, he has held numerous positions at LGH including his current positions of Medical Director for Performance Improvement & Patient Safety and Associate Director of Family & Community Medicine. Olin has been an LCCMS member for almost 40 years and is Treasurer of the organization. He also serves as an LCCMS delegate to PAMED’s annual House of Delegates meeting. Because of the Society’s advocacy–both locally and statewide– on legislative and regulatory issues that impact the lives of

doctors and patients, he believes LCCMS provides immense value to its members. “For the average physician or practice, the ability to affect needed change or to keep current on the status of pending legislation and regulations is almost impossible,” explains Olin. “But, collectively, the societies represent a respected voice sought out by legislators and policy makers, locally, regionally, and nationally.” In addition, he shares he has found the medical society to be “one of the best forums for learning management and leadership skills” and for putting those skills to practical use “with mentorship and support from staff and colleagues.”

REBECCA M. SHEPHERD, MD “I’ll continue my membership in the Medical Society because it’s a great way to remain up to date on current events and meet new providers.”

R

ebecca M. Shepherd, MD, is a physician at Arthritis and Rheumatology Specialists. She completed her residency and fellowship at Washington University School of Medicine in 2002 and 2006 respectively, and she has Board Certifications in Rheumatology and Internal Medicine. Shepherd serves on two national committees for the American College of Rheumatology and is pursuing an MBA at St. Joseph’s University through Lancaster General Health. Shepherd joined the Lancaster City & County Medical Society upon arriving in Lancaster County in 2006. Being relatively new to the Society, she has found membership to be an excellent

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way to meet other physicians and understand the culture of medicine in this community. Through her national committee work, she realizes how important it is to have a voice in medicine, and that physicians need to play an active role in shaping medicine for the future. “This starts at the county level,” shares Shepherd. “Belonging to the Lancaster City & County Medical Society is one of the easiest ways to make this happen, and to stay active and informed. I’ll continue my membership in the Medical Society because it’s a great way to remain up to date on current events and meet new providers.”


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L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Regulatory Update Learn more about the proposed rule at pamedsoc.org/valuebasedmodifier

Under the proposed rule, adjustments will be made to more than 200 “misvalued codes” where Medicare pays more for the services furnished in an office than in an outpatient hospital department or ambulatory surgery center. CMS stated that the expectation is resource costs required to furnish a service are higher in a hospital or ambulatory surgery center (ASC), which has to meet conditions of participation and hospitals’ requirement for standby capacity.

Complex Chronic Care Management

How the Proposed 2014 Physician Fee Schedule Impacts Physicians MARY ELLEN CORUM ASSOCIATE DIRECTOR OF PRACTICE ECONOMICS AND PAYER RELATIONS OF PAMED

T

he proposed 2014 Medicare fee schedule for physician services, which the Centers for Medicare and Medicaid Services (CMS) published on July 19, 2013, provides a preview of changes in Medicare programs and policies. Here are some of the key provisions in the proposed rule that may impact physicians.

Fee Schedule RVUs/SGR The proposed rule does not include any provisions for an update to fees or the sustainable growth rate (SGR). In March, CMS estimated the fee schedule update would be -24.4 percent. H.R. 2810, which passed by a vote of 51-0 through the Energy and Commerce Committee, will come to a full vote of the House upon Congress’s return in the fall. The bill has several

elements, but starts with repealing the SGR and providing five years of stable Medicare payments beginning next year, with reimbursements growing 0.5 percent for each year between then and 2018. Aside from the SGR-related adjustment, there are other proposed changes that will impact physician reimbursement. New geographic practice cost indices (GPCIs) will be developed using updated data. There will also be a modest impact to GPCIs due to changes in weighing where work will be increased and practice expense will be decreased. The GPCI work “floor,” currently at 1.0, will be eliminated and will result in 51 localities having a work GPCI below 1.0.

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CMS is developing and implementing a number of initiatives to enhance care coordination for Medicare beneficiaries. Currently, payment for non-faceto-face care management services is included into the payment for faceto-face evaluation and management (E&M) visits. However, the E&M codes do not reflect all the services and resources needed to furnish the kind of comprehensive, coordinated care management that is required for patients with multiple chronic conditions. CMS agrees and has proposed, beginning in 2015, to pay for the non-face-to-face complex chronic care management services for patients who have two or more significant chronic conditions. Two separate G-codes will be developed for establishing a plan of care and furnishing care management over 90-day periods. Patients must have had an Annual Wellness Exam (AWE) or an initial preventive physical exam, as the AWE can serve as an important foundation for establishing a plan of care. CMS is proposing that services be provided by a single practitioner and that the beneficiary must consent to receiving these services over a one-year period. CMS will establish practice standards necessary to support payment. Potential standards would include access to a U.S. Department of Health and Human Services certified


OCTOBER 2013

Regulatory Update

electronic health record (EHR) at the time of service and written protocols, such as steps for monitoring medical and functional patient needs. CMS may recognize patient-centered medical home (PCMH) designation as one means for a practice to demonstrate that it has met the requisite practice standards. CMS did not propose any RVUs for these services at this time.

Physician Quality Reporting System (PQRS) The proposed rule allows for PQRS incentives to continue through 2014 and penalties to begin in 2015. CMS is proposing the addition of 47 new individual measures and three measures groups to fill existing gaps. The proposed rule includes changes in individual, group practice, and registry. Here are some of those proposed changes that may be of interest to physicians and their practices: Changes to Individual Reporting Increases the number of measures required to be reported via claims or registry from three to nine Reporting threshold for individ- ual measures via registry decreas- es from 80 percent to 50 percent Eliminates the claims-based measure groups reporting option Criteria for using Clinical Data Registries Report at least nine measures to the registry covering at least three of the National Quality Strategy domains Report each measure at least 50 percent of the time Group Practice Reporting Option (GPRO) Eliminates the GPRO web interface reporting option for groups that have 25-99 physicians Adds Certified Survey Vendor Reporting for 25+ groups where

Clinician and Group Consumers Assessment of Healthcare Providers and Systems (CG CAHPS) report- ing would meet criteria for reporting in 2014 and avoid 2016 penalties Increases the number of measures from three to nine and 50 percent threshold (instead of 80 percent) for groups reporting individual mea - sures via registry Please note: Physician practices that don’t report PQRS in 2013 will experience a 1.5 percent adjustment that will be imposed in 2015. You can avoid the penalty in 2015 by reporting at least one PQRS measure or one measures group on one claim for at least one patient in 2013. Read more at www. pamedsoc.org/PQRS.

Physician Value-Based Payment Modifier A provision of the Affordable Care Act (ACA) implements a new value-based payment modifier (VBPM), which is directly linked to participation in PQRS. The VBPM will begin to be applied in 2015, starting with groups of 100 or more eligible professionals (EPs) and all physicians in 2017. Under the proposed rule, the group size threshold would drop to 10 or more beginning in 2016, estimating that nearly 60 percent of physicians would be under the VBPM in 2016. Application of the VBPM will use a two-category approach based on PQRS participation. Under the proposed rule, Category 1 includes physician groups of 10 or more that used the group reporting option (GPRO) to successfully report PQRS for 2014 (avoiding 2016 standing downward adjustment) or groups of 10 or more physicians who did not use the GPRO to report in 2014, but at least 70 percent of the physicians within the group successfully reported PQRS (individually). This category will not be subject to

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Physician fee schedule impact

a downward adjustment by VBPM. Category 2 includes groups of 10 or more not meeting either of the above two standards and will be subject to a 1.0 percent adjustment. Category 1 EPs will have an opportunity to increase their payments if they participate in the VBPM quality-tiering component which evaluates performance on quality and cost measures. Quality-tiering is mandatory for groups of 100 or more physicians and has a maximum downward adjustment of 2 percent for groups that are classified as low quality/high cost and 1 percent for groups classified as either low quality/ average cost or average quality/high cost. Groups of 10-99 participating in quality-tiering methodology can receive either an upward or neutral adjustment, but are exempt from any downward adjustments under quality-tiering in 2016. In the 2013 physician fee schedule final rule, CMS established a policy to create a cost composite for each group of physicians subject to the VBPM. They have since examined the distribution of cost scores among groups of physicians and solo practitioners to determine whether comparisons at the group level are appropriate when applied to smaller groups and solo practitioners. They found that their current peer grouping methodology could have varied impacts on different physician specialties. Therefore, they are proposing to refine their current peer group methodology to account for physician specialty mix.

MARY ELLEN CORUM ASSOCIATE DIRECTOR OF PRACTICE ECONOMICS AND PAYER RELATIONS OF PAMED


Lancaster NeuroScience & Spine Associates

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(standing) Eddy Garrido, MD • Chris Kager, MD • Keith Kuhlengel, MD Bill Monacci, MD • Elliot Sterenfeld, MD • Tony Ton-That, MD (seated) John Gastaldo, MD • James Thurmond, MD

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Originally from Ephrata, Joel A. Horning, M.D. returns to Lancaster County from San Antonio where he was fellowship trained in Sports Medicine at the University of Texas Health Science Center at San Antonio. Thomas M. Ring, M.D. joins OAL from the Johns Hopkins Department of Orthopaedic Surgery. Dr. Ring received fellowship training in hip and knee replacement at the State University of New York at Buffalo. OAL Lancaster

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Physicians • MRI • Physical Therapy • Hand Therapy • LANCASTER

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Outpatient Surgery • X-Rays • Pain Management PHYSICIAN


october 2013

UPCOMING EVENTS

“Representing Lancaster County’s Most Distinguished Homes”

Lancaster City & County Medical Society Board of Directors Meeting October 4, 2013 7:00 a.m. – 8:30 a.m. 480 New Holland Avenue, Lancaster

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October 25-27, 2013 Hershey Lodge and Convention Center

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It’s not too late to serve as a Delegate. Interested? Contact Kelly Lyons at 717.393.9588 or klyons@lancastermedicalsociety.org

100 Foxshire Drive Lancaster, PA 17601 (717) 291-9101 ©2013 BRER Affiliates LLC. An independently owned and operated broker member of BRER Affiliates LLC. Prudential, the Prudential logo and the Rock symbol are registered service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. Used under license with no other affiliation with Prudential. Equal Housing Opportunity

Lancaster City & County Medical Society Board of Directors Meeting

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December 6, 2013 7:00 a.m. – 8:30 a.m. 480 New Holland Avenue, Lancaster

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Lancaster City & County Medical Society Holiday Social

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December 14, 6:30 p.m. – 10:00 p.m. Lancaster Country Club This event benefits the Lancaster Medical Society Scholarship Foundation.

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Lancaster Physician Fall 2013