Spring 2014

OfďŹ cial Publication of The Lancaster City & County Medical Society

Improving Childrenâ€™s Mental & Behavioral Health Services RCCC Advanced Cancer Treatment

PCMH Accreditation

Opportunities & Challenges for Practices, Physicians & Patients

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

LANCASTER

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Contents

2014 BOARD OF DIRECTORS OFFICERS Paul N. Casale, MD

SPRING 2014

President The Heart Group of Lancaster General Health

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

James M. Kelly, MD

PCMH Accreditation

President-Elect Lincoln Family Medicine

Presents Opportunities— and Challenges—for Practices, Physicians and Patients. (p. 8)

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

Laura H. Fisher, MD

Lancaster County, Pennsylvania, & Nation Face Challenging Trend: Shortage of Beds Available for Psychiatric Patients (p. 34)

Elected Director Two Years Lancaster Family Allergy

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

Stacey Denlinger, DO Elected Resident Two Years Heart of Lancaster Regional Medical Center Residency Program

Shawn F. Phillips, MD Elected Resident One Year Lancaster General Hospital Family & Community Medical Residency Program

Venkatchalam Mangeshkumar, 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.

Best Practices 6 Laboratory Automation 8 PCMH Accreditation 16 RCCC Advanced Cancer Treatment 19 LPMA Opportunities 21 Lancaster Cataract & Glaucoma Specialist 22 Art & Science of Neuroimaging Lancaster Physician is published by Hoffmann Publishing Group, Inc. Reading PA HoffmannPublishing.com 610.685.0914 For Advertising Info Contact: Kay Shuey, Kay@hoffpubs.com, 717.454.9179

In Every Issue 4 Executive Director’s Message 26 Healthy Communities 36 Patient Advocacy 38 Legislative Updates 40 Restaurant Review 42 News & Announcements 46 LMS Foundation 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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Executive Director’s Message

Isn’t Peace of Mind

Worth $1.78 a day?

“Thank physicia you to the manage ns, practice rs, who ext and readers e congratu nded their lations o na job well done.”

ow much do you think you would have to pay to have experienced advocates representing your professional interests with the state government, regulators, and insurance companies —EVERY DAY? PAMED is the recognized leader in advocacy, education, and professional support for physicians. The Medical Society makes your voice heard and puts it front and center where it matters the most. And we do it for the equivalent of just $1.78 a day.

Because you’re focused on caring for your patients, staying involved with legislation and regulations is understandably difficult. But the issues move forward without regard for schedules, and they affect just what’s keeping you busy every day—your patients. PAMED works hard for you and your colleagues, but we can’t do it without your membership commitment. Doesn’t $1.78 a day for dedicated advocacy seem like an investment worth making? Don’t you, as an individual physician, want to be empowered and exert some control over the continuing transformation in medicine? PAMED and LCCMS are here to help you navigate the most daunting challenges and to provide vital benefits.

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.

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PAMED Membership Benefits Include: • ICD-10 Education and Training – Prepare for the arrival of ICD-10 on October 1, 2014, using PAMED’s online resources and live training. • Free CME – Access over 40 CME credits which meet patient safety and risk management requirements. New activities are added frequently. • Powerful Advocacy for Physicians – PAMED is looking out for you. Our priorities include physician-led teams, leveling the playing field with insurers, and fair contracts for physicians. • Practice Management Resources – Learn about meaningful use, health exchanges, and much more. Don’t forget: our expert staff provides individualized assistance with issues like reimbursement. • Professional Development Opportunities – Receive guidance in areas like negotiation, fostering communication, strengthening teams, building trust, facilitating change, and driving quality. • Webinars and Videos – Discover education on topics such as long-acting opioids and observation status. The activities are available 24/7, and many offer CME credit. Lancaster Medical Society Membership Benefits Include: • CME provided locally. • Opportunity to contribute to Lancaster Physician magazine, reaching 2,500 physicians and patients in Lancaster County. • Participation in media events such as “Docs on Call” at WGAL-TV. • Social and networking events. Go to www.pamedsoc.org/membership to join or renew now, or call 800.228.7823, ext. 2626, to speak with a Member Services Assistant.

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best

pr ctices Laboratory Automation PCMH Accreditation RCCC Advanced Cancer Treatment LPMA Opportunities Lancaster Cataract & Glaucoma Specialist Art & Science of Neuroimaging ANN M. HORNING, MT (ASCP), SM

Lab Services Manager, Microbiology and Point of Care Testing, Lancaster General Hospital

he Lancaster General Hospital microbiology laboratory has implemented leading edge technology and automation to improve patient care. In the past 30 years, while other areas of the laboratory moved toward automation, the microbiology lab continued using the same manual processes. Joseph Kontra, MD, director of the microbiology lab, said the many instrumentation platforms now available improve the hospital’s processes and turnaround times. “We have had tremendous success with our molecular platform (Cepheid) that allows us to diagnose infections in as little as a few hours, compared to processes that took days in the past,” he said. “Now, more targeted and cost-effective use of antibiotics is improving patient outcomes.” This new technology is the tip of the iceberg for what will be available in

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the near future as LGH strives to improve diagnostic accuracy and turnaround time of microbiology results to give physicians the information they need to impact patient care. As an example, the Cepheid Infinity molecular platform provides rapid diagnosis of a variety of specific pathogens including influenza (including H1N1 strain), MRSA, Staphylococcus aureus (SA), and Clostridium difficile, including the virulent NAP1 strain. This fully-automated PCR platform replaced a tedious 35-step manual process. Instead of having to batch and therefore delay processing and resulting, the Cepheid Infinity can simultaneously process a variety of different samples for different targets in a fully-automated fashion. A clinical application of this new methodology at LGH involved pre-surgical screening of orthopedic patients to identify carriers of SA, as these patients are at much higher risk of post-operative infection. Identification and pre-operative eradication of SA has resulted

Spring 2014

Best Practices

in a substantial reduction in MRSA/SA post-operative infections in prosthetic joint recipients. This screening is being expanded to other disciplines including thoracic surgery and cardiac pacemaker/defibrillator implantation. In February 2014, screening of blood cultures and soft tissue wounds for MRSA/SA was implemented, again allowing for rapid identification of patients infected with this dangerous pathogen. Appropriate antibiotic usage will be measured by the pharmacy to determine the impact of these new protocols. Newer technology still involves the ability to perform multiplex PCR analysis of clinical specimens for a large array of different pathogens simultaneously. The BioFire molecular diagnostic platform analyzes clinical specimens, such as blood or respiratory secretions, for molecular evidence of up to 20 to 30 pathogenic microbes simultaneously. Turnaround time and accurate pathogen identification now takes about an hour rather than days.

Laboratory Automation

The LGH microbiology lab recently celebrated the first installation in North America of the BD Kiestra™ InoqulA™ specimen processor. Developed in the Netherlands, the BD Kiestra™ InoqulA™ specimen processor automates the processing of both liquid and non-liquid microbiology specimens increasing efficiency, streamlining workflow, and providing a new way to deliver consistent results. LGH chose this specimen processor over its competitors because of its patent-pending magnetic rolling bead technology to streak agar plates using customizable patterns. This unique rolling bead technology has been demonstrated to generate up to three to five times more single bacterial colonies compared to manual streaking methods, reducing the time to isolation, identification and susceptibility. ¹Interfaced to the laboratory’s computer system, the technology allows patient specimens to move through the instrument using a barcode. Barcoding reduces errors in specimen identification and processing—a feature unavailable to microbiology in the past. The BD Kiestra™ InoqulA™ specimen processor is an important step in optimizing staff and improving patient outcomes through consistent, automated processes that eliminate hands-on time, human error and inconsistency. The lab currently processes over 2,000 urine cultures per month. The BD Kiestra™ InoqulA™ specimen processor has been used in Europe for several years and was part of BD’s acquisition of KIESTRA Lab Automation BV in 2012, when it saw the potential to revolutionize microbiology labs across the United States. LGH is proud to partner with BD in the initial launch of the platform. Eventually

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we hope that virtually all specimens will be processed using this new technology. Another major advance coming to the microbiology lab is the ability to use mass spectrometry to identify pathogens growing in culture media. An example is the Bruker System. Instead of taking days to manually process and identify colonies growing on petri plates using biochemical tests, the Bruker uses laser disruption of the microbes followed by mass spec analysis of the microbial ‘pieces.’ The instrument can identify with extreme accuracy 96 separate isolates all in about half an hour. Remarkably, the cost per result of this system is less than that of routine biochemical identification, not to mention days faster. So what is next for microbiology? These advances are all part of the march toward Total Lab Automation (TLA). Additional components will be added to the BD Kiestra™ InoqulA™ specimen processor including a system of tracks and conveyors to move plates to fully integrated incubators. Digital cameras will capture images of the media plates at specific times throughout incubation; meaning technologists can review the images at digital reading stations, and proceed with culture work-ups without ever removing the cultures from the incubator. Kathy Vasisko, Laboratory Director, said it is an exciting time for the laboratory. “With our newly completed renovations, we had the opportunity to acquire many cutting edge technologies that improved overall efficiency and patient care. We are proud of our accomplishments and look forward to the future.” (1) High amount of separated bacterial colonies with InoqulA. Jenny Rydback, Ingela Tjernberg and Mats Walder. 2010.

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Best Practices

COVER STORY PCMH Accreditation Presents Opportunities—and Challenges —for Practices, Physicians and Patients

atient-centered Medical Homes (PCMH) have become increasingly popular in primary care as a means of controlling health care costs, improving quality, and maximizing patient satisfaction. Over the last five years, the number of practices certified as PCMH sites has exploded, rising from 28 to 5739. As of last year, more than 27,000 providers had been certified by the National Committee for Quality Assurance (NCQA), one of the organizations that accredit providers and practices for this voluntary programi.

DAVID H. EMMERT, MD Physicians’ Alliance, Ltd.

The goal of the program is to engage patients in a cooperative health-care relationship that coordinates care, prevents disease, and manages chronic conditions. It harnesses the power of medical technology to ensure that patients get recommended care. Access via expanded office hours and after-hours support is required. Systems for tracking completion of recommended referrals and tests, and for analyzing and improving outcomes, are required as well. Efforts to address the needs of vulnerable and high-risk patient populations feed hope that emergency room use and hospitalization rates will decline.

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Description of PCMH and NCQA NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA is committed to providing health care quality information for consumers, purchasers, health care providers and researchers. NCQA’s PCMH 2011 program is a set of rigid standards designed to emphasize care coordination and communication to meet the needs of the patient. PCMH promotes partnerships between patients and their care team. The care team will coordinate care between the primary care provider, hospitals, and specialists. This approach focuses on the patient’s specific care needs which lead to higher quality and lower costs; further improving the patient’s overall health care experience. (some of the above is verbatim from the NCQA website— www.ncqa.org)

Spring 2014

PCMH Challenges & Opportunities

NCQA PCMH Growth 2008-2013

Dozens of requirements must be met by the practice seeking accreditationii, an ambitious transformation that requires extensive planning, increased staff hours, and buy-in from administration, participating physicians, and staff. Our own recent experience at Physicians’ Alliance, Ltd. (PAL) proved challenging (but ultimately successful) in achieving Level 3 PCMH, the highest level possible.

27,820

28000 24,544

24000 20000 16,191

16000

How does a primary care office approach such a project (and should it)?

Clinicians

12000

7,676

8000

Why PCMH?

4000

Health systems might contemplate a move to PCMH for a variety of reasons, including a desire to incorporate systematic evidence-based medicine into practice, a push for improved patient satisfaction, and a marketing advantage for the practice. Traditional non-systematic approaches to medical care allow patients to be lost to follow-up. Without PCMH, test results go missing, orders languish incomplete, and opportunities for services like cancer screening and immunizations are missed.

5,739

5,198 1,976 214

0 Dec-08

383

Dec-09

1,506 Dec-10

Sites

3,302

Dec-11

Dec-12

May-13

to happen. With a multi-site organization, it can be complex and daunting to design ways for dramatically different practice cultures with vastly different backgrounds and resources to adopt similar workflows. We had to consider how a large practice might achieve goals versus how small practices might do the same thing. Staffing issues—hiring new workers versus re-tasking current

PCMH offers a way to address these limitations by shifting to a team approach and use of electronic health records (EHRs). Automating routine workflows and redistributing office tasks allow staff to work up to the limits of their certification instead of relying on habit and tradition to define job descriptions.

Continued on page 10

While all of these advantages appealed to us, the financial incentives offered by insurers to undertake this program gave us the impetus needed to make our decision to participate. PAL president Michael Warren notes that non-traditional reimbursement sources (quality measures and cost efficiencies) account for ever-larger portions of revenue for physicians today: “We found that insurers were looking at PCMH accreditation as an obligated requirement to participate in next generation shared savings programs.” It became clear that PCMH certification would become a validated quality benchmark for the myriad of incentive programs so popular with insurers.

“Representing Lancaster County’s Most Distinguished Homes”

Planning PCMH Transformation

Once the decision to attempt PCMH accreditation had been made, we set about trying to understand the process. We spent weeks trying to decode the 153 separate factors, some of which are mandatory and others of which are optional, in an attempt to figure out what they meant, what they required, and how we would report compliance with them. The provided explanation of these specifications, however, is vague and filled with non-intuitive jargon, so we reached out to several different organizations for help in clarifying our options (see Resources list). We had intense and regular communication with NCQA regarding many of the details. Even then, until we received confirmation of PCMH status, we didn’t know if our interpretation of the criteria was accurate.

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Once we had determined which elements to pursue, we looked carefully at what sites were already doing and what changes needed

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Tips & Tricks

employees—were considered. Training demands were assessed, and we created a plan to introduce the main concepts and teach details to each staff member.

1. Information Wrangling Assign or hire personnel to organize the massive amount of information involved and keep track of progress. Our organization created a new position to manage all of our quality programs, including PCMH. It turned out to be the best investment we made. She has become an expert in the criteria needed to achieve PCMH, as well as Meaningful Use and insurer incentives. She helped us interpret what we needed to do and created reports to let us (and individual providers) know how we were doing. She fostered the creation of “Quality Team” staff members at each site, and communicated with them regularly to help give support to the providers. She communicated extensively with our NCQA representative to make sure our interpretation of the standards was acceptable.

Implementation

Much of the work of developing a PCMH involves documenting existing but unwritten protocols and rewriting existing protocols. Having committed staff to do the heavy lifting of drafting dozens of workflow descriptions in acceptable language is important. In addition, we decided to apply as an organization rather than as individual sites. This allowed us to centralize much of the administrative paperwork and standardize the application process. Organizations with at least three sites whose workflows can be described as being similar should consider applying as one rather than individually to save repetitive application processes. Understanding your electronic records’ capabilities is critical, as they vary in terms of the ease with which they can be adapted to the needs of PCMH. Our electronic medical record system is comprehensively modifiable, but it lacked integrated quality management tools and customer support was spotty. Working around these limitations demanded creativity and lots of trial and error.

2. Choose Carefully As part of the PCMH process, sites must choose preventative and chronic conditions to follow and

We were told that the process of applying for PCMH would take at least 6–12 months, and we indeed found this to be the case. We spent three months planning and an additional three months building electronic tools and training staff. We piloted the concept at six of our larger sites, thought to have more personnel resources and to be better able to absorb the disruption. When this proved successful, we took what we had learned, fine-tuned our workflows, and expanded the transformation process to include the remainder of our providers, who work in smaller practices. Make sure you plan realistically for how long this process will take. If buy-in is not universal, it could take longer to build consensus and move forward. Training was needed for every provider and each staff member in every practice, since each person at every site plays a role, and everyone’s jobs changed (usually significantly). Results of allowing staff more autonomy, within defined protocols, have been rewarding. We see improved satisfaction among nurses, who feel empowered to work directly with patients, providing services by protocol that used to rely on physician memory.

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Spring 2014

PCMH Challenges & Opportunities

address. We used several criteria for determining which of the optional measures we would satisfy. The first of the criteria was clinical relevance. We felt sure that we could avoid work that was merely “busy work” or “jumping through hoops.” We tried to overlap with our pre-existing quality programs as much as possible to minimize work and maximize additional financial incentives. For example, making sure we were collecting glycohemoglobin levels on diabetics seemed like a natural option, since we were already collecting this information for other quality programs. Similarly, in deciding which standing order to institute (a required factor), we chose rapid strep tests, since insurance guidelines look at how many kids with sore throats were tested for strep.

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PAL physicians are self-employed and therefore very sensitive to the cost of any programs we undertake, so when possible, we picked services that focused on improving patient outcomes in addition to enhancing the financial health of the practices. For instance, we chose as one of our preventative measures vision screening in 4-yearolds. Finding strabismus at an early age is critical in ensuring satisfactory correction in children, but the 4-year well child visit is often omitted by parents, since there are no vaccinations and the child is not yet going to school. By creating lists of kids who had not yet been in for a 4-year-old visit and contacting the parents to schedule an appointment, we helped our patients at the same time we received incentives for preventive care. 3. Change is Hard for Doctors It is easier to change our staffs’ behavior than our physicians’ behavior. Clinical and front office staff seem to respond more consistently to new protocols than doctors. Everyone, including physicians, must change in this process, but when there was a choice, we tended to distribute new responsibilities to others in the office when possible. Part of this relates to the relative difficulty of finding time for training, and part of it is due to a doctor’s traditional appreciation of independence. Another reason to assign new workflows to non-providers is to utilize every staff member to the fullest level of their certification, delegating repetitive work to staff and leaving doctors to make clinical decisions. 4. Change is Hard for Patients It is easier to change our staffs’ behavior than our patients’ behavior. We tried initially to focus

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Early Intervention (717) 569-8972 • speechcare.com Roberta Kornfield, M.S., CCC/SLP 2137 Embassy Dr. #103, Lancaster, PA 17603 on how often we saw patients or drew labs or did tests rather than actual patient outcomes. Of course, changing outcomes is the ultimate goal, and in other programs we actively engage efforts to lower our patients’ glycohemoglobins and LDLs. But we reasoned (correctly, I believe) that we needed to start by making sure we were actually seeing our highest-risk patients. So when it came to choosing a statistic which would show improvement, we chose to increase the percentage of diabetic patients who had an A1C in a 6-month period, coronary artery disease patients who had an LDL level measured in the past year, and congestive heart failure patients who had their blood pressure checked. We felt that we could more reliably show improvement in our behavior with our systematic changes. We were pleased to find that this approach led to better patient outcomes down the line as well. 5. Limit Clicks As with anything electronic, the “click burden” on physicians should not be underestimated. While we tried to limit the specific workflow Continued on page 12

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Best Practices

Research Confirms Use of CO2 During Colonoscopies Reduces Pain

responsibilities given to physicians, having to check boxes was the most frequent complaint we received from our partners. Doctors worry that every mandated click detracts from interpersonal connections with patients and decreases productivity. 6. Physician Buy-In Given the additional staff overhead, we had to work to make sure doctors understood the reality that the long-term financial rewards needed to outweigh the short-term investment. 7. Real-time Feedback We found that in addition to our training and teaching, doctors seemed to benefit from chart audits to make sure they were meeting targets for such standards as setting clinical goals, giving written plans of care, and documenting discussions of medication side effects. We devoted extra personnel during crunch time to ramping up awareness and polishing workflows when it really counted.

The use of CO 2 has been proven to reduce pain and bloating, decrease recovery time and improve patient satisfaction.

8. Patients Have a Learning Curve, Too A patient will be surprised the first time the office calls or sends a reminder to get a colonoscopy or a well child visit. Standard 1, Element E, requires that we publicize and explain our PCMH efforts to our patients. But it is apparently different to read about it on a pamphlet and to be contacted about care they need. Sometimes it takes a while for patients to accept the shift in culture and our expectations of increased engagement.

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

Results

IMPROVEMENTS

I’m happy to say that not only were we ultimately successful in our achievement of Level 3 PCMH, but we also saw significant improvement in our quality measures. We felt good about our care going into the process, but, like most physicians confronted with an electronic review of analog processes, we were missing opportunities for routine screening tests. By developing the type of systematic protocols PCMH requires, we became more successful in ensuring recommended care (See Table 1).

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

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In addition, we were gratified to see that our quality metrics improved universally as well. The percentages of diabetic patients with HA1Cs under 7 went from 35% to 37%, and the percentage of these patients with HA1Cs over 9 decreased from 32% to 26%. Blood pressures under 140/90 in CHF patients improved from 71% to 76%. Finally, the percentage of CAD patients with LDL

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Spring 2014

PCMH Challenges & Opportunities

readings <100 went from 44% to 51% (See Table 2). COST The cost for an organization to reach PCMH accreditation, of course, varies greatly between groups and practices, and is difficult to estimate. There is a lot of choice built into the application process. The decisions of which factors to address, and how to do it, could dramatically alter the money required to complete the transformation. For example, additional staff are hired to do extra preparatory work required by PCMH, training is needed for existing staff, and sometimes consultants are required for implementation or reporting expertise. Finally, electronic health records are generally very expensive to implement and maintain; while not required for achieving Stage 1, an EHR is needed to achieve either Stage 2 or Stage 3. Some systems might require an upgrade to allow the type of reporting and registry creation needed for some factors. Any estimates of PAL’s cost to transition to a PCMH model must be considered preliminary and approximate. However, it appears that PAL physicians spent roughly in the range of $12,000 to $16,000 apiece to achieve PCMH when all apparent costs are tallied.

Shortcomings of PCMH

The fact that lawmakers and insurers are jumping on the PCMH bandwagon should perhaps give us pause, as its appeal to administrators does not necessarily involve a stronger, more autonomous doctor-patient relationship. One inevitable result of our recent move to embrace technology is the ability to quantify physician care in ways that make it very easy for insurers and the government to impose their priorities on our medical care. The tendency for non-physicians to look for overly simplistic metrics of quality can put the emphasis more on making lists and checking boxes than it does on a patient’s quality of life. Medicine is rarely black and white, and caring for patients often involves negotiation and the gradual

TABLE 1: LEVELS OF PCMH PCMH LEVEL

POINTS NEEDED

INCLUDED

35–54

All 6 Must-Pass Items

60–84

All 6 Must-Pass Items

85–100

All 6 Must-Pass Items

Physicians’ Alliance, Ltd. sites ranged from 92.25–97 points earned out of a possible 100 points, awarding Level 3 recognition to 16 primary care sites.

PCMH 2011 Requirements, At a Glance: 6 Standards, 28 Elements, 153 Factors

TABLE 2: PCMH MUST-PASS ITEMS PCMH STANDARD/ ELEMENT

DESCRIPTION

Access During Office Hours

Use Data for Population Management

Care Management (Individualized Care Plans)

Self-Care Support and Community Resources

Track Referrals and Follow-Up

Implement Continuous Quality Improvement

build-up of a therapeutic relationship that respects the patient’s goals as well as our own. Not every patient approaches every health care encounter with the same level of engagement that makes PCMH work well, and sometimes we must make short-term compromises that don’t look good in the ledger sheet. Medical practice is messy and analog, sometimes resisting the direction administrators choose.

national stake-holders. This inconsistency, perhaps indicative of confusion or ignorance on the part of insurers, is frustrating to our physicians. Initial PCMH pilot programs were often financed by grants, but this will not continue. The process will need to sink or swim on its own, and if insurers are to benefit from the purported cost reductions, they would also seem to be the proper source of the investment in the process.

Will PCMH be profitable to primary care doctors? It is unclear. Our initial results have been mixed. One local insurer has invested in our efforts, but others have not, despite the fact that PCMH represents the evidence-based results of a large coalition of

In addition, data is mixed on the inevitability of cost savings and better patient outcomes. While many pilot programs have been promisingiii, a recent

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Continued on page 14

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 TABLE 3: QUALITY OUTCOMES IMPROVEMENT BASELINE

REMEASURE

4/1/12 – 4/1/13

4/1/13 – 4/1/14

A1C >=9

32%

26%

A1C 8.9-7

30%

37%

A1C <7

35%

37%

44%

51%

DM:

CAD: LDL <100 CHF: BP < 140/90

71%

76%

study of PCMH programs here in south-central Pennsylvaniaiv showed no improvement in cost, and only one out of eleven quality measures improved. The authors suggest that the model needs to be refined, though others, including the Pennsylvania Medical Society, note that the programs evaluated were based on the original, less-stringent 2008 criteria. Perhaps practices who achieved PCMH under the more recent 2011 standards (or the recently published 2014 revision) will save money, but no studies yet exist to support this. The PCMH model is evolving, and we can hope that future models build on past successes and learn from any failures.

• A1C Test for Diabetics Documented in the past 6 months—increased 4% • LDL Test for CAD Documented in the past 12 months—increased 10% • BP Recorded for CHF in the past 12 months—increased 3% • Vision Screening for 4-yearolds—increased 46% • Mammograms completed and documented in past 12 months—increased 25% • Pneumovax administered and documented once in patients 65 and over—increased 12% (This represents improvement in the number of patients having the recommended health care test or service performed in the indicated time period.)

REFER YOUR PATIENTS WITH CONFIDENCE TO THE WOUND HEALING CENTER. For your patients with hard-to-heal wounds, the Wound Healing Center of Heart of Lancaster:

Finally, the quality of medical care delivered through a PCMH model is only as good as the goals that are chosen, just like a quality incentive program is only as good as the criteria used. We approached our transformation with careful choices, full administrative buy-in, and a lot of hard work by every physician and staff member. Practices should be aware of the complexities of the project in addition to the benefits for patients. As it becomes a standard expectation for primary care medicine, the choice to transform to this flexible but demanding practice model is likely to be when, not if.

• Is one of only five PA hospitals to be nationally recognized as a Center of Distinction by Healogics™ for outstanding clinical outcomes • Has a healing rate of 95 percent and a patient satisfaction rate of 95 percent • Has physicians available for consults at all three Lancaster hospitals • Offers two hyperbaric chambers for oxygen therapy to speed the healing process • Has a multi-disciplinary physician panel to keep you up to date on your patients’ progress

i.) NCQA Fact Sheet, http://www.ncqa.org/Portals/0/Public%20Policy/2013%20 PDFS/pcmh%202011%20fact%20sheet.pdf, accessed 3/12/14

To learn more about sending your patients to the Wound Healing Center, call 717-299-3020.

ii.) NCQA 2011 PCMH Standards, http://www.ncqa.org/portals/0/Programs/ Recognition/PCMH_2011_Data_Sources_6.6.12.pdf, accessed 3/12/14 iii.) http://www.pcpcc.org/sites/default/files/media/benefits_of_implementing_the_primary_care_pcmh.pdf, accessed 3/9/14

90 Good Drive, Suite 101 Lancaster, PA 17603 This hospital is partially owned by physicians.

iv.) Friedberg MW, Schneider EC, Rosenthal MB, Volpp, KG, Werner RM. Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. JAMA. 2014;311(8):815-825

LANCASTER

Statistics—Average for 6 pilot sites. Baseline year ending March 2013; Measurement year ending December 2013

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Spring 2014

PCMH Challenges & Opportunities

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PCMH Resources: www.NCQA.com The National Committee for Quality Assurance is a recognizing body for Patient Centered Medical Home. NCQA defines the standards and guidelines necessary to become a medical home. This website/organization provides the standards required and educational webinars to aid a practice/organization in transforming to a medical home. http://paspread.com The federal Agency for Healthcare Research and Quality (AHRQ) is working with the state of Pennsylvania in efforts to lay the foundation for a Primary Care Extension Service. A learning collaborative, PA SPREAD: Pennsylvania Spreading Primary Care Enhanced Delivery Infrastructure, offers medical practices the opportunity to transform into a medical home by encouraging practices to implement improved workflows through the use of the PDSA (Plan, Do, Study, Act) model. The collaborative also challenges practices to develop reporting processes to track outcomes measures to aid in identifying and working with patients to improve disease management. www.allscripts.com Allscripts Touchworks EHR offers a client community where users can share information. This community has a dedicated user group for those clients seeking PCMH recognition and a user group for the analytics tool used to collect the data required for PCMH submission. This community allows clients to ask questions and share experiences among one another. Most EHRs have similar user groups; check with your vendor for details. http://pcmh.ahrq.gov The Agency for Healthcare Research and Quality (AHRQ) is a part of the U.S. Department of Health and Human Services offering tools and resources to aid medical practices in the transformation process to a medical home. The organization offers educational resources and webinars aiding in developing methods to improve workflow, data collection, and outcomes measurement. http://www.njpca.org/clinicalquality/pdf/Patient-Centered-Medical-Home-Recognition-Manual_PCDC.pdf This is a very detailed step-by-step description of nearly every organizational change needed to accomplish PCMH by a practice or group of practices.

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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

The Regional Center for Cancer Care

Brings Advanced Treatment Options Close to Home

for Lancaster–Area Patients

DANIELLE GILMORE Director of Marketing, Lancaster Regional Medical Center

aybe it will be a parent, child, friend or colleague. Or maybe it will be you. Cancer will affect most people at some point in life—a stressful situation for the patient and the whole family. Cancer is the second most common cause of death in the United States after heart disease. Each year, over 1.6 million people are diagnosed with—and one third will die of—the disease. That is why cancer patients benefit most from a collaborative and multidisciplinary approach to their care. And no longer do Lancaster County residents need to be referred to larger cities for that care.

RapidArc™ radiotherapy technology delivers accurate doses of radiation to cancer cells while sparing surrounding tissue. This technology allows physicians to target tumors three-dimensionally by rotating the machine around the patient, delivering beams from multiple angles with varying intensity.

The Regional Center for Cancer Care (RCCC) is a network of physicians, outpatient facilities and hospitals that provides convenient, efficient and compassionate care for cancer patients. An affiliate of the Penn State Hershey Cancer Institute and a program of Lancaster Regional and Heart of Lancaster Regional Medical Centers, the RCCC offers the latest in cancer research, clinical trials and treatment to our community. Patients can be treated locally, knowing that only a few miles away is an additional team of physicians, researchers and oncologic professionals ready to assist at a moment’s notice. The team of experts includes physicians who specialize in aggressive treatment of all aspects of cancer, including advanced stages of disease and complications that may result from cancer. The RCCC also provides other essentials

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including physical therapy and emotional and spiritual needs. “The goal is to provide patient-centered care via a comprehensive palette of leading-edge treatments and experienced cancer specialists,” states Paul Brown, MD, thoracic surgeon with Cardiothoracic and Vascular Surgeons of Lancaster. “Treatment should be as convenient and efficient as possible for the patient and referring physicians.” The RCCC uses advanced diagnostic imaging technology and techniques to help formulate treatment plans for patients’ individual needs. Advanced PET imaging, nuclear imaging and radiologic interventional care is used for diagnosis and treatment. Robert Springer, MD, and Kartik Shah, MD, with Lancaster Regional Imaging Associates provide expertise in these modalities. In addition to the advanced imaging technology, the RCCC also offers innovative radiation therapy technology. One such technology is RapidArc™, which delivers accurate doses of radiation to cancer cells while sparing surrounding tissue. This technology allows physicians to target tumors three-dimensionally by rotating the machine around the patient, delivering beams from multiple angles with varying intensity. RapidArc can slash treatment time by more than half, making it much less taxing for patients. The RCCC also offers brachytherapy with a GammaMedplus high-dose-rate system with 3-D BrachyVision. This enables physicians

Spring 2014

RCCC Advanced Cancer Treatment

Small incision. Big benefits! Ephrata Community OB/GYN offers Minimally Invasive Laparoscopic Surgery. Our providers perform a wide variety of minimally invasive laparoscopic procedures on an outpatient basis. Because laparoscopic surgeries are less invasive with smaller incisions and a lower risk of infection, they allow for a shorter recovery time, enabling patients to get back to normal activities in no time! For more information on our OB/GYN care, please call us at 717-721-5700.

A member practice of the Northern Lancaster County Medical Group

Ephrata,175 Martin Avenue, Suite 125 • Lancaster, 266 Granite Run Drive Lititz, 6 West Newport Road, Suite 7 • New Holland, 435 S. Kinzer Avenue, Suite 7

to radiate tumors utilizing catheters placed at or near the affected area. All of these advanced radiation therapy services are provided by Glenn Mieszkalski, MD, and Wallace Longton, MD, at the Keystone Cancer Center. Medical oncologists use innovative treatments and delivery of medication and utilize a proactive approach to manage common side effects of chemotherapy. Molecular testing is also performed to help guide ongoing treatment. Several RCCC hematology/oncology and radiation oncology physicians are involved in the latest research. “We are currently opening clinical trials to provide opportunity for applicable patients to enroll in cutting edge treatments for advanced and/ or rare cancers,” states Naeem Latif, MD, of Lancaster Hematology Oncology. “We are also screening high risk patients for genetic testing.”

Most patients diagnosed with cancer will require surgery at some point in their care. RCCC surgeons have performed thousands of oncologic procedures for the treatment of newly diagnosed cancers to complex aspects of cancer management, including complications caused by cancer, its recurrence or metastatic disease. Esophageal, gastric, pancreatic, liver and other abdominal cancers procedures are routinely performed by Robert Conter, MD, with General and Surgical Oncology Specialists of Central PA. Thoracic cancer surgeries are under the direction of Paul Brown, MD. Head and neck tumors and skull based surgeries are managed by Francis Ruggiero, MD, with ENT Head and Neck Surgery of Lancaster. Patients with orthopedic tumors and extremity sarcomas rely on William Parrish, MD, with Orthopaedic Specialists of Central PA. “Musculoskeletal tumor treatment may combine the expertise of fellowship trained physicians in orthopedic surgery, radiology

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and pathology for the diagnosis and coordination of treatment for patients with benign, primary malignant and metastatic bone and soft tissue tumors,” states Dr. Parrish. Pain caused by cancer can drastically change a patient’s life. Our pain management physicians work to relieve pain so that patients can focus on fighting the disease. Eric Greensmith, MD, with Lancaster Regional Anesthesia Consultants, directs the pain management program. Registered dieticians establish a plan to meet a patient’s nutritional needs during treatment. This helps to minimize potential side effects and maximize well-being. “It’s really great to be able to provide this level of care for our patients in a community hospital setting,” explains Dr. Mieszkalski. “It is even better to be able to work with a Continued on page 18

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

RCCC Advanced Cancer Treatment

team of experienced, highly specialized oncologic surgeons like Drs. Conter, Brown, Parrish and Ruggiero, who are all true experts in their fields. Together we can deliver a level of care that was once available only in a university hospital setting.â€?

Meet the Docs

Beginning with a call to the dedicated referral line at 855517-5008, an RCCC nurse navigator guides patients through all phases of care, a process that often begins with insurance authorizations. They arrange biopsies and imaging studies. (Quite often, appointments can be coordinated on the same day in the same building for patient convenience.) They arrange treatment and after care appointments. Ultimately, patients are returned to their referring physician for follow up care.

Robert Springer, MD

Wallace Longton, MD

Francis Ruggiero, MD

Naeem Latif, MD

What is important to patients is that the RCCC can provide the reassurance that comes from a clear and personalized treatment plan. They can beat cancer and get back to life. What is important to physicians is that the RCCC is able to provide advanced cancer care for patients who would otherwise need to leave Lancaster to receive it.

Glenn Mieszkalski, MD

2137 Embassy Drive Suite 105 PO Box 6423 Lancaster, PA 17607-8942

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Spring 2014

Best Practices

LPMA Brings Practice Managers Opportunities for Professional Development

Our current membership consists of 65 practices with 97 members. Any individual involved in representing health care related to administrative/management responsibilities may join. Health care practices include, but are not limited to, primary care practices, specialty practices, chiropractic practices, physical therapy practices, and dental practices. Practices from the Lancaster, York, Harrisburg, Lebanon, Reading and surrounding areas actively participate. The cost of membership is $35.00 annually for the first member and $15.00 for each additional member from the same practice/organization.

BONNIE L. OBERHOLTZER President, LPMA Board of Directors, Practice Administrator at Dermatology Associates of Lancaster

ancaster Practice Managers Association (LPMA) was established in 1992. The corporation was organized to provide a forum for the exchange of practice management experiences, academic advancement in the field of healthcare, networking, educational programs, and legislative updates which are offered by the Pennsylvania Medical Society and its governmental division.

LPMA has a membership of experienced and qualified practice managers seeking education, imagination, relationships, and so much more. We aspire to collate the county’s (and surrounding areas) leading Practice Managers/Administrators to create a dynamic association where skills and knowledge can thrive. Based in Lancaster, PA, our association works hard to provide the tools necessary for our local practices to prosper—in turn, helping Lancaster and the surrounding communities prosper. Lancaster Practice Managers Association is governed by a Board of Directors consisting of a President, Vice President, Secretary, Treasurer, two Vice Presidents of Programs and two Ambassadors who assist in the promotion of our organization. The Board of Directors has the administrative authority to manage the business and affairs of the association and determines its policies. In order to establish the agendas for the

general membership meetings, the Board of Directors meets regularly prior to the membership meetings. The general meetings of our association are held bi-monthly, excluding July and August, at various meeting sites throughout Lancaster County as agreed upon by the Board of Directors. Members must register in advance to attend meetings, and regular attendance is required to maintain active membership in the association. The Program Vice Presidents, with the direction of the Board of Directors, creates the meeting agenda for each educational session. Our meetings consist of one full-day and one half-day educational seminars with dynamic speakers whose topics are relevant to today’s ever-changing health care environment. The general meetings are comprised of a broad range of topics including: accounting, accounts receivable, collection management, personnel and human resource management, patient insurance, coding, current regulatory issues, practice marketing, risk management, auditing, customer service and other various topics. In addition, the spring meeting focuses mainly on legislative issues and updates, highlighted and presented by current government representatives and/ or representatives from the Pennsylvania Medical Society (such as Scot Chadwick, Legislative Counsel at the Pennsylvania Medical Society).

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For more information about membership visit

lancasterpracticemanagers.org

LPMA

Lancaster Practice Managers Association

The current Board of Directors consists of Bonnie L. Oberholtzer, President, who is the Practice Administrator at Dermatology Associates of Lancaster. She has been employed in health care since 1977 and for the past 20 years has been involved in health care administration. A member of the Executive Board since May 2007, she initially served as the treasurer from 2007 until 2011 before assuming the role of President. Marsha L. Miley, Vice President of LPMA, has been in practice management for 25 years and is currently Senior Practice Administrator for the Northern Lancaster County Medical Group which is affiliated with Ephrata Community Hospital. In her current role, she oversees operation and management for twelve primary care offices and one specialty practice. She has served on the Executive Board of LPMA since 2007.

Continued on page 20

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Best Practices

LPMA Opportunities

Marieke James is the Secretary for Lancaster Practice Managers Association and has been in health care for over 20 years. She is currently Office Manager for Gamber Physical Therapy & Fitness, a role she has held since February 2011. She has served on the Board of Directors for LPMA since 2006.

Jodi Highfield holds the position of Treasurer for the Lancaster Practice Managers Association. She is the Office Manager at A & E Audiology and Hearing Aid Center. With her practice since 2005, she has been the treasurer for LPMA since 2011.

Nina M. Mullins is Vice President of Programs for LPMA since 2001. She is the Director of Operations at Chiropractic 1st and has worked there since 2005. She is also a consultant for the largest chiropractic management company in the United States, Integrity Management.

We’re also proud to have two Ambassadors as part of the Executive Board of Directors. Dawn McCabe, an Account Executive for the Central Pennsylvania Physician’s Risk Retention Group, is part of the Healthcare Solutions Group within the Program Services Division. Previously, she was Specialty Sales Representative for Forest Pharmaceuticals. She has held the position of Ambassador for LPMA since 2013. Our second Ambassador is Aaron Wingert, Dental Plan Operations Manager for Smilebuilderz Dental Health Campus. He recently joined our Board of Directors. Leasing

Management

Sales

Practice makes perfect.

The term of office for all officers is one year or until their successors are elected. The association holds an annual meeting at which time an election of officers and directors is held. Through the Executive Board of Directors, the Lancaster Practice Managers Association strives to bring pertinent, up-to-date information to Lancaster and surrounding areas through education, resources and networking opportunities.

Development

I VA

A LL FA

Rebecca Deibler is also Vice President of Programs for our organization. She has held this role since May 2013. Rebecca is the Practice Manager for Red Rose Cardiology, an affiliate of Lancaster Regional Medical Center. She has over 30 years of experience in health care, and has been promoting heart health for the past 7 years.

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Donna Deerin Ward (717) 569-9373 x 915

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YORK OFFICE

1200 Greensprings Dr. York, PA 17402

www.LMS-PMA.com

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Spring 2014

Best Practices

LANCASTER CATARACT & GLAUCOMA SPECIALIST Offers Revolutionary Technology to Bring Unprecedented Precision to Cataract Surgery

ataract surgery is the most commonly performed surgery in the USA. And with the first wave of baby boomers turning 65, the number of people suffering from decreased vision due to cataracts is only expected to grow. Donna Leonardo, D.O., leading Cataract and Glaucoma Specialist at Family Eye Group, hopes to optimize cataract surgery for the increasing number of cataract patients by offering a revolutionary technology, ReLACS™.

ReLACS™, or Refractive Laser Assisted Cataract Surgery, brings a new standard of precision to cataract surgery. This customized blade-free, laser assisted cataract removal option allows surgeons to plan and perform cataract surgeries to individualized specifications unattainable with standard cataract surgery. While all human eyes share the same basic anatomical structure, every eye is just a bit different in terms of size, depth, curvature of the cornea and other key features. This is why every eye must be carefully measured and mapped prior to cataract surgery. While

these measurements have been routinely performed prior to surgery, the LenSx® Laser uses a range of highly advanced technologies—including integrated optical coherence tomography (OCT)—to capture incredibly precise, real-time high resolution images of the patients’ eyes at all times during the laser procedure. Dr. Leonardo performs her surgeries at Physicians Surgery Center in Lancaster which is the first surgery center to offer laser assisted surgery in the county. The LenSx® SoftFit™ Patient Interface Laser by Alcon, now in place at Physicians Surgery Center, is able to perform the most critical steps of cataract surgery which used to be done by hand. The proprietary soft contact lens technology enables the natural curvature of the cornea to conform to a soft lens insert. Advantages of using the LenSx® are lower intraocular pressure rise of 16mmHG, easier docking or centering and better visibility with no fogging and greater patient comfort. The high definition OCT delivers 2X the resolution for crisper visualization. Laser assisted cataract surgery delivers pristine

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capsulotomy edges and consistently produces free-floating capsulotomies. Surgical performance is dramatically improved with 66% less energy and 34% reduction in time. Patients not only receive the highest precision in surgical incision, but can also reduce their dependence on glasses after their surgery. “For years we have offered advanced intraocular lenses that replace the cloudy lens we remove in cataract surgery,” says Dr. Leonardo. “These lens options help people improve their vision at distance, at near, and even help people with astigmatism. When used in conjunction with LenSx® SoftFit™ Patient Interface, these lenses may mean a lot more freedom from glasses after cataract surgery for this group of people who remain very active for decades before and after their retirement.” “We see firsthand that just because someone needs eye surgery, it doesn’t mean they want to be dependent on their spectacles or reading glasses. They want to be educated about their surgical options and technology that is on the horizon. When patients have options, patients win.”

About Dr. Leonardo of Family Eye Group Dr. Leonardo has been serving the Lancaster County area for nearly twenty years. She has been distinguished as a 2013 Top Surgeon in the U.S. by Sightpath Medical, chosen from hundreds of surgeons nationwide. Sightpath has recognized Dr. Leonardo as a leading U.S. cataract surgeon based on the demonstration of surgical expertise and a continued pursuit of exceptional patient care through the use of the most advanced technology and surgical techniques.

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

Art

SCIENCE of Neuroimaging

he practice of neuroimaging, both an art and science, is a specialized extension of clinical neuroscience. Although different imaging modalities are all complementary to each other, MRI can be considered to represent the lion’s share of routine and advanced neuroimaging.

DR. KAVEER NANDIGAM, MD Consultant Neurologist, Director of Neuroimaging Neurology and Stroke Associates

There are several types of MRI machines available, with advanced features in newer generation machines. One significant improvement is in the magnetic field strength (measured in Tesla). Most MRI machines in routine clinical use today are 1.5 Tesla (1.5T). Higher magnetic field strength machines with 3 Tesla (3T) are clinically available in a few specialized centers.

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High magnetic field strength has several advantages, most importantly, the ability to obtain higher image resolution, thinner slices and improved tissue signal characteristics— which overall helps in better pathological differentiation. It can also reduce total time required for scanning a patient. Some of the 3T machines are available with a “large bore,” which can accommodate patients with larger body frames easily, and may also reduce claustrophobia. Without a correct set of image parameters for a particular sequence, a “3T MRI” may not always translate into “better” images. This requires in depth knowledge of MRI physics, especially when designing

Spring 2014

Art & Science of Neuroimaging

specialized scanning protocols with sequences tailored to specific anatomical areas or pathological processes. Examples of such specialistic protocols include: very thin slice (up to 0.4mm) images through posterior fossa to visualize cranial nerves, or of orbits to visualize optic nerves in patients with optic neuritis; pituitary images, high resolution images for volumetric analysis of different intracranial structures, such as hippocampi (memory areas) to help diagnose and monitor various neurodegenerative conditions causing cognitive impairment; T1-W double inversion recovery sequence for cortical dysplasia in epilepsy patients; T2-W double inversion sequences for cortical demyelinating lesions in MS; CSF flow dynamics quantitative analysis through cerebral aqueduct for NPH and through foremen magnum in patients with chiari 1 malformation, and so on. There are unending possibilities for neuroimagers to design such custom disease specific protocols, especially for those with a motivation to provide better clinical care and diagnosis for their patients. Our eyes cannot see the bugbear, if it is not photographed to be seen. Experienced and well trained technicians play a very important role in identifying pathology in real time as the patient is being scanned, so that they can add a special sequence or give contrast in the same scanning session. The final and the most important piece of this artwork is image interpretation. Errors of omission as well as commission arenâ€™t uncommon, especially due to increasing complexity of neuroimaging which requires a well-grounded anatomical, radiological, pathophysiological and clinical understanding of neuroscience, with focused and dedicated training in this enormously specialized area. In summary, just as clinicians take great care when referring patients to different clinical specialists, they have to adopt a similar approach when referring patients for neuroimaging. Understanding the various sub rosa elements involved in this process may help make an informed choice to provide the best care for our patients.

Figure 1

Figure 2

Figure 3

FIGURES LEGEND Figure 1: Cranial nerves: High-resolution 0.4 mm T2-Drive sequence showing (A) Oculomotor (white arrows), trigeminal nerves (black arrows). We can even see the three divisions of trigeminal nerve in meckleâ€™s cave. (B) Trochlear nerves (C) Abducens (white arrows), and facial & Vestibulocochlear nerves (black arrows) (D) Glossopharyngeal nerves. Figure 2: MRI special sequences: (A) Focused Pituitary T1-W images showing a small pituitary stalk adenoma. Notice the close proximity of optic chiasm to the tumor (white arrow). (B) Susceptibility weighted imaging (SWI) showing micro hemorrhages in a patient with traumatic brain injury, (C) T1-W double inversion scan with better contrast between white and grey matter, useful to diagnose cortical dysplasia and heterotopia in epilepsy patients, (D) T2-W double inversion scan showing demyelinating lesions in a patient with multiple sclerosis, on a dark white matter background. This is useful to identify small demyelinating lesions due to increased contrast with normal white matter.

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Figure 3: (A) Normal C-spine sagittal image on 3T with better visualization of the spinal cord without CSF pulsation artifacts, easier to identify cord lesions. (B) Axial C-spine image on 3T showing the dorsal and ventral cervical roots (white arrow), and dorsal root ganglion (dashed arrow). It is possible to visualize the extent of nerve root compression in radiculopathies. (C) Demyelinating cord lesion in MS (white arrow), (D) A tiny syringohydromyelia in thoracic cord seen easily on axial, and (E) in sagittal images (white arrow).

NEUROLOGY & STROKE ASSOCIATES, PC 640 East Oregon Road, Lititz, PA 17543 | 717• 569 • 8773

Our team of Providers offer expertise in acute and long term Stroke Care, Movement Disorders, Parkinson’s Disease, Dizziness and Vertigo, Neuromuscular Disease, and Neurologic Complications of Internal Medicine. MRI, CT and Neurovascular ultrasound. Partners with local and national Multiple Sclerosis Foundation.

Venkatachalam Mangeshkumar, MD, FRC P(I) Board Certified Neurologist, Fellow Neurocritical Care & Stroke, Board Certified in Neuroimaging; UCNS (MRI/CT) Chhinder P. Binning, MD Board Certified Neurologist, Fellow Neuroelectrodiagnostic Medicine Kaveer Nandigam, MD Board Certified Neurologist, Fellowship Trained in Neuroimaging Nagbhushan S. Rao, MD, FRC P (C) Board Certified Neurologist, Fellow Neuroimaging Heather Conner-Merz, PA-C Leah M. Ortiz, CRNP

COMPREHENSIVE SERVICES OFFERED IN OUR OFFICE INCLUDE: • Electromyography & Nerve Conduction Velocity (EMG/NCV)

• Vagal Nerve Stimulation (VNS) for Seizure Disorders

• Electroencephalograph (EEG) Routine & Long Term

• Infusions for Neurological Conditions

• Videonystagmography (VNG) for Dizziness and Vertigo • Deep Brain Stimulation (DBS) for Movement Disorders • EMG Guided Steroid Injections for CTS

• Botox for Neurological Conditions Including Migraine Headaches • Evoked Potentials for Neurological Conditions • Carotid Ultrasound and Trans cranial Doppler (TCD) studies

NEW PATIENTS WELCOME

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Preforming 3T MRI of the Brain and Spine on the Premises at 640 East Oregon Road in Lititz

Sharper, Clearer Images â€˘ Faster Scan Times Wide Bore Opening, 65cm â€˘ Special Imaging Protocols

24/7

Neurology Urgent Care/Consultation Starting Summer 2014, dedicated phone line 24/7

WELCOME NEW DOCTOR! Neeraj Dubey, MD, FAAN Neuroimaging and Vascular Neurology Dr. Neeraj Dubey received his medical degree in GMC in 1989. He trained in Internal Medicine in the UK and did his neurology residency at North Shore University Hospital, NY. He subsequently did fellowship training in neuroimaging cerebral fellowship at University of Texas, Houston. Neurology and Neuroimaging.

Dr. Dubey has published extensively in many leading journals. He served on the board of directors at the American Society of Neuroimaging from 2006-2012 and currently serves as the Treasurer to the society. He is currently serving on the board of directors for the IAC CT Board. He is a fellow of the American Academy of Neurology and Assc Prof (Clinical) of Neurology at TCMC. He has been actively involved in teaching and has been the MRI course director at the ASN meetings and lectured frequently at AAN national meetings.

PLEASE CALL FOR APPOINTMENT

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

Healthy Communities

Foundation Aims to Improve Mental & Behavioral Health Services

for Children

ANNA BRENDLE KENNEDY Lancaster Osteopathic Health Foundation Executive Director

he Lancaster Osteopathic Health Foundation is getting ready to celebrate its 15th Anniversary of enhancing the public health and well-being in Lancaster County. In recent years, the foundation has provided critical funding for programs aimed at children’s mental and behavioral health in Lancaster County. As the medical research mounts concerning the growing number of children suffering

from mental disorders and illnesses, the Lancaster Osteopathic Health Foundation is committed to finding practical solutions that make information concerning children’s mental health services accessible and that improve access to services. The basis of the foundation’s current vision can be traced back to its beginning and the role that osteopathic medicine

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has played in our community. The osteopathic philosophy was developed by pediatrician Dr. Andrew Taylor Still who, in the late 1800s, studied in depth the structure and function of the human body. Through his research, Dr. Still discovered the human body can heal itself if properly manipulated and that good medical treatment means focusing on the whole person rather than specific

Spring 2014

Improving children’s mental & behavioral health

BOTTOM LINE #1:

Young people live up or down to expectations we set for them. They need adults who believe in them unconditionally and hold them to the high expectations of being compassionate, generous, and creative.

symptoms. His beliefs led to the founding of the first school of osteopathy, the American School of Osteopathy in Kirksville, Missouri, in 1892. Today, there are twenty-nine accredited osteopathic medical schools. Osteopathic physicians (D.O.s) are trained to employ osteopathic manipulative treatment (OMT) techniques which are used to promote balance within the musculoskeletal systems under the belief that the system of bones and muscles influences all of the other body systems. Osteopathic physicians also emphasize lifestyle choices and encourage their patients to take preventative measures such as eating properly and keeping fit to ensure their own good health. And so the concept of “wellness”—an idea widely heralded today as a way for patients to take responsibility for their own health—is not a new concept at all and has its roots in the practice of osteopathic medicine.

COMPETENCE:

When we notice what young people are doing right and give them opportunities to develop important skills, they feel competent. We undermine competence when we don’t allow young people to recover themselves after the fall.

It is no surprise that osteopathic physicians constitute a large portion of primary care physicians. In fact, approximately 65% of all D.O.s practice in primary care areas, and many fill a critical need for doctors by practicing in rural and medically underserved areas. Lancaster County’s close proximity to Philadelphia College of Osteopathic Medicine has made our community a popular place for D.O.s to practice. This in turn led to the construction of Lancaster Osteopathic Hospital in 1942, which was important because at that time, osteopathic physicians were not allowed to practice in Lancaster County’s allopathic hospitals. By 1974, the hospital, now known as Community Hospital, served as an established teaching facility for residents in pathology, radiology, pediatrics, obstetrics/gynecology, internal medicine, general practice, urology, and anesthesiology. Many of the residents remained in Lancaster County and practiced here for the remainder of their careers. Today, D.O.s share the same training and specialties as M.D.s and the differences between the two types of physicians are insignificant.

CHARACTER: Young people need a clear sense of right and wrong and a commitment to integrity.

COPING: Young people who understand privileges and respect are earned through demonstrated responsibility will learn to make wise choices and feel a sense of control.

In 1999, Community Hospital was sold to Health Management Associates. The former hospital foundation was reborn as the Lancaster Osteopathic Health Foundation—a public charity committed to improving the public health and well-being in Lancaster County by strengthening the capacity of health care professionals and improving children’s behavioral health. A twelve-person Board

CONNECTION:

Connections with other people, schools, and communities offer young people the security that allows them to stand on their own and develop creative solutions.

CONTRIBUTION: Young people who contribute to the well-being of others will receive gratitude rather than condemnation. They will learn that contributing feels good, and may therefore more easily turn to others, and do so without shame.

BOTTOM LINE #2: What we do to model health resilience strategies for our children is more important than anything we say about them.

THE ESSENTIAL BUILDING BLOCKS OF RESILIENCE

Continued on page 28

LANCASTER

CONFIDENCE:

Young people need confidence to be able to navigate the world, think outside the box, and recover from challenges.

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Healthy Communities

of Directors comprised of local community leaders interested in the osteopathic/public health mission and a two-person staff set the overall direction and manage the operations. With a nod to its osteopathic heritage, the Lancaster Osteopathic Health Foundation has tightened its focus by identifying children’s behavioral health as a need in our community that must be addressed in terms of increased services and better access. This call for action has grown along with substantive medical research and the number of children with mental disorders and illnesses, not only on the local scale, but state and national as well. And it remains clear that good mental health affects overall health. The Lancaster Osteopathic Health Foundation aims to make children’s mental and behavioral health a priority and is currently planning a county-wide needs assessment that will identify specific gaps in availability and access to necessary behavioral and

mental health services. Initial feedback from primary care physicians, educators, families, and mental health providers indicates a huge interest in advancing the delivery of mental health services, specifically for children. “It is clear that at the state and local level, children’s behavioral health is at a critical juncture. Parents and caregivers as well as primary care practitioners frequently lack the tools to locate and connect with appropriate mental health p rov i d e r s a n d services. We are an underserved community as far as the number of people with mental health problems compared to the number of mental health practitioners,” explains Scott D. Silverstein,

D.O., M.S.P.H., and a member of the foundation’s Board of Directors. The foundation plans to pilot a resource center for children’s behavioral health through a call center and website, which will be a centralized information and referral center enabling better access and navigation of the children’s behavioral health system. According to Dr. Silverstein, “The children’s behavioral health program will look at how we can prevent or intervene early to reduce the severity of mental health problems for children. We want to find ways to define, improve, or reduce the factors that predispose some children to greater risk for developing mental health problems

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Improving children’s mental & behavioral health

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and increase the factors that promote child well-being. This can be achieved by broadening prevention services, early intervention services, and treatment of the child within the context of family needs.” Future plans also include specialized training for primary care physicians, pediatricians, educators, and behavioral health providers to help them understand their options when treating young patients with mental and behavioral health needs. The foundation is hopeful it can play a role in attracting additional behavioral health specialists to the area. The Lancaster Osteopathic Health Foundation welcomes the entire medical community to join its efforts to make mental health services for children a serious priority. Whether through participating in a specific volunteer activity or by networking with other physicians and behavioral health providers at various social and educational

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events sponsored by the foundation, community involvement is essential to the foundation’s success. As the Executive Director of the foundation, I’m encouraged that health care professionals recognize the focus on children’s mental and behavioral health is one that is critical to the overall health of our community. We are looking forward to studying the results of a comprehensive needs assessment so we can further identify where we can be most effective and share those results with the entire community. In order for our work to be relative and purposeful, we absolutely need the expertise of a wide variety of professionals.

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For more information on how you can help, please email the foundation at info@lohfoundation.org, or call the office, 717.397.8722.

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

Healthy Communities

ian Lancaster Physic ongoing series...

Part 3

CARING FOR THE LONG TERM County In Lancaster

Lancaster County has the largest number of senior living communities of any county in America. Right or wrong, people have perceptions of each community. Thatâ€™s why weâ€™re talking with the administrations of different Lancaster County facilities to set the record straight about retirement living in general and to share what individual facilities offer to those seeking long-term care.

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Spring 2014

Caring for the long term

Oak Leaf Manor This ongoing series in Lancaster Physician magazine features long-term care options in Lancaster County. Through it, we aim to provide insight to physicians and the patient community so people can be better equipped to navigate this major change in their families’ lives.

“O

ne of the most difficult challenges for families and seniors is finding personal care that’s both affordable and offers quality of life,” shares Sandy Brightbill, Community Relations Liaison at Oak Leaf Manor.

With locations in Millersville and Landisville, Oak Leaf Manor provides multiple levels of care with no entrance fees. They assist families in establishing a “roadmap” of cost-effective possibilities, and they do not take over residents’ finances or assets. Varied options coupled with no entrance fees allow families to make decisions that best suit a resident’s needs. They have five levels of care to choose from, and residents only pay for the care they need.

Health and Cognitive Levels of Care As a personal care retirement community, Oak Leaf Manor offers quality care that is unique to each resident. “Friendship Place,” a neighborhood inside of Oak Leaf Manor at both of its locations, provides specialized care for those affected by dementia in a secure, stable, structured, and home-like atmosphere. At Friendship Place, residents with memory impairments (including those with Alzheimer’s Disease, Lewy Body Disease, and other forms of dementia) receive the specialized care, treatment, and attention Continued on page 32

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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

Healthy Communities

they need. The cozy, relaxed atmosphere promotes participation in cognitive health enhancing activities through spending time in smaller groups with our trained staff.

“Our goal is to enhance each resident’s quality of life by customizing a detailed support plan unique to each resident’s specific needs.” According to Brightbill, “The emphasis is on support, positive redirection and encouragements. Friendship Place is a secured unit, which facilitates resident safety and peace of mind for families.” Oak Leaf Manor also offers respite stays and day services for individuals who need support and assistance on a short-term basis. Respite care is an alternative to expensive, hourly-rate home care. It works nicely for when individuals need temporary help getting back on their feet or when caregivers go

Caring for the long term

on vacation. Should you have an injury or illness or need to recuperate from a medical procedure or surgery, respite care can help you rebound and assist you through several days or several weeks of rehabilitation. A resident can take advantage of on-site therapy with the agency of their choice. Day services, which allow individuals to participate in activities and programs for either four or eight hours a day, are also offered on a limited basis.

Focus on Quality of Care While staying at Oak Leaf Manor, residents can keep their current physicians. They also have the option of seeing the physicians who work with the facility: Dr. Michael Leser, DO, Dr. Carol Struminger, DO, and Dr. Robert Shultz, MD. Oak Leaf Manor also has nurses on duty 24 hours a day. As a result of strict policies, consistent protocol reviews, and thorough quality-assurance

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reporting, Oak Leaf Manor has received perfect surveys for four years running and top honors in regulatory compliance. “Our goal is to enhance each resident’s quality of life by customizing a detailed support plan unique to each resident’s specific needs,” explains Brightbill. “We assist residents with their needs, while providing them with enrichment to enjoy their lives to the fullest.”

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LANCASTER COUNTY, PENNSYLVANIA, & NATION FACE CHALLENGING TREND:

Shortage of Beds Available for Psychiatric Patients

SUSAN SHELLY

ancaster County medical professionals acknowledge a scarcity of psychiatric beds in area hospitals, joining the rest of Pennsylvania and medical facilities across the country in dealing with a concerning trend. The number of psychiatric beds nationwide has decreased dramatically over the past decade, dropping by 14 percent between 2005 and 2010 (according to the Treatment Advocacy Center, a nonprofit that works to remove barriers to treatment for mental health issues). Treatment advocates claim this shortage has far-reaching implications, ranging from homelessness to incarceration to violent episodes. The shortage of psychiatric beds was cited as a key concern in the American College of Emergency Physician’s National Report Card

on Emergency Care. Released in January, the report card gave Pennsylvania a C+ in overall emergency care provided to patients. A primary concern was a lack of beds for psychiatric patients, which is forcing those patients to seek care in already crowded emergency departments. Leslie Naylor, Director of Behavioral Health Services at Ephrata Community Hospital, says that psychiatric patients often wait twice as long in emergency departments as medical patients, delaying care that is sometimes desperately needed. “It’s a real problem,” Naylor explains. “We don’t want the emergency department to be a holding area, because it’s really important to get the patient to the most appropriate treatment in the shortest time possible.”

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The cause of the problem, according to Naylor, is simple, but the solution is not as clear. “We have more patients requiring these types of services than our funding can cover,” she says. The shortage of psychiatric beds began more than 50 years ago when President John F. Kennedy signed the Community Mental Health Act on October 31, 1963. The act was intended to integrate mental health patients into their communities by shutting down or reducing the size of state psychiatric hospitals and replacing them with small, community-based centers. While the intent of the act was noble, the reality is that the community centers often didn’t materialize, leaving patients who had received care in psychiatric hospitals

Spring 2014

Psychiatric Bed Shortage

untreated or undertreated. Between 1960 and 2010, the number of public psychiatric beds nationwide decreased from 535,000 to 43,310, according to the Treatment Advocacy Center. And, large budget deficits in many states have resulted in recent cuts to public programs, including those providing care for the mentally ill. Pennsylvania was cited by the American Psychiatric Association in 2011 as one of nine states that had closed down some public psychiatric units and substance abuse programs in order to save money. Coupled with budget woes is the fact that reimbursement for mental health services from both public and private insurers often falls short, blocking access to services for patients most in need. The lack of reimbursement has also resulted in a serious shortage of psychiatrists to treat patients with mental health issues. The result is that many mental health patients simply don’t receive the treatment they need. This can result in crisis situations, during which patients turn to emergency departments for care. “Emergency departments have been filling the gap in meeting the needs of these patients, and that’s certainly not an ideal situation,” Naylor shares.

a statement in January. In the statement, MacLeod agreed with a recommendation from the College that Pennsylvania adopt a statewide psychiatric bed registry. Such a registry would enable hospitals to track where and how many beds are available at any given time, reducing the need to hold psychiatric patients in emergency departments while staff members work to locate beds for them.

“We have to look at a different way to treat our mental health patients. The system needs to look different.” The state Medical Society has asked the Pennsylvania Department of Health and The Hospital & Healthsystem Association of Pennsylvania to work together to develop

a reporting system so that psychiatric and substance abuse detoxification beds can be tracked by region. Meanwhile, Naylor is hopeful that the Affordable Care Act may enable some mental health patients to gain access to care through insurance, although insurance does not always guarantee that care will be available. “Access is an issue, and even if you have insurance it doesn’t guarantee that you’ll be able to access treatment,” she says. The problem is huge, and the stakes are high. Untreated mental illness affects not only patients, but families and entire communities. “This is something our nation is facing, and we have to figure out how to address it,” Naylor stresses. While incidents like the recent shootings at Fort Hood Military Base in Texas call attention to problems caused by mental

Limited funding for mental health services is an enduring problem, explains Dr. Laurence Miller, head of the American Psychiatric Association’s Committee on Public and Community Psychiatry. Miller cites a lack of an advocating constituency and stigma as key issues in funding shortages. The Pennsylvania medical community recognizes the problem of not enough beds for psychiatric patients. After learning of our state’s C+ rating on the Physician’s National Report Card on Emergency Care, Dr. Bruce A. MacLeod, President of the Pennsylvania Medical Society and a practicing emergency medicine physician in Pittsburgh, responded to the American College of Emergency with

disorders and encourage conversation, conversation is not enough. “We have to look at a different way to treat our mental health patients,” she explains. “The system needs to look different.”

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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

Patient Advocacy

PAMED & LCCMS:

Where We Stand on the Medical Marijuana Debate SARAH SCHAEFFER LCCMS Intern

using marijuana cannot be legally conducted, despite anecdotal evidence.

he mission of PAMED and LCCMS to advance physician-led, patient-centered care is the touchstone in times of debate over what is best for patients. As the dispute over the use of marijuana for medical purposes intensifies, the medical society must balance two vital concerns: a physician’s duty to do no harm and the responsibility to treat patients who are suffering with the safest tools available.

The Food & Drug Administration (FDA) currently lists marijuana as a Schedule I drug. Schedule I drugs are those that have high potential for abuse, are not currently used in the U.S., and that lack accepted safety for use under medical supervision. Schedule I drugs are illegal both recreationally and medically. This means empirical studies of the potential positive or negative effects of

“We believe a compelling case exists for a serious scientific examination of the potential medical use of marijuana,” said Mike Fraser, executive vice president at PAMED, during a recent media call-in held by the society. He added, “The legalization of marijuana for medical use is premature and unwise.” Those who support the current medical marijuana legalization bill, Senate Bill 1182—a bipartisan bill—argue that medical marijuana can be highly effective in treating uncontrollable pain, side effects caused by cancer treatments, and other conditions. However, these arguments must be put to an empirical test in order to study which, if any, populations of patients would benefit from this change in legislation. PAMED and LCCMS stand firmly in the position that legalizing marijuana for medical purposes at the present time would be a mistake due to the unknown validity of claimed benefits and the unknown consequences, especially those associated with the common, but unusual, route of administration of the substance—smoking.

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“The most commonly used delivery system, which is smoking, has a number of adverse side effects which make it the least desirable way to consume cannabis,” said Dr. Bruce MacLeod, MD, an emergency medicine physician and president of PAMED. “There’s been some other products which have been made available, but unfortunately their delivery doesn’t get the medication into the bloodstream as quickly. Some folks aren’t as enthusiastic about that.” Instead, PAMED and LCCMS support the proposal to change the categorization of marijuana from Schedule I to Schedule II, legalizing scientific studies of the substance.

PAMED and LCCMS hold this position for various reasons: • Abrogation of the role of the FDA • Evidence of efficacy • Concerns about potency, purity, and composition • Effect on teenage use and marijuana dependence • Marijuana side effects • Concern that medical marijuana is a stalking horse for legalization of recreational marijuana • The role of individual physicians in the care of their patients While individual physicians across the state remain on the fence in regard to the legalization of medical marijuana, PAMED, LCCMS, and Governor Corbett agree in their opposition to this proposed legislation. PAMED and LCCMS will maintain their stance that until marijuana can be reclassified as a Schedule II substance by the FDA and clinical trials can be conducted to develop an understanding of the drug’s effects, it has no place being prescribed as a medication.

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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

Legislative Updates

Association (AMA), and countless other medical organizations and physicians nationwide continue to strongly advocate for permanent SGR repeal. Tell Congress no more patches, pass permanent SGR repeal now by sending them an urgent email. You can also call your senators using the AMA’s toll-free grassroots hotline at (800) 833-6354 to urge them to VOTE NO on this temporary patch bill they are now considering—H.R. 4302. According to the AMA, cuts of this magnitude will make it extremely difficult for physicians to pay for office space and other expenses and avoid staff layoffs. In Pennsylvania alone, the jobs of 161,232 employees of medical practices, as well as access to care for 2,350,558 Medicare patients and 168,228 TRICARE patients, are at risk due to these cuts.

A MESSAGE FROM THE PENNSYLVANIA MEDICAL SOCIETY:

House Passes One-Year SGR-Patch, ICD-10 Delay TAKE ACTION!

Send a message to Congress. Demand that they take action NOW! It’ s time to repeal the broken SGR formula, stop painful physician payment cuts and help protect access to care. You can also call your senators using the AMA’s toll-free grassroots hotline at 800.833.6354.

espite opposition from many in the medical community, including the Pennsylvania Medical Society (PAMED), another temporary Sustainable Growth Rate (SGR) patch appears to be on the horizon.

On March 27, 2014, the U.S. House of Representatives passed the “Protecting Access to Medicare Act of 2014” (H.R. 4302), which would delay the 24.1 percent cut physicians face after March 31 due to flawed Medicare payment formula and also postpone ICD-10 implementation another year until Oct. 1, 2015. While the deadline is March 31, the exact timing of Senate consideration is uncertain. The Pennsylvania Medical Society (PAMED), the American Medical

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PAMED and the AMA do not support short-term patches and continue to call for Congress to move forward to enact the Medicare physician payment reforms contained in H.R. 4015/S. 2000. Earlier this month, by a vote of 237 to 182, the U.S. House of Representatives passed H.R. 4015, which would repeal the SGR formula and pay for it by delaying financial penalties by five years for those without health insurance coverage. However, the Democrat-led Senate opposes the plan to tie repealing the individual mandate to this measure. Since 2003, Congress has enacted 16 patches to temporarily stop Medicare physician payment cuts, creating uncertainty for both physicians and patients. The potential patches for 2014 are estimated to cost $18.1 billion. The cost of a decade of temporary patches now exceeds the cost of a permanent fix. Send a message to Congress. Demand that they take immediate, permanent action NOW! It’s time to repeal the broken SGR formula, stop painful physician payment cuts and help protect access to care.

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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

Restaurant Review

AROMAS DEL SUR

DAWN MENTZER, Freelance Writer Lancaster Physician Content Coordinator

“A

romas Del Sur” offers cuisine and ambiance quite a bit different from most other restaurants in Ephrata and northern Lancaster County. If you’re like me and enjoy Spanish food, I believe you’ll find the restaurant’s authentic Colombian fare a breath of fresh air.

Upon entering the dining room, you’ll find Aromas Del Sur to have a casually inviting atmosphere with touches of South American culture. It’s not fancy, but it has a subtle air of elegance. The music, the table settings, the lighting, the genuine hospitality…they all blend together to make you feel welcome and relaxed.

Because the menu offers selections unique to anything I and my two dinner companions have experienced elsewhere, we asked Aromas del Sur owner, Arturo, to advise us. He was most accommodating. And we observed he visited every table to assist in that way and to check in to make sure everything was to his guests’ liking. Aromas del Sur has an ample assortment of appetizers, salads, and desserts and an array of entrees featuring beef, pork, chicken, and seafood. We began our meal by sharing a sampling of Empanadas (Colombian meat pies)—one chicken, one beef, and one cheese. They were delightful…and perfectly

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accompanied by Aromas’ salsa-style sauce which has got some serious kick (if you’re a fan of hot and spicy like me, you’ll love it!). Of course, our adventurous appetites weren’t satisfied with just one variety of appetizer, so we also ordered what Arturo told us is another crowd favorite, “Yucca Frita” (deep-fried root of the cassava plant). It reminded us of sweet potato fries, but with a lighter taste and color. They served it with their tasty, creamy own-made dipping sauce. While we aimed to choose three different entrees, one of my friends and I both set our sights on the same dish. So we ended up sampling just two main menu items.

Spring 2014

Aromas Del Sur

Two of us dined on Sobrebarriga a la Criolla, flank steak marinated in criolla sauce and served with potato, cassava, salad, rice, beans and plantains. It was remarkable both in taste and presentation. Because I like food with some “heat,” I ordered mine spicy while my friend ordered hers mild. Both versions pleased the palate. With portions far more than we could handle in a single sitting, we happily took what remained on our plates “to go.” My husband, who was under the weather at the time of our meal, ate my leftovers the next day and affirmed the magnificence of my selection.

Our other dinner companion ordered Camarones al Ajillo, which is shrimp in a creamy garlic butter sauce. It, too, was served with a salad, rice, and plantains. While the portion wasn’t as plentiful as the flank steak, he said he found it outstanding and would definitely order it again. I should note that although Aromas del Sur does not have a liquor license, you are welcome to bring a bottle of your favorite wine, beer, or cocktail ingredients (which they will mix for you) to accompany your meal.

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After a couple at the table next to us sang the praises of their dessert, Brevas con Queso (figs with cheese and caramel), we decided to try it, too. We found it decadent to just the right degree as the finale to our memorable meal. I very much recommend Aromas del Sur for both the cuisine and the taste of Colombian pride and culture. I hope you’ll take the opportunity to experience dining there. When you do, tell Arturo I sent you!

AROMAS DEL SUR

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June 10, 2014

SAVE

THE DATE

News & Announcements

LANCASTER CITY & COUNTY MEDICAL SOCIETY Annual Business Meeting & Dinner WHEN: Tuesday, June 10, 2014 6:15 pm – 9:30 pm WHERE: Lancaster Country Club REGISTRATION: $45 members $55 non-members

RSVP by May 27, 2014 to Kelly Lyons at klyons@lancastermedicalsociety.org or 717.393.9588

FDA’s Critical Path Initiative, and public-private initiatives to develop better information on the quality and cost of care. Dr. McClellan chairs the FDA’s Reagan-Udall Foundation, is co-chair of the Quality Alliance Steering Committee, sits on the National Quality Forum’s Board of Directors, is a member of the Institute of Medicine, and is a research associate at the National Bureau of Economic Research. He previously served as a member of the President’s Council of Economic Advisers and senior director for health care policy at the White House, and was an associate professor of economics and medicine at Stanford University.

KEYNOTE SPEAKER Mark McClellan, MD, PhD, Brookings Institution TOPIC: TBD Mark McClellan, MD, PhD, is a senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution. Within Brookings, his work focuses on promoting quality and value in patient-centered health care. A doctor and economist by training, he also has a highly distinguished record in public service and in academic research. Dr. McClellan is a former administrator of the Centers for Medicare & Medicaid Services (CMS) and former commissioner of the U.S. Food and Drug Administration (FDA), where he developed and implemented major reforms in health policy. These include the Medicare prescription drug benefit, the

McClellan holds an MD from the Harvard University-Massachusetts Institute of Technology (MIT) Division of Health Sciences and Technology, a PhD in economics from MIT, an MPA from Harvard University, and a BA from the University of Texas at Austin. He completed his residency training in internal medicine at Boston’s Brigham and Women’s Hospital, is board-certified in Internal Medicine, and has been a practicing internist during his career.

CME CREDIT WILL BE AVAILABLE. Special thanks to Lancaster General Health for their generous support of this program.

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Spring 2014

News & Announcements

Pennsylvania Medical Society “Business of Medicine” Series Brief #1

What’s Driving Physician Uncertainty Around the Affordable Care Act? 7 Issues for Pennsylvania Physicians to Consider

Why this Brief? With the Affordable Care Act (ACA) moving closer to full implementation in 2014, many Pennsylvania physicians continue to express concern over how the ACA will impact their practice and care of patients in the state. One of the biggest concerns about the ACA is the degree of uncertainty that it has introduced to an already complicated, competitive, and increasingly consolidated health care system. This Brief provides an overview of some of the factors that contribute to physician uncertainty surrounding the ACA and highlights seven issues that physicians should consider as the ACA unfolds in Pennsylvania. There are several unknowns related to ACA implementation in Pennsylvania, for example the state’s Medicaid waiver proposal to expand health insurance to over 500,000 residents of the state; and the insurance products that Pennsylvania insurers will offer in the state as part of the new Marketplace. PAMED has a number of resources available to assist physicians in each of the areas of uncertainty identified below. Please contact your County representative or PAMED at 800.228.7823 or ask your question at stat@pamedsoc.org. 1. Practice Consolidation The trend toward the consolation of independent physician practices into larger medical groups, including hospital and health plan purchases of physician practices, was clearly taking place in Pennsylvania well before the passage of the ACA. However, the ACA has driven an increase in practice consolidations for a number of reasons such as declining reimbursement rates, increased regulation of physician practices, complicated e-Health systems, new patient referral patterns, and a movement from “volume-based” payment models to “value-based” models. 2. New Payment Models The ACA codifies what was once labeled an “innovation”—the trend toward physician payment based on population health or bundled services rather than fee-for-service. While not universal, physician offices are now living in two worlds: payments based on fee-for-service and payments based on new models such as patient-centered medical homes or shared savings plans.

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3. Changing Physician-Insurer Relations Because the central goal of the ACA was to expand health insurance coverage to uninsured Americans, much of the physician uncertainty about the ACA relates to specific issues concerning physician-insurer relationships. There are a number of issues related to the changing physician-insurer relationship and include: a downward trend in physician reimbursement rates, use of insurer contract language to require provider acceptance of lower rates, the creation of narrow and tiered provider networks, and an increase in patient out-of-pocket costs that the physician must collect. 4. New Penalties The ACA and other federal laws contain several penalties for physicians that do not comply with certain policies or procedures. For example, physicians that do not prescribe electronically after 2013 will face a 2% penalty in 2014. Likewise, physicians that do not participate in the Physician Quality Reporting System (PQRS) as of 2014 will face a 2% penalty in 2016. 5. Patient Demand One major uncertainty with regards to the ACA is the patient demand for physician services, especially primary care services, as the newly insured obtain coverage. PAMED will continue to work with partners at the state and national level working to address physician workforce issues, including the leadership of Pennsylvania’s nine medical schools. 6. Patient Insurance Changes or “Churn” While patients currently change insurers on a periodic basis because their employer-sponsored coverage changes and/or a provider is no longer “in network,” this issue could be compounded by the ACA. Under the ACA, small business may be able to shift their employees to Marketplace plans, rather than provide employer-sponsored insurance. If a physician is not in that patient’s Marketplace plan network they may have to terminate care to that patient because the patient will not be able to afford out-of-network costs of care. 7. Quality Measures As the trend in reimbursement moves from “volume” to “value,” new measures will be needed to monitor the quality of care. Many existing quality measures and standards are based on a fee-for-service model. PAMED is working to assure that physicians are represented in statewide discussions on physician quality, especially as they relate to payment reform and reimbursement policies.

Summary Uncertainty regarding the implementation of the ACA is a major issue for physicians across the state. These seven challenges clearly indicate that the ACA will impact physicians and patients. As the statewide advocate and resource for Pennsylvania physicians, PAMED will continue to share information and resources to members about the impact of the ACA and our work to address physician concerns moving forward.

SOURCES: Paige, Leigh. “How Insurance Exchanges Will Affect Doctors’ Income.” July 10, 2013 in Medscape, Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13. Paige, Leigh. “8 Ways that the ACA is Affecting Doctors’ Income.” August 15, 2013 in Medscape Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13.

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News & Announcements

Welcome... New Members Joshua Peterson, DO

Frontline Groups Groups with 100% physician membership as of 4.01.14

Southeast Lancaster Health Services Inc.

Allergy & Asthma Center

Lancaster Physicians For Women

Brain Orthopedic Spine Specialists

Lancaster Radiology Associates Ltd

Srikanta Banerjee

Cardiac Consultants PC

Lincoln Family Medicine

Adam P. Calusic, DO

Community Anesthesia Associates

Manheim Family Medicine

Eden Family Medicine

Community Services Group

New Holland Family Medicine

Felicia DeJesus, MD

Conestoga Pulmonary & Sleep Medicine

OBGYN of Lancaster

Dermatology Associates of Lancaster Ltd

Orthopedic Associates of Lancaster Ltd

Eastbrook Family Health Center

Otolaryngology Physicians of Lancaster

Eye Associates of Lancaster Ltd Family Eye Group Hypertension and Kidney Specialists Internal Medicine Specialists of Lancaster County Keyser & O’Connor Surgical Associates Ltd Lancaster Cancer Center Ltd

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Red Rose Cardiology Rothsville Family Practice Southeast Lancaster Health Services Inc Southeast Lancaster Health Services-Arch St Surgical Specialists of Lancaster The Heart Group of Lancaster General Health

Spring 2014

News & Announcements

Charles A. Castle, MD

Paul N. Casale, MD, FACC

Dr. Charles A. Castle was nominated by the Corbett administration on March 10, 2014, to a position on the Pennsylvania State Board of Medicine. The nomination is currently under consideration in the state senate.

Dr. Paul Casale has been elected to the American College of Cardiology (ACC) Board of Trustees. His fiveyear term became effective March 31, 2013, during the ACC’s annual conference held in Washington, D.C.

The State Board of Medicine regulates the practice of medicine through the licensure, registration and certification of members of the medical profession in the Commonwealth of Pennsylvania.

Dr. Casale, an interventional cardiologist with the Heart Group of Lancaster General Health, is Chief of the Division of Cardiology and Medical Director of Quality at Lancaster General Health.

The Board periodically reviews the character of the instruction and the facilities possessed by each of the medical colleges and other medical training facilities offering or desiring to offer medical training in accordance with the laws of the Commonwealth. It also reviews the facilities and qualifications of medical colleges and other medical facilities outside the Commonwealth whose trainees or graduates desire to obtain licensure, certification or graduate medical training in the Commonwealth.

A graduate of Cornell University Medical College, he completed an internal medicine residency at The New York Hospital-Cornell University Medical Center and his clinical and research fellowship in Cardiology at Massachusetts General Hospital and Harvard Medical School. Dr. Casale is completing a Master of Public Health at the Harvard School of Public Health. He is active in clinical research and medical education and is a Clinical Professor of Medicine at Temple University School of Medicine.

Dr. Castle is the Associate Physician Executive of Lancaster General Hospital. In that capacity, he oversees care management, quality improvement and physician relations for the hospital. Prior to his current position with the hospital, he served as the Senior Vice President of Operations for Women and Babies Hospital of Lancaster General.

Dr. Casale currently serves as the president of the Lancaster City & County Medical Society.

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Dr. Castle is a Board Certified Obstetrician and Gynecologist, and he has been in practice in that specialty since 1980 in Lancaster. He currently practices in the office of Drs. May-Grant Associates. He has served as Chairman of the Department of Obstetrics and Gynecology and was the Medical Director of Women and Babies Hospital from 1999 to 2006. Dr. Castle holds the rank of Captain in the Medical Corps of the United States Navy Reserve and retired from the Navy after 32 years of service in 2004.

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

Lee A. Klombers, M.D.

Graduating cum laude from Amherst College, he received his M.D. degree from the University of Virginia. Dr. Castle completed his residency training at Naval Regional Medical Center, Portsmouth, Virginia. He is the past Chair of the Pennsylvania Section of the American College of Obstetricians and Gynecologists.

Eye infections Eye injuries Eyelid growths Foreign bodies Glaucoma Macular degeneration

Pediatric and NeuroOphthalmology Premium Intraocular Lenses (IOLs) 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 Two Convenient Locations: Health Campus: 717.544.3900

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

Dr. Castle currently serves as the Lancaster County Business Group on Health liaison for the Lancaster City & County Medical Society.

Lisa J. Kott, O.D.

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Willow Lakes: 717.464.4333

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Olga A. Womer, O.D.

www.CampusEyeCtr.com

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LMS Foundation Updates

LANCASTER MEDICAL SOCIETY FOUNDATION: Supporting the Future of Health Care in Our Community

ince 1991, the Lancaster City & County Medical Society, through its charitable foundation, has been supporting local students who are exploring—or working toward—a career in health.

wide variety of health topics students are investigating, as well as the depth of research they undertake.

Sara J. Sigafoos Memorial Award

The Lancaster Medical Society Foundation is dedicated to supporting a strong health care team. Each year the foundation honors this commitment by recognizing four nursing student graduates from the Lancaster Campus of Harrisburg Area Community College.

In addition to the Lancaster Medical Society Scholarship Awards*, given to students who are beginning or continuing their education in medical school, the foundation also encourages those interested in science.

The Sara J. Sigafoos Memorial Award is a financial award presented to nursing students who demonstrate outstanding clinical skills and passion for medical service.

North Museum Science and Engineering Fair

Each year, eligible junior and senior high school students from around the county participate in the North Museum Science & Engineering Fair held at Franklin & Marshall College’s campus. Students have the opportunity to explore their curiosity about science through hands-on research. Competition categories range from computer science to biology. Recent winning projects in the senior division health care field reflect the variety and depth of students’ interests:

The Lancaster City & County Medical Society is pleased to be a part of NMSEF and HACC’s award. As we strive to promote physician-led, patient-centered care, we recognize the importance in reaching out to students with the potential to become valuable members of health service teams. *ABOUT THE LANCASTER MEDICAL SOCIETY SCHOLARSHIP FOUNDATION

• “Do Grass or Turf Surfaces Affect Concussion Rates in Football?” • “A Study of the Molecular Genetics of the Agents that Cause Lyme Disease” • “Chitosan Nanoparticles as a Drug Delivery System for the Ocular Surface”

The Lancaster Medical Society Scholarship Foundation provides funding to Lancaster County residents attending medical school. Recipients must exemplify good character, motivation, academic excellence, and demonstrate financial need. Since its establishment in 1991, the Foundation has awarded over $200,000 in scholarship funds. Any Lancaster County resident fulfilling the criteria listed above and accepted to—or continuing—a medical degree at an accredited medical school may now apply for the Lancaster Medical Society Scholarship Foundation scholarship. Applications are due by July 1, 2014 for the 2014–2015 academic years.

Student projects are judged on three criteria: 1. Originality of idea 2. Thoroughness of investigative process 3. Presentation and communication of knowledge Winners of the Health Sciences division are awarded first, second, and third place cash prizes from the Lancaster Medical Society Foundation.

Apply now by visiting our website: www. lancastermedicalsociety.org

For the past several years, Laura Good, MD, of Doctors MayGrant Associates, has volunteered on behalf of the medical society to serve as judge of the Health Sciences Senior Division projects. She notes that her enthusiasm to participate comes from her own love of science and provides a way for her to encourage young students to consider a career in the sciences. She is always impressed by the

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If you wish to contribute to the foundation, please contact Kelly Lyons at 717.393.9588 or klyons@lancastermedicalsociety.org. Contributions are tax-deductible.

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