Fall 2014
LANCASTER COUNTY AGENCIES WORK TO ADDRESS
DOMESTIC VIOLENCE & ABUSE
Immunizations: Childhood Hero
or Public Enemy No. 1?
GLUTEN FREE:
A Mandate, Not An Option
For Those with Celiac Disease
5 Things to Look For in an MRI Provider By Patrick N. Weybright, MD, MRI Group
You may have noticed that more and more MRI providers are setting up shop these days. On the surface, it sounds like a good deal for patients—more locations means more convenient access to the studies they need. What patients and many referring physicians may not realize, however, is that not all MRI providers are the same. Having the latest technology or strongest magnet is not necessarily a harbinger of quality. As a referring physician who depends on the accuracy of imaging studies to provide timely, effective and appropriate treatment to your patients, you may want to keep the following five quality indicators in mind when recommending an MRI provider for your patients.
1. Accreditation by the American College of Radiology The American College of Radiology (ACR) is the oldest and most experienced medical imaging accreditation body in the nation, and ACR accreditation is recognized as the highest industry standard. The ACR’s MRI Accreditation Program evaluates staff qualifications, quality control, MR safety policies and image quality. Look for an ACR accredited facility to ensure that your patients are receiving the safest and best quality care. All eight MRI Group locations are ACR accredited.
2. ABMS board-certified radiologists You may have noticed in recent years a number of unfamiliar board certification programs popping up. These enable physicians to complete a designated number of Continuing Medical Education (CME) hours and take an exam to be granted certification in fields that are not normally certified under their existing medical board. While this practice is currently legal in the state of Pennsylvania, it is important to keep in mind that not all board certifications are created equal.
In the United States, there are 24 national medical specialty boards—such as the American Board of Radiology, American Board of Surgery and American Board of Family Medicine—under the American Board of Medical Specialties (ABMS). Certification by an ABMS member board involves a rigorous process of testing and peer evaluation, and has long been considered the gold standard in physician credentialing. Likewise, not all training programs are created equal. The Accreditation Council for Graduate Medical Education (ACGME) is one of the largest accrediting organizations in the world. They accredit residency and fellowship programs in 133 specialty and subspecialty areas of medicine, including all programs leading to primary board certification by the 24 member boards of the ABMS. In short, look for an MRI provider whose physicians are board certified by the American Board of Radiology (ABR), which indicates completion of medical training in ACGME accredited programs. All 25 physicians at MRI Group are board certified by the American Board of Radiology.
3. 24/7 access
5. Accountability
Does your MRI provider offer 24/7 access 365 days a year? Can your patients get MRI scans around the clock? As the referring physician, can you speak with a board-certified radiologist about your patient any time, day or night? Do the technologists who are performing the studies have direct access to a board-certified radiologist during all procedures? Is that radiologist able to review scans in real-time and suggest adjustments while the patient is still on the scanner? Does your MRI provider have 24/7 electronic access to previous imaging studies—regardless of the modality?
As a referring physician, the quality of your patients’ MRI scans is critical to diagnosis and treatment decisions. When recommending an MRI provider, consider not only who is performing the scans, but who is reading them. Many facilities outsource the interpretation of studies. Look for a provider with ABR board-certified radiologists on staff who read studies, consult with technologists and referring physicians, provide peer review, and set protocols. Is the provider an imaging practice, or a medical practice that owns a piece of imaging equipment? Practices focused solely on imaging are more likely to keep up with the latest guidelines and improvements in technology, and are knowledgeable about the best protocols for safety and quality.
Round-the-clock access ensures timeliness of care, quality control, patient safety and open communication for the best possible outcomes. As part of Lancaster General Health (which includes Lancaster General Hospital), MRI Group offers year-round, 24/7 service and connectivity to its Epic shared medical record and centralized PACS system. Our radiologists have access to all prior, multi-modality imaging studies performed within the vast LG Health network. MRI studies are performed 24/7, and most reports are available to the referring physician within 24 hours of the patient study. A board-certified radiologist is always available to consult with technologists and referring physicians … even at 2 a.m. on a holiday weekend.
At MRI Group, imaging is all we do. All studies performed by MRI Group are read by board-certified radiologists employed by MRI Group/Lancaster Radiology Associates. Random double reads are conducted daily for quality control, and all procedures conform to American College of Radiology guidelines.
4. Customization When it comes to MRI, one size does not fit all. For example, while a 3T magnet offers unquestionable strength, if the patient has post-op hardware in his back, a 1.5T magnet will create fewer artifacts, resulting in better images. Magnet strength is one factor. Other capabilities to look for are specialty coils for specialized studies, such as breast, cardiac or prostate; open-bore MRI, for larger or claustrophobic patients; sedation services for young children; and a knowledgeable, experienced team that sets and follows protocols for each area of specialization. MRI Group provides a full range of MRI procedures for patients of all ages—neonatal through geriatric—with protocols set by radiologists who are fellowship-trained in that area, such as neuroradiology or cardiovascular and interventional radiology.
When it comes to MRI providers, there is a difference. To learn more about MRI Group, please visit www.MRIGroup.com or call (717) 291-1016 or (888) MRI-1377.
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Contents
2014 BOARD OF DIRECTORS
FALL 2014
OFFICERS James M. Kelly, MD President
Lincoln Family Medicine
David J. Simons, DO President Elect
Community Anesthesia Associates
Robert K. Aichele, MD Vice President
Aichele & Frey Family Practice Associates
Paul N. Casale, MD Past President
Immunizations:
C. David Noll, DO
Childhood Hero or Public Enemy No. 1? (p.8)
The Heart Group of Lancaster General Health
Secretary Ephrata Community Hospital
Stephen T. Olin, MD Treasurer
Lancaster General Hospital
DIRECTORS Charles A. Castle, MD Stacey Denlinger, DO
Lancaster County Agencies Work to Address
Domestic Violence & Abuse (p.12)
Gluten Free: A Mandate, Not An Option For Those with Celiac Disease (p.24)
Laura H. Fisher, MD Alyssa K. Jones, M.D. John A. King, MD Venkatchalam Mangeshkumar, MD Karen A. Rizzo, MD, FACS Jennifer Zatorski, M.D.
Editor-in-chief: Kelly Lyons Executive Director, LCCMS
Editors: Laura Fisher, MD Lancaster Family Allergy James Kelly, MD Lincoln Family Medicine
Best Practices 8 Immunizations
In Every Issue 6 President’s Message
12 Domestic Violence & Abuse
24 Healthy Communities
18 LGH Advanced Care Through Technology
32 Patient Advocacy
21 Tattletale or Whistleblower?
34 Legislative Updates 42 Restaurant Review 44 News & Announcements
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.
48 LMS Foundation Updates Content Submission The Lancaster Physician magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Lancaster City & County Medical Society. For more information or submission suggestions, please email klyons@lancastermedicalsociety.org 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
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
President’s Message
T
hree months into my term as county medical society president, I am working to gain understanding of organized medicine’s hot button issues on the state level. My goal for this quarterly column is to highlight health care related legislative and medical society advocacy items. There are generally twenty or more health care policy related bills that PAMED lobbyists are actively tracking and working to influence at any given time. PAMED also carries its own list of goals—these items focus on problems hindering physicians or jeopardizing patient care.
James Kelly, M.D. President
The physician Maintenance of Certification (MOC) process recently caught my eye as an area that PAMED has identified as needing reform. MOC is the set of guidelines physicians must follow in order to retain board certification in their given specialty. The American Board of Medical Specialties is the governing board supervising this four-step process with specific requirements in place for each specialty. Board certification is generally required to hold staff privileges at local hospitals and maintain employment in a hospital system. Many insurances also mandate board certification to become an “in network” physician. Thus, a physician who fails to meet requirements for board certification is often not employable and will incur a penalty when seeking reimbursement from health insurances. The four-step MOC process is: 1. Licensure and Professional Standing 2. Lifelong Learning and Self-Assessment 3. Cognitive Expertise 4. Practice Performance Assessment The purpose of the process is to assure all practicing physicians are competent and up to date with current medical literature. As physicians, we are not disputing the relevance or importance of having guidelines in place. We certainly need checks and balances to assure patients are receiving quality care from any physician they encounter. Physicians as a group also understand the need for lifelong learning and continuing education. The controversy surrounding MOC and the need for reform involves concerns regarding a time-consuming, arduous, and often expensive process. Steps needed seem at times to have little relevance to clinical medicine or patient care. There are also concerns the exams do not provide an accurate assessment of physician clinical competence.
Visit lancastermedicalsociety.org
For this reason, PAMED physician representatives presented their concerns regarding MOC to the American Medical Association at their annual meeting in June 2014. PA physician leaders have also convened a task force at the state level to address reform. A report and formal proposal is expected at the PAMED Annual Meeting in Hershey, which seven physician delegates from Lancaster County and I (see page 39) will be attending in late October. I anticipate we will see positive changes in the next few years to hopefully take the burden out of MOC while maintaining the primary goal—assuring quality and patient safety in medicine. We will certainly continue to post updates as more information is available!
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Meet our Team
Expanding our ExpErtisE in vascular surgery.
Our board-certified and fellowship-trained surgeons are experienced in vascular and endovascular surgery, including the diagnosis and treatment of peripheral arterial, venous, carotid and aortic pathology. John Affuso, MD, RPVI Undergraduate: Seton Hall University Medical School: Thomas Jefferson University Hospital Residency: Robert Wood Johnson University Hospital Fellowship: Temple University Hospital Meghan Dermody, MD, MS, RPVI Undergraduate: Syracuse University Medical School: Georgetown University School of Medicine Residency: Tufts Medical Center Fellowship: Tufts Medical Center Stacey Mazzacco, MD, FACS, RPVI Undergraduate: University of Scranton Medical School: Temple University Residency: Temple University Fellowship: University of Utah
Vascular Procedures • Open and endovascular abdominal and thoracic aneurysm repair • Open and endovascular (including hybrid) peripheral arterial bypass, angioplasty and stenting • Renal and mesenteric artery stenting and bypass • Carotid endarterectomy • Vein ablations, phlebectomy and sclerotherapy • Endovenous thrombolysis and stenting • Dialysis access creation and percutaneous interventions Diagnoses for Consultation • Abdominal and thoracic aortic aneurysm and dissection • Cerebrovascular disease • Peripheral arterial disease • Venous disease, including extensive DVT and May Thurner Syndrome • Renal and mesenteric occlusive disease • AV fistula/graft creation and maintenance • Wound care, diabetic ulceration
Drs. Affuso, Dermody and Mazzacco are part of the Lancaster Heart & Vascular Institute’s Peripheral Vascular Disease Clinic. They work collaboratively with other specialized surgeons, interventional radiologists and cardiologists in a multidisciplinary environment to offer patients the best possible treatment. To discuss a case please call (717) 544-3626. For more information about LG Health Physicians Surgical Group, visit LGHealthPhysicians.org.
Choose well. Be well.®
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
pr ctices Immunizations Domestic Violence & Abuse LGH Advanced Care Through Technology Tattletale or Whistleblower?
Immunizations: Childhood Hero
or Public Enemy No. 1? DAWN MENTZER
Lancaster Physician Content Manager
W
ith immunizations getting their fair share of negative press lately, what’s a parent to believe? Are immunizations safe? Are they even necessary anymore? Lancaster Physician has asked two Lancaster Medical Society member physicians to weigh in on the topic and help us cut through some myths and misconceptions.
Our special thanks to family medicine specialist Dr. Celeste Heckman, MD of Strasburg Family Medicine and pediatrician Dr. Sara Bowen, MD, FAAP of Roseville Pediatrics for their insight in this Q&A.
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1. Why do children need immunizations if so many diseases seem to have been eradicated? Dr. Heckman: Although some diseases have been dramatically reduced by the use of effective vaccines, there are still reasons to get your child vaccinated. Some infections are present at very low levels in the United States, but could easily re-emerge if the vaccine rates are low. Haemophilus influenza (bacterial influenza), measles, and pertussis (whooping cough) are examples of this. Other diseases that have been eliminated in our country (such as polio and diphtheria) are still
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Immunizations
prevalent in other parts of the world. We are a global community with people traveling from country to country and these diseases have the possibility of being reintroduced. 2. When parents refuse to get their children immunized, what are the primary reasons? Dr. Heckman: Parents often refuse vaccination because they are concerned about vaccine safety. They usually have read information on the Internet or in books or magazines that raises concerns. Often these sources appear to be quite reliable, but they can do a great disservice to the health of our community. For some reason, some parents mistrust information from the CDC (Center for Disease Control) or the AAP (American
Academy of Pediatrics). In general, there seems to be a mistrust of large—especially government—organizations. Also, some parents believe that since disease rates are so low, the odds are in their favor that their child will not get sick from these infections. And so, they elect not to immunize their child. 3. What is the biggest public misconception about the safety of immunizations? Dr. Bowen: Vaccine refusal is becoming increasingly more common. One reason parents refuse vaccines or choose an alternate schedule is the fear of overwhelming an infant’s immune system. An infant’s immune system begins responding to the environment as it exits the birth canal! It is more than ready
ADULTS ALSO NEED VACCINES It is important to remember that vaccines are not just for kids. Adults need to be vaccinated as well, and some of those vaccines prevent infections in children by preventing spread from an infected adult. Adult immunization is particularly important in preventing diseases in vulnerable children who are too young to be vaccinated against infections like pertussis and influenza. A vaccinated, protected adult will not spread infection to an infant child or grandchild in the household or community. -- Pennsylvania Medical Society
to respond to multiple vaccines given at one time. Separating vaccines means more visits to the Pediatrician’s office, exposing the baby to sick children each time. It also leaves the infant unprotected against serious, potentially fatal, preventable illnesses for a longer period of time. Additionally, infants are exposed to millions of new germs on a daily basis; purposeful exposure to viruses and bacteria, completed in a safe way through vaccines, will not overwhelm the immune system. Another reason parents refuse or delay vaccine(s) is the fear that vaccines may cause autism. This claim has been refuted and the American Academy of Pediatrics recommends all children receive the MMR (measles, mumps, rubella) vaccine. Parents are often also concerned with the preservative thimerosal. There has been no link shown between thimerosal and autism. Thimerosal has been removed from all vaccines for children, with the exception of the inactivated flu vaccine. There is a preservative-free vaccine available for children 3 and under. Continued on page 10
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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
Immunizations
4. When parents refuse to immunize their children, what are the risks (to those children, other children, and adults)? Dr. Bowen: Unimmunized children are at risk for serious and potentially fatal illnesses. These children also place others at risk; newborn babies who are too young to be immunized and children who have immunologic conditions that prevent them from safely receiving vaccines are also at risk when the illnesses reappear in communities. The recent resurgence of measles and pertussis are prime examples of vaccine-preventable illnesses causing serious illness, hospitalization, and even death. Adults who have not had a tetanus booster, or Tdap, which contains a pertussis vaccine are equally at risk of being infected. While many adults may only suffer from a prolonged cough, they can spread the illness to the elderly and to infants who may suffer more severe consequences.
You can find more about the safety of vaccines at: • http://www2.aap.org/immunization/families/faq/vaccinestudies.pdf • www.aap.org • www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ UCM096228 • www.cdc.gov/vaccinesafety/Concerns/Thimerosal/Index.html
5. What adverse effects to immunizations are most common, and what should parents do if their child exhibits them? Dr. Heckman: Like with any medication or procedure, vaccines do carry the possibility of side effects. The most common side effects are pain and swelling at the injection site or fever. Most side effects are mild, but some can be more severe. For example, the pertussis vaccine has a rare possibility of causing high fever and inconsolable crying. These reactions do not cause permanent harm to the child, but should be reported to your physician. In Summary If you’re a parent with questions about the necessity and safety of vaccinations, have a heart-to-heart talk with your child’s doctor to get the facts.
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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
LANCASTER COUNTY AGENCIES WORK TO ADDRESS
DOMESTIC VIOLENCE & ABUSE SUSAN SHELLY
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Best Practices
T
he issue of domestic violence has risen to the forefront of public consciousness with recent videos of Ray Rice, a 27-year-old former running back for the Baltimore Ravens, who was caught on tape as he viciously punched his wife in an elevator, rendering her unconscious. And, while professionals who work to stop domestic violence applaud the National Football League’s decision to suspend Rice indefinitely (although many are upset and angry that it took a second video and public pressure to make that happen), the high-profile incident stands in stark contrast to the vast majority of cases of abuse.
“Domestic violence doesn’t care where you live, it doesn’t discriminate.”
“What about all the victims who don’t get the act caught on camera,” asked Bonnie Glover, the director of Domestic Violence Services for the Community Action Program of Lancaster County. “We need to be looking at and talking about all the victims of domestic abuse.” The fact is, domestic abuse and violence at all levels is as serious a problem in Lancaster County as it is in communities across the nation and around the world. The statistics, no matter how many times you read or hear them, remain startling and deeply disturbing. One in four women and one in nine men report having had experienced domestic violence, according to Glover. And every year, more than three million children watch as domestic violence unfolds in their homes, increasing the risk that they will abuse or be abused in the future. Kari Stanley, program supervisor for the Lancaster County Children’s Alliance, a children’s advocacy center under the
umbrella of Lancaster General Health, said the number of reports of allegations of abuse has increased every year since the agency opened in 2006.
supervisor with Lancaster County Office of Aging, said this past July set a record for reports of alleged elder abuse or neglect, with 171 reports filed.
Lancaster General Health cites statistics that one in five girls and one in ten boys will be sexually victimized before reaching adulthood.
“We get 1,500 reports a year about cases of possible financial exploitation, physical abuse, or neglect,” Nieli said. “And it just keeps increasing.”
At the other end of the abuse spectrum, Kevin Nieli, protective service unit
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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
Lancaster General Hospital provides pediatric-adult Sexual Assault Forensic Exams (commonly referred to as SAFE). This is a specialized exam to collect forensic evidence of a sexual assault. It is most effective within 72 hours of the assault. All medical providers throughout the county should immediately refer any sexual assault that has occurred within 72 hrs to LGH. LCCA and the LGH SAFE Program will be co-hosting a Pediatric–Adult Sexual Assault Nurse Examiner Training from February 2 through February 6, 2015, for medical providers interested in becoming trained. Those interested can email Kari Stanley at knstanle@lghealth.org for more information.
Like many social problems, domestic violence affects people of all ages and socioeconomic groups. Its victims are our children, our nieces and nephews, our friends, our neighbors, our brothers and sisters, our parents and our grandparents—even our pets are not immune to violence within the home.
County provided services to 89 residents of Columbia, 58 from Elizabethtown, 52 from Lititz, 46 from Mount Joy, 42 from Manheim, 27 from Quarryville, 26 from Willow Street, 22 from Leola, 20 from Denver, and others from various communities throughout the county.
This type of violence takes on many names and shapes, inflicting victims not only with physical wounds, but with emotional and mental scars as well. It’s not unusual for survivors of domestic violence to experience depression, anxiety, flashbacks, problems sleeping, and other emotional distress.
“Domestic violence doesn’t care where you live, it doesn’t discriminate.”
Jessica Laspino, executive director of Court Appointed Special Advocates (CASA) Lancaster, shared that there is a perception that domestic abuse is confined to cities or poor areas but that this is not true. “This is an issue that plagues every single corner of the county, and it’s an issue that people don’t like to talk about,” Laspino said. “It’s a very difficult topic, and it’s always easier to think that it’s not happening in your neighborhood.”
ADULT VICTIMS of Domestic Violence
Glover, whose agency works with adult victims of domestic violence (the great majority of whom are women), said that of the 1,703 Lancaster County residents who received services between August 1, 2013 and July 31, 2014, 927 resided in the city zip codes of 17601, 17602 and 17603. The other 776 victims lived throughout the county. “It’s fair to say that a little more than half of who we see are from Lancaster and areas just outside of the city,” Glover said. But, suburban and rural areas were represented as well. During the same time period, the Community Action Program of Lancaster
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While the Community Action Program and other agencies were busy helping victims of domestic violence, Glover said that most cases are never reported. She estimates there are between 10,000 and 15,000 cases of domestic abuse a year, but only between 15 and 20 percent are reported. “What we see is only the tip of the iceberg,” Glover said. Abuse goes unreported for a variety of complex reasons, including fear of increased violence, fear for the safety of children, fear of losing financial support, shame and humiliation that the abuse has occurred, lack of access to resources, lack of support of friends and family, and loyalty to the abuser. No one wants to be abused, Glover said, but sometimes it seems better to a victim to remain silent and endure the situation. “They have to weigh out which is safer for them: the known or the unknown,” Glover said.
CHILD VICTIMS of Domestic Violence Child abuse and neglect are serious problems nationwide, including in Lancaster County where, according to the Pennsylvania Department of Public Welfare’s annual child abuse report, there were 1,117 reports of potential child abuse in 2013. Of the suspected cases reported, 97 (8.7 percent) were substantiated.
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“But we certainly also see cases of physical and sexual abuse,” Laspino said. Children who are most at risk for child abuse and neglect are those who live in poverty, particularly in a poor, rural setting, according to Stanley.
The Lancaster County Children and Youth Agency received 1,143 reports of child neglect during 2012, according to its website. Cases of child neglect have increased dramatically in recent years due to increased use of drugs by parents, homelessness, and a general decline in stable living environments, shared Stanley. Laspino, who oversees the placement of trained, court-appointed volunteer advocates with children who have been abused and neglected and are living in foster care, said the majority of cases in which CASA participates involve child neglect.
While children who live with two biological parents are considered low-risk for abuse or neglect, a child who lives with a single parent and a live-in partner is 20 times more likely to be abused or neglected. Children between the ages of seven and 13 are most vulnerable for abuse and neglect, Stanley said. Changes to legislation dealing with child abuse and neglect are underway in Pennsylvania, the result of sharp scrutiny to the laws in the aftermath of investigation and arrest of Jerry Sandusky in 2012. Continued on page 16
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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 U.S. Administration on Aging’s National Center on Elder Abuse estimates that for every known case of elder abuse, there are five more cases that go unreported. With financial exploitation, it may be that as few as one in every 25 cases becomes known to investigators.
The changes, Stanley explained, expand the definition of child abuse and amend reporting requirements. “We need to keep talking about this,” Stanley said. “The conversation has to continue. Any time an injustice occurs against a person, whether it is a man, woman, or child, there needs to be action taken to make it stop.”
Nieli noted a sharp increase in financial exploitation of elderly people following the financial crisis of 2008. As millions of people lost their jobs and moved in with older relatives, the number of cases of financial exploitation or abuse jumped.
ELDERLY VICTIMS
Physical abuse might be visually evident, but if the elderly person rarely leaves the house it can go unnoticed. An abusive caregiver may prevent the elderly person from having any contact with others so that evidence of abuse will not be noticed.
of Domestic Violence
Sexual abuse also can be difficult to detect, and many elderly people who experience this type of abuse are reluctant to report it because they’re afraid they won’t be believed, they are ashamed, or they fear retaliation from the perpetrator. Neglect by a caregiver and self-neglect also can go unnoticed if the elderly person is isolated and has little contact with others. Most of the calls the Office of Aging receives regarding elder abuse come from family members, friends, and neighbors, Nieli explained. And most of them pertain to individuals who live in housing within the community, not in a nursing home or other facility. Hospitals also will notify the office upon discharge of an elderly patient if there is reason to believe that the patient will not be able to care for himself or will not receive proper care from a caregiver. Each call is investigated and, if necessary, protective services are put into place. “If the person is in need of protective services, we will put a plan into place,” Nieli said. Elder abuse does not always receive the widespread attention given to other forms of domestic violence, but it also is a serious problem in Lancaster County.
However, if the elderly person has not been declared incapacitated, he or she is not obligated to follow the guidelines of the plan. “It’s a tough issue and it’s not getting any easier to deal with,” Nieli said. “We had 171 reports just in July this year. That was a record for us.”
According to the Pennsylvania Department of Aging, Lancaster County has more reports of elder abuse than any other county in the state, with the exception of Philadelphia and Allegheny counties. Nieli said that of the approximately 1,500 reports of possible elder abuse filed with the county’s Office of Aging each year, about half of them are substantiated and require some sort of action.
WHAT DOES ABUSE OR DOMESTIC VIOLENCE LOOK LIKE?
Elder abuse can include physical abuse, sexual abuse, neglect by a caregiver, self-neglect, or financial exploitation.
There are many types of abuse, and each case looks different. There are, however, some common signs that someone is being abused.
Often, it’s difficult to spot.
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Domestic Violence & Abuse
Free training is available for pediatricians from the Pennsylvania Chapter of the American Academy of Pediatrics. For more information go to scan@paaap.org or call 484-446-3007. If you are being abused, or you are a physician or anyone else who suspects that domestic violence or abuse is occurring, there are resources you can access. • To report suspected child abuse, call the Lancaster County Children and Youth Services at 717-299-7925 or call Childline at 1-800-932-0313. • The Community Action Program of Lancaster County offers an emergency shelter, counseling, and legal services. A phone center is staffed 24/7. Call 717-299-1249. Collect calls are accepted.
• A person who is being physically abused may have unexplained injuries, including cuts, bruises and broken bones. The victim may try to make excuses for her injuries. This also pertains to children and elderly persons.
• The National Domestic Violence Hot Line is available 24/7 at 1-800799-SAFE (7233). • If you are an elderly person who is being abused or suspect elder abuse is occurring, contact the Lancaster County Office of Aging at 717-299-7979 or the Lancaster County District Attorney office at 717-299-8100.
• A child who is being sexually abused may experience a range of symptoms, including sleep problems or nightmares, drastic changes in eating habits, sudden mood swings, unusual fear of particular places or people, expressing sexual images in writing or drawings, suddenly acquiring gifts or money with no explanation, or exhibiting inappropriate sexual behaviors.
• To report animal abuse, call the Pennsylvania Society for Prevention of Cruelty to Animals at 267-294-1043.
• An elderly person suffering from sexual abuse may have physical signs such as bruising or cuts on the genital areas, buttocks or breasts, or may exhibit sudden fear of a caregiver who approaches the elderly person for bathing, toileting, or clothes changing. The person may express thoughts of suicide or become suddenly combative.
• To learn more about volunteering with CASA, see CASA Lancaster’s website at www.casalancaster.org.
• An elderly person suffering from neglect may appear to be malnourished or dehydrated, have body odor, wear the same clothing repeatedly, and have skin breakdown or sores. • A person who is emotionally abused may make excuses to friends and family members for not being able to leave the house or talk on the phone. They may appear to be fearful and nervous, have no access to money, be missing time at work, or withdrawing from social occasions.
WHAT TO DO IF YOU SUSPECT DOMESTIC VIOLENCE OR ABUSE IS OCCURRING Physicians play a critical role in identifying victims of domestic violence, Glover said. If a woman shows up in the emergency room or doctor’s office with injuries she can’t or won’t explain, doctors should be vigilant and ask the right questions. If a partner accompanies the woman and is reluctant to leave her alone with medical personnel, more red flags should go up. Pediatricians also are first-line defense for children who may be victims of abuse or neglect, Stanley said. A pediatrician who suspects abuse is obligated to report those suspicions immediately.
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Best Practices
LANCASTER GENERAL HEALTH
Honored for Advancing Care Through Technology
records to other care providers, and use patient data to drive improved care delivery. For example, LG Health physicians easily collaborate with their colleagues at Penn Medicine through a simple, secure method to access patients’ charts at either location. LG Health also leverages disease-based reporting dashboards to help physicians and their care teams closely follow patients, create effective care transitions, manage gaps in care, reduce preventable admissions, and prevent readmissions. These initiatives have led to improvements in caring for patients with strokes, reducing hospital acquired infections, and preventing blood clots. It’s also important to note that LGH has better than national average rates for unplanned heart attack and heart failure readmissions. It ranks in the top three percent of hospitals in the nation, according to Medicare data.
of Healthcare Information Management Executives, and McKesson for the successful adoption and implementation of health information technology (IT).
MICHAEL RIPCHINSKI, MD
Chief Medical Information Officer & Family Physician at Lancaster General Health
L
ancaster General Health stands at the national forefront of transforming patient care through its use of technology. Within the past year, it was recognized as one of 26 “Most Wired” hospitals and health systems in Pennsylvania and among 375 “Most Wired” in the nation by Hospitals & Health Networks in partnership with the American Hospital Association, AT&T, CareTech Solutions, The College
The health system’s flagship, Lancaster General Hospital (LGH), also attained the Stage 7 Award from the Healthcare Information and Management Systems Society for the highest level of electronic medical record (EMR) adoption. LG Health is only the second health system in Pennsylvania and one of three percent in the nation to receive this honor. The use of new technology improved the health system’s clinical and business processes. This has had a dramatic impact on its ability to improve the health and well-being of the communities LG Health serves. By implementing a sophisticated EMR, LG Health is able to treat patients without the use of paper charts, share patient information by sending secure, summary-of-care
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To protect clinical and financial patient data, LG Health routinely performs security assessments of its computers and systems. Physicians and patients also benefit from advances in safer medication administration. LG Health has more than 10 years’ experience with bar-coded medication administration and leads the country in medication safety for IV pumps connected to medical records. Innovative technology is also making it easier to access clinical images for ongoing treatment and to provide reminders to improve quality and safety. Providing patients with quick and easy access, LG Health’s online portal, MyLGHealth.org, is used by more than 86,000 patients, enabling them to see information about their health whenever they need it. It offers a convenient way to contact doctors’ offices, view test results, refill medications, and schedule appointments. And patients with chronic conditions like diabetes, hypertension, and asthma can track the progress of their health goals with the click of a mouse. With the health care reforms ahead of us, LG Health remains dedicated to improving the health of its patients through continual process change, enabled by new technologies.
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IMPROVING LIVES ACROSS
LANCASTER COUNTY For more than nine decades, United Way of Lancaster County has been making change happen in Lancaster County through the caring generosity of people like you. And it’s working. Last year—in partnership with 36 other nonprofit community organizations— we touched more than 165,000 children, women, and men in these three focus areas: • Education: Helping children and youth come to school ready to learn and stay there to achieve their full potential • Financial Stability: Helping families stay in their homes and become financially independent • Health: Helping give our neighbors pathways to good physical and mental health Make a lasting difference in this community by donating online at www.UWLanc.org/Give or contact our local Leadership Giving Team at (717) 824-8131.
United Way of Lancaster County 630 Janet Avenue Lancaster, PA 17601 LeadershipGiving@UWLanc.org www.LiveUnitedLancaster.org (717) 824-8131
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Best Practices
Tattletale O or Whistleblower: What’s an Employer To Do?
ne does not need to look hard to find stories of one or more persons in an organization either doing wrong or blowing the whistle on those who do wrong. The words “wrong” and “illegal” in the context of this article can be used almost interchangeably. No organization is immune from having its name besmirched when someone is caught violating ethical or legal standards, and the fallout can be damaging in many ways. We read almost daily about deliberate misdeeds, either illegal or certainly wrong behavior. Many of these acts came to light because a current or former employee, for one reason or another, felt their internal avenues to correct things were or would be ineffective. Many revealers also remain silent out of fear of retaliation. When wrongdoing is revealed to one or more regulatory or law enforcement agencies, we commonly refer to this revealing act as “whistleblowing.”
BOB ORZECHOWSKI, MBA, SPHR Chief Operating Officer at Lancaster Cancer Center
In certain cases, whistleblowing can be profitable. In a recent medical billing case, a physician was awarded $283,412.90 as part of a settlement involving a case in Kentucky. This case and settlement are under the qui tam, or whistleblower, provisions of the Federal False Claims Act. This law allows private citizens with knowledge of fraud to bring civil actions on behalf of the USA and to also share in any recovery. In other organizations (businesses, notfor-profit, government, small or large) the opportunity exists daily for people to behave in a legal and ethical manner, or to choose Continued on page 22
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not to. Those that choose not to usually have need (financial), opportunity (access to cash, data, or other company assets), and rationalization for their behavior. You may ask why people can’t just follow the law, regulations, and rules of common decency in their working lives. Why do they choose instead to behave unethically or illegally? I submit there is a larger elephant in the room—those who have knowledge of such acts but remain silent. A recent National Business Ethics Survey found that about one-third of workers who witness misconduct do not report it. High retaliation rates will dampen reporting and also increase the likelihood that wrong behavior remains undiscovered. 1. Manifesting the organization’s position on ethical behavior through all the available and various forms of communication. Written standards are imperative. Meetings at all levels serve to maintain an aura of openness, too, and can prime the pump of ethical behavior expectations.
So what is an employer to do? There are numerous tactical responses to the question, but good tactics can never compensate for a bad strategy. The real strategic challenge is to create a culture of ethical decision-making and behavior. Creating an ethical culture is beyond the scope of this article. Sharing tactical options must suffice for now, and (with the obvious top management support) include:
2. Train everyone on the standards and relevant topics for that organization’s sphere of operations. 3. Provide a resource for employees, such as a specific executive or HR leader. 4. Promulgate a policy and position for everyone to sign. Include a process for internally expressing concerns about suspected or witnessed questionable behavior. An ethics, or “Whistleblower,” hotline can be especially valuable. A policy should receive legal review, address the company’s position and standards clearly, provide examples of prohibited behavior as a guide to what may be reportable violations, and prohibit retaliation against anyone who reports possible violations. 5. Include in staff performance appraisals and job descriptions a section of compliance with policies, laws, etc. Employee surveys can also support a compliance effort. 6. Provide for sanctions for all violators. Ethical behavior necessarily deals with the vagaries of human life and must remain flexible enough to account for the variety and possibilities in the working world. To provide clear expectations and the support and processes to achieve an ethical culture and compliant workforce is the real challenge for any organization seeking to create and sustain an engaged workforce. Executives, owners, and human resources professionals are especially suited to lead such efforts.
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To learn more about SmartLife, call us today at 717.299.5673 • smartlifewv.org
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Healthy Communities
GLUTEN FREE: A Mandate, Not An Option For Those with Celiac Disease AMY B. KLATT, Freelance Writer
Y
ou have surely seen the shelves of gluten-free stamped foods at the grocery store or know of people who’ve gone “gluten free.” According to a market research report published by Packaged Facts, the gluten-free foods market in the U.S. has hit $4.2 billion. Currently, there are more than 2,000 gluten-free food items available in the United States. Health and grocery stores everywhere stock gluten-free products, which has offered convenience for people diagnosed with either gluten sensitivity or celiac disease.
What Is Gluten? Gluten is a protein composite found in wheat, barley, and rye, and in foods processed from those grains. Oats also may be
suspect because they are usually grown and processed in ways that contaminate them with gluten. People with gluten issues will typically have one of two conditions: a gluten sensitivity or celiac disease. The symptoms are similar, so you may find it difficult to determine which one (if either) you have without the use of medical tests.
Gluten Sensitivity Some people may be sensitive to gluten even though they don’t have celiac disease. Gluten sensitivities are not nearly as well defined as is celiac disease and many in the medical community debate them as an issue independent of celiac disease. Symptoms may vary according to the degree of intolerance and could include nausea, bloating, headaches, excess flatus, and diarrhea.
Celiac Disease Celiac disease (also called celiac sprue, gluten-sensitive enteropathy, and nontropical sprue) is a chronic intestinal disease caused by an intolerance to gluten. When a person with celiac disease ingests gluten, their body views it as a toxin. The body releases antibodies to attack the gluten—and attacks itself in the process. The villi in the small intestine are damaged, reducing the surface area through which the body can absorb nutrients.
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It is estimated that about 1% of all Americans have celiac disease. At least 3 million people are living with it, and 97% of them are undiagnosed. According to Dr. David M. Smith, M.D., gastroenterologist at the Regional Gastroenterology Associates of Lancaster, “Typically celiac disease affects Caucasians of northern European descent. Given the fact that many people either do not know their ancestry or have a mixed ancestry makes this more difficult to classify in this regard. It can also affect both males and females, and can be diagnosed at any age.” Symptoms of celiac disease can vary greatly, and it is even possible for some people to exhibit almost no symptoms. There are more than 200 signs and symptoms of celiac disease. Symptoms usually occur because the damaged intestine allows food to pass through the intestine unprocessed. Dr. Smith explains that classic celiac disease patients have symptoms such as diarrhea and vitamin deficiencies, as well as weight loss. There are also more atypical presentations, such as skin rash, headaches, bloating, IBS-like symptoms, elevated liver function tests, neurologic symptoms, anemia, or arthritis. Those who have no symptoms are diagnosed simply by antibody testing and small bowel biopsy.
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RGAL Recognized for Patient Safety and Quality of Care
Over time, the lack of nutrient absorption can result in conditions such as anemia, skin rashes, depression, and more. However, if the disease is left untreated, it will lead to an increased risk of small intestine cancer and lymphoma of the small bowel.
For a complete list of symptoms, visit the University of Chicago Celiac Disease Center’s website. www.cureceliacdisease.org
RGAL is honored to be the only GI practice in Central Pennsylvania to receive two prestigious National and State recognitions for patient safety and quality of care.
Taking Action Celiac Disease is diagnosed through a two-step process beginning with a panel of blood tests that look for the antibodies that attack gluten, followed by an upper endoscope.
• National Quality and Safety Recognition from the American Society of Gastrointestinal Endoscopy (ASGE) for commitment to quality and safety of the RGAL endoscopy centers.
If you or someone you know is dealing with celiac-like symptoms, see your doctor right away.
• Pennsylvania Patient Safety Authority Recognition as a leader in quality initiatives focused on patient safety.
According to Dr. Smith, “It is important that anyone who has concerns regarding the possibility of celiac disease be seen by a gastroenterologist so appropriate testing can be pursued. Empirically placing someone on a gluten-free diet may help with symptoms, but is not diagnostic of celiac disease. This also makes it more difficult to go through traditional testing for celiac disease.” Early diagnosis of celiac disease is key as it may prevent complications later on. It is important to note that there is no cure for celiac disease. The only treatment is a lifelong change in diet.
Getting Support The diagnosis of celiac disease is difficult and requires a lifetime commitment to a gluten-free diet. There are many who struggle with this, but support is available.
Four Convenient Locations
The Lancaster area has its own support group available to help both adults and children with celiac disease. Lancaster Area Celiacs holds educational sessions, support meetings, guides for eating out and diet changes, and a detailed list of symptoms on their website and Facebook page.
• Lancaster Health Campus • Oregon Pike-Brownstown • Women’s Digestive Health Center • Elizabethtown
• Phone Number: 717-478-8647 • Website: http://lancasterareaceliacs.org/index.html • Facebook Page: https://www.facebook.com/groups/194376710596986
www.RGAL.com • 717.544.3400
Regional Gastroenterology Associates of Lancaster also has some information about celiac disease and other conditions on their website: http://www.rgal.com.
LANCASTER
To learn more about the commitment to quality and patient safety by RGAL physicians and staff, visit www. RGAL.com.
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NEUROLOGY & STROKE ASSOCIATES, PC 640 East Oregon Road, Lititz, PA 17543
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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
Neeraj Dubey, MD, FAAN Board Certified in Neurology, Neuroimaging and Vascular Neurology
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
A N C A S T E R 26 WELCOME PHYSICIAN NEW LPATIENTS
G N I N E P O D N A R G
Now scheduling 3T MRI of the Brain and Spine on the Premises at 640 East Oregon Road in Lititz
Sharper, Clearer Images • Faster Scan Times • Special Imaging Protocols
FOR MORE INFORMATION: Please contact the Practice Manager Monday – Friday, 8:00am – 4:00pm at 717.569.8773
WELCOME NEW DOCTOR! Wen Ying (Helena) Wu-Chen, MD Dr. Helena Wu-Chen received her board certification in 2009 by the American Board of Psychiatry and Neurology. She practices general neurology and also has a subspecialty in Neuro-Ophthalmology, where she treats patients with visual problems that are related to the nervous system. She has published in several research journals and has written several book chapters. In her leisure time, she enjoys spending time with her family. She is happily married and has two children. She is also fluent in Spanish and Mandarin. Education: Wilmer Ophthalmological Institute at Johns Hopkins University, Temple University Hospital, Lankenau Hospital, University of Minnesota Membership: American Academy of Neurology, North American Neuro-Ophthalmology Society Dr. Wu-Chen will also be providing services in her specialty of Neuro-Ophthalmology at Eye Doctors of Lancaster.
PLEASE CALL FOR APPOINTMENT
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Healthy Communities
NO SHAME in Using a Cane
DR. KAVEER NANDIGAM, MD
Consultant Neurologist, Director of Neuroimaging Neurology and Stroke Associates
There has been a lot of emphasis on disease prevention over the past few decades, which has led to more people living into their late 80s and 90s. As age increases, so does the incidence of hospitalizations. One of the common and potentially preventable causes for hospitalization among the elderly is falls. Centers for Disease Control and Prevention (CDC) statistics report the prevalence of those older than 65 years having experienced any fall in the past 12 months at about 27%, which costs billions of dollars in direct medical costs. For many, falls with ensuing spine or hip fractures or intracranial hemorrhage are not uncommonly a terminal event. As a neurologist, I emphasize vehemently in my practice about falls prevention among the elderly. The goal of this article is to spread
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this message and identify the risk factors for falls from a neurological point of view. To prevent falls, it is important to recognize the conditions which increase the risk for falls. From a neurological standpoint, the most common conditions which escalate falls risk include peripheral neuropathy (diabetic polyneuropathy being the most common) and Parkinson’s disease. Other common causes include cervical myelopathy, normal pressure hydrocephalus, sequelae of strokes, neuromuscular conditions causing foot weakness, advanced cognitive impairment, visual field defects, poor visual acuity, musculoskeletal conditions, and joint pain/arthritis.
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No Shame in Using a Cane
In patients with peripheral sensory neuropathy, the proprioceptive signals about the ankle position are not relayed promptly to the brain, which consequently relies on visual cues. Such patients generally have a wide-based gait, and are vulnerable to falling in the absence of visual cues, such as at night or when their eyes are closed during showers, etc. Walking on uneven ground requires quickly changing the ankle position to adapt to the surface, which is an ability also impaired due to delay in ankle proprioceptive signals as discussed. This is another situation when such patients are endangered to fall. Electromyogram (EMG) and nerve conduction studies will be helpful in assessing the severity of neuropathy and for identifying the possible etiology of the neuropathy. Early identification and treatment of etiology may delay progression of neuropathy. Such patients must be counseled to be careful in bathroom and install grab bars, use night lights, and be very cautious on uneven surfaces such as unpaved paths. Motor involvement of peripheral neuropathy or a severe L5 lumbar radiculopathy (Figure C) often leads to foot drop. Early recognition of foot dorsiflexion weakness and referral for ankle foot orthosis (AFO) are important for preventing falls. Another relatively common neurological condition among the elderly that significantly elevates falls risk is Parkinson’s disease. Due to truncal rigidity and bradykinesia, these patients are unable to quickly adjust their center of gravity, especially during turns. They often have a tendency to fall backwards. Early recognition and referral for pharmacological treatment will help in reducing the rigidity/bradykinesia symptoms, improving motor function, and preventing falls. Chronic cervical degenerative spine disease is not uncommon in elderly, and some may develop cervical spinal canal stenosis with myelopathy (Figure B). These patients commonly have brisk deep tendon reflexes and may develop sensory motor deficits depending on the severity. In terms of falls risk, they share features similar to those with peripheral neuropathy, i.e. instability with eyes closed, in the dark, and on uneven
FIGURES LEGEND (A) MRI brain T2-weighted sequence shows severely enlarged ventricles in a patient with normal pressure hydrocephalus. (B) Cervical spine MRI sagittal view shows large disc protrusion into spinal canal at C4-5 level (arrow) causing severe spinal canal stenosis and compression of cervical spinal cord, causing myelopathy. (C) MRI of lumbar spine sagittal view shows L5 nerve root compression in the neural foramen (arrow) which caused foot drop in this patient.
surfaces. MRIs of the cervical spine in suspected individuals will be helpful in diagnosis (Figure B). In patients with cognitive difficulty and gait impairment, especially if they walk as if their feet are stuck to the ground (magnetic gait), suspect normal pressure hydrocephalus (Figure A). Although not as common as the other conditions discussed, variable motor weakness and spasticity as in sequela of stroke or other neurological conditions like multiple sclerosis increase the risk of falls. The possibility of these conditions should certainly be considered when evaluating elderly patients with gait problems. Such patients must be counseled to use appropriate supportive devices such as canes or walkers, or they may require an AFO. From my personal experience, patients often are unwilling to use a cane despite their increased falls risk. The severity of the underlying neurological condition, or even age in general, has no bearing on this reluctance. This is likely from a social stigma against use of a cane, which could be looked upon as a sign of poor health or aging. It is our natural instinct to portray
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a healthy youthful exuberance among our peers, and using a cane projects the contrary. Overcoming this will be a great challenge for providers counseling patients about falls prevention, and will require repeat efforts. If Centers for Medicare & Medicaid Services (CMS) and third party payers can take up the cost of providing canes, there will be fewer falls overall—and significant savings in medical expenditure. Early recognition of the described neurological conditions with appropriate referrals to establish diagnosis and initiate treatment will save lives by preventing falls.
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Healthy Communities
Years of Personalized, Genomic Medicine in Lancaster County Co-founders Holmes & Caroline Morton celebrate a milestone & look to train the future clinician-scientists of tomorrow
MATTHEW SWARE
CSC Development Director
I
n 1989, Holmes and Caroline Morton shared a vision to serve the vulnerable Amish and Mennonite children of Lancaster County suffering from rare diseases.
Focused on the core belief that the most advanced medical technologies could be integrated into primary care, the Mortons rallied the local communities, personal friends, and a few key institutional partners to create the Clinic for Special Children (CSC). Today, the CSC serves over 2,500 patients from 34 states and 17 countries, representing 150 unique genetic disorders. The clinic saves millions of dollars in unspent medical costs year over year by providing efficient diagnostics, drastically reducing hospitalizations, and by preventing major disabilities. More importantly, the CSC is now a model for care that is being replicated throughout the world—a Lancaster County medical innovation. The Mortons’ vision also attracted brilliant colleagues like Laboratory Director Erik Puffenberger and Medical Director Kevin Strauss who have helped to see the clinic grow and thrive. With a dedicated staff of fourteen, the clinic has expanded its clinical services while simultaneously publishing 3–5 peer-reviewed scientific publications each year.
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“Special children are not just interesting medical problems, subjects of grants and research. Nor should they be called burdens to their families and communities. They are children who need our help, and if we allow them to, they will teach us compassion. They are children who need our help, and if we allow them to, they will teach us love. If we come to know these children as we should, they will make us better scientists, better physicians, and thoughtful people.” – D. Holmes Morton, MD Co-founder
“We have learned how to close the implementation gap,” says Kevin Strauss. “Our unique combination of clinical care and research has made all the difference in the lives of the children and families we serve.” Now celebrating 25 years, the CSC is not resting on past accomplishments or accolades. Instead, the clinic has begun a
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25 Years of Personalized, Genomic Medicine
rigorous training program for the clinician-scientists of tomorrow. “One of the best investments we can make for the future is to train young, talented students so that we always have exceptional physicians and scientists ready to serve the most vulnerable children of Lancaster County,” says Strauss.
AT EPHR ATA
A Catalyst Gift for Clinical Research & Education
“I have a winning hand with
Dr. Morton’s greatest mentor from his training at Boston Children’s Hospital was Mary Ellen Avery, a pioneering clinician-scientist who discovered surfactant in 1959. When Dr. Avery passed away in 2011, Dr. Morton was invited to speak at her memorial service. Dr. Morton spoke of Avery’s tenacity and intellect; how he would long remember her tough questions and focus on public health late in life. As only Dr. Morton could do, he also shared a surprise announcement with the crowd of close friends and colleagues.
Keystone Villa. They have been aces all the way. Since living at another Keystone Villa for two years, I am so excited to reserve my new apartment in my hometown.” — resident and bridge player, Mildred Fitterling
“…For this reason the Clinic for Special Children has established a Mary Ellen Avery Fellowship. Our Avery Fellows will learn about disparities in rural health care, the education and work of midwives, the culture of the Plain Communities, and they will learn how the Clinic for Special Children could bring genomic medicine to the everyday work of doctors outside university hospitals.”
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“A cancer diagnosis is a life-changing event that requires hope, strength and support. Providing comfort and compassionate care is my passion and purpose. As your doctor, I will be your tireless partner and advocate.”
Lancaster General Health has supported the Mortons’ efforts since their arrival in Lancaster, and on the 25th anniversary, LG Health has stepped forward with a leadership gift to support clinical research and education. The clinic seeks to raise $1 million over the next two years to fully fund the Avery Fellowship program in perpetuity, and LG Health’s gift of $150,000 will be a catalyst for giving from other organizations and individuals. With the community’s support, CSC will serve a new generation of clinician-scientists that will propel the Mortons’ vision forward.
Please Join Us in Welcoming Dr. Rodriguez to Our Fine Community. Lancaster Cancer Center, Ltd. (“LCC”) is proud to announce that Joanna Rodriguez, M.D., has joined our medical group. Dr. Rodriguez earned her Doctor of Medicine degree in 2008 from St. George’s University School of Medicine, her Internal Medicine certification in 2011 from Thomas Jefferson University Hospital in Philadelphia, as well as her Fellowship in Hematology and Medical Oncology in 2014. Dr. Rodriguez earned numerous awards during her academic career, is Board certified in Internal Medicine, and board eligible in both Hematology and Medical Oncology. She has extensive research experience and holds membership in the American Society of Hematology, the American Society of Clinical Oncology, and the American College of Physicians. After an extensive search, we are excited that Dr. Rodriguez has joined LCC and know that she will continue to deliver the care expected of LCC physicians: dedicated to patients, family and the community.
The Mortons came to Lancaster County in 1989 with hope for children suffering from rare diseases. That hope is now firmly rooted in strong medical outcomes and treatments they never could have imagined possible. The Clinic for Special Children’s growth has paralleled the development of the human genome project, yet CSC is an unparalleled example of implementation and efficacy of personalized genomic medicine. Lancaster can claim a unique medical innovation, and communities throughout the world will benefit from the clinic’s ingenuity.
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H. Peter DeGreen, M.D. Lena Dumasia, M.D. H.P. DeGreen III, D.O.
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1858 Charter Lane, Suite 202, Lancaster PA 17605 lancastercancercenter.com • 717.291.1313
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Employees & Employers Win With CoActive Wellness Program JIM SCHMUCKER
Executive Director at LCBGH
W
ellness is dead. At least that’s the opinion of most small to medium-sized employers. Why? Because they can’t figure out what’s in it for them…If they invest to help support the health of their employees, what do they get in return? Although the health care industry found in study after study a three-to-one return on investment for companies that have invested in wellness (meaning that the company will get back $3 dollars for every $1 invested) most employers haven’t been able to document their own returns. These employers are saying in response to these surveys—“Show me the money!” And they are right. Typical studies show “savings,” but they are for things that are unseen by the investor employer. Improved employee attitudes, higher presenteeism, lower absenteeism, lower medical claims, and lower usage of medications are regularly touted as benefits and values are attached to them. But, how exactly are these benefits measured and when does the employer’s dividend check show up in the mail? The reality is the check never comes. What most employers actually see in the market is: 1) their medical insurance premiums only going one direction—up. 2) providers rapidly building new facilities and offering additional services. 3) the expansion of direct-to-consumer advertising which drives utilization while enhancing individual
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expectations that the health care system can “fix” whatever aliment they conceive of at little or no out-of-pocket cost. So, is it any surprise employers find wellness initiatives, despite the promise of a great ROI, an exercise in futility? Everyone agrees a different approach is warranted. Health and wellness is important on all stages. Groups working together creating collaborations to address population health issues are everywhere. Even the federal government is now taking a crack at it, via ACA regulation, to encourage health care entities to think differently and work toward proven outcomes-based practices. Time will tell if these new models will work. We do know they will take years to implement, still more years to evaluate, and they will surely have unintended consequences no one saw coming. Remember HMOs? We need simple, actionable programs now—things employers can do now that give them immediate incentives to take actions that we know inherently will improve the individual’s health. Employers play a vital role. An individual encounters no other entity in their life where they spend more waking hours and where they experience more influence (by their associates at work) over their choices. No physician, no hospital, no marketer, not even the television has as much impact. As a result, the employer is situated in a unique position to drive a real and sustainable culture of health.
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Employees & Employers Win
The Lancaster County Business Group on Health (LCBGH), an affiliate of the Lancaster Chamber, has recognized this opportunity. LCBGH has taken steps to develop and implement a new way for all health care partners to participate in a program where each contributes actionable items or financial incentives while gaining direct benefits from participation. With grants from the Robert Woods Johnson Foundation, United Health Foundation, and the Lancaster County Community Foundation, LCBGH has developed an infrastructure where employer, employee, provider, insurance carrier, intervention companies, and brokers all connect and participate in a coordinated effort to help companies achieve real outcomes while receiving real rewards. We call this infrastructure the “CoActive Health Network.” Here’s how it works. A certified CoActive insurance broker markets the program to their clients, sharing two simple facts—1) CoActive can increase their health benefits by 20% if they accomplish two things. 2) If they are successful in doing these two things, the program will cost them nothing. The first task they need to accomplish requires the employer to provide an employee sign-up incentive of at least a 20% health insurance payroll cost differential between those employees who volunteer to participate and those who do not. Secondly (here’s the hard part), a company must enroll in CoActive at least 75% of those employees who are on the health plan. If they don’t, the company cannot participate. Most quickly ask, “Why will employees sign up?” When most people are asked to do something, they subconsciously ask themselves two questions: “Can I do what I am being asked?” and “What’s in it for me?” The second question is easy in this case. The participants get a 20% reduction in their payroll deduction for health insurance, provided by their employer, and a 20% increase in their benefits. What does CoActive ask employees to do? 1) If your BMI is 30 or over, you must lose
an additional five lbs. each twelve months you are in the program. 2) If you use tobacco, you must complete a cessation class within 12 months. That’s it? That’s it. CoActive is focused on the masses, the 80% who are healthy now and want to stay that way. Getting these people engaged in a monitoring system where they see benefits of participation and can actually see themselves accomplishing simple goals is a meaningful way to keep them from falling into the unhealthy population bucket. Two questions remain. Who provides the 20% increase in the benefits, and how can this be free of cost to employers? That’s where the providers and carriers come in. Given the new “population health” view of health care, providers know they must look beyond their current unhealthy patient population. With that, CoActive becomes a partner in keeping healthy people healthy and driving all employees to the primary care physician’s office. The program requires the employee to get annual biometric screenings each twelve months in the program. In the new world of packaged reimbursements and pay for value, a healthy patient population is more “profitable” for providers than an unhealthy one. For this, CoActive asks participating providers to waive 20% of their patient’s balance-due bill for deductibles and co-insurance. This direct reward to patients for maintaining their health is provided after the patient’s insurance carrier has adjudicated the charges so that the actual reward is individually capped annually. Lastly, if the group accomplishes these goals, the carrier wins with reduced claims. Therefore, CoActive asks carriers to reward the employer with an annual $100 per
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employee “wellness credit” to be paid as a reward for enrolling and maintaining 75% of the eligible employees in the CoActive plan. There are many details about the program beyond what this article has space to provide. But please understand—this program is different. In our pilot, we had sixteen “small” employers participate and all sixteen got 75% of their employees to participate. A key factor in culture shift is group dynamics. Traditional wellness plans focus on the individual. CoActive uses the group dynamics that naturally exist in the employer/employee relationship to accomplish remarkable organic results for groups who are ready to get real about healthy employees. CoActive has commitments from select carriers and hospitals at this point and expects to launch this fall. Being a community-based program, all providers, brokers, and carriers are welcome to participate in this exciting new venture. For more information, call LCBGH at (717) 239-6954.
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
Pennsylvania Medical Society Quarterly Legislative Update September 2014
SCOT CHADWICK
Legislative Counsel, State Legislative Affairs
T
he past month has seen a flurry of legislative activity, as lawmakers rush to finish as much of the 2013–2014 session’s work as possible before the term ends on November 30. In recent years lawmakers have not returned to Harrisburg for a “lame duck” session after the November election, so whatever gets done by October 15—currently the last scheduled pre-election session day—will probably be it until the newly elected legislature returns in January. Much will probably change by the time you read this, so check back with PAMED for updates. Following are highlights of legislative activity over the past three months.
Naloxone Bill on Governor Corbett’s Desk As expected, on September 24, 2014, the state Senate approved House amendments to an important drug abuse initiative, sending Senate Bill 1164 to Governor Corbett, who is expected to sign it into law on September 30. The bill was the brainchild of Senate Majority Leader Dominic Pileggi (R-Delaware County), who worked hard to get it across the finish line.
As originally introduced and passed by the Senate, Senate Bill 1164 provided Good Samaritan immunity to individuals who seek to obtain aid for someone experiencing a drug overdose. The reason this matters is that individuals in the company of someone experiencing an overdose may have been engaged in illegal activity at the time (i.e. using or selling drugs), and may be reluctant to seek help for fear of getting themselves in trouble with the law. The bill removes that obstacle, prohibiting law enforcement personnel from prosecuting an individual if they only became aware of the criminal activity because the individual was aiding a person experiencing a drug overdose. The House of Representatives added an equally significant amendment to the bill, allowing naloxone, a lifesaving opioid antagonist, to be prescribed to first responders like firemen and police officers, as well as to friends and family members of persons identified as being at risk of experiencing a drug overdose. Importantly for prescribers, the House amendment also provides liability protection to prescribers and the aforementioned individuals if they administer naloxone in good faith to someone who they believe is experiencing a drug overdose. The only portion of the bill that was somewhat controversial was the section granting health care providers authority to
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prescribe or dispense naloxone to a friend or family member of an individual at risk of experiencing an opioid-related overdose. The concern was that giving naloxone to the friends of an at-risk individual might give them a false sense of security and actually encourage risky behavior. However, naloxone is known to precipitate withdrawal in individuals receiving opioids, making them extremely miserable. Hopefully that knowledge will mitigate the concern that having naloxone may encourage risky behavior. The bottom line: naloxone saves lives, and PAMED is pleased that the bill is on the verge of becoming law.
Controlled Substance Database Senate Bill 1180, which would establish a statewide controlled substance database, is close to enactment, though its fate is by no means assured. Earlier this session the House passed a House bill (HB 1694) by a vote of 191-7, and subsequently the Senate passed a Senate bill (SB 1180) 47-2. Progress subsequently stalled, as House members advocated for their bill while Senators pushed for their version. However, on September 24, 2014,
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PA Medical Society Quarterly Legislative Update
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there was a breakthrough when the House Health Committee amended and approved the Senate bill. At this writing, time is growing short, as the House and Senate are each scheduled to be in session doing substantive business for only five more days—October 6, 7, 8, 14 and 15—before the two-year term ends on November 30. Still, five days is enough if the commitment exists to get it done. Under its rules, the House could consider the bill on final passage as soon as October 7, leaving the Senate at least three days to schedule a yes/no vote on the amendments added by the House. A yes vote would send the bill to Governor Corbett’s desk. The major remaining hurdle appears to be the disagreement that remains over the degree of access law enforcement personnel should have to the patient records in the database. Civil libertarians and patient
advocates (including PAMED) argue that establish standards for patient monitoring patients have constitutionally protected pri- and safety. Both originator and “biosimilar” vacy rights when it comes to their sensitive products have the potential to cause adverse medical records, and that law enforcement effects throughout their product lifecycles personnel should be required to obtain a as the result of differences in patients or court order based on probable cause to in the product. For this reason, the FDA view them. Meanwhile, law enforcement has the authority to not only approve agencies believe they need more liberal “biosimilar” products, but also to develop access to the database to aid them in their appropriate conditions for products that efforts to apprehend lawbreakers. are interchangeable. PAMED is working to resolve the issue and get the bill before Governor Corbett for his signature.
“Biosimilars” Legislation Moving As more biologic medications are approved in the United States, the need for state and federal oversight is clearly necessary to
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Although prescribers can mark “dispense as written” or “brand medically necessary” on a prescription, PAMED does not believe this is a sufficient safeguard for the purposes of interchangeable “biosimilar” products. Senate Bill 405 addresses the need for additional patient safety protections by including language that requires physician notification for “biosimilar” substitution by a pharmacist in the absence of a physician instruction to prescribe the brand name product. Continued on page 36
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
PA Medical Society Quarterly Legislative Update
A recently added amendment to the bill would require pharmacists to actively notify prescribing physicians when a biosimilar is substituted for a prescribed biologic medication, with passive notification permitted after five years. The assumption is that most pharmacists and physicians will be connected to an electronic patient record system by that time, which will make knowledge of substitution automatically available to prescribing physicians. The bill was passed by the Senate in June of 2014, and the House Health Committee approved it with the new amendment on September 24. The full House is expected to vote on the bill in early October, and Senate agreement to the House amendment would send the bill to Governor Corbett’s desk for his signature.
Acupuncture Bill Signed Into Law Senate Bill 990, which amends the Acupuncture Licensure Act, was signed into law by Governor Corbett on September 24, 2014. Now known as Act 134, Senate Bill 990 clarifies the existing provision of the Act that permits acupuncturists to administer to those who visit them beyond 60 days without obtaining a medical diagnosis from a physician, dentist or podiatrist, as long as the person is not being treated for a condition. Under the law, if a person presents any symptoms of a condition, the acupuncturist would continue, as before, to be required to obtain a medical diagnosis before continuing treatment beyond 60 days.
The requirement of a medical diagnosis after 60 days when a patient is being treated for a condition is essential for patient safety. For example, lower back pain could be caused by any number of serious conditions, including cancer. The 60-day diagnosis requirement provides assurance that serious underlying conditions are discovered sooner rather than later. The language of the new law is consistent with current law, while clarifying the provision that wellness patients who present no symptoms of a condition may be seen beyond 60 days without a referral for a medical diagnosis. Act 134 also adds a provision requiring acupuncturists to carry liability insurance coverage.
Rodney Brenneman, M.D.
Kathryne J. Stabile, M.D., M.S.
A graduate of Penn State College of Medicine, serving at Penn State Hershey Orthopaedic Surgery Residency, Dr. Brenneman is a surgeon skilled in General Orthopedics. Originally from Virginia, he has family ties to Lancaster County.
With a Fellowship in Sports Medicine from Duke University Medical Center, Dr. Stabile adds a new dimension to OAL. A graduate of the University of Pittsburgh and Drexel University College of Medicine, she is the first female physician to join the practice.
Jackson Liu, M.D.
Colin Heinle, M.D. Fellowship trained in orthopedic trauma, Dr. Heinle possesses a crucial skill set focused on treating the most severe orthopedic injuries. He was born and raised in Lancaster County. Dr. Heinle is a graduate of Bowdoin College and Georgetown University.
Specializing in pain management and musculoskeletal ultrasound, Dr. Liu is fellowship trained in Interventional Spine & Sports Medicine. He completed his residency and served as a chief resident in Physical Medicine and Rehabilitation at New York University Langone. Recognized for his compassionate care, he was inducted into the Gold Humanism Society in 2013. He is a graduate of SUNY Downstate Medical Center. OAL Lancaster
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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
2015 EMPLOYED PHYSICIAN ADVOCACY:
Our Employed Physician Advocacy Priorities for 2015 include:
PAMED Is Your Voice & Advocate
PAMED advocates that physicians employed by hospitals or health systems should retain their independent medical judgment in providing care to patients, and that the hospitals or health systems may not discipline a physician for reasonably advocating for a patient. A hospital or health system that violates a physician’s clinical autonomy or retaliates against a physician for exercising rights afforded by this safeguard should be subject to licensure action by the Department of Health under the Health Care Facilities Act.
ASSURING PHYSICIANS’ CLINICAL AUTONOMY
A
s your voice in Harrisburg, the Pennsylvania Medical Society (PAMED) is working tirelessly to make Pennsylvania a positive practice environment for all physicians. With the consolidation of physician practices and the increased employment of physicians by hospitals and health systems, PAMED believes it is essential to develop comprehensive legislation to safeguard the rights of employed physicians. These rights include the right to practice independently; the right to reasonably advocate for patient care without fear of discipline or reprisal; and the right to continue to care for patients without interruption of that care by the patient’s change of employers.
KEEPING PHYSICIANS IN CHARGE OF MEDICAL DECISION MAKING To assure that physicians remain the leaders of patient care, PAMED will advocate for the requirement that hospitals and health systems that employ physicians must appoint someone who is responsible for monitoring and reporting to the Department of Health any actions or events that they believe in good faith constitute a compromise of the independent medical judgment of a physician. This individual would be appointed in consultation with the physician advisory committee of that institution and would serve on the physician advisory committee ex-officio, without a vote.
PAMED is actively advocating on several fronts to support employed physicians across the Commonwealth. We urge you to join us and support our work to represent your interests here in Harrisburg and statewide.
RESOLVING COMPLAINTS WHEN A PHYSICIAN REPORTS CONCERNS ABOUT CLINICAL INTERFERENCE PAMED advocates that a mechanism be created to resolve complaints regarding interference or attempted interference with a physician’s independent medical judgment. DUE PROCESS PROTECTIONS FOR CLINICAL PRIVILEGES PAMED advocates that physicians who are terminated by a hospital or health system must be given due process according to medical staff bylaws before their clinical privileges can be adversely affected. PAMED asserts that physicians must have a private cause of action if their employment is terminated or otherwise subject to retaliation in violation of these safeguards. ELIMINATING RESTRICTIVE COVENANTS PAMED supports prohibiting employers from requiring a physician to sign a restrictive covenant that precludes the physician from competing with the employer if their employment is terminated. Elimination of restrictive covenants is crucial to assuring physicians are not limited in their ability to practice medicine despite prior employment agreements. These priorities are critical to assuring that physicians remain the leaders in clinical decision making in hospitals and health systems. To join us in our work, please visit www.pamedsoc.org/join or call 855-PAMED4U. From PAMED’s September 2014 “PA Physicians: Legislative Consult”
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LANCASTER CITY & COUNTY MEDICAL SOCIETY MEMBERS Serving at PAMED House of Delegates
Jim Kelly, MD
Stephen Olin, MD
Bob Aichele, DO
Laura Fisher, MD
Charles A. Castle, MD
Dave Simons, DO
Paul N. Casale, MD
Venkatachalam Mangeshkumar, MD
Lancaster City & County Medical Society is pleased to welcome two new resident board members to two-year terms as they complete their residencies at Lancaster General Health’s Family Medicine Residency Program. Both are also representing LCCMS in PAMED’s House of Delegates. Alyssa Jones, MD
Jennifer Zatorski, MD
Alyssa grew up in a small farm town in northeast Pennsylvania between Scranton, Pennsylvania and Binghamton, New York. Living in the farm country and experiencing the full spectrum family medicine from the patient's perspective, her interest in medicine sparked at an early age - in particular family medicine in rural settings. She moved to the 'big city' for college and attended Syracuse University where she obtained her bachelor's degree in biomedical engineering. While she decided to enter the medical field rather than pursue engineering, the background in biomechanics fueled her interest in sports medicine. From Syracuse, she relocated to the 'sweetest place on earth' for medical school at Penn State Hershey where, through a number of experiences, she found her passion in family medicine. She is excited to be able to live in and explore another part of Central Pennsylvania and she is looking forward to spending her training years in Lancaster practicing full spectrum family medicine! Outside of medicine, Alyssa enjoys spending time with family and friends, traveling, trying new recipes, Zumba, music and the outdoors.
Jennifer grew up in a small town in northeastern Pennsylvania, one of three children and surrounded by a large extended family. For college, she attended Duquesne University in Pittsburgh. While there, she earned a bachelor's in biochemistry and a master's in forensic science and law. She loved applying science to solve real world problems, but really missed the interaction with people. Medical school gave her the opportunity to mesh all the things she loved. She completed medical school in Philadelphia at Thomas Jefferson University. While there, she was involved with Jeff HOPE, a set of student run health clinics in homeless shelters throughout the city, and Jeff Mentors, an organization which allowed her to mentor a young girl. Having the support of so many family members growing up gave her the love and passion for treating family units, and these organizations helped her to realize this. Some of her interests in medicine include women's health, geriatrics and palliative care, but she is incredibly excited to learn the full spectrum of family medicine in Lancaster. Jennifer's interests outside of medicine include Pittsburgh sports, cooking and baking and board games with friends.
Syracuse University, BS Pennsylvania State University College of Medicine, MD
Duquesne University, BA, MS Jefferson Medical College of Thomas Jefferson University, MD
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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
COLLECTION STRATEGIES Can Help Physician-Patient Relationship, Protect Bottom Line
CAROL BISHOP
Associate Director of Practice Economics & Payer Relations at the Pennsylvania Medical Society
C
ollecting money from patients is one of those necessary things that few physicians or their staffs are comfortable doing. But practices must have a good process in place to collect deductibles, co-payments, and co-insurances if they want to continue to offer quality health care. When communicated clearly and respectfully to patients, these processes may also help avoid negative impacts on the physician-patient relationship and damage to the practice and/or physician’s reputation. Practices should take a step back and examine their current procedures—from how patients check in, to patient billing and collections.
Clearly Communicating Policies and Procedures with Patients
The first steps in creating this process should include finding a reliable system for checking eligibility, accurately estimating the patient’s financial obligation, and reviewing the estimate with the patients prior to their appointment or when they check in. When patients know upfront what their financial obligation may be, they are more likely to pay all or some of what they owe at the time of service. To ensure accuracy, it is absolutely vital that staff collect and enter demographic and insurance information correctly at time of check in. The best practice is to
verify coverage and the applicable cost share amounts (i.e., co-payment, deductible, and co-insurance).
The Practice’s Bottom Line: Collection Strategies
with automatic withdrawals is one that is The bottom line: Health care costs money. becoming more prevalent. With payments from patients for services provided poised to make up a larger and far Practices should also: more critical percentage of providers’ total revenue, bad debt can no longer be viewed • Implement a solid financial and as simply a cost of doing business. It now billing policy detailing their expechas the potential to damage your practice. tations for charging, billing, and For many practices, it’s a change in thinking. collection of accounts receivable.
• Educate patients, especially new patients, on their financial responsibilities and on their billing policies and procedures. This will encourage them to comply. Some • Collecting payment (e.g., co-payexamples are office brochures, ment, co-insurance, deductible) welcome letters, and websites. The information should include the prior to services being provided insurance companies the practice participates with, policies for col• Increasing the pace of collections lecting co-payments, deductibles, to include reducing the number of and co-insurances, as well as days between when a bill is sent and when payment is due payments for non-covered services. Information should also be includThere is no better time to collect than ed on the practice’s process for when the patient is already at the office. filing claims, credit cards that are This will help to avoid wasting more time accepted, the process and timing for sending out patient statements, and money for billing patients later. Even when payment is due, and the if a patient is not able to pay in full, the policy for turning balances over to opportunity for patients to pay a portion of a collection agency. their bill or set up a payment arrangement Practices need to ensure that the policies and procedures that are in place are doing everything possible to prevent balances from becoming delinquent, such as:
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Collection Strategies
• Review financial policies annually, especially due to the ever-changing rules of private and public health insurance carriers. • Ensure that their office staff is fully knowledgeable of the policies and procedures, as well of any changes which may be made to the financial policy. • Train their front office staff to double-check for past due balances on the patient account and consider reminding the patients of such balance. • Consider payment plans. The patient may be more inclined to make a payment or pay the balance if this option is available to them. Find more tools, valuable information, and suggested strategies from the Pennsylvania Medical Society (PAMED) at www.pamedsoc.org/collections.
Hard to Collect Balances
For those hard to collect balances, practices should stick to their protocols listed in their financial policy and procedure manual, such as phone calls, late payment notices, and the process for placing patients on payment plans. The practices’ physicians should also be fully aware of the financial policies and procedures, because many times physicians want to know who may be sent to a collection agency.
R E F E R E N C E S :
Some practices find it very difficult to pursue patients who owe the practice money or who fail to pay their co-payments, deductibles, co-insurances, or past due balances at time of service. However, it is important to keep in mind that the physician has provided important services to the patient and deserves to be paid for such services. When the patient claims he or she cannot pay a balance due, the practice should do their due diligence to work out a payment arrangement that is comfortable for both parties.
Collection Protocols for the Medical Practice, PAMED www.pamedsoc.org/collectionprotocols Patient Liquidity at Time of Service Big New Problem for Providers, Insurers, Managed Care www.managedcaremag.com/archives/2014/3/ patient-liquidity-time-service-big-new-problem-providers-insurers Higher Copayments and Deductibles Delay Medical Care, A Common Problem for Americans, Managed Care www.managedcaremag.com/archives/1001/1001.downstream.html
For those patients who simply refuse to pay their balance, this should be handled in accordance to the practice’s financial policy. As stated in the beginning of this article, it must be understood that health care costs money. If the patient is truly in difficult circumstances, the practice’s willingness to work with the patient will show patient loyalty and goodwill.
How to Clearly Communicate Patients’ Financial Obligations, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/ how-clearly-communicate-patients-financial-obligations Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services, Kaiser Family Foundation http://kff.org/medicare/issue-brief/paying-a-visit-to-the-doctorcurrent-financial-protections-for-medicare-patients-when-receivingphysician-services/
Changing Your Thinking on Patient Collections, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/ changing-your-thinking-patient-collections
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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
The Iron Horse Inn
KELLY LYONS LCCMS Executive Director
I
’d like to preface this review by saying The Iron Horse Inn is one of my favorite restaurants outside of Lancaster City. The less than stellar experience I had there on Saturday, September 27, was unusual for this long-standing establishment in Strasburg. I called early that day to make a reservation for two at 6:00 pm. The hostess sounded harried. She said they were very busy, so if we could arrive at 5:45 pm that would be helpful. (Reservations are recommended, particularly for weekends.)
I arrived at 5:40 pm. The parking lot and available street parking were full. As I entered the door, a server pushed past me with a tray of food for the diners on the porch—a lovely area to sit on a nice evening. At the hostess stand immediately inside the front door, two women were trying to seat a party of six and two parties of two. I waited my turn. I told them I had a reservation and had arrived 15 minutes early as requested. I also informed them I was waiting for my friend, Judy. I provided her description and name and was assured they would keep an
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eye out for her and show her to our table. With that established, the hostess led me to the table. The restaurant was full, so unfortunately our table was not in the main dining room and was near the restroom. The staff was quite busy because many tourists were in town, having dinner before going to a show at Sight and Sound Theater. After nearly ten minutes, a server showed up with water, asking if I wanted a beverage.
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The Iron Horse Inn
CAMPUS EYE CENTER
I chose sangria because the wine list for ordering by the glass was limited. A bit later, my drink arrived, and the server asked if I wanted to order an appetizer. I said I’d prefer to wait for my friend.
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I had texted Judy before entering the restaurant to let her know I was there and would be seated at a table. About 20 minutes passed and still no sign of her. It was unusual for her to be late. I later found out that she had been standing at the hostess’ station trying to get through to them that her friend was already seated. She provided her name. She was told to wait while they seated other couples. A server then showed her to the table. She asked Judy if she wanted a drink and if we were ready to order. Judy ordered a peach mojito, but at that point in time, she hadn’t had the chance to look at the menu. We opted to explore it a while longer before ordering.
Lee A. Klombers, M.D.
David S. Williams, M.D.
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Although our experience was not up to par for the Iron Horse Inn, I realize it was an unusually busy night for the staff. If you’ve never been there before, I would recommend going for lunch or perhaps dinner on a weekday evening to try it out. If you decide to go on the weekend, first ask if tour groups will also be there that night. If “yes,” consider planning your visit for another time.
For dessert, I ordered chocolate shoofly pie. As a Lancaster County Native, I was looking forward to a traditional wet-bottom shoofly pie (the kind with the gooey molasses bottom). This one was the all cake through and through variety. I suppose that type of shoofly might be more acceptable in taste and texture to people not from this area, but it just seemed a bit inauthentic to me. Despite that, it was very fresh as has been my experience with other desserts (freshly made by a local bakery) served at the Iron Horse Inn.
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Pediatric and NeuroOphthalmology Premium Intraocular Lenses (IOL s) Strabismus (lazy eye) Thyroid-related eye problems
2108 Harrisburg Pike | Suite 100 | Lancaster, PA 17601
For dinner, I ordered a salad with grilled salmon, and Judy ordered one of the specials for the evening, Crab & Corn Risotto (creamy aborio rice, roasted corn, jumbo lump crab, and leeks).
After dinner, Judy ordered coffee. The server didn’t offer cream with it, so Judy had to ask for it. By the time it arrived, her coffee was cold and needed to be reheated.
Eye infections Eye injuries Eyelid growths Foreign bodies Glaucoma Macular degeneration
Two Convenient Locations: Health Campus: 717.544.3900
The Iron Horse Inn menu has appetizers in the realm of $7 to $12, and their dinner specials fall around the $25 to $29 range. They offer some vegetarian and low-carb options, but there didn’t appear to be anything explicitly gluten free on the menu.
My salad was done perfectly. The salmon was prepared medium as requested, and served at the perfect temperature. Judy said her entree was flavorful, but the dish was only slightly warm when delivered to the table. Her peach mojito (which was rather weak) arrived during dinner—a good while after she had ordered it.
Astigmatism (Toric Lens) Blepharitis Cataracts Diabetic eye problems Dry eyes
The Iron Horse Inn Reservations encouraged
135 E Main St, Strasburg, PA 17579 717.687.6362 Hours Sunday: Noon – 7 p.m. Monday, Wednesday & Thursday: Noon – 9 p.m. Tuesday: Closed Friday & Saturday: Noon – 10 p.m.
www.ironhorsepa.com
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News & Announcements
Welcome... New Members
Frontline Groups The Lancaster City & County Medical Society thanks these groups for 100% membership in the Medical Society for 2014.
Sana Hanafi, MD Cocalico Family and Sports Medicine
Allergy & Asthma Center
Jeffrey H. Chaby, DO & Associates
Baron Family Practice
Justin L. Cappiello, MD, PC
Kevin J. Hines Student
Campus Eye Center Cardiac Consultants PC
Chet Morrison, MD LGHP—Trauma and Acute Care
Cardiothoracic & Vascular Surgeons of Lancaster
Keyser & O’Connor Surgical Associates Ltd
Lancaster Arthritis & Rheumatology Care Lancaster Cardiology Group LLC
Care Connections Clinic Christine E. Kreider Student
Child & Adolescent Psychiatric Associates
Congratulations... Reinstated Members
David W. Hartley, MD LGHP—County Line Family Medicine
Alyssa K. Jones, MD Resident, Lancaster General Hospital Graduate Medical Education
Neva Andrea Ouilikon, MD Ephrata Community Hospital Hospitalist Group Randall Alan Oyer, MD LGHP—Hematology & Medical Oncology
Bakhti Sinor, MD Affiliate
Lancaster Family Allergy
Community Services Group
Lancaster Physicians for Women
Conestoga Pulmonary & Sleep Medicine
Lancaster Plastic Surgery
Dermasurgery Center PC
Lancaster Radiology Associates, Ltd
Eastbrook Family Health Center
Lancaster Retina Specialists
Eden Family Medicine
Lancaster Skin Center, PC
Electrodiagnostic Medicine Group Ltd
Lincoln Family Medicine Manheim Family Medicine
The EMG Group at The Electrodiagnostic Center of Lancaster ENT Head and Neck Surgery of Lancaster Eye Associates of Lancaster Ltd Eye Health Physicians of Lancaster
Maternal-Fetal Specialists OBGYN of Lancaster
Orthopaedic Specialists of Central PA
Otolaryngology Physicians of Lancaster Pain Medicine & Rehab Specialists
Eye Physicians of Lancaster PC
Patient First – Lancaster
Family Eye Group Family Medicine of Ephrata
Lancaster County Center for Plastic Surgery Lancaster Ear, Nose and Throat
Community Anesthesia Associates
Lora S. Regan, MD Lancaster General Occupational Medicine Philip D. Rodenberger, MD Retired—Psychiatry
General & Vascular Surgery of Lancaster
Pennsylvania Specialty Pathology Red Rose Cardiology
Georgetown Family Health
Rothsville Family Practice
Glah Medical Group The Heart Group of Lancaster Health Heritage Surgical Associates
Pennsylvania Counseling Services – Lancaster
Southeast Lancaster Health Services, Inc.
Stephen G. Diamantoni, MD & Associates – Leola
Highlands Family Practice
Welsh Mountain Health Center
Hyperbaric & Wound Care
Westphal Orthopedics
Hypertension and Kidney Specialists
MARK YOUR CALENDARS FOR OUR HOLIDAY SOCIAL! Saturday, December 13, 2014, 6:00 pm, at the Lancaster Country Club
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FA L L 2 0 1 4
News & Announcements
VASCULAR SURGEONS Join LG Health Physicians Surgical Group
J
ohn Affuso, M.D., of Lancaster, PA, and Meghan Dermody, M.D., M.S., of Milton, MA, have joined Lancaster General Health Physicians Surgical Group, specializing in Vascular Surgery.
Dr. Affuso completed his Fellowship in Vascular Surgery at Temple University Hospital, Philadelphia. He has a special interest in endovascular and open surgical treatment of aortic aneurysms, carotid artery disease, and peripheral vascular disease and expertise in dialysis access, wound care, and management of venous insufficiency. Certified by the American Board of Surgery, Dr. Affuso is a Candidate Member of the Society for Vascular Surgery. He completed his Internship and Residency at Robert Wood Johnson Medical School, New Brunswick, NJ, and earned his Doctorate of Medicine at Jefferson Medical College of Thomas Jefferson University, Philadelphia.
Leasing
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Dr. Dermody completed both Vascular Surgery Fellowship and General Surgery Residency at Tufts Medical Center, Boston. She has a special interest in carotid artery disease, treatment of thoracic and aortic aneurysms, minimally invasive techniques to treat peripheral arterial disease, wound care, and management of venous insufficiency. Dr. Dermody is accredited as a Registered Physician in Vascular Interpretation and is a member of the American College of Surgeons and a Candidate Member of the Society for Vascular Surgery. She earned her Doctorate of Medicine at Georgetown University School of Medicine, Washington, D.C. and her Master of Science at Georgetown University, Washington, D.C.
Development
Construction
Acquisition
AVA IL FA L L A B L E 2 014
Convenient to Everywhere.
Oregon Pike Professional Center
Located near intersection of Route 30 & Oregon Pike.
1613 Oregon Pike Lancaster, PA 17601
“Creating Value Through Experience” For more information contact:
LANCASTER OFFICE 120 North Pointe Blvd. Suite 301 Lancaster, PA 17601
Donna Deerin Ward (717) 569-9373 x 915
LANCASTER
YORK OFFICE
1200 Greensprings Dr. York, PA 17402
www.LMS-PMA.com
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News & Announcements
Forward Progress in Preserving the History of the Medical Profession An Update From the Edward Hand Medical Heritage Foundation
NIKITAS J. ZERVANOS, M.D., President
D
r. Paul Ripple and other members of the Lancaster County Medical Society established the Edward Hand Medical Heritage Foundation in 1982. We have come a long way and can now boast a collection of over 11,000 artifacts and memorabilia. We are impressed that nearly each month somebody either lets us know about or donates very useful items to enhance the very special treasures in our wonderful collection.
You will be impressed with the progress we continue to make, as our mission is to preserve the history of our medical profession and make accessible the rich heritage of the healing arts in Lancaster County. We operate with eighteen volunteer working-board members and a part-time curator. Up until now, we have not been all that accessible to the public, but the big news is that we have been able to open our museum
at the Burle Business Park in March of this year. This museum came about through the generosity and support of Lancaster General Health, the Burle Business Park, and our many donors. Some of you may have attended our open house on Friday, March 21, 2014. The theme that dominates our current exhibition is 19th century medical practice, highlighting various surgical instruments, microscopes, infant feeders, a pharmacy, ophthalmology, and dentistry. Visitors will be able to see various home visit treatments, including scarifiers for bloodletting, cupping, and birthing instruments. All the items are taken from our warehouse, which is contiguous to the museum and contains the remainder of our collection. The museum will be open to the public, but because we do not have full-time staff, we are unable to have regular hours. Nonetheless, we encourage groups who want to arrange a time to visit and see our museum to contact Mrs. Donna Mann, our part-time curator/archivist, by email at curator@edwardhandmedicalheritage.org. The other important development, as the result of a generous grant from the General Hospital, is the institution of our virtual museum project. This will enable us to make our collection accessible to medical personnel, historians, and researchers, as well as to
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libraries all across America and even around the world. Thanks to the grant, many of the artifacts are now displayed in 3D images along with detailed descriptions of their historical significance. We will also be able to provide academic opportunities for-credit to the area-wide college students who wish to work on this project with Donna during the school year. In the meantime, we continue to publish articles regarding the history of our medical profession and its specialties, as well as on the history of the hospitals and the allied health professions. These articles and our virtual museum can be viewed on our website: www.Edwardhandmedicalheritage.org. I wish to take this opportunity to thank all of you who continue to support the Foundation. We do not have a revenue stream, so all work of the Foundation is funded by donations from the community or through grant support. Please see our website for information about how you can help. We hope you are so gratified with our progress that you might be moved to remit a donation made payable to Edward Hand Medical Heritage Foundation. Contributions should be sent to P.O. Box 10302, Lancaster, PA 17605. Please be assured we appreciate even the most modest donations. I know, as a fellow physician, we get bombarded to donate to many causes. Please try to include us in your giving even if it’s a token amount. I suspect we all feel a part of Lancaster County’s medical history and wish to play a role in some way in this endeavor.
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News & Announcements
Lancaster Physician Elected Vice President of PAMED
K
aren A. Rizzo, MD, FACS, an otolaryngologist/ENT in Lancaster, was elected by her peers to serve as president of the Pennsylvania Medical Society (PAMED).
Dr. Rizzo will serve one year as president. Afterwards, she becomes president-elect for one year. In October 2014, she’ll take over as president of the statewide organization. Dr. Rizzo was elected to the position of president during the organization’s annual statewide meeting held in Hershey, Pa. An active 27-year member of the Lancaster City & County Medical Society (LCCMS), she served as its president from 2008 to 2010. At the state level, she served on PAMED’s board of trustees from 2003 to 2011 as a
surgical specialty trustee. She was vice chair of the board from 2009 to 2011. Currently, Dr. Rizzo is a member of PAMED’s Political Advocacy Council, Task Force on the State of Medicine, and Task Force to Improve Governance Processes and Structures. She has also aided several other councils in the past and served as the chair of the Specialty Leadership Cabinet from 2009 to 2011. Since becoming a physician, Dr. Rizzo has been active in several medical organizations and has made humanitarian trips to Vietnam, South Africa, and Egypt. In addition to being a member of LCCMS and PAMED, she holds membership in the American Medical Association and the Keystone Chapter of the American College
JOIN NOW! Membership in the Pennsylvania Medical Society is a statement of your commitment to the medical profession and to the patient-physician relationship. Here’s how to join today:
Talk to a member services assistant by calling 855-PAMED4U Complete an application online at www.pamedsoc.org/YourAdvocate
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of Surgeons. She served as president of the American Academy of Otolaryngologists/ Head & Neck Surgery from 2001 to 2003. Outside of organized medicine, Dr. Rizzo is an active alumna of Villanova University, from which she graduated magna cum laude. She was inducted into the Philadelphia Big Five and Villanova University Basketball Hall of Fame. Dr. Rizzo is a graduate of Temple University School of Medicine and currently practices medicine at Lancaster Ear, Nose, and Throat. She and husband Jay, a general dentist, reside in Lancaster. They have two daughters, Nicole and Marci.
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
LMS Foundation Updates
A Message From PALCO
Project Access Lancaster County (PALCO), a program of the Lancaster County Medical Foundation, began in 2007 out of a concern of the local medical community for the uninsured in Lancaster County. PALCO’s mission is to provide a coordinated health care network of volunteer physicians, other health care providers, hospital services, diagnostic services and pharmaceutical assistance for the low income uninsured residents of Lancaster County. PALCO provides a health care bridge for people who cannot afford health insurance, but who do not qualify for Medical Assistance, Veterans Benefits, or Medicare. In the first four years of operation, PALCO has served over 3,400 participants. Over 900 physicians and other providers, and four area hospitals, volunteer their services. With the implementation of the Affordable Care Act (ACA), PALCO’s services will be changing. What follows is an open letter from Charles Mershon, MD, President of the Lancaster County Medical Foundation, to all physicians and providers who will be affected.
A letter from Project Access (PALCO)* to participating physicians (June 19, 2014)
Dear Colleagues: Many of you have been asking about the impact of the Affordable Care Act (ACA) on Project Access Lancaster County and the patients we serve. The Affordable Care Act increased access to health care for many Americans by enabling them to enroll in the federally-operated Insurance Exchange (“Insurance Exchange”). The law requires that all people who can afford insurance take responsibility for their own health care by participating in the Insurance Exchange or by paying a Personal Responsibility Fee. With these added options for the uninsured, PALCO adjusted its eligibility requirements for enrollment and re-enrollment. • PALCO now requires that all patients first apply for insurance through the Insurance Exchange. Through the Insurance Exchange, many patients may be eligible for premium tax credits and/or subsidies to help cover the cost of a health insurance policy. Each PALCO patient whose enrollment expires in 2014 was sent a letter requiring him or her to apply for coverage through the Insurance Exchange and that he/she would not be re-enrolled in PALCO if he/she were eligible for subsidies and coverage under the ACA. • Individuals under 100% of the Federal Poverty Level (FPL) do not qualify for subsidies through the Insurance Exchange. Once the Supreme Court ruled that the federal government could not force Medicaid expansion onto States as part of the ACA, Pennsylvania opted not to expand Medicaid. To illustrate the effects of this decision, a 35-yearold making $12,000 a year can purchase a silver level health plan for $11 a month, with a deductible of $100. The same individual, making $10,000 a year (below the 100% FPL), would have to pay $186 a month for the same plan, with a deductible of $2,100. Individuals who find themselves in a similar situation will continue to need PALCO.
Governor Corbett has proposed expanding the state’s Medicaid program through his Healthy Pennsylvania Program. His proposal has been submitted to the Federal Government, but has not yet been approved. The implementation date for Healthy PA is January of 2015. Additionally, there will be a gubernatorial election this November; the manner in which Medicaid is expanded may change if a new governor is elected. Therefore, we ask for your continued support and participation until the eligibility issues are resolved because, until then, there will be uninsureds in need of your care. Our intention at PALCO is to discontinue direct medical services when our target population is covered either through the Insurance Exchange or through Medicaid or equivalent coverage. We expect that to occur in 2015, and we will let you know as
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LMS Foundation Updates soon as that is clear. In the meantime, PALCO is already actively transitioning eligible patients away from PALCO and into the Insurance Exchange. PALCO has received a grant to fund Certified Navigators who have been actively working for several months to assist PALCO patients and others in the community with Insurance Exchange enrollment. We are committed to helping your patients receive the assistance and support necessary to understand the Affordable Care Act and access the Insurance Exchange.
Primary Care Physicians & Hearing Care Primary care physicians are the entry level medical care providers that see the majority of hearing-impaired individuals; and there is great potential for PCPs to provide some basic hearing services while supplementing normal revenues. “On-site” hearing services is a similar concept to on-site blood and on-site x-ray services. Given an open mind to this, PCPs can provide basic hearing services which can provide a positive step in patient management, and it represents unencumbered additional revenue without a great deal of complexity. This brings better patient management because the hearing-impaired are not left to navigate that territory without initial guidance, and it brings unencumbered revenue because it can be billable yet it does not require significant space or equipment. It is simple to deliver because all that is required is a simple screening process that can be delivered by your technician when doing the standard blood pressure and temperature checks. To further treat individuals on-site where the hearing screening indicates the need for a full hearing test/consultation, a hearing health provider would reside on the PCP premises part time to conduct it. This is also billable, while adding this much-needed service to patient care and management — statistics show that individuals left alone to navigate the plethora of hearing aid providers and devices will commonly feel overwhelmed, and not take needed action. Cerumen management and amplification approval can naturally be scheduled for the PCP once the hearing evaluation is completed. The diagnosis code and procedure codes then are applied for the services provided to your patients and the hearing healthcare provider forwards that to the front office. Often, patients do have insurance reimbursement for amplification and the hearing care professional can assist your patient in applying for same. The final result is that the PCP provides a better path to hearing care services by being the first to add these screenings and total hearing test/evaluations without expense to your practices when your patients schedule the hearing evaluation through the front office.
We appreciate that our community has a broader perspective than many others and that the physicians and hospital systems recognize the current health care reform is a step, but not the end step. We are grateful to work with community leaders, like you, who continue to care for the individuals who fall through the cracks of our health system. Sincerely, Charles Mershon, MD President, Lancaster County Medical Foundation *The Lancaster County Medical Foundation is a project of the Lancaster City & County Medical Society.
For more information, contact:
Jack French
Zounds Hearing Center
(in the Kissel / Target Shopping Center)
717.625.1004 Jack@ZoundsLancaster.com
Zounds Hearing » 1004 Lititz Pike, Lititz, PA 17543 » 717.625.1004 » zoundshearing.com
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HAVE YOU HEARD? 9
Only % of Internists offer hearing testing to patients age 65 and older* DEMENTIA & ALZHEIMER’S Hearing loss is linked to 5 times increased risk of Dementia.
Hearing Loss is associated with other health conditions
CVD Hearing loss is linked to Cardiovascular Disease.
DIABETES Diabetes is associated with 2 times increased risk of hearing loss.
DEPRESSION Hearing aid use is associated with increased quality of life.
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Refer your patients with confidence • Hearing Aids • Tinnitus • Diagnostic Testing • Adults, Children and Babies
Moderate Chronic Kidney Disease is linked to 43% increased risk of hearing loss.
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717-283-4661
HaveBetterHearing.com Lancaster • Lititz • Willow Street (*Yueh, et al., 2003; JAMA)