Lancaster Physician Fall 2015

Contents

2015 BOARD OF DIRECTORS OFFICERS James M. Kelly, MD President

Lincoln Family Medicine

David J. Simons, DO President Elect

Community Anesthesia Associates

Robert K. Aichele, DO

COVER STORY

The ABCs of Vitamin D Why Is It So Important, & How Much Do You Really Need? (p. 18)

Vice President

Aichele & Frey Family Practice Associates

FALL 2015

In Every Issue 4 President’s Message 18 Healthy Communities 26 Passion Outside of Practice

Paul N. Casale, MD Immediate Past President

28 Patient Advocacy

The Heart Group of Lancaster General Health

Laura H. Fisher, MD

34 Legislative & Regulatory Updates

Secretary

Lancaster Family Allergy

40 Medical Society Updates

Stephen T. Olin, MD Treasurer

Lancaster General Hospital

42 Restaurant Review

DIRECTORS

44 News & Announcements

Charles A. Castle, MD Stacey Denlinger, DO Robin Hicks, DO John A. King, MD Venkatchalam Mangeshkumar, MD Kathryn McKenna, MD Ashley Morrison, MD Karen A. Rizzo, MD, FACS

Interim Editor: Dawn Mentzer

Editors: Susan Neville PAMED James Kelly, MD Lincoln Family Medicine

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

Best Practices 6 Urogynecology: Dedicated

to Helping Women with

Pelvic Floor Disorders 8 State-of-the-Art Imaging System

Upgrade At WellSpan Ephrata

Community Hospital Enhances

Patient Care 10 Our Younger Women Deserve

Better: A Call to Action

United Way of Lancaster County Sets Goal of Finding a Medical Home for Every Resident (p. 30)

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

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President’s Message

Is ICD-10

the Next Y2K?

James Kelly, MD President

B

y the time this issue is published, the above question will be answered at least in part. The 10th revision of the International Classification of Diseases (ICD) was completed in 1992, however, the U.S. medical system is among the last of the medically developed nations to adopt the new coding classification. On October 1, 2015, all medical encounters and billing switched over to ICD-10, and preparation to avoid a medical system “crash” was reminiscent of Y2K back in 1999.

ICD-10 contains codes for medical diagnoses, symptoms, and diagnostic findings, but with more specificity than prior versions. While our current ICD-9 system contained approximately 14,000 codes, ICD-10 numbers over 68,000 diagnostic codes.

The purpose of the system upgrade in basic terms is:

❶ To allow more accurate statistical tracking of medical diagnoses. ❷ To better classify severity and complexity of illness. ❸ To allow more accurate billing for medical encounters.

CORRECTION: In the article “Minor Emergency Care Facilities In Lancaster County” in the Summer 2015 issue of Lancaster Physician, there was an error on page 29 in the quote by Dr. Kenneth Hurst. His quote, “Most of us who work at Patient First are family doctors or interns who understand and appreciate the value of continuity of care,” should have read, “Most of us who work at Patient First are family doctors or internal medicine physicians who understand and appreciate the value of continuity of care.” We sincerely apologize for the error and any misunderstanding it may have caused.

Visit lancastermedicalsociety.org

In the past year, physicians have been bombarded with information in preparation for the transition. When I list a diagnosis, my electronic medical record (EMR) prompts me for specificity (left or right, acute or chronic, complications) and asks me to save the code for future use. EMRs can also convert a current ICD-9 to an applicable ICD-10 code with a few mouse clicks. Lancaster General has mandated I complete several online education sessions, and I receive monthly newsletters from our coding department with educational information regarding ICD-10. In all, ICD-10 has been a bit of a nuisance by requiring extra administrative time to finish and close a patient encounter.

Fortunately, most of the hassle has been behind the scenes in administrative offices.

As we have now passed the October 1, 2015 deadline, I sense additional anxiety and uncertainty from physicians regarding the transition. Many providers fear delays in patient care because of being forced to code differently, and I have heard of plans to cut schedules to avoid excessive patient wait times. Practices were also advised to have several months of cash reserves on hand and to prepare for reimbursement delays as insurance companies adjust to the changes. Medical offices are anticipating a temporary increase in denials for inaccurate or improperly submitted coding. Financial concerns and patient care delays are expected as medical offices adjust over the next few months.

It remains to be seen whether the medical community’s transfer to ICD-10 will give us the similar hype without substance seen with Y2K. On the patient side, you might expect to spend more time in the waiting room before seeing the doctor, to find your non-emergent appointments can’t be scheduled as promptly as before, and a delay in receiving your bill over the next six months. For physicians, the change will provide a more accurate assessment of the complexity of a patient panel.

Enhanced tracking for quality of care and improvements in insurance reimbursement will be a positive result. In the end, the transition to ICD-10 is a must for our health care system to move forward.

PAMED has resources available to assist physicians and practice administrators with the transition to ICD-10. Please check online at www.pamedsoc.org/icd10 or call the Lancaster City and County Medical Society office at 717.393.9588 for more information.

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best

pr ctices Urogynecology: Helping Women with Pelvic Floor Disorders

UROGYNECOLOGY: Dedicated to Helping Women with Pelvic Floor Disorders

Imaging System Upgrade At WellSpan Ephrata Community Hospital Our Younger Women Deserve Better

LAUREN WESTERMANN, DO

LG Health Physicians Urogynecology & Pelvic Reconstructive Surgery

T

he subspecialty of urogynecology offers women a specialized approach to the evaluation and treatment of conditions that affect the female pelvic organs. The official ABMS subspecialty is called Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Training for the subspecialty of FPMRS requires a four-year residency in ob/gyn and a three-year fellowship in FPMRS before clinical practice.

Pelvic floor disorders (PFD) include conditions involving weakening of the pelvic floor muscles or tears in the connective tissues resulting in conditions such as urinary incontinence or pelvic organ prolapse.

It is more common than

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many realize, because in many cases it goes unreported. Approximately 30 percent of women suffer from a pelvic floor disorder, but many are uncomfortable discussing these issues with their primary care providers and therefore suffer in silence. At LG Health Physicians Urogynecology & Pelvic Reconstructive Surgery, our practice offers the additional comfort of only female providers.

In addition, as part of LG Health’s Women’s Specialty Center, patients are treated in an environment solely dedicated to women’s healthcare. A nurse coordinator makes referrals as needed to help women manage all of their healthcare needs.

One of the most common PFDs we see in our practice is urinary incontinence. This presents in two forms: stress incontinence and urge incontinence. Stress incontinence is leakage caused by laughing, sneezing, coughing or exercise. This constitutes about 50 percent of cases. Urge incontinence, also

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Urogynecology

known as overactive bladder, is characterized by frequent urination and leakage associated with urgency.

Incontinence can occur at any age and it is important for women to know that there are many treatments available. Often we find that patients have delayed seeking treatment, not only because of embarrassment, but because they believe they have no options.

Another common misconception is that incontinence is a natural part of aging. This delay in treatment can lead to depression, anxiety, and even isolation. In reality, a wide array of treatment options is available for our patients, including changes in diet, pelvic floor physical therapy, medications, bladder Botox injections, neuromodulation, and minimally invasive surgery.

Another common PFD that we see in our practice is pelvic organ prolapse. This involves loss of normal support of the vagina, leading to dropping of the pelvic organs.

Symptoms include vaginal bulge or pressure, difficulty emptying the bladder or bowels, urinary incontinence, and sexual dysfunction.

Both non-surgical and surgical treatments are available for pelvic organ prolapse. Many women are concerned about large incisions or scarring. The good news is that minimally invasive surgery can be performed via vaginal, laparoscopic, or robotic routes. They usually involve minimal trauma, a one-night hospital stay, and a short recovery period.

Education is an important part of our practice. Although the development of PFDs is multifactorial, there are several prevention

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strategies for women to keep in mind.

Maintaining a healthy weight, abstaining from tobacco use, a healthy diet with fiber, and muscle strengthening techniques, such as Kegel exercises and yoga, all play a vital role in avoiding these conditions.

Remember, pelvic floor disorders are common and women should seek help as soon as possible. Don’t let your patients suffer in silence. Subspecialty care is available to help women improve their quality of life and get back to doing the things they love.

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Best Practices

State-of-the-Art Imaging System Upgrade At WellSpan Ephrata Community Hospital

Enhances Patient Care

John Nawa, MD, a diagnostic radiologist and chair of Imaging Services at WellSpan Ephrata Community Hospital, uses the upgraded PACS system to review a patient’s X-ray.

I

n June, WellSpan Ephrata Community Hospital switched to a new PACS computer system for handling imaging studies such as X-rays, MRIs and CT scans.

The new system will soon be installed at other WellSpan facilities, creating unprecedented opportunity for collaboration across the regional health system’s facilities in Lancaster, Lebanon, York and Adams counties.

PACS stands for Picture Archiving and Communication System, a digital technology that emerged in the 1990s to replace old-fashioned film. Over the years, PACS has grown in sophistication and storage capacity, with numerous vendors offering PACS products.

“Having the right hardware and software means you’re going to be able to do your job better—with quality, with excellence and with safety. Overall, it’s going to result in better patient care.”

The Ephrata PACS software dated back to 2006 and was in serious need of an upgrade.

Under the guidance of Michael “Mick” Murphy, Vice President and Chief

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Technology Officer, WellSpan information technologists drew up a bold plan. Rather than merely upgrading the existing PACS software at each hospital, they proposed an entirely new system, one that would connect

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System Upgrade At WellSpan Ephrata Community Hospital

radiologists all across WellSpan, enabling them to work together.

Imaging for clinical retrieval and display; and PowerScribe 360 for dictating reports.

“The data is encrypted, and access is limited to only people who need it.”

“We decided to look toward a best-ofbreed solution that would meet the needs of the entire health system,” said L. John Jabour, WellSpan Regional Chief Information Officer.

Before the new system could come online, there was a massive job to do.

For Nawa, one of the best improvements is speed. Some cases may contain as many as 2,000 images, he said, making a fast system invaluable.

Jabour and his IT colleagues began by discussing the concept with clinicians, including John Nawa, MD, a diagnostic radiologist and the chair of Imaging Services at WellSpan Ephrata Community Hospital.

“They did a very good job of letting all the players chime in and take part in the decision-making,” Nawa said.

Planning and preparation took more than a year, as the team built a custom PACS setup: Medicalis software for storing images; Visage

“We had to take all the old images—and there were millions of them—and copy them over to the new archive,” Jabour explained.

The transfer took several weeks and involved terabytes of data, but when it was finished, all previous Ephrata imaging studies were ready to be called up on brand new PACS viewing stations.

Jabour noted that the new PACS monitors are larger and have more than double the resolution of their predecessors.

“We’ve also really enhanced the security of protected health information,” he said.

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“Having the right hardware and software means you’re going to be able to do your job better—with quality, with excellence and with safety,” Nawa said. “Overall, it’s going to result in better patient care.”

Preparations are underway to bring the new PACS to WellSpan York Hospital and then to the rest of the health system, including WellSpan Surgery and Rehabilitation Hospital, WellSpan Gettysburg Hospital and WellSpan Good Samaritan Hospital.

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Best Practices

Our Younger Women Deserve Better:

A CALL TO ACTION

THOMAS FROMUTH, MD OBGYN of Lancaster

S

evere cramps as a young adolescent girl are just normal. Lying on the floor in a fetal position because of your menstrual cramps is just attention-seeking behavior and a way to avoid going to school. Right? NO THEY ARE NOT! Rather, they may be signs of a very common but under-diagnosed disease of young women, endometriosis.

Endometriosis is a disease caused by the growth of ectopic endometrial cells. The currently accepted theory to explain the origin of those ectopic endometrial cells is retrograde menstruation. Endometrial cells flow backwards out of the fallopian tubes as a result of either obstruction to the vaginal outlet or possibly dyssynchronous muscular activity of the uterus. Once these endometrial cells are in the peritoneal cavity of a genetically susceptible woman, they will attach, stimulate a local hormonal milieu that produces inflammation, scarring, vascular and nerve cell ingrowth.

Laparoscopically these areas of ectopic endometrial cells on the

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Younger Women Deserve Better

peritoneum can initially appear to be small red, black, gray, or clear dots. Looking under a pool of methylene blue-stained saline at laparoscopy will often demonstrate small micro menses floating in the fluid but still attached to the peritoneum.

Over the years, repetitive micro menses with associated inflammation and scarring result in severe pelvic adhesions and anatomic distortion. This ultimately leads to debilitating dysmenorrhea, chronic pelvic pain, infertility, and dyspareunia. These symptoms deeply affect a woman’s quality of life, fertility, ability to perform her job, and the health of her relationships. Generally, she will find that her physicians do not listen to her complaints. As a result, today it takes an average of ten years for a woman with endometriosis to finally reach a physician who will be able to diagnose and treat her disease. Unfortunately, after ten years endometriosis is often so deeply invasive that treatment becomes difficult, resulting in higher surgical risk and a higher percentage of recurrent symptoms.

Endometriosis can affect up to 10 percent of the reproductive age population. We are probably not identifying most of that 10 percent and likely only finding patients with severe disease and symptoms. Treating a patient with severe endometriosis properly often requires surgical skills found only at centers with specialized surgical expertise.

The call to action continues by asking all of those who surgically treat endometriosis to have humility. Endometriosis is sometimes very difficult to see and often missed at the time of initial laparoscopy. It requires a set of surgical skills that not everybody possesses.

Surgically in our area, we have not done a very good job at treating endometriosis, myself included. Too often surgery consists of looking and diagnosing endometriosis but not treating it—or worse, under treating it. This often has resulted in patients having multiple laparoscopies with little improvement in symptoms. If you do not have a great interest in endometriosis, then send the patient to someone who does. If at the time of initial laparoscopy you do not have the surgical skills to remove all of the endometriosis at that time, then don’t continue. Stop and send the patient to someone who does.

Our goal to strive for should be to find endometriosis early so we can increase the chance of a good quality of life and preserved fertility for our patients. Our goal should be to make the very first laparoscopy to diagnose endometriosis also be the last laparoscopy needed to treat endometriosis. We will not achieve this in all cases.

But our younger women with endometriosis need us to try. They deserve a future with a better life.

For an informational video on endometriosis you can direct your patients to obgynol.com in the GYN Surgery section.

So what can we do? The best way to treat severe endometriosis is to prevent it. That means we need to find it early, in our adolescent females before it becomes severe.

Young girls will often present to their pediatrician or family physician complaining of severe debilitating dysmenorrhea beginning with their very first menses, i.e. menarche. But how is it possible for a young woman to have symptoms of endometriosis at menarche before she has had her first menses with retrograde flow to start the disease process? Some researchers have postulated an answer.

Pediatricians and family physicians know very well that sometimes two percent of newborn females will have vaginal bleeding as a result of withdrawal from the high levels of female hormones in the maternal environment. The current suspicion is that this is the index event, the very first menses a young woman will have with retrograde flow. Most female newborns will not demonstrate vaginal bleeding but will have retrograde flow as a result of a very long, thick mucus filled cervix obstructing normal forward flow. In the genetically susceptible girl, the cells will attach and grow over the years resulting in classic dysmenorrhea at the time of menarche.

The call to action begins by asking all of you who see young women with dysmenorrhea early in adolescence to believe them, to believe that they are truly in pain. Treat them with nonsteroidal agents. Treat them with contraceptive pills. But if after six months they continue to have debilitating symptoms, send them along to someone who is very interested and experienced in treating endometriosis. Up to 75 percent of those adolescents who fail to respond to nonsteroidal agents and contraceptive pills will have endometriosis.

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Healthy Communities

the s

Why Is It So Important & How Much Do You Really Need?

I ALAN S. PETERSON, MD

n 2012 alone there were more than 3,600 publications in PubMed on vitamin D. By the time this is in print, several other articles will undoubtedly be published. (I just received one yesterday titled Cognitive Decline in Older Adults and Lower Levels of Vitamin D.) What do we know and what do we think we know about vitamin D? Vitamin D is a fat-soluble vitamin. Or is it? It’s actually a steroid hormone precursor involved in multiple organs at all ages. It’s naturally present in some foods (beef liver, fatty fish, egg yolks, fortified milk, and cod liver oil) and available as a supplement. It’s produced in the body when ultraviolet rays from sunlight hit the skin and trigger vitamin D synthesis. In healthy, non-obese people

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wearing t-shirts and shorts, ten minutes of sunlight during hours of 10 a.m. and 3 p.m. will yield 3,000 International Units (IU) of vitamin D. Because exposure to sunlight is a risk for skin cancers, use a sunscreen after that initial 10 minutes and discuss sun exposure with your physician.

Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable mineralization of bone. It’s needed for bone growth and remodeling. Many feel that vitamin D also helps with cell growth, neuromuscular and immune function, reduction of inflammation and other things. We’ll look at some of the research data about this later.

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The ABCs of Vitamin D

The issue is to find truly randomized controlled trials (RCTs), studies to demonstrate cause and effect with vitamin D. There are lots of associations of low vitamin D and medical problems, but is low vitamin D the cause or something that occurred from a disease or condition secondarily? We also must be mindful of what results we are looking at. Is it, for example, primarily mortality rates, less muscle aches, or risk for certain diseases? Some causes or associations of low vitamin D are felt to be: O HIV drugs, anticonvulsants, ketoconazole, mineral oil, orlistat, cholestryramine, colestipol; O Nephrotic syndrome; O Granuloma-forming disorders, lymphomas, primary hyperparathyroidism; O Bariatric surgery;

O Fat malabsorption syndromes, like celiac disease;

surgery, chronic liver or renal disease, or aluminum intake;

O Obesity;

O Psoriasis;

O Inadequate exposure to sunlight, including dark skin.

O Rickets (bone weakening in children)—Such as babies only fed milk without vitamin D supplementation;

Let’s look at what the Mayo Clinic feels is strong evidence (Grade A), after tests in humans and other animals, of increased need for vitamin D. The list includes: O Familial phosphate deficiency— A rare inherited condition; O Kidney disease with low phosphate levels—Fanconi syndrome is an example; O Osteomalacia (bone softening in adults)—Can be found in elderly with poor diets or with poor absorption without sun exposure, some gut

O Thyroid conditions causing low calcium levels—Such as after parathyroid surgery or overactive parathyroid glands; O Vitamin D deficiency—Associated with many conditions like bone loss, kidney disease, lung disorders, stomach and intestinal problems, and heart disease.

Vitamin D supplementation has been found to help prevent or treat vitamin D deficiency.

Continued on page 14

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Healthy Communities

And those conditions that the Mayo Clinic feels there is strong evidence against (Grade F) vitamin D use are shown below.

They point out further high quality research is needed for these: O Atopic eczema; O Cancer treatment (prostate); O Heart disease—Although recognized for heart health, research isn’t consistent and some negative effects of vitamin D on heart health have also been found; O High cholesterol—Results have been inconsistent.

What about the 49 other conditions in between Grade A and F in their list? They range between B (“Good” scientific evidence) and D (“Fair” evidence) against this use.

Many of us fit into those areas.

SCREENING

What might we do? We can get a 25-hydroxyvitamin D (25-(OH)D) blood level drawn. The United States Preventative Health Task Force recently said there is insufficient evidence to assess the benefits and harms of screening for vitamin D deficiency in healthy individuals. Maybe future research will change that.

The answers to the questions of who needs screening for vitamin D deficiency and then treatment, and how much of the supplement they will need will have to await further RCTs. Generally, older and sicker adults are more likely to have inadequate

The ABCs of Vitamin D

vitamin D levels. An article in the Mayo Clinic Proceedings suggested the following groups might be tested: O Dark skin, those with osteoporosis or previous fracture; O Certain lab abnormalities (low urine calcium, low serum calcium, low serum phosphorus, elevated alkaline phosphatase, elevated parathyroid hormone); O Chronic kidney disease, renal insufficiency or nephrotic syndrome; O Chronic musculoskeletal pain or weakness; O Malnutrition/poor oral intake; O Malabsorption syndromes, celiac disease, inflammatory bowel disease; O Liver disease, liver failure.

What are the harms of getting screened?

Of course, expense is a big one. The test for a 25 (OH)D is over $100.00 and, of course, may prompt other tests. Then there is the interpretation of the test level in that individual. As discussed previously, if one has a condition with few or no RCTs supporting supplementation, it is open to interpretation between the health provider and the individual. Of course, that interpretation may change with the next RCT. Luckily too much vitamin D is hard to get, but if you are someone with past kidney stones, vitamin D can potentially increase your risk. The Institute of Medicine

(IOM) suggests excessive amounts of vitamin D might possibly also increase the risk for pancreatic or prostate cancer. These studies weren’t RCTs. One study in The Journal of the American Medical Association found women receiving a single dose of 500,000 IU once a year resulted in vitamin D levels over 40 ng/mL (100 nmol/L) and a higher risk of fractures.

True vitamin D toxicity in a healthy person usually occurs only if someone is on 40,000 IU daily for more than three months with blood levels over 150 ng/mL. Obviously significant levels in serum calcium can occur from being on too much vitamin D. Calcium can deposit in soft tissue such as the heart and lungs. (This toxicity is different from the calcium in arteries from coronary artery disease.) Confusion and disorientation, damage to kidneys, nausea, vomiting, constipation, poor appetite, weakness and weight loss can be found with the high blood calcium associated with very high levels of vitamin D.

BLOOD LEVELS

These are described either as nanograms per milliliter (ng/mL) or nanomoles per liter (nmol/L), where 0.4 ng/mL = 1 nmol/L. The IOM states we should keep 25 (OH) D levels below 50 ng/mL. Most feel that levels below 30 ng/mL are too low for maximum bone health and other organ functions. Optimum levels of serum 25 (OH) D, however, are controversial. The IOM supports concentrations above 20 ng/ mL (50 nmol/L) but not chronically exceeding 50 ng/mL (125 nmol/L) for skeletal health. I favor 30-40 ng/mL (75-100 nmol/L)—which is supported by The American Geriatrics Society, National Osteoporosis Foundation, Endocrine Society, and the International Osteoporosis Foundation—to decrease risk of falls and fractures.

Continued on page 17

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Healthy Communities

The ABCs of Vitamin D

There are no optimal levels of vitamin D established for conditions outside of the skeleton. Let’s look at some of the possible reasons for vitamin D supplementation for those conditions, keeping in mind that there are no prospective RCT studies to define recommended levels.  MUSCLE WEAKNESS—Some observational studies suggest an association with low vitamin D levels and muscle weakness. Causal relationships have not been proven.

 FALLS—There are some metaanalyses showing a reduction in falls in the elderly following vitamin D supplements of 700 to 1000 units/day.

 CANCER—There have not been enough studies to support large dose supplementation to prevent cancer or treat it.

 IMMUNITY—Although vitamin D has major effects on most immune systems, a link of low vitamin D and autoimmune diseases is unclear at this time.

 CARDIOVASCULAR, INCLUDING HYPERTENSION—Most randomized studies have not shown a benefit.

 DIABETES—Vitamin D levels are lower in the obese and in diabetics, but again, we don’t know if this is causal.

Studies are underway.

 NEUROPSYCHIATRIC—There have been few trials on these symptoms. Causal relationships between low vitamin D and brain dysfunction remain uncertain.

 PREGNANCY—Once again randomized intervention trials in pregnancy have been few and data poor to prove protection in birth outcomes.

 MORTALITY—Some studies, but not all, show those with low vitamin D levels have higher mortality, but RCTs with mortality as a primary end point are lacking.

As one can see, much more research to prove low vitamin D levels cause specific conditions or diseases is needed. Associations of low vitamin D could be a manifestation of general “poor” health due to many chronic problems. Rather than screen low risk patients, some medical groups weakly recommend an intake of 800 IU daily. This should be determined by you and your physician. High risk patients should be screened and supplemented to adequate levels.

Physicians generally prefer cholecalciferol (vitamin D3) over ergocalciferol (vitamin D2). Vitamin D3 is found in fish oil, eggs, animal fat, and cod liver oil, and is

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equivalent to the vitamin D3 formed in our skin from ultraviolet B rays. Vitamin D2 is from plants, and found in fortified foods and some supplements. This is felt to be less biologically active than vitamin D3. Also, at higher doses, vitamin D2 has greater potential for harm than D3 due to formation of toxic metabolites.

Three to four months after starting a vitamin D supplement, a 25 (OH) D blood level is suggested. As is the recommendation for most of us, try to maintain a healthy lifestyle by eating plenty of fruits, vegetables, and nuts; exercising regularly; and not smoking.

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Healthy Communities

EPILEPS

T N H O : M S S E N E R A W YA

A Look Inside Today’s Progress ROSE BOETTINGER

F

He goes on to explain the difficulties faced of mind and the ability to go about living the average workaday life with little to no by those whose seizures are not controlled: “There are certain jobs they won’t be able interference from their seizures. to do, like those involving machinery or Approximately three million people in open flames.”

America are living with epilepsy. Given each Uncontrolled seizures can be dangerous person’s unique DNA and the multiple forms of epilepsy, no single way to treat the condi- to those experiencing them and the people tion will ever exist. However, medicines are around them. For example, an individual being developed, tested, and approved daily. with uncontrolled seizures puts not only his own life in danger by getting behind According to a 2015 report published the wheel of a vehicle but also the lives of by the Pharmaceutical Research and other drivers and pedestrians. Therefore, in Manufacturers of America (PhRMA) in Pennsylvania, it is required that a person be partnership with the Epilepsy Foundation, six months seizure free in order to receive 420 medicines are currently being devel- permission to drive. Proper medical treatThousands of years old, this seizure dis- oped by biopharmaceutical companies for ment is essential for people who experience order was initially believed to have been a the treatment of hundreds of neurological seizures in order to reduce risks of incidents, sign of demonic possession. Some societies disorders. Twenty-two of these medicines such as car accidents, so individuals afflicted with epilepsy are able to perform daily tasks even believed it was contagious, that the are targeted to treat epilepsy and seizures. and lead normal lives. demon could leave one individual to enter Neurologist Justin Fisher, MD, of Wellanother—a claim we know today to be Today’s medical progress is proving treata fallacy. Even in the early 1900s, people Span in Ephrata, Pennsylvania states, “The with epilepsy were placed in asylums by biggest change I’ve seen in my own practice ment to be more manageable. With newer, their own families. Today, however, we have is that the medications have gotten better more effective medications, Fisher explains, other more effective treatment methods that in terms of fewer side effects and seem to “A lot of these drugs are long-acting mediprovide many of these individuals with peace have less impact on a patient’s quality of life.” cations—sustain-relief medications—so for

rom the concept of demonic possession in need of exorcism to medications and life-changing surgery, we have been making progress for centuries in understanding and treating what many consider a life-disrupting medical condition.

Epilepsy is not only now more understood and accepted, but also much easier to treat as time continues to bring hope for those afflicted. The 21st Century has brought with it countless new medical discoveries and advanced treatments that continue to evolve.

As November is Epilepsy Awareness Month, here’s a closer look at the condition and news on the progress being made in treating it.

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Epilepsy Awareness Month

young people with epilepsy who want to still try to live a normal life, they can take one pill a day with manageable side effects and go about their business. In olden times, people would take drugs two or three times a day and deal with more severe side effects.”

One downside of utilizing the medicinal approach to controlling seizures, Fisher also says, is the possibility of missing dosages.

“The number one cause of breakthrough seizures is medication incompliance—patients missing a dose or two of their medication.”

An article published in a late April 2015 issue of Neurology®, the medical journal of the American Academy of Neurology (AAN), announced a new guideline advising neurologists when to administer treatment to

someone who has experienced a first seizure.

This guideline, released by AAN and the American Epilepsy Society (AES), states that administering an antiepileptic drug immediately following the initial seizure can reduce that person’s risk of experiencing a second seizure within the course of two years.

With one in 26 people developing epilepsy in their lifetime, medical professionals are doing everything they can to help individuals control their seizures medicinally.

Fisher elaborates, “It comes down to what’s called the kindling theory in epilepsy—a theory that seizures beget more seizures. If somebody has a seizure and then they go on to have another seizure, through the process getting set up in the brain, those regions of the brain are sort of sensitized and

are more likely to go on to have additional seizures; whereas, if you quickly snuff out the fire by treating right away, the chance of having additional seizures is reduced.”

But how, then, can doctors properly diagnose patients’ conditions if the patients receive immediate treatment?

“If somebody has one seizure,” Fisher explains, “their lifetime likelihood of having another one is less than 50 percent, so we generally do not treat the patient after the first seizure.”

Despite the increasingly accurate development in medication, approximately just under 30 percent of people with epilepsy still face the struggle of uncontrolled seizures.

Continued on page 20

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Healthy Communities

Fisher notes that as time progresses, more and more individuals who are trying to cope with no control over their seizures are considering alternative treatments. “It’s not exactly new, but vagus nerve stimulation, or VNS, is one treatment a little bit different from everything else out there. It is a procedure in which a coil of wire is wound around the vagus nerve and electrical stimulation is given to the nerve.”

Inserting the wire, he explains, is similar to the way doctors also implant pacemakers.

“This method has been shown to help control seizures in people who have intractable or frequent seizures despite being on medication.”

The probability of patients’ bodies being receptive to the third or fourth types of medication in attempts to control their seizures is extremely low if they were not receptive to the first or second medications; and if VNS treatments also prove ineffective, neurologists may refer their patients for epilepsy

Epilepsy Awareness Month

surgery. Most surgeries are performed on the non-dominant portion of the temporal lobe in an effort to avoid affecting language or memory skills. However, there are always risks when undergoing any type of surgery.

It is thought that over time, neurosurgeons will become more comfortable with performing the surgery more frequently on individuals of various ages. The more often this type of surgery is performed, the more likely it is to become more cost-effective in the future as well, so more people will be able to afford the treatment necessary to experience living life to its fullest.

“People with controlled seizures generally do fine cognitively, but it’s been shown that uncontrolled epilepsy is bad for the brain and does result in lower test scores and greater cognitive deficit,”

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Fisher explains. “But if you factor in the improvement in their seizure control and the difficulties they would have if they didn’t undergo the surgery, even that benefit is going to end up being for the better.”

He also goes on to say, “These other treatment options, even though they’re not new, are probably going to become more widely done because we do recognize that prescribing more medication will not always resolve the issues for patients.”

Individuals facing various forms of this seizure disorder daily can now look to the future for more advanced and even potentially more cost-effective treatment methods for this not-so-rare condition in order to improve their lifestyle and reach personal goals.

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

Healthy Communities

Is Retirement Calling You?

A Few Things to Consider…

If you decide to keep your active license, you must meet all of the current licensure requirements:  Complete the biennial application and pay the required fee.

ANGELA BOATENG Regulatory Counsel

M

any of our physician members can see retirement on the horizon and for some others, retirement has finally arrived.

&

MARY ELLEN CORUM

Director of Practice Support, Pennsylvania Medical Society (PAMED)

obligations regarding vacation time, sick pay, insurance benefits, and any other benefits.

 Meet continuing medical education (CME) requirements (See PAMED’s FAQs for MD and DO CME requirements at www.pamedsoc. org/MDrequirements and www. pamedsoc.org/DOrequirements).

INSURANCE COMPANIES/PAYERS:  Fulfill mandatory child abuse recognition and reporting training, as a Although timeframes may vary from condition of license renewal. (Note: Physicians contemplating this particular contract to contract, a 90-day notice of PAMED developed online training capstone in their careers have a number of termination without cause is fairly typical. to meet this requirement and is things to consider. In addition to how you When notifying the insurers, be sure to proawaiting approval from the state.) will spend your well-earned free time, you vide them with an effective termination date. may also be thinking about what to do Make sure that addresses are provided so about notification to patients, employees, that any payments may be forwarded to you.  Maintain medical professional liability insurance, including particiinsurance companies, and your medical pation in Mcare. license, medical malpractice insurance, and DRUG ENFORCEMENT AGENCY (DEA): medical records. Even though these issues You are required to notify the DEA of may be the tip of the iceberg (and maybe your intent to stop practicing medicine GET AN ACTIVE-RETIRED LICENSE: not even high on your list of priorities) when and request that your DEA number be With this license, physicians are only it comes to the many retirement issues you deleted from its system. You can achieve allowed to write prescriptions for themselves will need to think about, they are definitely this by sending a letter to the DEA or you and immediate family members who live with worth your time and attention. can make a notation of “non-renewal due them (spouse, children, parents, siblings). to retirement” on your DEA renewal form (if the two events are occurring within a Physicians with an active-retired license reasonable time of one another).

Notifications are required to do all of the following: PATIENTS: Notifying your patients may seem obvious,  Complete the biennial application and submit the required fee. but it is more than a question of logistics. Your Medical License & Retirement You have an ethical and legal obligation to do so. Physicians must provide adequate Retiring Pennsylvania physicians have the  Fulfill the mandatory child abuse recognition and reporting training. notice to patients before discontinuing care daunting task of figuring out what they want or possibly face abandonment charges. There to do with their license to practice. There is no set rule regarding the number of days are a few options available and each option Active-retired physicians are not required of prior notice that must be provided. The has its own conditions and requirements. to have medical professional liability insurappropriate time period will vary depending ance, participate in Mcare, or meet 100 upon the circumstances. Providing sufficient KEEP YOUR ACTIVE LICENSE: credit CME requirements. time for your patients to obtain necessary There may be many reasons why phycare from another physician is the key. sicians choose this option. Some believe GO TO INACTIVE STATUS: that they might return to practice at some Ah! Total state of retirement relaxation! Do EMPLOYEES: point in time and don’t want to go through whatever you like…except practice medicine.

The time and way you notify your the “hassle” of meeting the requirements to employees about your retirement plans and reactivate their license. Others, although the resulting changes is an individual call technically “retired,” plan to (eventually) Continued on page 24 that will vary. Be prepared to discuss your consult or moonlight at their convenience.

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Healthy Communities When your Pennsylvania medical license is inactive status, you are no longer licensed to practice medicine in the state, which means:  You do not have to complete the biennial application and pay the required fee.  You do not have to complete the CME requirements.  You do not have to complete the mandatory child abuse recognition and reporting training.  You do not have to maintain medical professional liability insurance or participate in Mcare.

Medical Malpractice Insurance—Tail Coverage

Whether or not you maintain medical malpractice insurance depends on your license status.

Is Retirement Calling You? Pennsylvania, however, requires tail coverage for physicians who cancel their claims-made coverage. The tail covers losses and expenses occurring during a claimsmade coverage period. The one-time fee paid for the tail coverage would protect the physician indefinitely for any claim made after the cancellation, termination, or non-renewal of the claims-made coverage in Pennsylvania.

The physician’s malpractice carrier is required to offer tail coverage upon cancellation, termination, or non-renewal of claims-made coverage. Physicians must purchase tail coverage to be in compliance with state law, but they are not required to purchase it from their current malpractice insurance provider; physicians can shop around for alternative malpractice carriers.

Medical Records

And, you thought your obligation to medicine was done once you retired. Not so

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fast. You may still have an obligation from the state and your medical malpractice carrier regarding your patient medical records.

State regulations require MDs to maintain medical records for adults for at least seven years from the last date of service. For minor patients, medical records must be kept at least seven years from the last date of service and one year after the patient turns 18, whichever is longer.

Regulations for DOs are almost identical, except that the extended period of time for minors is two years after the patient turns 18.

When you are ready to turn your retirement plans into a concrete plan, these are just a few items you should consider. As always, if you have questions about any of the information please feel free to contact us at PAMED at (717) DOC-HELP (that’s 717-362-4357).

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

Passion Outside of Practice It’s our pleasure to introduce this new column to Lancaster Physician readers. In each issue, we will highlight a Lancaster City & County Medical Society member’s “passion outside of practice.” Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you.

Leigh Shuman, MD holding a fish he caught and released last Fall

Leigh S. Shuman, M.D.

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Passion Outside of Practice: Fly Fishing

1. Can you briefly describe

your passion outside of practice for those who might be unfamiliar with it?

Everyone knows what fishing is. Someone once described a fishing pole (or “rod,” as fly fishers prefer) as a long stick with a jerk at each end. What makes fly fishing different is that the rod is used to cast a heavy line, which in turn propels a nearly weightless fly, usually made of feathers and fur. The fly is designed to imitate an insect or small baitfish that will fool the intended target into thinking it is something good to eat. In all other forms of fishing, the bait or lure is heavy and the line is light. One of the most attractive features of fly fishing is the beautiful form of the cast. Those of you who saw “A River Runs Through It” will know what I mean.

Even when the fish aren’t biting, the casting is pure pleasure. Also, because the fish are only hooked in the lip and do not swallow the bait, they can be released unharmed.

With all the people fishing these days, fish are too valuable to be caught only once.

Fly fishing has been practiced for nearly 2,000 years, and it is said that there are more books about it than any other sport.

(My basement “fish room” is living proof of this!) While originally developed to catch trout and salmon in Europe, the world of fly fishing has expanded to go after almost every species of fish, from 4-inch trout to 400-lb. marlin in every part of the world.

2. How did you develop an interest in your passion outside of practice?

This one is really hard to explain. No one in my family did it, nor did my friends. The reality is that I saw a short movie about fly fishing when I was about 11 years old, and I decided then and there I wanted to do it.

I went to the library and read everything they had, which wasn’t much. There were no YouTube videos or educational courses when I started. I badgered my parents into getting me a basic rod and a kit to tie my own flies, and got them to take me on the occasional trip to someplace where I could fish. My mother really encouraged me in the sport, since she could see how much I loved it. I watched other fishermen and asked questions. Once I could drive, I was unstoppable. I grew up near Philadelphia, and I was on the trout streams of central Pennsylvania and the Poconos every chance I got until medical school and residency put a prolonged gap in my chances to fish.

3. How long have you been doing it?

A Victorian-style salmon fly that Shuman tied. It demonstrates the artistic aspect of fly tying. While no longer used today, this style would have been used in the Victorian era.

More than 50 years. I still can’t sleep the night before I go fishing, because I’m too excited. It has been said that I didn’t so much catch the fish as that the fish caught me. Now I have fly fished all over the US, Canada, the Caribbean, and South America, and dream of Alaska, New Zealand, and parts of Europe. I’ll never get to all the places I’d like to fish.

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4. What makes it special to you?

Many things. For one, it has been said that trout do not live in ugly places. While this isn’t entirely true, I am generally fishing in beautiful places like the Rocky Mountains.

I love the sound of the rivers and streams, and find great beauty in moving water.

I’m less keen to fish lakes and oceans, but would probably fish in a bathtub if there was nothing else available. Another thing about fly fishing is that it can never be mastered. There are always new things to learn, new flies to tie and try, and no river is ever the same from day to day. People often ask me what I think about when I’m fishing. The answer is, “fishing.” I find that the problems of day-to-day life tend to vanish and I’m just focused on the act of fishing rather than anything extraneous. In addition, there is the related hobby of making one’s own flies for fishing. This is an utterly absorbing pastime on its own, and can be done in the middle of winter (I’ve been known to go fishing in the snow, though).

5. What else would you like to share about it?

Having someone who shares the passion makes fishing all the more pleasurable.

For the last 15 years, I’ve been fortunate to travel all over the globe with Dr. Michael Eckhart, a local oral surgeon, who is as crazy about fishing as I am. We have a great time fishing together, and both of us typically have to be dragged off the stream at the end of the day, since we just want to make one more cast and catch one more fish.

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Patient Advocacy

AT HOME with the Medicare-Certified Home Health Benefit

HELP KEEP SENIORS SAFE

to offer, it’s important to understand the eligibility requirements and services housed under this benefit.

Understanding the Home Health Benefit

The Medicare home health care benefit is covered 100 percent under the Part A benefit when qualifying conditions are met. Its main purpose is to give seniors access to health care at home after a hospitalization, illness, or injury, helping them to remain safe and independent and to avoid unnecessary hospitalizations. With a physician’s referral, patients may receive a variety of skilled care services including nursing, rehabilitative, and therapeutic care. The care is provided by registered nurses (RNs), physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), home health aides (HHAs), and medical social workers (MSWs).

The benefit covers care that is short-term— commonly, 60-day episodes—but can be extended if needed with the approval of the referring physician. The care is covered at 100 percent, so there are no out-of-pocket costs to the patient—and they are receiving the care where they are most comfortable: in their own homes.

F ANGELA ECENBARGER

BAYADA Home Health Care Area Director

or many senior citizens in the U.S., Medicare is a lifesaver. It gives them access to medical services, medications, and equipment that they may not otherwise be able to afford. Although most seniors are aware of the Medicare benefits available to them for doctor and hospital visits, many don’t realize just how much the home health coverage can help them. To help your senior patients take full advantage of all it has

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Typically, home health care is recommended for treatment of an injury, such as recovery from hip replacement or a fracture from a fall, recovery from an illness (with or without a hospitalization), to manage multiple medications, or to manage one or more chronic conditions.

Who Qualifies for the Benefit?

As with all Medicare health benefits, there are specific eligibility requirements to follow. The home health benefit has

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Help Keep Seniors Safe at Home

its own set of specific criteria, where the patient must be:  Under the care of a physician, and services must be medically necessary  Referred by a physician  In need of skilled nursing care, physical therapy, or speech language pathology, or have a continuing need for occupational therapy  Homebound, where it is a taxing effort to leave home Many people—including some medical providers—are often unclear of the definition of homebound status. Being homebound doesn’t mean a person must be confined to her home at all times, without ever leaving the house. Rather, it would require a person has to make a taxing effort to do so. Homebound individuals are able to leave their homes for outings that are infrequent and/or of short duration. Examples include but are not limited to going to a doctor’s appointment or to a non-medical destination such as a religious service.

A Medicare-certified home health agency can help determine when patients qualify for services. Typically, people with the following needs are often eligible for home health care:  Newly diagnosed with a chronic condition or with the need to learn how to manage a chronic condition  Multiple medications: The average home health patient takes five or more medications. Home health care reconciles, educates, and teaches adherence to a medication regimen.  Recovering from an injury such as a fracture from a fall  Recovering from surgery such as a hip replacement  Has fallen or is at risk of falling

Which Service is Needed?

Any physician—PCP or specialist—can refer a patient for Medicare-certified home health. Depending on the diagnosis, the physician—along with the home health agency evaluation—will determine which services are medically appropriate. Non-medical services such as personal care services from a home health aide, or medical social worker, can only be provided along with skilled care from a nurse or therapist.

Nursing care, after a hospital stay, injury, or illness, or for care needs related to a chronic condition, is one of the key services of the home health benefit. Whether caring for a wound, monitoring vital signs to ensure a client remains stable, or teaching, nurses provide a wide variety of care services in the home.

Many referring physicians would expect these services would fall under a patient’s in-home plan of care. However, what may be surprising to some referral sources is the critical role that nurses play in patient education. They are responsible for teaching and training patients and family caregivers to manage a treatment regimen related to a functional loss, illness, or injury. From instruction on diet and proper nutrition and medication reconciliation, to teaching signs and symptoms of diseases and self-management of wounds, ostomies, catheters and IV medications, nurses help people self-manage their conditions at home.

Skilled therapy services, which include physical therapy, occupational therapy, and speech language pathology services, can be ordered for the treatment of functional loss, illness, or injury.

Physical therapy services, for improving function through therapeutic exercise, balance and coordination training, and education, are provided to help recovery from an injury, deconditioning from a hospitalization, or a decline from immobility.

Services often include therapeutic exercises, gait training (when the ability to walk is impaired by a neurological, muscular, or skeletal abnormality), and range of motion to treat the loss or restriction of mobility.

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Speech language pathology services, for evaluating and treating speech, language, voice, cognition, and swallowing issues, often include speech/voice production, improvement of cognition and communication.

Occupational therapy services, for improving motor skills and reasoning abilities, to compensate for permanent loss of function, or to help people regain the ability to do their activities of daily living, such as eating and dressing independently. Occupational therapy services in the home help to restore sensory-integrative function, teach compensatory techniques to improve the level of independence in ADLs, and more.

Assistive care (home health aide services), for help with personal care, include services such as assisting with bathing, dressing, oral hygiene, medication reminders, and more. Services from a home health aide can only be provided if the patient is receiving the skilled services of a nurse or therapist.

Medical social work, for relieving the social and emotional obstacles that present an impediment to effective treatment and recovery, include a comprehensive assessment and connecting clients and families to community resources.

Keeping seniors safe at home, reducing hospitalizations, and maintaining their quality of life can be accomplished with the Medicare-certified home health benefit.

And with no or little cost to the patient, it’s a benefit they can’t afford not to use.

For more information about the Medicare-certified home health benefit or to refer a patient, call 717.295.4555 or visit www. bayada.com.

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Patient Advocacy

United Way of Lancaster County Sets Goal of Finding a Medical Home for Every Resident SUSAN SHELLY

U

nited Way of Lancaster County has established “Four Bold Goals for 2025”—one of which is to make sure all children and adults in the county have a medical home by that year.

To be able to work more effectively toward those goals, United Way also has made some fundamental changes in the way it invests donor gifts to better serve the residents of Lancaster County.

A medical home is popularly described as “a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.”

“We started out 15 years ago by recognizing that, as a United Way, we needed to seek better outcomes for the residents of Lancaster County,” said Adrienne Washington, vice president and chief operating officer.

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The new model is called “collective impact,” and it calls for varied partners throughout the county to form Community Impact Partnerships that will address and work toward solving complex social problems. When nonprofits and other sectors of the community team up and work together—change can occur more quickly, Washington said.

Other sectors include schools, health care providers, faith-based organizations,

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Finding a Medical Home for Every Resident

businesses, and government, she noted.

Seventeen Partnerships have been formed to date, with nearly $3 million allocated between them.

The other three Bold Goals involve education and economic wellness. They are:

 100 percent of Lancaster County children will enter kindergarten ready to learn.

 100 percent of students and adults will achieve postsecondary credentials.

 The number of individuals, children and families living in poverty will decrease by 50 percent.

Inter-Connected Goals

Each of these goals affects the others, said Jan Bergen, a member of United Way’s Board who recently was honored for her role as a volunteer during the agency’s transition to the “collective impact” model.

Having access to good medical care is directly related to issues of education and poverty, said Bergen, who also is President and Chief Executive Officer of Lancaster General Health.

“All of these things are closely related,” she said. “So, if one of our Community Impact Partnerships is looking at early childhood education, we’re asking it to also look at CHIP (Children’s Health Insurance Program).”

That means that each Community Impact Partnership should include members that are able to address a variety of needs and issues.

One example of the type of Partnerships that have been formed is the Lancaster Medical Legal Partnership. With a mission of advancing the financial stability and health of Lancaster County residents who need frequent health services by integrating civil legal aid and financial case management with an intensive, high-utilization health

care treatment model, the Partnership is led

by MidPenn Legal Services. Also included in the new Lancaster Medical Legal Partnership are Care Connections, Lancaster General Health, Neighborhood Services and SouthEast Lancaster Health Services.

“Ultimately, we realized that no one organization can address these complex and complicated issues by itself,” Washington said.

Berwood Yost, director of the Center for Opinion Research at Franklin & Marshall College, and a consultant to United Way, agreed. “Community Impact Partners must be willing to work together on a long-term basis to address and solve these problems,” Yost said.

Of the 17 Partnerships in place, nine of them will be addressing the need for a medical home for all residents of Lancaster County.

Needs Assessment to Establish Priorities

“This research underscored that we had some serious problems associated with education, financial stability and health,” Washington said.

The needs assessment was designed to not only identify the most pressing needs of county residents—but to help drive the criteria for funding, according to Yost. Once the United Way had identified the greatest needs of the community, it also could identify the Community Impact Partners best equipped to address them.

Long-Recognized Need for Increased Number of Medical Homes

Washington said that United Way has recognized and discussed the need for a higher rate of medical homes among county residents for some time. It was identified as one of the Bold Goals based on the needs assessment and statistics from the Robert Wood Johnson’s 2015 County Health Rankings, which revealed that:

United Way identified its Four Bold Goals following the completion of a community needs assessment that was designed and administered by the Center for Opinion Research. More than 600 residents during a six-week period participated in telephone surveys designed to determine the greatest needs of the county.

Continued on page 32

15% of Lancaster County residents were uninsured.

11% of Lancaster County adults reported fair or poor health.

1 in 10 Americans did not seek medical treatment due to cost.

Lancaster County residents reported in the past month (age-adjusted).

3.2 mentally unhealthy days

In Lancaster County there is only:

1 1,341 patients  1 dentist for every 2,029 patients  1 mental health provider for every 934.1 patients  primary care physician for every

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Patient Advocacy

The goal of ensuring that everyone in Lancaster County has a medical home would not only connect every resident to a physician, dentist, and mental health professional, but also is about identifying and removing barriers that have prevented that from occurring.

While cost and lack of insurance are two of the biggest obstacles, issues such as transportation, childcare, language, stigma and inability to navigate the system also are factors. Those types of issues can prevent

Finding a Medical Home for Every Resident

someone from attaining a primary care provider, which makes it more likely they will rely on emergency rooms for care, according to Bergen. She believes that most people who rely on emergency room care would much rather have primary care physicians.

“They are using the emergency room because their lives are very, very complicated,” she said. “If you get to the core issues of what causes people to use the emergency room, then you can work on making the changes that will benefit everyone.”

“Community Impact Partners must be willing to work together on a long-term basis to address & solve these problems.”

Optimism That Goals Will Result in Change

While everyone recognizes that the Four Bold Goals, including a medical home for every Lancaster County resident, are ambitious, there is much optimism that change will come from them.

“I personally believe that in five years we can make a very significant difference regarding medical homes,” Bergen said.

Bringing resources together can better serve residents and keep the process of change moving along. The teams will be closely monitored, Yost said, and will receive feedback on a regular basis.

The Center for Opinion Research will evaluate progress of the 17 Community Impact Partnerships by looking at goals, processes used to reach goals and intermediate goals, and other factors. It also will work with United Way staff members to ensure that organizations within the Community Impact Partnerships continue to move ahead.

The process of identifying community need, changing the business model of United Way to make it more responsive, engaging nonprofits to get involved in collaborating with one another, and selecting collaborations for funding has been a long and challenging task, Washington said.

“This has been a complex and thoughtful journey for us,” Washington said. “But, we’ve been extremely intentional and transparent through this entire process.”

As nonprofits get used to the different funding methods and embrace the idea of multiple organizations working together, more and more people are becoming excited about the prospects for improving health, education, and financial stability for all residents of Lancaster County.

“The reaction we’re getting from the community is that it just makes sense,” Washington said.

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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 & Regulatory Updates

Pennsylvania Medical Society Quarterly Legislative Update J. SCOT CHADWICK Legislative Counsel

F

or the first time since 2010, Pennsylvania did not have a conduct by the defendant, could not exceed $200,000. Although new state budget in place when the fiscal year ended on punitive damages are rarely awarded against physicians in medical June 30. Governor Tom Wolf, a Democrat, and the Repub- liability actions, this provision can play an important positive role, lican-dominated state House and Senate remained far apart on primarily in settlement negotiations, by eliminating the calculation several significant issues, including the state income tax, the state that a runaway jury might issue an award that bears little or no sales tax, a natural gas extraction tax, property tax reform and connection to the seriousness of the injuries suffered by a plaintiff. education spending, liquor privatization, and pension reform. On June 30 the House and Senate passed a no tax increase budget that On June 25, 2015, the Senate passed SB 747, legislation that did not address the governor’s proposed tax and spending increases, would extend this protection to personal care homes, assisted living which Wolf promptly vetoed. Budget stalemates like these are not communities, and long-term care nursing facilities, by a vote of uncommon when control of state government is divided between 40-9. Three days later, the bill was approved by the House Judiciary the two parties, and while some are resolved quickly others drag Committee, setting the stage for consideration by the full House. on for months. As of this writing there is no way to predict how These entities have been under assault from personal injury lawthis one will play out. However, while the budget debate continues, yers in recent years and are seeking the same protection extended there has been movement in the House and Senate on a number to physicians 19 years ago. While PAMED supports the bill, we’re of health care-related measures. watching it closely to make sure it doesn’t also become a vehicle for trial lawyer-generated amendments that would be counterproductive and poor public policy.

Expanding Punitive Damages Cap

In 1996, the General Assembly enacted a cap on punitive damages that can be assessed against physicians in medical liability actions, limiting those awards to no more than 200 percent of the compensatory damages. In other words, if a jury awarded a plaintiff $100,000 for medical bills, lost wages, and pain and suffering, an additional award of punitive damages, if warranted due to egregious

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Licensure Board Reporting SB 538, which would impose new reporting requirements on state licensees (everybody from crane operators to landscape architects to physicians and other health care professionals) who run afoul of the criminal law or another state’s licensing body, is one step away from the governor’s desk. The bill will require anyone who holds a license, certificate or registration issued by the Bureau of Professional and Occupational Affairs to, as a condition of licensure, certification or registration, report to their licensing board or commission within 30 days (1) any disciplinary action by a licensing agency of another jurisdiction; and (2) a finding or verdict of guilt, an admission of guilt, a plea of nolo contendere, probation without verdict, a disposition in lieu of trial or an accelerated rehabilitative disposition (ARD) of any felony or misdemeanor offense, and any drug or alcohol related summary offense. Depending on the nature of the action reported, the licensing boards and commissions would be authorized to issue temporary suspensions where warranted. In the case of a legal commitment to an institution due to mental incompetency or a felony conviction under the Controlled Substance,

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PA Medical Society Quarterly Legislative Update

Drug, Device and Cosmetic Act (or its equivalent in another state), the suspension would be automatic.

Approved 49-0 by the Senate on June 9, and 192-0 as amended by the House on June 28, all that remains is a Senate vote to concur with the House amendments. If enacted, the measure would go into effect in 60 days.

Oral Chemotherapy Insurance Coverage Another bill that moved a step closer to enactment is HB 60, which provides that whenever a health insurance policy contains coverage for intravenously administered or injected chemotherapy medications to treat cancer, the policy may not provide coverage or impose cost sharing for an orally administered chemotherapy medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intravenously administered or injected chemotherapy medications. The legislation would not preclude health insurance policies from requiring an enrollee to obtain prior authorization for the oral medication, and it only applies to oral chemotherapy medications where an intravenously administered or injected chemotherapy medication is not equally effective. That last point is controversial, though, which could slow the process down.

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The bill, which passed the House 197-3 back in February, was amended and approved by the Senate Banking and Insurance Committee on June 25, putting it in position for full Senate ratification. Senate approval would send the bill back to the House for concurrence in Senate amendments, a necessary step before the bill reaches the governor’s desk.

Alternatively, the same language is contained in SB 536, which passed the Senate 49-0 on June 28, and is now in the House Health Committee. As both chambers have overwhelmingly passed identical language, though in separate bills, it is clear that the measure has bipartisan, bicameral support, and one or the other is likely to reach the governor’s desk.

Pharmacists Administering Influenza Vaccine to Minors On June 15, the Senate unanimously passed HB 182, legislation that will allow pharmacists to administer influenza vaccines to minors age nine and older. Because the upper chamber did not change the already House-passed bill, it went straight to Gov. Wolf, who Continued on page 36

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Legislative & Regulatory Updates

PA Medical Society Quarterly Legislative Update

Banning E-Cigarette Sales to Minors Progress was also made during the June flurry on legislation restricting the sale of e-cigarettes. On June 15, the House unanimously passed PAMED-endorsed legislation that would ban the sale of e-cigarettes to minors.

HB 954 would simply add “nicotine delivery systems,” specifically including e-cigarettes, to the existing law prohibiting the sale of tobacco products to minors. The following day the Senate moved a similar bill, SB 751, into position for consideration by that chamber in the near future, signaling that one of the two bills stands a good chance of making it to the governor’s desk.

Controlled Substances Database Update On October 27, 2014, then-Gov. Corbett signed Senate Bill 1180 (now Act 191 of 2014) into law, authorizing the creation of a statewide controlled substance database. The system, which will be a valuable tool for prescribers and dispensers of opioid medications to identify doctor-shopping patients, was supposed to be up and running by June 30, 2015.

signed it into law on June 26. Under the measure, pharmacists will have to obtain parental consent before administering influenza vaccine to anyone under age 18, and notify the minor’s primary care provider, if known, within 48 hours after administration of either injectable or needle-free vaccine.

Finally, pharmacists who administer influenza vaccine to minors will have to carry professional liability insurance coverage in the minimum amount of $1 million per occurrence or claims made. PAMED had opposed earlier bills that were far broader in scope, but does not object to HB 182 in its current form. The bill will go into effect in 60 days, in time for the fall influenza vaccine push.

However, the legislature did not appropriate any money to fund the construction and operation of the database, and the process is behind schedule. Governor Wolf has included $2.1 million in the 2015-2016 state budget to cover those costs, and legislative leaders seem supportive.

However, those funds may be held up until the currently ongoing budget battle is resolved. Administration officials have signaled that they hope to have the database operational by the end of the year.

Impersonating a Physician Another bill signed into law by the governor is SB 485, which will increase the penalty for impersonating a physician. Under existing law, impersonating someone holding a professional license is a misdemeanor of the second degree, unless the intent of the actor is to harm, defraud or injure anyone, which makes it a misdemeanor of the first degree.

SB 485 makes impersonating a physician and then providing treatment or medical advice a first degree misdemeanor, regardless of whether or not the other person suffers harm. A second degree misdemeanor is punishable by up to two years in jail and a fine of up to $5,000. A first degree misdemeanor is more serious, carrying a possible prison term of up to five years and a maximum fine of $10,000. The bill will take effect in 60 days.

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Legislative & Regulatory Updates

UPDATES & TOOLS to Help PA Physicians

Understand Proposed 2016 Medicare Fee Schedule & Ease the Transition to ICD-10

JENNIFER SWINNICH

Associate Director of Practice Support, Pennsylvania Medical Society

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he Centers for Medicare and Medicaid Services (CMS) has been busy with the release of the 2016 Medicare Physician Fee Schedule (MPFS) Proposed Rule and clarification on the joint statement with the American Medical Association (AMA) on ICD-10 implementation.

Here are a few highlights.

The MPFS Proposed Rule aims to enhance support for primary care practices through several different initiatives. This includes allowing payment for Advance Care Planning Services for Medicare beneficiaries.

CMS defines advance care planning as a face-to-face meeting with the patient, family members, and/or surrogate for “the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health professional.”

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CPT code 99497 is used for the first 30 minutes, and then add-on CPT code 99498 for 30-minute increments thereafter.

Although advance care planning was available in the past, it was only covered when included with the Initial Preventive Physical Exam (IPPE), also known as the “Welcome to Medicare” visit. Most beneficiaries were not likely to discuss advance care planning at the time of that visit. This enhancement will allow for greater flexibility for scheduling advance care planning services for both beneficiaries and providers.

In recent years, CMS has recognized the need for care management. As a result, CMS developed payment for Transitional Care Management (TCM) for patients recently discharged from inpatient hospitals and Chronic Care Management (CCM) for

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Understanding ICD-10

patients with multiple chronic conditions.

Although these codes were approved in rules from prior years, in the 2016 proposed rule CMS is looking for feedback to relieve some of the administrative burden when billing for care management services. The Pennsylvania Medical Society (PAMED) also offers resources to help providers understand TCM reimbursement at www.pamedsoc.org/ TCM and CCM reimbursement at www. pamedsoc.org/CCM. In an effort to clarify “incident to” requirements, CMS reiterates the supervising physician is the physician who bills for “incident to” services. In a recent conversation with CMS’ subject matter expert, PAMED was told, “The proposal is intended to clarify that the ordering physician or other practitioner and the supervising physician or other practitioner DO NOT need to be one in the same. Rather, the proposal is intended to clarify that the physician or

other practitioner who bills for the “incident to” services must always be the supervising physician or other practitioner.”

have more than three characters—most valid codes will have a fourth, fifth, sixth, or seventh digit for greatest specificity.

Lastly, CMS and AMA released a joint statement on the implementation of ICD-10 scheduled for Oct. 1, 2015 and later issued clarifications to their statement. The initial statement reiterated that there will be no delay for implementing ICD-10. Medicare will not accept any ICD-9 codes with a date of service on or after Oct. 1, 2015, and all claims must have a valid ICD-10 code. The statement also claimed that Medicare can be “flexible” with ICD-10 implementation.

CMS will not deny claims based on the specificity of the ICD-10 diagnosis code alone. However, claims will be held to the same coverage standards under ICD10 as they were under ICD-9. Therefore, national coverage determinations (NCDs) and local coverage determinations (LCDs) that required specific ICD-9 codes will continue to require specific diagnosis codes under ICD-10.

The clarification defines flexibility with ICD-10 codes to include the “family of codes.” A family of codes is the first three characters of the code within a category that are clinically related. One must report a valid code within the code family and not simply a category. In most instances, the code will

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PAMED has more information and resources on ICD-10 at www.pamedsoc.org/ ICD10, including specialty-specific crosswalks, online documentation training for physicians, education, and coding scenarios.

PAMED members who have questions can contact our Practice Support Team at (717) DOC-HELP, that’s (717) 362-4357.

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Medical Society Updates

Here, There, & Everywhere H O W W I L L T H I S A F F E C T P H Y S I C I A N S & PAT I E N T S ?

HEATH MACKLEY, MD, FACRO

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atients and physicians in the fifth district have seen a steady stream of headlines over the last few years, with different hospitals and physician groups joining larger health systems. Although this is certainly not an exhaustive list, announcements include Holy Spirit Hospital in Camp Hill joining Geisinger Health System, Good Samaritan Hospital in Lebanon joining WellSpan Health, Lancaster General Hospital joining Penn Medicine, St. Joseph’s Regional Health Network of Reading joining Penn State Health, and Pinnacle Health of Harrisburg seeking to join Penn State Health. Most observers expect additional mergers to happen in central Pennsylvania and beyond.

This is not meant to be a sound of alarm.

It would be presumptuous to say this is either “good” or “bad.” But this trend is clear, and it has a clear antecedent. With the passing, and subsequent affirmation by the Supreme Court, of the Affordable Care Act, the federal government has set a clear mandate. Through the creation of accountable care organizations and expanding the insured population by incentivizing younger, healthier adults to purchase health coverage, managing the health of populations is going to be the means by which health care costs are contained. Conventional wisdom states that larger integrated health networks will need to form in order to make this possible, but this remains to be seen.

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This consolidation is not limited to health care providers. In the month of July, two takeovers were announced involving the five biggest insurance providers in the United States. Anthem announced the intention to buy Cigna for $48 billion, and Aetna wishes to purchase Humana for $37 billion.

In a large, lower-margin industry, insurers have felt an impetus to consolidate, leading antitrust regulators to debate whether three or four insurers are enough competition to protect the interest of consumers.

And of course, there is nothing to prevent insurers from buying health care networks, like Highmark merging with West Penn Allegheny Health System, or health care

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Consolidation Here, There, & Everywhere

networks from offering health insurance products, like UPMC and Geisinger. Other Pennsylvania health networks are likely to follow suit.

This is a natural extension of the work the AMA has done as a watchdog when it comes to insurance mergers. This includes publishing annual reports. The most recent report reveals that a single health insurer All of this begs the question: At what point has over fifty percent of the market share do we as physicians become concerned? Is in seventeen states and forty percent of the it when a patient “only” has three choices metropolitan areas of the U.S. In central of health plans? Is it when a patient “only” PA, Harrisburg-Carlisle, Lancaster, Lebahas two choices of hospital systems? While non, Reading, and York-Hanover were all no one would advocate a patient have only classified as “highly concentrated” using the one choice of a health care provider, or a Herfindahl-Hirschman Index, a measure of physician of any particular county have only market concentration. For more information one choice of employer, the matter is more on the AMA’s concerns, please visit the complex than that. news section of the organization’s website (www.ama-assn.org) to read the press release, Insurance mergers have been associated “Insurance Mergers Will Reduce Competiwith premium hikes, not the cost-savings tion and Choice.” that are often promised because of increases in efficiency. Additionally, less competition Thankfully, the AMA has not limited its can make it easier for health insurers and actions to dusty reports. The AMA successhealth provider networks to prioritize cor- fully opposed the merger of Highmark and porate policy over good clinical decisions.

Independence BlueCross in Pennsylvania in part by providing expert testimony to the PAMED and the AMA did not make a U.S. Senate Judiciary Committee Subcomclear policy position, for or against, health mittee on Antitrust. In other cases, the AMA care provider mergers, such as what occurred didn’t prevent a merger, but gained importin the 1990s, in the same way that they have ant conditions that preserved reimbursement with health plans. Larger health provider for physicians and choice for patients. networks can lead to clear advantages for The AMA has worked with the Antitrust patients and physicians, such as the creation Division of the Department of Justice and of integrated electronic medical records. the Federal Trade Commission, testified in However, PAMED has also acknowledged the the U.S. House of Representatives’ Small importance of regulators minding the poten- Business Committee, and provided expertise tial downside of decreased competition. In for the FTC competition workshop. The its statement, “The Eight Essential Principles AMA provides comments on DOJ/FTC of Health System Reform,” PAMED states, merger guidelines and model legislation “Health care delivery markets should be con- for state governments. This is a “battle” structed to be competitive, thus increasing with many fronts. The insurance efficiency, innovation and quality as well as companies are organized, and we reinforcing a physician’s ability to compete.” need to be as well!

Similarly, the AMA has recently expressed concerns about hospital monopolies, stating in an amicus brief to the U.S. Supreme Court, “When physicians lack practice options due to a hospital monopoly created by a hospital merger, they cannot bargain effectively for a competitive income sufficient to stay in the market or for equipment, staffing, laboratory and other services— dimensions along which hospitals typically compete for physician relationships, to the benefit of patients.”

PAMED has always had a “large tent.” Our physician members are employed physicians working for large corporations, independent practitioners running small businesses that compete and/or collaborate with large networks, executives for health insurance companies and health systems, and regulators in the state and federal governments. We stand with all of these physician members as one body, representing the physicians of Pennsylvania,

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cognizant of the inevitable issues that arise from legitimate competition or differences of opinion.

PAMED also stands for the patients of Pennsylvania. With the gradual increase in public access to outcomes data, whether or not these systemic changes are good for the health of Pennsylvanians will become clear.

As long as our patients are doing well, and physicians are being treated fairly, this can be a win-win situation. But we, the physicians of PAMED, must remain vigilant, because we will always be the best advocates for the interests of our members and our patients.

So, please, keep your eyes and ears open, and let us know what you’re seeing in your practice. We need each other, now more than ever!

Dr. Mackley is a radiation oncologist in the Penn State Hershey Cancer Institute and serves as the 5th District Trustee on the PAMED Board, representing physicians of this county.

This article previously appeared in The Reporter (Dauphin County Medical Society’s newsletter).

Health care delivery markets should be constructed to be competitive, thus increasing efficiency, innovation & quality as well as reinforcing a physician’s ability to compete.

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Restaurant Review

Reviewed By

LINDSI DeARMENT, DO

Family Practice Physician, Highlands Family Practice

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Bistro Barberet & Bakery

Article photos by Lindsi DeArment, DO

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ho says you can’t eat dessert first? soon seated in a cozy booth. Our waiter, My first visit to Bistro Barberet Alex, was attentive and very knowledgeable & Bakery was on a Saturday about the menu. morning. I stopped in with my sister-in-law, Allison, after a great Rooftop Yoga session We started off the evening dinner with at Tellus360. We drooled over the rows of a chef-selected cheese board that included brightly colored macarons and beautiful, a rich, buttery French brie along with two delicately designed pastries. I settled on a other delicious cheeses. My husband ordered pink macaron filled with raspberries, and the onion soup as a starter, which he stated Allison chose the tarte aux fruits. Both was “one of the best” he has ever tasted. We were delightful. I returned that evening for also had the beet & strawberry salad, which dinner along with my husband, Andy, and had a splendid array of colors. For our entrees, close friend, Stacey.

I chose the chicken breast roulade, which was topped with a black truffle mousse and As a self-proclaimed Lancaster foodie, I au jus and accompanied by pommes puree had been very excited to hear that a French & haricot verts. My husband went with bistro and rooftop bar was going in on King a traditional French entrée, moules frites Street. I watched the Bistro Barberet & (mussels & fries), which were soaked in a Bakery Facebook page in anticipation for an garlic white wine sauce. Stacey chose the leek opening date. When the doors finally opened & ricotta linguini, full of heirloom tomatoes, in early August, we made our anticipated black olives, arugula and mushrooms. Entree reservations soon after. prices ranged from $12-$26. All entrees were presented beautifully in nice portion sizes Bistro Barberet is owned by a French that weren’t overly large to make anyone couple, Cedric & Estelle Barberet. Cedric “too full for dessert.” is a nationally renowned pastry chef, which is truly evident in viewing the bakery. From So back to desserts…my favorite part. the previously mentioned macarons to rich The dessert menu at the bistro was slightly truffles to raspberry and coconut tarts to milk chocolate desserts with crème brûlée centers, it all looks absolutely scrumptious.

Estelle meets customers walking into the bakery with a smile and charming hospitality.

From the street, Bistro Barberet & Bakery has large windows providing a view into the bakery’s rows of macarons, pastries, and freshly made breads, elegantly accentuated by pink & white pastry packaging. The bistro is tucked in the back of the first floor, with a modern chic vibe. Upon arrival, we were greeted by the friendly hostess and

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different than the one at the bakery, but of course included a choice of macarons and a tarte aux fruits. Although tempted by the crème brûlée (one of my go-tos), we went with the French doughnuts to share, which came with blueberry jam and dark chocolate sauce on the side. It was the perfect amount for sharing and a perfect way to end our experience at Bistro Barberet.

I recommend a visit to Bistro Barberet & Bakery for a romantic date, night out with friends, or special celebration. And don’t forget to save room for dessert. Or better yet, do as I did, and eat dessert first!

Bistro Barberet & Bakery 26 East King Street Lancaster, PA 17602 (717) 690-2354 Facebook Page: Bistro Barberet & Bakery

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News & Announcements

FRONTLINE GROUPS The Lancaster City & County Medical Society thanks these groups for 100% membership in the Medical Society.

Allergy & Asthma Center

Hospice & Community Care

LGHP–Women’s Internal Medicine

Baron Family Practice

Hyperbaric & Wound Care

Neurology & Stroke Associates PC

Brain Orthopedic Spine Specialists

Hypertension & Kidney Specialists

OBGYN of Lancaster

Internal Medicine Specialists of Lancaster County

Orthopaedic Specialists of Central Pa

Campus Eye Center Cardiac Consultants PC

Jeffrey H Chaby DO & Associates

Cardiothoracic & Vascular Surgeons of Lancaster Care Connections Clinic Community Anesthesia Associates

Conestoga Family Practice –Terre Hill Dermasurgery Center PC

Dermatology Associates of Lancaster Ltd Eastbrook Family Health Center Eden Family Medicine

Electrodiagnostic Medicine Group Ltd ENT Head & Neck Surgery of Lancaster Eye Health Physicians of Lancaster

Pain Medicine & Rehab Specialists

Keyser & O’Connor Surgical Associates Ltd

Patient First–Lancaster

Lancaster Arthritis & Rheumatology Care

Pennsylvania Specialty Pathology

Lancaster County Center for Plastic Surgery

Lancaster Family Allergy

Southeast Lancaster Health Services Inc

Southeast Lancaster Health Services–Arch Street

Southeast Lancaster Health Services–Hershey Avenue

Stephen G Diamantoni MD & Associates–Leola

Lancaster General Health Physicians Lancaster HMA Physician Management Lancaster Physicians For Women Lancaster Plastic Surgery

Family Medicine of Ephrata

Lancaster Skin Center PC Leacock Family Practice

Rehabilitation Medicine Associates of Lancaster PC Rothsville Family Practice

Lancaster Ear, Nose and Throat

Lancaster Retina Specialists

Highlands Family Practice

Red Rose Cardiology

Lancaster Cardiology Group LLC

Family Eye Group

Glah Medical Group

Pennsylvania Counseling Services–Lancaster

Lancaster Cancer Center Ltd

Lancaster Radiology Associates Ltd

Georgetown Family Health

Otolaryngology Physicians of Lancaster

Justin L Cappiello MD PC

Eye Physicians of Lancaster PC

General & Vascular Surgery of Lancaster

Stuart H Goldberg MD PC Surgical Specialists of Lancaster

The EMG Group at The Electrodiagnostic Center of Lancaster

LGHP–Lincoln Family Medicine

Trout Run Family Practice

LGHP–Manheim Family Medicine

Wellspan General Surgery–Ephrata

LGHP–New Holland Family Medicine

Welsh Mountain Health Center

LGHP–Susquehanna Family Medicine

Westphal Orthopedics

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News & Announcements

Welcome…New Members Livia K. Baublitz, DO Rehabilitation Medicine Associates of Lancaster PC

Robin Marie Hicks, DO Heart of Lancaster Regional Medical Center Graduate Medical Education

Lindsi Anne DeArment, DO Highlands Family Practice

Jessica Amanda Lee, MD Lancaster General Hospital

Steven Donnelly, MD Eye Doctors of Lancaster

Anne Rickert Practice Administrator, Community Anesthesia Associates

Stephen F. Gold, DO David Silverstein Assoc

Congratulations...Reinstated Members Robert B. Belser, Jr., MD Lancaster Otolaryngology LLP

Adrienne K. Kuhlengel, MD LGHP Twin Rose Family Medicine

J. Eric Greensmith, MD LRMC Anesthesia Consultants

William Weik Practice Administrator Orthopedic Associates of Lancaster Ltd

In Remembrance…DECEASED Members William H. Bachman, MD William Hampton Bachman, 88, passed away in Hamilton, Montana on Thursday, September 25, 2014 as the result of complications following heart surgery.

Professional achievements and accolades included life membership in the American Academy of Family Physicians. In 1990 he received a Distinguished Service Award from the Lancaster City and County Medical Society “in recognition of his many years of dedicated, unselfish service to his patients, his community and his profession.”

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Foundation Updates

Save the Date

SATURDAY, DECEMBER 12, 2015 • 6:30 PM

Holiday Social At the Lancaster Country Club

Fine Fare • Good Company • Music • Dancing Silent Auction to benefit the Lancaster Medical Society Foundation Scholarship Fund*

*Since its establishment in 1991, the Lancaster Medical Society Foundation has awarded over $200,000 in scholarship funds to Lancaster County residents attending medical school. Recipients must exemplify good character, motivation and academic excellence, and demonstrate financial need.

If you wish to contribute, please contact the foundation at 717-393-9588 or info@lancastermedicalsociety.org.

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