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Raleigh Neurosurgical Clinic

Looking back on 60 Years and Looking Ahead

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in This Issue

Genetic Guidance Advocacy for Independence


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“My Husband’s Heart Surgeon Said, ‘We Don’t Usually Do This Procedure On Victims Of His Type Of Heart Attack.’ I Asked Why. He Said, ‘They Usually Don’t Make It To Surgery.’ ” Debbie Woodruff Smithfield, NC

Gordon Woodruff with his lifesaving heroes Johnston Heath ER Nurses Lisa Johnson & Kenny Gooch

Around 9:00 a.m. June 24, 2013, Smithfield Attorney Gordon Woodruff felt heavy pressure in his chest while driving to court. He decided to divert to Johnston Health’s ER, a Certified Chest Pain Center. He told them,“I think I’m having a heart attack!” ER Nurse Lisa Johnson quickly assessed his condition. She and Chest Pain Coordinator Kenny Gooch administered initial treatment to stabilize and prepare him for transport to a cardiac trauma center. Kenny accompanied Gordon on the ambulance. Unaware he was experiencing a type of cardiac event known as the “Widow Maker,” Gordon called his wife Debbie from the ambulance.

2013 AHA Mission Lifeline Recipient

“I was alarmed, but relieved to be talking to him,” said Debbie. “He told me where they were heading, but then, as we talked, Gordon went into full cardiac arrest.” Kenny immediately had the EMS driver pull off the road, then administered CPR until they could get the defib unit on him. Gordon responded to the defib and they continued to the hospital where he had emergency procedures, installing two stents. “The fact that everyone at Johnston Health knew exactly what to do at every turn was so obvious to everyone, including my surgeon,” says Gordon. “Their actions and professionalism are the reason I am alive. Debbie and I are so very grateful.”

Two Accredited Chest Pain Centers

Healing Neighbors... It’s What We Do - It’s Who We Are! 509 N. Bright Leaf Blvd. Smithfield, NC 919-934-8171

www.johnstonhealth.org

2138 NC Hwy. 42 W. Clayton, NC 919-585-8000


COVER STORY

6

Raleigh Neurosurgical Clinic Looking back on 60 Years and Looking Ahead

a p r i l 2 0 15

Vol. 6, Issue 3

FEATURES

10

Women’s Wellness

Genetic Testing: Information Empowers Family nurse practitioner Makayla Downs talks about the power of genetics to better manage care.

14

DEPARTMENTS 9 Physician Spotlight – NEW

12 Physician Advocacy

Abdomino-Phrenic Dyssynergia: Effective Diagnosis and Management Dr. Douglas Drossman says hype boils down to correct diagnosis and management of a chronic

Organization Gives Voice to Independent Doctors

14 Practice Management

Gastroenterology

Get to Know Michael Paul Bolognesi

On Your Own or Part of a Larger Health Care System?

16 News “Shared” Health Care Delivery Company Gets Name and President

17 News

Welcome to the Area

condition. COVER PHOTO: The medical team within Raleigh Neurosurgical Clinic, this month’s cover story, includes: (from left) Russell Margraf, M.D., Ph.D.; Timothy Garner, M.D.; Ali Thomas, P.A.-C.; Charlotte Spangler, P.A.-C.; and Robert Allen, M.D.

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The Triangle Physician


From the Editor

Keeping Pace It’s enlightening to pause for an inventory of strides that are made over time.

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

This month’s cover story on Raleigh Neurosurgical Clinic does that, with an overview of medical advances since 1954, when the practice opened. It was a time of limited medical understanding, on the cusp of the “Decade of Technology. Fast forward to today, and we’re worlds away. New cases of naturally occurring polio in the United States are practically none existent. Robotics and brain-machine interface are no longer figments of the imagination. Having kept pace with the advances, Raleigh Neurosurgical plans to continue to integrate the best of new patient care and treatment advances.

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Douglas Drossman, M.D. Margie Satinsky, M.B.A. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Creative Director Joseph Dally jdally@newdallydesign.com

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Also this month gastroenterologist Douglas Drossman tells us why abdominophrenic dyssynergia causes a lot of head scratching. Makayla Downs, a family nurse practitioner, helps educate patients and colleagues on the value of genetic testing options and the latest options. Another new contributor this month, association executive Marni Jameson describes the genesis and advocacy role of the relatively new Association of Independent Doctors. Practice management consultant Margie Satinsky discusses the decisions physicians face in making the switch from private practice to health system. Because professional perspective changes with medical advances, The Triangle Physician offers news and cutting-edge insight. So as your practice evolves to keep pace, let us know. Information in The Triangle Physician reaches more than 9,000 professionals within your medical community. Editorial space is available at no cost. Advertising rates are competitive. Please send information and inquiries by e-mail to info@trianglephysician.com. Respectfully,

Heidi Ketler Editor

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The Triangle Physician

info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.


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Cover Story

Raleigh Neurosurgical Clinic

Looking back on 60 Years and Looking Ahead Raleigh Neurosurgical Clinic has thrived for six decades, maintain-

search and technology that have led to the wide range of surgical

ing a commitment to excellence and incorporating the best in medi-

techniques available today.

cal science and practice. Today, sights are set on continuing a legacy. A look back reveals an amazing evolution. Interestingly, some conLeRoy Allen, M.D., founded the practice in 1954, a time when the

cepts that emerged since the 1950s are still important to this day.

field of neurosurgery was still in its infancy, and neurosurgeons were extremely sparse. In the 60 years since, neurology and neu-

Before the polio vaccine was introduced in 1955, the disease had

rosurgery have experienced a series of major advancements in re-

reached epidemic proportions. In the first half of the decade, neurologists spent most of their time treating polio patients, and it was not uncommon for them to perform whatever surgical procedures were needed. While spinal surgery was available, it only included a limited number of procedures and diagnostic tests, and surgeons still didn’t understand the cause of many common problems. At the time, Xrays and myelography were considered less reliable than a physical exam. Throughout the decade, neurosurgery experienced a number of dramatic improvements in the diagnosis and treatment of neurological problems. The angiography was introduced, and neurosurgeons began seeing many more patients with chronic neck and back pain, head trauma, headaches and disorders of the spine or peripheral nerves. The integrated circuit also was invented in the late 1950s, which paved the way for the introduction of automated and programmable computational machines. The ’50s may have experienced some major advances, but the techniques that truly revolutionized the field of neurosurgery were mostly developed in the 1960s. Sometimes referred to as the “de-

Robert Allen, M.D.

6

The Triangle Physician

cade of technology,” transformation occurred on many fronts for neurology and neurosurgery.


While NASA focused on putting a man

agement of a wide variety of neurologi-

on the moon, physicians developed

cal disorders. Research into both Par-

concepts that would lead to the first

kinson’s and Alzheimer’s disease was

computed tomography (CT) scanner

enhanced during the ’80s with landmark

and the first microscope to be used in

discoveries that would lead to improved

the operating room.

treatment methods.

Important surgical advances were made

The era – which witnessed the first re-

for lumbar fusion, and a number of new

ports of acquired immune deficiency

approaches were developed for treating

syndrome, identification of the prion

thoracic disc herniation. Microsurgical

in causing spongiform encephalopathy

techniques also were developed for the

and application of antiplatelet agents for

first time and would go on to become an

stroke – also saw greater understanding

essential component of neurosurgery in

of neuroimmunology. Finally, stereo-

the future.

tactic surgery experienced significant improvements of its own that would be

This momentum continued into the

expanded upon in coming decades.

Timothy Garner, M.D.

1970s, which were regarded as a period of tremendous growth in research, edu-

The 1990s were defined by a continu-

cation and patient care for neurology.

ing explosion in knowledge about the

By far the most significant discovery of

biology of neurological disease and an

this era for neurology – and one of the

increase in the application of many tech-

greatest discoveries in the field of medi-

niques that had only been studied in the

cine – was proliferation of neuroimaging

past. For the first time, a variety of new

technologies.

options became available for several neurological problems that had not yet

In 1972, G.N. Hounsfield produced the

been used. These included the first use

first prototype of the CT scan and intro-

of intraoperative imaging and the intro-

duced it to the market in 1973. Magnetic

duction of artificial discs to the United

resonance imaging (MRI) and positron

States, which had been used in Europe

emission tomography (PET) followed

previously.

in the next few years, and though they

In addition, though pharmacotherapy

were primarily used for research pur-

remained the most widely used means

poses only in their earlier days, their

of coping with illness, interest in deep

invention radically improved the ability

brain stimulation and pulsed radiofre-

of neurosurgeons to view the brain and

quency (PRF) lesioning experienced re-

spine. The decade also saw the devel-

surgence and soon began to be used in

opment of many important treatment

conjunction with pharmacotherapy.

Kenneth Rich, M.D.

modalities for various neurological disorders like stroke, epilepsy and muscle

Electrical stimulation of the brain us-

disorders.

ing fish (the electric ray) to treat headaches was first conceived in ancient

With the advent of neuroimaging, im-

times, according to Vittorio A. Sironi in

provements in neurosurgery continued

his study Origin and Evolution of Deep

on into the 1980s. CT, PET and MRI scans

Brain Stimulation. Since then, electrical

became commercially available during

stimulation has been used to modulate

this time, and they soon experienced

the nervous system and to treat some

widespread application throughout the

neurological disorders

entire country. Their introduction to clinical practice helped neurosurgeons

Today, deep brain stimulation uses an im-

exponentially in the diagnosis and man-

plantable pulse generator to deliver elec

Russell Margraf, M.D., Ph.D.

april 2015

7


trical stimulation to specific areas in the brain as a way to block ab-

to grow as neurosurgeons brave novel techniques never before

normal nerve signals that cause debilitating neurological symptoms.

thought possible.

Radiofrequency lesioning to block the transmission of chronic,

During the past 60 years, Raleigh Neurosurgical Clinic has wit-

debilitating pain is a variation of conventional continuous radiofre-

nessed these advancements in neurosurgery, and efforts have

quency (CRF), which has been in use since the mid-1970s. Todayâ&#x20AC;&#x2122;s

been focused on integrating the best in neurosurgical practices

CRF technology uses safer pulsed radiofrequency heat to create

into its services.

the pain-blocking lesions on nerve tissue. Today, Dr. LeRoy Allenâ&#x20AC;&#x2122;s son, Robert L. Allen, M.D., his partners Significant progress also was made in the treatment of spinal cord

Russell R. Margraf, M.D., and Timothy B. Garner, M.D., and Ken-

diseases and traumatic brain injuries, and campaigns continue to-

neth J. Rich, M.D., are continuing the practice with an unyielding

day to help increase public awareness about the dangers of these

commitment to excellence. This assures a new generation of pa-

problems.

tients can benefit from even more effective treatment as medical advances continue in the coming years and beyond.

Progress in the fields of neurology and neurosurgery has shown no signs of slowing down in the current century and into today.

Raleigh Neurosurgical Clinic is located at 5838 Six Forks Road.,

Breakthrough discoveries linked to molecular biology and genetic

Suite 100, Raleigh, 27609. For more information, call (919) 785-3400

engineering apply directly to the nervous systems and have helped

or visit online at www.raleighneurosurgical.com.

usher in a new understanding of many conditions with novel approaches to treatment.

References http://www.aans.org/Media/Article.aspx?ArticleId=10560

The fields of biology and technology have continued to merge and

http://cp.neurology.org/content/2/3/201.abstract

open up new possibilities in neurosurgery, like robotic surgery

http://www.sciencedirect.com/science/article/pii/

and the brain-machine interface and optogenetics, in which a light

S1878875012010169

source is used to activate certain neurons and inactivate others.

http://onlinelibrary.wiley.com/doi/10.1002/ana.1346/pdf

With continued innovations and technological advancements, the

http://www.neurosurgical.com/medical_history_and_ethics/

potential of neurosurgery in the years to come is only expected

history/history_of_spinal_neurosurgery.htm

Kenneth Rich, M.D.; Timothy Garner, M.D.; Russell Margraf, M.D., Ph.D.; and Robert Allen, M.D.

8

The Triangle Physician


Women’s Wellness

Genetic Testing Information Empowers By Makayla Downs, FNP-BC

Identifying those at risk of developing can-

A review of the patient’s family history

cer is an important part of effective risk

may include first cousins, nieces, neph-

management that increases the potential

ews, aunts, uncles, grandparents and great

of prolonging one’s life. Yet, the process

grandparents. Information about all can-

of genetic screening can be an emotional

cers on both sides of the family, includ-

endeavor.

ing what age they occurred, is necessary and may include such examples as: breast

With genomic technology advancing rap-

cancer before age 50 or multiple breast

idly, the ability to practice personalized

cancers in the same person, male breast

medicine and tailor patient care based on

cancer, ovarian cancer or colon cancer

individual risk is now possible.

before age 50.

Every person fits into one of three risk

We encourage the patient to gather this

categories for cancer: those that carry

information prior to the screening visit. At

sporadic, familial or hereditary cancer risk.

the screening visit we discuss family histo-

• Sporadic risk is also referred to as gen-

ry and evaluate whether a woman qualifies

eral population risk.

for genetic testing. If so, her family history

Makayla Downs is a board certified Family Nurse Practitioner at the Women’s Wellness Clinic. She earned her bachelor of science in nursing degree from Southern Illinois University Edwardsville and her master of science in nursing degree, Family Nurse Practitioner from the University of St. Francis in Joliet, Ill. She is dedicated to women’s health both for primary care and gynecology. Further, Ms. Downs has a focus on genetic cancer risk and the evaluation of a woman’s personal risk of cancer and her family’s risk of cancer.

• Familial risk is elevated beyond sporad-

of cancer and blood work are submitted to

ic risk due to the presence of personal

the genetic testing lab. A follow-up appoint-

or a family history of cancer.

ment is then made to discuss the results

Personalized medicine allows us to tailor

and management plan.

medical care (prevention, diagnosis, treat-

• Hereditary cancer risk includes the presence of a genetic mutation in a fam-

ment and follow up) to an individual’s

ily that increases the risk of cancer and

The genetic testing results include a man-

clinical, genetic and environmental back-

is the highest risk threshold.

agement tool that provides a personalized

ground. The goal is to make treatment as

cancer risk and management guide based

individualized as possible. Genetic testing,

Identifying which category an individual

on professional medical society guide-

such as myRisk, allows a precise diagnos-

fits into is necessary to correctly adapt

lines. If a genetic mutation is identified,

tic test to help focus management and en-

screening and management decisions.

recommendations will include more fre-

able patients, along with their health care

Additionally, a focus on family history and

quent screening visits and testing.

provider, to make the most informed deci-

risk stratification allows the opportunity to

sion possible.

detect those individuals who carry one of

Recommendations for those with a genetic

several genetic mutations that dramatically

risk of colon cancer, management may

It can be daunting to learn of one’s in-

increase their risk of developing cancer.

include earlier, more frequent colonosco-

creased risk for cancer. However, with

pies. Recommendation for those found to

proper education and counseling, a

In our practice, we offer the myRisk he-

have an altered BRCA1 or BRCA2 gene may

woman can have more control over her

reditary cancer panel, a 25-gene panel that

include breast magnetic resonance imag-

own health and life and, likewise, help em-

identifies elevated risk for eight different

ing and more frequent mammograms; in

power her children and family. We cannot

cancers: breast, ovarian, gastric, colorec-

addition to biyearly clinical breast exams

change a woman’s genetic makeup, but

tal, pancreatic, melanoma, prostate and

and an emphasis on monthly self-breast ex-

we can help her manage the devastating

endometrial. The genetic test includes a

ams. Our goal is to provide the resources

effects that a genetic mutation may have.

screening tool used to evaluate a woman’s

necessary for the patient to be successful

family history and potential genetic risk.

in reducing the devastating effects that cancer can have.

april 2015

9


Physician sPotlight

Michael Paul

Bolognesi Place of current employment: Duke University Department of Orthopaedics

Credentials: Associate Professor, Director of Adult Reconstructive Surgery Undergraduate degree: University of North Carolina-Chapel Hill, 1993 Medical degree and others: Duke University School of Medicine, 1998

Do you have a personal hero or mentor? James Urbaniak, Tad Vail, Jim Nunley, Aaron Hofmann Your advice to aspiring physicians: Work hard, enjoy what you do, do not take yourself too seriously What word describes you? Bolo.... My last name is not the easiest to pronounce so most people in the hospital uses this shorter version. What’s your extracurricular passion? My family What’s your favorite restaurant? Bin 54 What’s your favorite getaway? Wrightsville Beach

Residency: Duke University Medical Center, 1998-2003

Tell us something surprising about yourself, your practice or your medical specialty. I work at Duke but played football at UNC

Fellowship: University of Utah Medical Center, 2003-2004

Married Yes, Kelly Bolognesi

Special medical interest(s): Hip and Knee Replacement

Children 3 children - John (9), Rina (8), Julia (5)


Gastroenterology

Abdomino-Phrenic Dyssynergia Effective Diagnosis and Management By Douglas Drossman, M.D.

In September of 2013, The New York Times

physiological factors2. In addition, her con-

Magazine posted a case report of a 15-year-

stipation was due to incomplete relaxation

old, world-class gymnast who mysteriously

of the pelvic floor muscles, called pelvic

developed abdominal cramps, acute diar-

floor dyssynergia, which responded to bio-

rhea followed by constipation and an inex-

feedback treatment.

Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment.

plicable swelling of her abdomen1. I am fascinated by the high level of public The article goes on to say that numerous

interest that leads this case to be featured

diagnostic tests, including magnetic reso-

in The New York Times. What is it that ren-

nance imaging scans and ultrasounds, and

ders so much attention? And what are the

trips to a half dozen hospitals that left gas-

problems with this kind of attention?

troenterologists, neurologists, urologists, psychiatrists, surgeons, physical thera-

There are several factors we should con-

pists, an endocrinologist and a cardiologist

sider: The diagnosis of a functional gas-

scratching their heads in wonder. No one

trointestinal (GI) disorder was made after

understood why the girl looked pregnant

many expensive and unnecessary tests

or why she couldn’t go to the bathroom

were performed and by exclusion. Irritable

without laxatives. When the tests kept

bowel disorders (IBS) and other functional

coming back negative the doctors began

GI disorders are positive diagnoses estab-

to suspect that, “there was nothing really

lished by the Rome Foundation (www.

wrong: it was in her head.” The young lady

theromefoundation.org).

Dr. Drossman is president of the Rome Foundation (www.theromefoundation.org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www. drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www. drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.

was placed empirically on numerous treatments, including hypnosis, acupuncture,

To recognize and accept these conditions

Chinese herbals and prescription medica-

as real will lead to fewer unneeded studies

tions, all without benefit.

to exclude “organic disease.”

In the end, one pediatric gastroenterolo-

When diagnostic studies were negative, it

gist came to the conclusion that she must

was presumed that the patient had a psy-

functional GI disorders must often deal

have a functional gastrointestinal disorder

chiatric problem. This relates to the lack of

with a lifelong history of symptom relapses

(FGID). More specifically she had irritable

knowledge of the biopsychosocial model

and remissions. While we can hope for

bowel syndrome that was associated with

of illness and disease: “If the studies are

cure, the majority of patients need to ac-

a not uncommon condition known as ab-

negative then the symptoms must be in her

cept FGIDs as a chronic disorder with a

domino-phrenic dyssynergia.

head.”

goal of symptom reduction and improved

3

quality of life. Each year, about six to eight patients are

Once the diagnosis was made, the patient

referred to my practice with this condition,

had a miraculous cure to the treatment.

References

in which there is a paradoxical redistribu-

The article leads us to believe that the

1

tion of abdominal contents associated with

gymnast’s biofeedback treatment led to a

15/magazine/diagnosis-gymnast.html

descent of the diaphragm and relaxation

dramatic cure of all symptoms.

2

of the abdominal musculature leading to

http://www.nytimes.com/interactive/2013/09/ Accarino A, Perez F, Azpiroz F, Quiroga S,

Malagelada JR. Abdominal distention results

distension. This is not an increase of gas

Pelvic floor dyssynergia does respond to

or fluid in the abdomen; it’s an inappropri-

anorectal biofeedback, but the abdominal

Gastroenterol 2009; 136(5):1544-1551.

ate pushing out of the abdominal wall that

distension is a more complex physiologi-

3

can fluctuate during the day depending on

cal entity and should not respond to bio-

a Name? Gastroenterol 2005; 128(7):1771-1772.

stimuli like meals, pain, stress and other

feedback. More important, patients with

from caudo-ventral redistribution of contents. Drossman DA. Functional GI Disorders: What’s in

april 2015

11


Physician Advocacy

Organization Gives Voice to Independent Doctors By Marni Jameson

“Certainly, the only happy doctors I still

In 2000, well over half (57 percent) of all

know are all in private practice,” said the

physicians in the United States worked for

e-mail from a physician who works for a

themselves; as of last year, that number

large hospital system.

was closer to one in three (36 percent), according to a report out from Accenture.

The e-mail came in response to my news that I had left my job as senior health re-

The rest went to work for hospitals.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or marni@aid-us.org.

porter of the Orlando Sentinel to run a national nonprofit trade association whose

And who can blame them? The lure to be-

contract much higher rates for the same

sole purpose is to represent the interests

come a hospital employee – the promise

services.

of independent doctors.

of more money, perceived job security, no

• Education – Patients, the community

more overhead, guaranteed referrals – is

and regulators need to know how this

As a reporter, when a hospital system

strong. But, as many physicians, including

trend affects access, choice and cost of

acquired a medical group, I interviewed

the author of the e-mail to me, learned,

care.

sources on all sides: doctors, hospital ex-

the move comes at a price.

ecutives, insurers, academics, patient ad-

• Camaraderie – Independent physicians want to work with a network of doctors

vocates, consumers and government offi-

The Association of Independent Doctors

who share their practice philosophies.

cials. I got a full-circle look at why more

(AID) was formed in April 2013, when two

• Autonomy – By working to reverse the

doctors were going to work for hospitals

certified public accountants in Winter

trend of medical practice acquisitions,

and the impact that had on patient care

Park, Fla., saw the impact that the acqui-

the association makes it easier for doc-

and health-care costs.

sition of independent practices by hospi-

tors to stay independent and enjoy

tals was having on not only doctors, but

greater job satisfaction.

I also saw that while the independent na-

also patients, local communities and the

ture of private practitioners was mostly to

nation. They wanted to create a trade as-

“Physicians have a tendency to not get in-

their advantage, in one important respect

sociation to stop the trend.

volved in critical changes affecting them

independence was contributing to their

and specifically avoid the political end of

undoing. Independent doctors are by

I covered the inaugural meeting for the

medicine,” said Orlando orthopedic sur-

definition not well organized as a group.

paper. About 120 doctors attended, and

geon John McCutchen, who serves on the

By not being allied, they didn’t have a col-

nearly everyone joined that night. (Indi-

executive committee for AID.

lective bargaining voice.

vidual physician memberships cost $1,000 a year.)

Thus, their numbers were shrinking.

“We no longer have the luxury of doing nothing,” he said. “If physicians don’t

Since then, AID has grown to include

want non-physicians telling them how to

Unless you have been living in a yurt off the

members in eight states. More doctors

practice, they need to get engaged.”

grid, you know that the rate at which hos-

and health care advocates join every day.

pitals have been buying doctors’ practices

Of course, the Florida Medical Associa-

has been brisk in the past several years.

Most join because AID stands for what

tion and the American Medical Associa-

Such roll-ups help hospitals capture market

they care about, but don’t have the time,

tion represent physicians, too. However,

share, channel referrals to their other em-

resources or clout to fight for:

because most of their physician members

ployed physicians and hospital-owned di-

Parity – Independent doctors receive

are employed or in academia, they are not

agnostic and treatment centers and receive

substantially lower reimbursements from

in a position to champion the unique in-

more money for same-day procedures.

payers, compared to hospitals, which

terests of the independent physician.

12

The Triangle Physician


“The future of health care is changing,

be heard.”

Drossman Gastroenterology

Dr. Snook, like other physicians who

55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514

Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.

919.929.7990

www.drossmangastroenterology.com

and we as independent physicians need to come together to steer the boat in the right direction,” said Pamela Snook, M.D., F.A.C.O.G., a Winter Park ob-gyn and AID member. “I joined because this is an avenue where I feel I have a voice that I don’t have otherwise. It’s a way to

have resisted hospital employment, wants to remain independent so her allegiance remains unequivocally to her patients. As the only national organization of its kind, AID has already established itself as a formidable, articulate force. Its founders have spoken on Capitol Hill, and the association was asked in the summer of 2014 to support the Federal Trade Commission in an important antitrust case involving a hospital’s purchase of a large medical group in Idaho. This past February, the U.S. District Court of Appeals for the Ninth Circuit

ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS

ruled as AID requested, that the merger

“He wanted his confidence back.”

between St. Luke’s Health System and Saltzer Medical Group violated antitrust laws and had to be unwound.

I REFERRED HIM TO SOUTHERN DERMATOLOGY AID was proud to have been part of this verdict, which sets an important precedent for others contemplating such mergers. AID’s involvement put the voice of independent doctors on the national stage, making them part of a debate whose outcome will impact every American. Thanks to the growing support of doctors, we can collectively do what individuals alone cannot. FOR THE MOST ADVANCED DERMATOLOGY TREATMENTS, REFER YOUR PATIENTS TODAY!

Next month, we will discuss the seven consequences of hospitals acquiring physician groups.

southernderm.com

919-782-2152

ROSACEA • HIVES • VITILIGO • KERATOSIS • WART REMOVAL • ALOPECIA

DER131_AD_Triangle Physican I Want 4.indd 2

april 20153:56 PM 13 3/18/15


Practice Management

On Your Own…

or Part of a Larger Health Care System? By Margie Satinsky, M.B.A.

“Should I open or retain my own private

Organization and Management

practice or become part of a larger health

If you own and manage your practice,

care system? That’s the question we’ve

you must thoughtfully address the way in

heard from 10 physicians during the past

which you set up your business and affilia-

six months.

tions with other health care organizations.

We’ve worked with three types of people:

Some physician clients have the interest

1) Physicians who are certain they want to

and skill to manage their own practices.

own their own practices and have the

Others don’t.

skills to make that happen; 2) Physicians who are carefully examining the issues; and

Will you be comfortable collaborating with

Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She’s the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.

a professional practice administrator or

3) Physicians who have a sincere interest

manager, and if so can you afford to hire

health care system. “We received mixed

in running their own practices but lack

an individual that has the required knowl-

messages from the system administration.

the personal characteristics needed for

edge and experience? How will you di-

On the one hand, we were told that qual-

success.

vide administrative responsibilities among

ity and safety mattered. On the other hand,

physicians, your practice administrator/

the budget for those tasks was significantly

One size doesn’t fit all. Only you can de-

manager and external resources? Do you

reduced. Only when the threat of federal

cide. We’ve written this article to help

understand the role that strategic business

financial penalties became a reality did the

you address the appropriate issues with

planning, budgeting and marketing play in

administration restore the funds needed to

respect to your own personal readiness,

managing a successful practice?

get the job done.”

management, managing staff and external

If you work for someone else, you are not

Financial Management

resources, maintaining quality and out-

exempt from organization and manage-

When you own a medical practice or any

comes and compliance.

ment challenges. “Entangled” might be a

other business, it’s your responsibility to

more appropriate adjective.

develop operating and capital budgets that

organization and management, financial

support your strategic business plan. With

Personal Readiness First and foremost, what’s your personal

Given your personal and professional ob-

respect to reimbursement, you must under-

readiness to run a successful business?

jectives, can you work within a larger or-

stand both the public and private sectors.

ganizational structure without sacrificing Good intentions are admirable, but they

your needs and goals? If you want to par-

Government policies for reimbursement

won’t come to fruition without drive, focus

ticipate actively in managing your practice,

shift like sand. For example, CMS is quickly

and decisiveness.

can you learn to do that within the context

moving in the direction of payment for

of organizational priorities? Can you toler-

quality and value. In the private sector, you

When someone asks about setting up a new

ate decision-making processes that will

must deal with a variety of payers, each of

private practice or remaining in an existing

probably move more slowly than you per-

which has a unique approach to provider

one, we provide a long list of tasks to be done

sonally might like?

reimbursement.

hensive guidance, but only you know your

Here’s what one practice manager said

As a practice owner, you should regularly

personal strengths and weaknesses.

about his experience working for a large

renegotiate managed care contracts, so

or questions to be asked. We offer compre-

14

The Triangle Physician


you can maximize reimbursement. With

tice settings without providing adequate

for delivering care, but you are not the ul-

respect to billing and collections, ulti-

training. For example, in the practice from

timate decision maker about processes in

mately it’s your responsibility, even if your

which we sought care, the nurse had come

your office. If the organization is a midsize,

practice management system software

from a hospital department and didn’t

large medical group or an academic medi-

includes revenue cycle management or if

know how to request a Tier 3 prescription

cal center, it may have substantial financial

you outsource billing and collections to an

that required physician authorization. With-

resources and information technology to

external vendor.

out that authorization, the additional out-of-

support quality improvement programs.

pocket cost to the patient was $3,600/year!. On paper, it sounds as if quality of care is

When you work for someone else, you work within financial constraints. You may

With respect to outside resources, when

simpler in a large organization with signifi-

contribute to the development of an orga-

you own your practice, you decide if and

cant financial resources to devote to the ef-

nizational budget, but you don’t make the

when to seek outside assistance. You de-

fort. But here’s the caveat that we hear over

final decisions. Obtaining the resources

termine which professionals should be on

and over again: “Quality takes second place

that you would like may be more difficult

your team and you select them. After you

to expectations for productivity. Pushed to

because you are competing with other

identify one or more external consultants

see a large volume of patients each day, I

physicians who believe their priorities are

with whom you want to work, you must

have insufficient time to practice medicine

equally as important as yours.

sign a formal agreement and develop a

the way I think it should be done.”

strategy for overseeing the work. Compliance

We could write a book about our own negative experience with a medical prac-

When you work for someone else, you

The final area of practice management is

tice owned by a large health care system.

can still access outside resources, but the

compliance. Federal, state, and local laws,

The telephone system had limited hours,

decision may be somewhat complicated.

regulations and rules govern both adminis-

because the health care system, not the

Depending on your scope of authority and

trative and clinical aspects of health care.

practice, decided on the way in which it

your organization’s rules, you may have to

As a practice owner, you must be famil-

would work. From a patient perspective,

follow a list of specific steps to obtain the

iar with the concepts and requirements

the practice was inaccessible by phone.

help that you yourself want.

regarding antitrust, anti-fraud and abuse, Stark, HIPAA (Health Insurance Portabil-

Managing Staff and

Improving Health Care

ity and Accountability Act of 1996) privacy

Outside Resources

Delivery and Outcomes

and security and OSHA (Occupational

Physicians who own their practices devote

Regardless of whether or not you own your

Safety and Health Administration). You are

a great deal of time managing internal staff.

own practice, the delivery of care to patients

obligated to establish and maintain compli-

With guidance from legal counsel, you

and the outcomes that you achieve should

ance programs.

need to understand employment law. What

be the focus of your efforts. The practice of

questions can you ask/not ask during an in-

medicine demands attention to both quality

When you work for someone else, the or-

terview? How do you terminate an employ-

of care and quality improvement.

ganization creates the systems. Your job is to learn how the organization approaches

ee? Can you create a performance evaluation system, pay grades for your employees

When you own the practice, you and your

each area of compliance and to meet the

and a compensation system for physicians?

entire workforce have opportunities to cre-

requirements.

What about a personnel handbook and op-

ate processes that meet patient and clini-

erating policies and procedures?

cal needs. You can analyze your workflow

Conclusion

and improve what isn’t working well. You

So what’s your response to the question?

When you work for a larger health care

can decide how to use patient registries

Do you want to open or retain your own

system, systems for managing staff will al-

to benchmark your care. You can mea-

medical practice or become part of a

ready be in place. Your challenge isn’t the

sure the impact of the changes you have

health care system? We can tell you what

creation of systems, but learning the rules

made – provided you know how to do it.

ownership requires, but you know what’s

for systems that already exist.

Your decisions on supporting information

best for you. If you decide that owning your

technology can help with both delivery

own practice is the right strategy for you,

and outcomes.

be sure to order A Handbook for Medical

One common complaint from physicians

Practice in the 21st Century written by Mar-

who are part of large health care systems is recruitment. Larger systems often rotate

If you work for someone else, you have

gie Satinsky with Randall T. Curnow, MD,

employees from hospital to private prac-

some input to that organization’s method

now President of Mercy Health in Ohio.

april 2015

15


WakeMed News

“Shared” Health Care Delivery Company Gets Name and President An innovative health care delivery partnership continues to take shape, with the recent announcement of its name, Socius Health Solutions, and its president, Mark W. Tribbett, F.A.C.H.E. Owned by Vidant Health, Wake Forest Baptist Medical Center and WakeMed Health & Hospitals, the company is using a sharedservices approach to improve quality and affordability for patients across the state. The name “Socius” has Latin roots that mean – shared, associated, allied. It reflects the “individual health care systems’ similar missions, visions, values and strategic focus,” according to a press advisory. “Socius Health Solutions brings together the collective talents and best practices of three like-minded organizations while retaining independent structure, governance and local identity. The shared-services approach leverages each of the systems’ areas of expertise, both clinically and operationally,” the advisory said. The company will reportedly support health care reform initiatives − including Accountable Care Organization development and implementation, as well as care coordination for population health − and create business and clinical efficiencies. It also will assist in” meeting the challenges posed by reduced reimbursement rates as well as technological changes, while keeping patient-centered care at the forefront.” “Socius Health fits perfectly with our mission and goals of seeking preferred partners to deliver an exceptional level of health care service by sharing our strengths and resources,” said Donald Gintzig, WakeMed president and CEO as well as chair of the Socius Health Board of Directors. “Our organizations want to deliver the best care and value to our state’s citizens.” The company will be based out of Raleigh,

16

The Triangle Physician

which is central among the three organizations. The next steps for Socius Health are to refine areas of focus as well as initiatives and methods of tracking. Supply chain management, select information technology infrastructure and clinical protocols are among the sharable opportunities available for its member institutions. “We will be building on the work of clinical teams from last fall to codify best practices and spread them throughout our health systems,” said John McConnell, M.D., chief executive officer of Wake Forest Baptist Medical Center. “Some of the benefit from this work will come from identifying select specialty patients with the most commonly diagnosed conditions in the specialty across the three systems. This clinical work will benefit patients in today’s health care environment as well as prepare the health systems for population health.” At the helm of the new company, Mr. Tribbett brings with him more than 30 years of health care management, with extensive experience as a hospital administrator and consultant. As president of Socius Health, he will lead efforts to transform health care models and support infrastructure that improve quality, reduce costs and best meet the needs of diverse patient populations. “We believe Mark is the right leader, with the right credentials and a proven track record to help improve all of our health systems’ efficiencies and value in order to invest more in the care of our patients,” said Janet Mullaney, interim CEO of Vidant Health. Prior to joining Socius Health, Mr. Tribbett established AlphaHealth L.L.C., a health care innovations firm focused on strategic planning and the development of health care enterprises. As founder and president of AlphaHealth, he steered more than 100 major projects for more than 50 health care organizations, including strategic, facility and operations improvement plans. He also

developed new hospital models and provided executive operations leadership in this role. Additionally, Mr. Tribbett served in leadership positions within hospital and health care systems for 17 years. His career path includes a 10-year tenure with Novant Health and Presbyterian Healthcare System as executive vice president for the Charlotte region. He led hospital operations, the development of Presbyterian Matthews Hospital – a national leader in the patient-centered care model – and oversaw outpatient centers and physician practices. Mr. Tribbett earned a master’s degree in health care administration from Duke University. He also has a bachelor’s degree in business with a focus on marketing management from Virginia Tech. Socius Health Solutions operates as a separate limited liability company with a board comprised of representatives from all three health systems.

2014 Editorial Calendar May Women’s Health, Neurology, Infertility June Men’s Health, Pulmonary July New Imaging Technologies, Vein Diseases, Rheumatology August Gastroenterology, Nephrology, Sports Medicine September Bariatrics/Neonatology Advances in NICU, Obstetrics/Gynecology October Cancer in Women Wound Management, Dermatology November Urology, ADHD, Austism December Sports Medicine, Otorhinolaryngology Pain Management


News Welcome to the Area

Physicians

Anna Xuzi Hang, MD

Co-May Dang Pasdar-Shirazi, MD

Duncan Thomas Vincent, MD

Hassan Haissam Amhaz, MD

Otorhinolaryngology

Internal Medicine; Pediatrics

General Practice; Hospitalist; Internal Medicine

University of North Carolina Hospitals Chapel Hill

University of North Carolina Hospitals Chapel Hill

University of North Carolina Hospitals Chapel Hill

James Jones, MD

Eric Gon-Chee Poon, MD

Marcella Gevonne Willis-Gray, MD

Administrative Medicine; Internal Medicine

Gynecology; Obstetrics; Gynecologic Surgery; Gynecology - Critical Care Medicine; Endocrinology/Infertility

Anesthesiology - Critical Care Medicine

Duke University Medical Center Durham

Matthew Francis Baldwin, MD Pediatrics

Adolescent Medicine

Raleigh

Durham Medical Center Durham

Blue Ridge Pediatrics Raleigh

Elizabeth Nora Jovanovich, MD Physical Medicine and Rehabilitation

Joseph Michael Reardon, MD

Ethan Alan Bean, MD

University of North Carolina Hospitals Chapel Hill

Emergency Medicine

Psychiatry

Duke University Hospitals Durham

Raleigh II CBOC Raleigh

Martyn Knowles, MD Vascular Surgery

Molly Moriarty Rusin, MD

Michael David Brown, MD

Rex Vascular Specialists Raleigh

Pediatrics

Hospitalist; Pediatrics

Wake Med Raleigh

Sachin Basiq Malik, MD

Anna Jaclyn Conterato, MD

Duke Dept of Radiology Durham

Pulmonary Disease and Critical Care, Internal Medicine

University of North Carolina Hospitals Chapel Hill

Shaina Rose Eckhouse, MD General Surgery; Surgery

Duke Surgery, Division of Metabolic and Weight Loss Surgery Durham

John Walker Greene, MD Internal Medicine; Pediatrics

Duke University Hospitals Durham

Gaorav P Gupta, MD Radiation Oncology

UNC Chapel Hill Chapel Hill

Whitney Ivy Haddix, MD Pediatrics

UNC Pediatrics Education Chapel Hill

Diagnostic Radiology

Milica Margeta, MD Ophthalmology

Duke University Eye Center Durham

Shannon Marie Matthews, MD Emergency Medicine

University of North Carolina Hospitals Chapel Hill

Matthew Ramseur McDaniel, MD Anesthesiology

UNC Hospitals Chapel Hill

Robert George MorganJr., MD Pediatrics

UNC Pediatrics Residency Program Chapel Hill

Samilia Obeng-Gyasi, MD General Surgery; Surgery

UNC Medical Center Chapel Hill

Physician Assistants

University of North Carolina Hospitals Chapel Hill

Sarah Emily Schmitz, MD

Cara Marie Bailey, PA General Practice

Raleigh

Elizabeth Bee Goldbach, PA

Psychiatry

University of North Carolina Hospitals Chapel Hill

Orthopedic Surgery

Cary

Grace Chae-Wha Park, PA

Andrea Stallsmith Senter, MD

Oncology, Internal Medicine

Radiology

University of North Carolina Hospitals Chapel Hill

Robert Alan Van Der Vaart, MD Ophthalmology

University of North Carolina Hospitals Chapel Hill

Durham

Mariam Rashid, PA Cardiology; Emergency Medicine; Family Medicine; Hospitalist; Internal Medicine; Pediatrics; Urgent Care

Raleigh

Taja Walker, PA

Sreenath Vellanki, MD Anesthesiology

University of North Carolina Hospitals Chapel Hill

Dermatology; Emergency Medicine; Facial Plastic Surgery; Gynecology; Obstetrics; Orthopedic Sports Medicine; Orthopedic Surgery of the Spine; Reconstructive Surgery; Plastic Surgery; Student Health; Urgent Care

Ashok Venkataraman, MD

Cary

Abdominal Surgery; General Surgery; Surgery; Thoracic Cardiovascular Surgery

Mary Carol Younginer, PA

University of North Carolina Hospitals Chapel Hill

Cardiology; Emergency Medicine; Gastroenterology, Internal Medicine

Cary

Duke University Medical Center Durham

AUTISM

Awareness Month The Autism Society of North Carolina (ASNC) will kick off Autism Awareness Month with a celebration on Thursday, April 2. The World Autism Awareness and Acceptance Day event, from 10 a.m. to 4 p.m. at Camp Royall in Moncure, is open to the public.

Sporting Clay Course

• Open Tuesday–Saturday 8a.m. till 6p.m. • Sunday 1p.m. till 6p.m. •Monday by appointment only • Over a mile course • 14 Stations

Families and self-advocates will gather for fellowship and fun, with access to many of Camp Royall’s unique features, including the Snoezelen Sensory room and the zapline. The day’s activities will also include inflatables, music, arts and crafts, and a cookout. ASNC’s summer camp program was

• Covered 5 Stand • Wing Shooting- Quail/ Pheasant/ Chukar Hunts • Driven Pheasant Hunts • European Tower Hunts • Shooting Instructions • Gun Rental • Ammo Available • Dog Training

established in 1972 and is the nation’s oldest and largest summer camp program for individuals with autism. Last year, Camp Royall served more than 1,800 individuals with autism through its overnight camp and yearround educational and recreational programs.

• Fishing • Corporate Events/ Retreats/Team Building • Birthday Parties, Bachelor/ Bachelorette Parties • Church Groups , Individual Outings • Complete Packages Available

For more details about World Autism Awareness and Acceptance Day at Camp Royall, visit http://bit.ly/WAAAD2015.

april 2015

17


3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.

3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | Select Locations | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 30 minutes from check-in to exam completion

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The Triangle Physician April 2015

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The Triangle Physician April 2015

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