Dent Institute Becomes NYS Center of Excellence

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PHYSICIAN the local voice of practice management and the business of medicine

VOLUME 6 / 2018

Dent Institute Becomes NYS Center of Excellence in Dementia Care The Real Cost of “Couponing” Short-term Benefit, Long-term Cost

Making Your MLMIC Payout Work for You

Stroke Neurologist Steve Dofitas, MD, and Jianing Xiao, NP, of Mercy Hospital‘s Stroke Team

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buffalo and the great lakes

Financial Insights 03 Making Your MLMIC Payout Work


for You

Medical Research

15 Study: Attention Requires Balance in the Brain Study Points to New Method to 15 Deliver Drugs to the Brain 16 For Chronic Leukemia Patients, the 05

News Just Got Even Better

Dent Institute Becomes NYS Center of Excellence in Dementia Care

As a Center of Excellence in Dementia Care, the Dent Institute is strategically poised to provide a comprehensive program of care for dementia patients. From early-onset through treatment and supported by Dent’s long-rooted engagement in clinical trials and research, patients gain access to the most advanced and promising treatments available.


Research Review Underscores Progress in Treating Kidney Cancer


Update on Blood Pressure Medication Recall: Amlodipine and Hydrochlorothiazide are Safe

Clinical Features


11 Opioid Prescriptions Can Be

22 Menopause

Drastically Reduced After Surgery with No Increase in Pain, Study

Neurons in the Brain Work as a Team to Guide Movement of Arms, Hands

21 E-Cigarette Users Have Lower Exposure to Toxicants —


As Long as They Don’t Smoke

19 Improving Outcomes: Patient Care

Combustible Cigarettes Too

in Today’s Value-Based Health Care


Practice Management It Pays To See The Revenue Cycle

Through Your Patients’ Eyes


The Real Cost of "Couponing"

Short-term Benefit, Long-term Cost

27 The Cost of “Compassionate Care”

12 14


What’s New in Area Healthcare


Editorial Calendar


from the publisher

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Welcome to our latest issue of Western New York Physician – Buffalo and the Great Lakes where you will find informative stories and articles about and for physicians in western NY. Welcome Readers— With this issue Western NY Physician Magazine wraps up our third year of publishing in the Buffalo & Great Lakes region. It’s been an exciting time in Buffalo, witnessing a totally revitalized and newly designed physical infrastructure drawing patients, clinical talent and national recognition to WNY. We look forward to highlighting the continued growth in the medical landscape and hometown innovation in 2019! Our cover story discusses dementia the Dent Institute’s recent designation as a NYS Center of Excellence in Dementia Care. How did the Dent achieve such distinction? This innovative program is designed to provide comprehensive and coordinated access to the variety of specialists through each progressive stage of dementia along with the essential support families need to navigate their loved ones care. As a top US neurological center, the Dent creates a model to follow and brings Buffalo into a national view. Coming Up: • Obesity on the Rise • Interventional Radiology • Medical Marijuana in NY Be a Part of the Conversation in 2019 Share your expertise in a relevant way with your medical colleagues and referring physicians when you contribute an article, take part in a Q&A or share your expertise in an interview. Please email or call me directly to discuss suggestions, focus, timing and submission criteria. In the meantime, please enjoy the numerous other articles within the issue. As always, we thank each of our supporting advertisers -- your continued partnership ensures that all physicians in the region benefit from this collaborative sharing of information and provides the WNYP editorial staff with a deep pool of expert resources for future interviews and articles. All the best in 2019,



PHYSICIAN the local voice of

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financial insights

Making Your MLMIC Payout Work for You Andrew DelMedico, CFP® Senior Consultant/Financial Planning Coordinator at Manning & Napier If you currently or have previously used Medical Liability

The Case for Paying Down Medical School Loans and Other Debt

Mutual Insurance Company (MLMIC) for your malpractice

In attractive investment environments, it may be advantageous

Hathaway’s acquisition of the company and may have already

existing loans. The theory is that such an environment creates

insurance coverage, you have likely been following Berkshire

to divert excess dollars into investments instead of paying down

received a payout. In short, the deal, first announced in 2017,

an arbitrage opportunity where investment returns exceed

by policyholders) to a stock insurance company (owned by the

the current market environment (low interest rates, moderate-

converts MLMIC from a mutual insurance company (owned

shareholders of Berkshire Hathaway). As a result, MLMIC

policyholders with policies in effect between July 15, 2013

and July 14, 2016 are eligible to share in the proceeds of the

loan-servicing expenses, resulting in a surplus. However, given to-high stock valuations), investors may find returns harder to come by over the short- to intermediate-term.

Using some MLMIC proceeds to pay down debt provides

sale. Individual awards are formulaic, with payouts equivalent

a “guaranteed return” in the form of a reduction in the com-

three-year period. For example, if a physician paid average an-

loans can help insulate you from the financial impact of rising

projected payout is nearly $200,000.

tax advantages for continuing to carry some types of debt (e.g.,

to approximately 1.9 times the total premiums paid over the

nual malpractice premiums of $35,000 over three years, the

pound interest on accumulated debt. Paying down variable rate

interest rates. Keep in mind, however, that there are potential

mortgage debt and potentially some college loan debt—subject

Year 1 Premiums:

$ 35,000

to income requirements).

Year 3 Premiums:

$ 35,000

The Case for Investing the Proceeds to Fund Retirement, MultiGenerational Wealth Transfer, or Charitable Goals

Year 2 Premiums:

$ 35,000

$105,000 x 1.9 = $199,500

Once you receive your payout, the question then becomes,

how do you maximize the benefit of the unplanned cash infusion? Pay down remaining medical school or other debt (e.g.,

Investing the proceeds of your MLMIC payment can help to

jump-start your retirement preparedness, or be the basis for achieving multi-generational or charitable goals you have been

keeping on the back burner. As the charts below illustrate, in-

mortgage, business loans)? Add to your retirement nest egg?

vesting the proceeds could present a potential opportunity to

a trip or vacation home down payment? Any of these can be

to achieve goals that were formerly believed to be out of reach.

Fund multi-generational and/or charitable goals? Splurge on

the right answer depending on the situation. Below, we lay out different cases for each situation.

create excess wealth to ease the retirement burden and/or help

In contrast, failing to invest could result in a meaningful op-

portunity cost over the investment time frame. Consider that

a $200,000 infusion into an investment account of a 40 year


old would grow to more than $1.1 million by age 70 under a

their wealth while they are still alive. By picking up the tab at

6% straight-line annual return and would grow to nearly $3.5

family dinners whenever possible, funding grand family vaca-

initial $200,000 investment would grow to $2.7 million under

goals, and helping children/grandchildren/great-grandchildren

sumption, and $14.5 million under a 10% return assumption.

es, retirees can make differences in their own lives and the lives

million under a 10% annual return assumption. By age 85, the

a 6% return assumption, $6.3 million under an 8% return as-

tions, purchasing family vacation homes, fulfilling charitable

with college tuition, wedding expenses, and first home purchas-

The charts and tables below show the potential appreciation

of others that goes well beyond dollars and cents. However, this

and scenarios. Given that the portfolio will endure ever-chang-

pared for your own retirement and other financial obligations.

of a $200,000 one-time contribution under various timeframes

approach is prudent only in cases where you are properly pre-

ing market, economic, and interest rate environments over the

Prior to making any meaningful financial decisions, you should

proach (or approaches) that employ a disciplined mechanism

ing your financial goals and understand the financial impact of

timeframes illustrated, it is important to invest under an apto adjust to changing conditions.

One-Time $200,000 Investment - Potential Market Value at Retirement*

work with your advisor to evaluate your progress towards meetthose decisions.

Proceeds from the MLMIC payout present an opportunity

to reduce debt, enrich your retirement/multi-generational

goals, and/or fulfill “bucket list� type items. The three paths are

starkly different and there is no one-size-fits-all answer. There-

fore, you should take the time to evaluate the potential impact

of the proceeds on your ability to fulfill your financial and non-

financial goals and work with your trusted circle of professionals to ensure that you make the best decision for your situation.

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*Age 70 for illustrative purposes (i.e., the year required minimum distributions begin). **Illustrative joint life expectancy for a couple of age 85.

The Case for Spending the Money While prior generations traditionally followed the path of

maintaining control and ownership of wealth long into their

lives, current generations are increasingly taking a lifetime leg-

acy approach with their wealth – placing emphasis on sharing


Has Your Office Moved? New address New name New practitioner

Email your updates to:

cover story

Dent Institute Becomes NYS Center of Excellence in Dementia Care Randi Minetor


“We’ve been in the community for about fifty-five years, and t the Dent Neurologic Institute in Amherst, NY, the dihave always been structured around the mission of clinical agnosis and treatment of Alzheimer’s disease and other care,” said Dr. Fritz. “Clinical excellence doesn’t just come beforms of dementia are all in a day’s work. Starting in 2016, howcause you came out of a fellowship program. It comes from ever, Dent became one of ten medical centers across the state being a learning organization, with an infrastructure for conthat serve as New York State Department of Health Centers of tinual research and education -- education for other providExcellence for the diagnosis and treatment of individuals living ers, for caregivers, and participating at with Alzheimer’s and other dementias. a national level.” This means that Dent’s already strong Most patients tell their primary care program of care for people with dementia, physician when they become confrom diagnosis and treatment to support cerned about memory loss, but their of care partners, has been recognized as doctor may not have the time, resourcone of the most comprehensive in the es or experience to diagnose and treat state. the issue. This often results in a refer“Dent was already doing this, but now ral to Dent’s comprehensive program we’re part of a network,” said Joseph in Amherst, Orchard Park, or Batavia. V. Fritz, Ph.D., Dent Institute chief exDent’s medical staff works to diagecutive officer. “Obtaining this Center of nose the specific cause of the patient’s Excellence implies a very comprehensive memory disorder, and to determine if program for patients and their care partthe condition can be treated with lifeners. Meeting the requirements of these style changes or medications. programs means that we have checked “When we’re talking about memory the boxes for so many things that the eviimpairment or changes in people’s dence demonstrates really make a differcognition, it’s important that they unence in overall care.” Joseph V. Fritz, PhD, derstand that there are other things According to New York Department of Dent Institute chief executive officer. that can cause dementia,” says Sarah Health statistics, as many as 390,000 New Harlock, program director of the Dent Yorkers are living with Alzheimer’s disIntegrative Center for Memory. “Vitamin deficiency, thyroid ease or another form of dementia—and that number is likely to problems, urinary tract infection, and other things need to be climb to 460,000 people by 2025. Research has made inroads in assessed before coming to a diagnosis. These can be reversible understanding the causes of dementia, but no cure or long-term if detected early.” prevention method has surfaced to date. This means that paDr. Fritz added, “Furthermore, Alzheimer’s itself may have tients with dementia and their families need services that help roots in modifiable risk factors. It has even been referred to as them understand the disease, connect with available treatments ‘Diabetes Type III’. We have therefore initiated clinical and that may slow functional loss, and maintain a safe environment for these patients at home.


Erica Colligan, MD

Bela Ajtai, MD

research activities in an ‘integrative medicine’ approach, led by nurse practitioner Laura Funke. These specially trained providers rigorously assess and coach patients and caregivers on lifestyle choices that mitigate risk factors and optimize health.” Board-certified adult nurse practitioner Ariel Clay specializes in memory disorders and general neurology, working closely with supervising neurologists Dr. Bela Ajtai and Dr. Ericka Colligan. “When a patient comes in with a complaint of memory disorders, our approach is that we are treating the patient and the care partners, and we are also educating them on healthy lifestyle,” said Clay. “We have a physician directed team trained in dementia diagnosis and management. The initial visit consists of a thorough clinical exam by a neurologist, ideally supported by a close family member or friend who is often able to shed more light on the memory concerns, as well as provide ongoing support for the patient. The neurologic exam is then followed by additional diagnostic testing, such as MRI, to rule out obvious pathology including brain tumors or strokes, and also establishes a baseline measure of brain structures that tend to deteriorate over time in dementia.”

Various lab tests are also ordered, and other testing will be ordered based on insights gained from these initial diagnostics. “These may include a sleep study, more advanced labs, neuropsychological testing and other forms imaging, such as PET scan, which can help differentiate functional pathologies,” said Clay. Following the initial diagnostic process, the patient may be referred to Sarah Harlock’s team, which plays a critical role in connecting the patient’s care partners with the support they need, both to take care of the patient and to see to their own health. “We have printed information, and classes here at Dent around topics that relate to brain health, memory impairment, and care partner challenges, as well as online opportunities for education,” she said. “We have licensed clinical social workers who are able to provide counseling. They work very closely with the doctors and Advanced Practice Providers to provide further assessments of psychological and social determinants, and to provide counseling, when appropriate, to both patients and care partners.” Dent maintains relationships with resources in the community that can support care providers, making connections that


Sarah Harlock, MBA

Ariel Clay, ANP-BC

can mean the world to a stressed patient and family. “We provide access to community services that are available to them: adult day programs, grant money, in-home help, community respite programs, and support navigating the system of services” said Harlock.

vested in Alzheimer’s clinical trials over the last thirteen years than ever before,” she said. “We’ve been doing them for over thirty years for neurological indications including Alzheimer’s, but Alzheimer’s has become a clinical focus. There are trials to prevent or slow the disease, trials to understand the disease, and trials to treat the symptoms.” Caregivers, patients, and clinicians are passionate about the field, but many avenues have not produced the hoped-for results. Most of the recent trials target the buildup of amyloid plaques, which are found in the brains of Alzheimer’s patients and destroy the connections between nerve cells that preserve memory and perform other cognitive functions. “There are several different ways that we are targeting the building up amyloid,” Dr. Rainka said. “One is actually targeting the amyloid itself, while others target the pathway for the amyloid. There are still other trials that are observational, that are trying to understand why someone developed Alzheimer’s, and what takes them from having normal cognition to mild impairment to Alzheimer’s.”

Research and clinical trials In addition to clinical care, Dent Institute conducts its own investigative research, and it participates in clinical trials that connect patients with the most advanced and promising treatments. “We are mostly interested in research that can be applied to our patients as quickly as possible,” said Dr. Fritz. “We participate in just about all phase three clinical trials associated with new drug development. Our ability to see a high volume and wide range of patients in an outpatient setting, together with a strong research infrastructure, makes Dent a uniquely attractive trial site.” Clinical pharmacist Michelle Rainka, Pharm.D., CCRP, develops the clinical trials at Dent Institute. “We’ve been more in-


Other clinical trials look for solutions that target the symppatient neurology. For example, we’re among the first in the toms of the disease, such as agitation and compulsive behaviors. nation to implement a groundbreaking therapy for a devastat“We did an ideas trial, sponsored by Medicare and Medicaid as ing neurologic condition called spinal muscular atrophy. We well as the Alzheimer’s Association, in which patients have a are encouraged that breakthroughs based on similar technoloPET scan to see if they have amyloid plaques. We took patients gies will be available for Alzheimer’s disease and other forms with memory complaints where we were unsure of the diagnoof dementia.” Recent discoveries in dementia progression have not only sis, and follow them to see if having that expensive test leads to brought hope for future therapies that may improve the lives a more accurate diagnosis.” Current news stories about progress in developing an Alof people with memory loss, but also there is greater emphasis zheimer’s vaccine have brought the poson mitigating risk factors and maximizing sibility of a working preventative measure cognition. Dent’s research and community involvement, therefore, expands beyond to national attention. Dr. Rainka caupharmacologic clinical trials. tioned that there have been such developments before. “There’s been a lot of con“We are moving out of the dark world troversy about the amyloid vaccine that where if you can’t figure out where your keys are, you basically get a death senwas worked on in the early 2000s,” she tence,” said Dr. Fritz, “Yes, advance plansaid. “They seemed to be showing that ning is important to ensure your affairs are they could make some of the amyloid in addressed, but when that’s all you have to the brain disappear, but they had side efoffer, it creates a dismal and defeatist picfects that made them not pan out. Since ture.” then, around eight years ago, there’s been Today, however, research has led to more a renewed interest in amyloid vaccines. A discerning diagnoses and new solutions. few years ago, one vaccine did slow down “We constantly evaluate available and upthe decline, but it seemed to work better if coming diagnostics and therapies. With it was given earlier rather than later. Now over 250,000 visits per year, our own clinithey are trying to move the targets earlier cal data is extremely powerful. We are also and earlier, before people have symptoms.” Michelle Rainka, Pharm.D., CCRP involved in prospective studies of novel inAlzheimer’s can begin to develop in the tegrative medicine approaches, funded by brain long before symptoms emerge, she the Dent Family Foundation.” said. “The changes in the brain actually start ten to twenty Dent recognizes the important role of community in solving years before the person has a memory loss. So we need to start complex health issues. Its leaders are on the board of directors earlier, we can’t wait until it’s full blown and then try to attack of the Population Health Collaborative, which bridges many it. So while we are looking for patients who have Alzheimer’s Western New York resources looking to dramatically improve disease, we are also looking for people who are very early on in our community status as among the nation’s least healthy. the disease process. Some are looking for volunteers who don’t “Nutrition, exercise and smoking habits lead to ninety percent even have it yet, so we can slow down the process. The earlier of our local mortality,” Fritz said. “Brain health is absolutely we can identify them, the better.” tied to these same risk factors, and the fix involves cooperative behavioral and social intervention. By targeting our current weaknesses, we can turn fear, loneliness and despair into comDiscoveries about other diseases can help munal motivation and hope. We can reframe lifestyles, maxiThere are some amazing new pharmaceutical technologies in mize health, and present opportunities that are missed if you the pipeline, Dr. Fritz noted. “We have already seen disease get stuck in that helplessly dark tunnel.” modifying therapies make a significant impact in other chronic neurologic disorders, and how Dent can offer a leadership role Randi Minetor is an author and freelance writer based in upstate in quickly transitioning these solutions to the real world of outNew York.


practice management

The Real Cost of “Couponing” Short-term Benefit, Long-term Cost Thomas Hughes, MD Chief Medical Officer at Optimum Physician Alliance

“Couponing” or the practice of distributing pharmacy

and sitting at the office front desk. The medical commu-

discount cards to patients in order to significantly reduce

nity has always chafed against the notion that it is their

or eliminate insurance co-pays for medication is a prac-

responsibility to manage cost for the insurance industry.

tice that was designed by the pharmaceutical industry in

Instead, it has always been the role of the physician to

the 1990s as the first generation of high cost medicines

serve as an advocate for their patients and any device

like Tagamet came off patent. It really began to take off

such as the coupon which allows the patient to afford

over the last several years as manufactures sought pro-

medications which were otherwise unaffordable is seen

tect profits when payers began to deploy tools like the

as a good thing. Unfortunately, the realities of medicine

high deductible pharmacy benefit that caused patients to

in 2018 means that physicians can no longer stand on

move away from name brand medications.

the sidelines.

As insurance companies became more aggressive in

As more data has become available, it is now apparent,

working to control the cost of care, patients had an in-

if not surprising, that the practice of using coupons to

centive to go towards less expensive generic medica-

underwrite high cost medications is neither as simple or

tions. The pharmaceutical industry embraced couponing

benign as it may at first have appeared. There is now sol-

as part of strategy to out flank the cost control systems

id data to show that patients with access to coupons are

and gain an ally in the patient at the same time.

less likely to switch over to identical generic medications

A decade ago fewer than 100 medications had associ-

and remain on high cost medications for longer. The use

ated coupons, but by 2017 that number had grown to

of brand-name medications was found to be 60% higher

exceed 700. Today over 20% of all brand name prescrip-

in markets where patients had access to coupons com-

tions are filled using a coupon. This number is expected

pared with those where they didn’t and more than 60%

to rise to greater than 50% in the next several years. This

of all coupons were for medications with a lower cost

shift is supported by an investment from the pharmaceu-

generic equivalent.

tical industry that is estimated to be between three and

The textbook example of this is name brand Lipitor. It

six billion dollars a year. Industry experts estimate that

is a medication owned by Pfizer that came off of patent

they will see a return of between four and six dollars on

in 2011 and is widely available at low price under its

every dollar they invest in coupons, so it is likely they will

generic name – atorvastatin. Despite this low cost op-

not back away from this strategy any time soon.

tion, Lipitor continued to generate $1.9 billion in revenue

Historically, the practice of providing coupons to pa-

in 2017. This is a particularly curious because Pfizer no

tients is one which has been tacitly accepted if not

longer produces the medication itself. It contracts out

openly embraced by the physician community. It is not

production to a generic manufacturer who produces un-

uncommon to see coupons available in waiting rooms

der the Lipitor label. Continued sales are driven not by


superior efficacy, but rather by marketing and coupon

and money spent foolishly in one arena will not be avail-

cards which make it an attractive option for consumers.

able where it is needed. As unnecessary high cost medications take money out of the system, that expense will

Couponing discount cards lower the patient’s out of pocket expense, but the costs are then absorbed by the system as a whole. It is estimated that medications associated with couponing are responsible for a five percent increase in the cost of insurance and are used as a

be absorbed by raising premiums or reducing services. Neither of these benefits the patient in the long run. Physicians must take the time to understand the impact coupons have on their patients and across the system. As a profession, we need to acknowledge that the short term benefit of reduced co-pays has an insidious effect on the system and a real downstream cost. We must work to guide our patients towards options which are better for them in both the short and long term.

cover by the pharmaceutical industry to

Dr. Thomas Hughes serves as the Chief Medical Of-

maintain high prices for their products.

ficer of the Optimum Physician Alliance/Great Lakes

It is not the responsibility of the physician to manage costs for the insurance industry, but it is the physician’s responsibility to be appropriate stewards of resources. There are a finite number of available health care dollars

Integrated Network and is also s a practicing physician with an office in Elma. Dr. Hughes received his medical degree from SUNY-Buffalo School of Medicine, remained in Buffalo to complete his residency and is board certified in family medicine and bariatrics.

VALU E O F ADVE RTI S I N G Are Referrals Important to your Practice? Western NY Physician Magazine is the only regionally-focused publication reaching more than 3,500 physicians in the Buffalo region. Call or email to learn more about positioning your practice, service line or business in Western NY Physician Magazine. (585) 721-5238 10 I VOLUME 6 I 2018 WNYPHYSICIAN.COM


Opioid Prescriptions Can Be Drastically Reduced After Surgery with No Increase in Pain, Study Shows Striking Roswell Park research leads to center-wide policy change to combat opioid crisis


ain after surgery can be effectively managed with minimal or no opioids, according to research conducted at Roswell Park Comprehensive Cancer Center and published today in JAMA Network Open. A two-year study by a multidisciplinary team of surgeons and other cancer specialists shows that the amount of opioid medications prescribed after surgery can be drastically reduced without negatively affecting pain scores, postoperative complications or patient requests for additional opioids, demonstrating that alternative approaches to pain management can be both safe and highly effective. The publication presents the findings of a two-year pilot study at Roswell Park in which patients undergoing gynecologic or

abdominal surgery were prescribed fewer opioids at discharge. The impact of the pilot was striking. During its first year alone, the restrictive protocol eliminated the circulation of 16,374 opioid tablets (5 mg oxycodone equivalent), significantly reducing the volume of opioids that could be misused or diverted. The results of the full two-year study in 1,231 patients demonstrate that because postoperative pain can be managed effectively without opioids for minor or minimally invasive surgical procedures or with only a three-day supply for major surgery, the risks of chronic opioid misuse can be managed by reducing or eliminating opioid prescriptions in the first place. Based on the success of the opioid-sparing approach to postsurgical pain management, the new restrictive protocol will go into effect throughout all Roswell Park surgical services beginning January 1, 2019. Roswell Park is believed to be the first cancer center in the U.S. to implement such a radical opioidsparing policy so broadly. This change in practice is expected to reduce health care costs while protecting patients and the greater community from the risks associated with opioid use.


Emese Zsiros, MD, PhD, FACOG, Assistant Professor of Oncology with Roswell Park’s Department of Gynecologic Oncology and Center for Immunotherapy

Opioids are a group of drugs that include prescription pain relievers such as hydrocodone (Vicodin, Norco) and oxycodone (OxyContin, Percocet), as well as morphine and heroin. Millions of Americans are routinely prescribed opioids for acute pain following surgery despite the serious risks associated with opioid use, such as addiction, overdose and death. Opioid misuse has become a major health and economic issue in the U.S., claiming more than 100 lives per day. Nearly 5 million people misuse prescription pain relievers each year, and 80% of heroin users report that their addiction started with a prescription opioid painkiller. In 2016, to combat the opioid crisis, New York State began limiting opioid prescriptions to a seven-day supply for acute


pain. However, pain associated with cancer treatment is exempt from this rule, leaving the decision to the treating physicians, who currently have no clear guidelines on the amount of opioid pain medications needed after cancer-related surgery. “Nearly all of my patients would call to ask what to do with their leftover pain pills,” says Emese Zsiros, MD, PhD, FACOG, Assistant Professor of Oncology with Roswell Park’s Department of Gynecologic Oncology and Center for Immunotherapy and senior author of the new study. “I didn’t have a clear answer for them, as these medications are difficult to dispose of, and you don’t want them sitting in an unlocked medicine cabinet, where family members or friends can easily access them.” Based on patient feedback and her own clinical experience, Dr. Zsiros hypothesized that she was most likely overprescribing opioid pain medication to her patients, particularly those undergoing minor laparoscopic and robotic surgeries, thereby increasing the risk of opioid use, abuse and diversion not only among her patients but also the community at large. “I knew that postoperative acute pain can be effectively managed without opioids from what I observed during my training in Europe,” Dr. Zsiros adds.

Implementing a New Approach She convinced her team to drastically reduce or eliminate opioid prescriptions for patients following gynecologic surgery from a seven-day supply to a three-day supply or none, based on the type of surgery. Beginning in June 2017, patients undergoing ambulatory or minimally invasive surgery for gynecologic conditions were not prescribed opioids at the time of hospital discharge unless they required more than five doses of opioids while in the hospital. Patients undergoing major surgery (laparotomy) were given only a three-day supply of prescription opioids (12 pills) at discharge, unless they needed more opioids during the last 24 hours of their hospital stay, in which case they were given 24 pills. All patients were prescribed a pain regimen of 600 mg ibuprofen (Advil or Motrin) and 500 mg acetaminophen (Tylenol) every 6 hours as needed for seven days. Before undergoing surgery, all patients were educated about the revised protocol, including what to expect in terms of pain or possible complications, the adverse effects of opioid pain medications, and alternative methods of pain control. Patients were also encouraged to contact their clinical team with any questions or concerns, particularly if their pain was not adequately managed, and staff were educated about how to introduce this new protocol to their patients.


The new ultrarestrictive opioid prescription protocol (UROPP) was a major change in clinical practice for these patients. Before the restrictive protocol was implemented, the average patient received 44 opioid pills after major open surgery, 38 pills after minimally invasive (robotic or laparoscopic) surgery and 14 pills after minor surgery, an approach that is typical of most U.S. cancer centers. The new protocol radically decreased this amount to an average of 12 tablets after major surgery, one tablet after minimally invasive surgery, and essentially none after minor or ambulatory surgery.

Study Results During the first two weeks of the new protocol, not a single patient complained of pain or requested an opioid prescription refill. The number of patients who eventually requested opioid refills within 30 days of surgery during the first year of the new protocol — 16% — was no different from the year prior to the opioid restrictions, when 16.5% of patients requested refills. “We were quite surprised by how few requests for medication we got from our patients,” says Jaron Mark, MD, Clinical Fellow at Roswell Park and the first author of the study. “We expected we would be able to reduce the use of opioids without detrimental consequences, but the extent to which our hypothesis was supported by these results was really striking.” He added that proper patient education before surgery helped manage each patient’s expectations about what to expect after surgery in terms of pain and recovery, which helped to ensure good patient compliance with the protocol after discharge. The new protocol appeared to be highly effective, and after a full year, Dr. Zsiros and her team did a prospective analysis to compare pain management and surgical recovery in the 605 patients treated from June 2017 through June 2018 on the restrictive opioid prescription protocol to a control group of 626 patients treated during the previous year, before the new protocol was implemented. Particular attention was paid to opioid use, pain scores, and complications in the 30 days before and after surgery, and ISTOP, New York State’s opioid prescription tracking system, was used to confirm that patients did not receive opioid prescriptions elsewhere (such as a primary care physician or emergency room) during this 60-day period.

The researchers found that the two groups of patients were similar in terms of age, race, diagnosis and type of surgery performed. Both groups had similarly low rates of complications during and after surgery. Although these two groups received vastly different amounts of opioids after surgery, pain scores at time of discharge and two weeks after surgery were also low and nearly identical in both groups, as were the number of patients requesting opioid prescription refills, despite the drastic difference in the amount of opioids prescribed between groups. Regardless of the amount of opioids prescribed, 84% of patients in both groups did not request additional pain medication, showing that patients can recover just as well after surgery with few or no opioids. This finding also suggests that these refill requests may not be pain related and that some patients use opioid medication as a way of coping with the stress, anxiety and emotional discomfort that accompany surgery or a health crisis, such as cancer. “Physicians are often concerned that reducing or eliminating opioid prescriptions will be very challenging, especially for

patients who are accustomed to managing pain with opioids,” adds Dr. Zsiros. “However, our study clearly shows that patients can recover from major surgery just as well with over-thecounter pain medications such as ibuprofen or acetaminophen and minimal or no opioids, with no increase in pain or postoperative complications — and without the side effects of opioids, such as nausea, constipation, sluggishness and dizziness, as well as the risk of long-term opioid use, abuse and diversion. About one in every 20 patients prescribed opioid medication for acute pain will become chronic users, so in my opinion, opioid addiction can be viewed as a significant postoperative complication that clinical teams must work to prevent.” The study, “Ultrarestrictive Opioid Protocol for Pain Management After Gynecologic and Abdominal Surgery,” was supported by grants from the National Cancer Institute (project nos. P30CA016056 and T32CA108456) and by donations to Roswell Park. The published article is available at

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As a physician, you apply your knowledge and skills to achieve the best possible outcomes for your patients. When it’s time to transition your practice, Bonadio Succession Advisors can help you achieve the best possible outcome for your personal circumstances. We integrate financial planners, business appraisers, experienced M&A advisors, and tax experts to help create a clear path forward to help ensure a positive outcome for one of the most significant financial transactions of your life.

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practice management

It Pays To See The Revenue Cycle Through Your Patients’ Eyes By April Wilson If you’ve never seen a “perspective sculpture” in person, you’ve probably run across a few online. One of the most famous is dedicated to Nelson Mandela. From one angle, the sculpture looks like a random gathering of misshapen steel columns. But if you move just slightly, an image emerges of one of the most famous figures in modern history. The sculpture was created to commemorate the 50th anniversary of Mandela’s arrest by the apartheid police. Perspective is also key in the healthcare revenue cycle. From one angle, you’ll see a mass of disjointed payments, frustrated patients, and mounting bad debt. With a small shift toward a perspective that centers on patients, an entirely different picture emerges – one that shows simplified payments and a new level of financial engagement.

Here are four tips to smoothing the payment process: Start predicting You might feel like you have deep insight into your patients’ payment behaviors right now, but you have more to work with than you think. Each of your patients has a payment history that is rich in information, including how likely they are to pay, how they prefer making payments, and how consistently they settle their bills. Predictive models can help you evaluate their propensity to pay, assign a score, and establish a starting point for any communications and discussions. Scoring allows you to create order out of the complexity of your patients’ preferences, behaviors and predicted outcomes. Ideally, you will want to turn all that into analytics-based, targeted payment pathways and an intelligent communication plan that promotes patient payment awareness and increases cash flows.

Tailor communications It might seem like the entire world relies on their smartphones in every aspect of their lives, but if you take a few steps to shift your perspective on your patients, you’ll find something interesting. Some of your patients are highly responsive to receiving paper bills, others are moved by electronic statements via email, while a few might be more likely to act on text message reminders. These traits can vary by age, location, and even educational level. 14 I VOLUME 6 I 2018 WNYPHYSICIAN.COM

Notice that we aren’t talking about what methods of communication they prefer. Truly aligning with your patients’ perspectives means paying attention to their behavior. Predictive analytics algorithms can be especially useful in optimizing medium, message, and overall communication strategies for each patient.

Throw time out the window Your patients live in a world where, if they wanted to book a flight to see that sculpture of Nelson Mandela at 2 a.m., there would be little stopping them from rolling over in bed and doing just that. If they wanted to pay their latest statement for the knee replacement they had last year at your facility, would they have the same flexibility? Hospitals have seen hundreds of thousands of dollars in returns just by expanding payment options to include mobile and online payment portal methods, and that’s on top of a boost to patient satisfaction. This is because convenience matters. Shift your viewpoint on patient payment to focus on convenience and you’ll be looking at a new world of revenue cycle results.

Leverage technology We’ve mentioned technology already, and mostly on the patient-facing side. But there are also back-end solutions that help keep payment experiences centered on the patient. One of the most effective tools is a merchant-service agreement. Merchant services are more of a collection of technologies than a stand-alone solution. A comprehensive merchant-services strategy includes card readers, patient portals, check processing, and cloud-based reconciliation. When these elements play together, hospitals see higher cost transparency, streamlined reconciliation, and a payment experience patients prefer. The age of healthcare consumerization has arrived, and heightened patient expectations have come along with it. If you haven’t started shifting your perspective on patient payments yet, now is a great time to start. April Wilson is Vice President of Marketing and Analytics for RevSpring (www., a company that provides patient engagement and billing solutions for healthcare providers. Since 1981, RevSpring has built the industry’s most comprehensive suite of consumer engagement, communications, and payment pathways that is backed by consumer behavior analysis, propensity-to-pay scoring, intelligent design, and user experience best practices.

medical research

Study Points to New Method to Deliver Drugs to the Brain Researchers at the University of Rochester Medical Center (URMC) have discovered a potentially new approach to deliver therapeutics more effectively to the brain. The research could have implications for the treatment of a wide range of diseases, including Alzheimer’s, Parkinson’s, ALS, and brain cancer. “Improving the delivery of drugs to the central nervous system is a considerable clinical challenge,” said Maiken Nedergaard MD, DMSc, co-director of the URMC Center for Translational Neuromedicine and lead author of the article which recently appeared in the journal JCI Insight. “The findings of this study demonstrate that the brain’s waste removal system could be harnessed to transport drugs quickly and efficiently into the brain.” Many promising therapies for diseases of the central nervous system have failed in clinical trials because of the difficulty in getting enough of the drugs into the brain to be effective. This is because the brain maintains its own closed environment that is protected by a complex system of molecular gateways – called the blood-brain barrier – that tightly control what can enter and exit the brain. A prominent example of this challenge is efforts to use antibodies to treat the buildup of amyloid beta plaques that accumulate in the brains of people with Alzheimer’s. Because antibodies are typically administered intravenously, the entry of these large proteins into the brain is thwarted by the bloodbrain barrier and, as a result, it is estimated that only two percent actually enter the organ. The new research taps into the power of the glymphatic system, the brain’s unique process of removing waste that was first discovered by Nedergaard in 2012. The system consists of a plumbing system that piggybacks on the brain’s blood vessels and pumps cerebral spinal fluid (CSF) through the brain’s tissue, flushing away waste. Nedergaard’s lab has also shown that the glymphatic system works primarily while we sleep, could be a key player in diseases like Alzheimer’s, and is disrupted after traumatic brain injury. In the study, the researchers took advantage of the mechanics of the glymphatic system to deliver drugs deep into the brain. In the experiments, which were conducted on mice, the researchers administered antibodies directly into CSF. They then injected the animals with hypertonic saline, a treatment frequently used to reduce intracranial pressure on patients with traumatic brain injury. The saline triggers an ion imbalance which pulls CSF out of the brain. When this occurs, new CSF delivered by the glym-

phatic system flows in to take its place, carrying the antibodies with it into brain tissue. The researchers developed a new imaging system by customizing a macroscope to non-invasively observe the proliferation of the antibodies into the brains of the animals. The researchers believe that this method could be used to not only deliver into the brain large proteins such as antibodies, but also small molecule drugs and viruses used for gene therapies. Additional co-authors on the study include Benjamin Plog, Humberto Mestre, Genaro Olveda, Amanda Sweeney, H. Mark Kenney, Alexander Cove, Kosha Dholakia, Jeffrey Tithof, Thomas Nevins, Iben Lundgaard, Ting Du, and Douglas Kelley with the University of Rochester. The research was supported with funding from the National Institute of Neurological Disorders and Stroke and the Department of Defense.

Study: Attention Requires Balance in the Brain

The ability to focus attention is a fundamental challenge that the brain must solve and one that is essential to navigating our daily lives. In developmental disorders such as Autism this ability is impaired. New research published in the journal Nature Communications shows that nerve cells maintain a state of balance when preparing to interpret what we see and this may explain why the healthy brain can block out distractions. The new research, which was co-authored by Adam Snyder, Ph.D., an assistant professor in the University of Rochester Department of Brain and Cognitive Sciences and UR Medicine Del Monte Institute for Neuroscience, marks a departure from the established view of how the brain tackles the task of identifying what is important.


ticipating stimulus, the brain maintains a pattern consisting of stimulated and unstimulated neurons and that these patterns differ from when the brain is actually processing information.” While it is known that the process of paying attention amplifies neural signals in the brain in order to prepare for relevant information, how the brain achieves this state of readiness remains unknown. One theory that has gained acceptance among the neuroscience community is that the nerve cells in the brain anticipate stimuli and maintain a heightened state of readiness. “The prevailing view is that something happens to activate neurons so they will amplify the response to stimuli, like turning up the stereo so when the music starts it is already louder,” said Snyder. “Our suspicion is that the brain doesn’t work this way because the problem when you crank up the volume is you also get static noise.” Disorders like Autism are characterized by the inability to parse through stimuli and identify what is important. This is often manifested in oversensitivity to certain visual or auditory environments where the brain has difficulty in separating the relevant information from ‘static.’ Over time, this inability to focus and block out distractions can give rise to atypical social behavior. In the new research, Snyder and his colleagues monitored a large number of neurons simultaneously in the visual cortex – the part of the brain responsible for processing visual stimuli – in animals. They recorded neural activity as the animals performed tasks that required a response to visual cues. The researchers found that when anticipating stimuli, the neurons in the visual cortex essentially maintained a state of balance. For every neuron that was stimulated and at the threshold of firing, there were others that were in a resting state. “This tension between alert and relaxing neurons is akin to when our muscles tense in anticipation,” said Snyder. “While some muscle fibers are contracting, others are extending, allowing us to quickly and strongly react and move.” While the research focused on the visual cortex, the mechanisms appear to be consistent across the brain and could explain difficulties associated with the processing of other forms of stimuli, like sound and touch. Understanding how the brain prepares to receive stimuli – and how dysfunction in this system leads to impairment – could open the door to new electrical stimulation therapies that could help teach the brain how to process information more effectively.


For Chronic Leukemia Patients, the News Just Got Even Better Several chronic lymphocytic leukemia (CLL) patients at the Wilmot Cancer Institute took part in two groundbreaking, nationwide phase 3 studies that are changing the way doctors treat the disease. The positive results are being reported this weekend at the 2018 American Society of Hematology (ASH) annual meeting — and will immediately impact CLL patients in the Rochester region and across the U.S., said Paul Barr, MD, director of Wilmot’s Clinical Trials Office. “We plan to share these results with the many patients who participated in these studies,” Barr said. “Not only were they able to receive the safest, most effective cutting-edge therapy, but they helped to define future treatment options for patients coming after them.” Already the median overall survival for patients with CLL has tripled during the last 30 years, thanks to better understanding of the disease biology and new drug development, and the latest clinical trials will result in further improvements, Barr said. The new studies compared the current standard treatments for front-line chemotherapy with regimens using a combination of ibrutinib, a drug that targets BTK, a critical protein in CLL, and rituximab, a type of immunotherapy. Ibrutinib is taken as a pill and is often less toxic than chemotherapy. One study was designed for patients younger than 70 years old, while the other was designed for older patients. The clinical research represents the first time ibrutinib/rituximab has been directly compared to the most aggressive and promising therapies available today. Both studies showed that ibrutinib provided a longer time of remission compared to chemotherapy. The same drug has been extensively tested in certain patients with relapsed CLL, and was also shown to be safe and effective.

Research Review Underscores Progress in Treating Kidney Cancer Importance of Close Patient Monitoring Checkpoint inhibitors have led to ‘remarkable progress’ as well as need for greater integration of care, authors note With the swift introduction of approved immunotherapy approaches into the treatment landscape for many cancers, medical professionals across many care-delivery settings and specialties are tasked with the need to follow and understand a set of treatment standards that are changing rapidly. The treatment

medical research

of renal cell carcinoma (RCC), or kidney cancer, has been one of the fields most dramatically affected by what the authors of a new research review article call a period of “remarkable progress,” with FDA approval of the first immunotherapy combination regimen for the treatment of patients newly diagnosed with kidney cancer coming just a few months ago, in April 2018. In an effort to compile and summarize the latest knowledge about these immunotherapy combinations and their implications, a group of kidney cancer immunotherapy experts led by Saby George, MD, of Roswell Park Comprehensive Cancer Center have written a new research review article assessing current approaches to treating patients newly diagnosed with kidney cancer and also looking ahead to some of the most pressing questions still to be answered related to these emerging therapies. Published online Nov. 21 by the journal JAMA Oncology, the review article highlights the path to approval for the new standard of care for these patients — ipilimumab, also known as Yervoy, together with nivolumab, also known as Opdivo. “Remarkable progress has been made recently in the clinical application of newer immunotherapies, of which the most notable are immune checkpoint inhibitors (ICIs) that increase antitumor immunity by blocking native immune regulators such as cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1),” the authors write. “However, current evidence indicates that not all patients may find singleagent immunotherapy advantageous, underscoring the unmet need for combination treatment strategies that can improve efficacy in a broader patient population without exacerbating toxic effects.” “Our goal in crafting this review was not only to summarize the path to approval for these breakthrough immunotherapies, but also to present that information in context with other emerging immuno-oncology therapy combinations that are still being studied,” notes Dr. George, first author on the new publication. “Critically, given what we are learning about the effects of checkpoint inhibitors given in combination, we also highlight the importance of identifying and appropriately managing immune-related toxicities.” Treating physicians who prescribe checkpoint inhibitors for patients with advanced kidney cancer — whether alone or in combination with other therapies — “must adopt a multidisciplinary management approach, enlisting the assistance of specialists such as endocrinologists, pulmonologists, nephrologists, gastroenterologists, dermatologists, and neurologists,” the authors conclude.

Neurons in the Brain Work as a Team to Guide Movement of Arms, Hands

The apparent simplicity of picking up a cup of coffee or turning a doorknob belies the complex sequence of calculations and processes that the brain must undergo to identify the location of an item in space, move the arm and hand toward it, and shape the fingers to hold or manipulate the object. New research, published today in the journal Cell Reports, reveals how the nerve cells responsible for motor control modify their activity as we reach and grasp for objects. These findings upend the established understanding of how the brain undertakes this complex task and could have implications for the development of neuro-prosthetics. “This study shows that activity patterns in populations of neurons shift progressively during the course of a single movement,” said Marc Schieber, MD, PhD, a professor in the University of Rochester Medical Center (URMC) Department of Neurology and the Del Monte Institute for Neuroscience and a coauthor of the study. “Interpreting these shifts in activity that allow groups of neurons to work together to perform distinctive and precise movements is the first step in understanding how to harness this information for potential new therapies.” The established model of how the brain performs these movements dates back to the 1980’s and contends that separate populations of neurons in the brain are dedicated to reaching versus grasping. The analogy is akin to the organization of a football team, with one set of players dedicated to defense and another to offence. The new study shows that these cells act more like a basketball team, with the same group of players switching from defensive to offensive responsibilities depending upon the circumstances at any given moment. “Reaching and grasping traditionally have been thought to be driven concurrently by two separate channels in the brain with


one controlling the reaching arm and another controlling the grasping hand,” said Adam Rouse, MD, PhD, a research assistant professor in the Del Monte Institute for Neuroscience and co-author. “We have found, however, that individual neurons in the motor cortex transition from encoding the reach location early in a movement to encoding the object to be grasped later on.” The new findings were possible because of advanced microelectrode arrays that allowed the researchers to simultaneously monitor and record hundreds of neurons in the motor cortex – the part of the brain responsible for controlling movement – of animals as they reached for and manipulated objects. Using new analysis designed for the large dataset, the researchers observed that the neurons altered their firing patterns as the animals transitioned from projecting the arm and hand toward an object’s location to then shaping the hand and arm as needed to grasp the object. Both patterns of activity would spread rapidly through the motor cortex, a phenomenon akin to the ripples formed when dropping pebbles in a pond. The findings imply that, instead of specializing in specific motor control tasks, the individual motor neurons work collectively to carry out multiple functions. The research has significant implications for the creation of brain-computer interfaces which tap into the electrical activity of the brain and use this information to control prosthetic devices, like a mechanical arm. While previous efforts have sought to tap into the electrical activity of individual or groups of neurons, the new findings show that these systems will likely need to employ more advanced machine learning algorithms to interpret the shifting patterns of activity. “These finding could revolutionize how we extract information from the brain,” said Rouse. “Instead of individual neurons, we now have a foundation that will enable us to build systems that decode brain activity to recognize patterns and this information could be employed to develop a new generation of assistive devices.” The study was funded with support from the National Institute of Neurological Disorders and Stroke.

Update on Blood Pressure Medication Recall: Amlodipine and Hydrochlorothiazide are Safe Over the past several months, several lots of blood pressure medications have been recalled by the FDA due to concerns that the products may contain a small amount of a chemical called


NDEA, which is found in some smoked and cured meats but has also been shown to potentially be linked to causing cancer in higher exposure. All of the medications recalled were blood pressure medications known as angiotensin receptor blockers, which are also called “ARBs”. Pills used to control blood pressure can contain a single drug, such as valsartan (Diovan®), or multiple drugs, also known as “combination products”, such as valsartan/amlodipine (Exforge®) or valsartan/amlodipine/hydrochlorothiazide (Exforge-HCT®). There has been some recent confusion about what drugs have been recalled and what patients should do if they are taking medications they think may have been recalled. First and foremost, our recommendation is to CONTINUE taking the medication, and verify with your pharmacy that the medication you are taking is part of the recall. Secondly, if you are taking one of the recalled medications, CONTINUE taking the drug until you have spoken to your physician to receive an alternate treatment, as the risk of sudden discontinuation of the drug is greater than the small risk of exposure to the NDMA potentially contained in the affected drugs. Only prescriptions containing valsartan are affected by this recall. Fortunately, this recall affects a very small amount of medications currently dispensed to patients. More information is available on the FDA’s website:

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Improving Outcomes: Patient Care in Today’s Value-Based Health Care Richard Charles, MD, Chief Medical Officer for General Physician, PC

Primary care physicians in WNY have experienced the transition from volume to value-based care over the last several years. Insurance programs like BestPractice from BlueCross BlueShield and Primary Value from Independent Health precipitated the transition from managing patient visits to managing patient populations. High complexity coding, patient satisfaction surveys, IPA incentive programs, Pharmacy incentive programs, and the alphabet soup of additional reimbursement programs such as CPC+, PCMH and MIPS have forced medical practices to transform into efficient medical homes. Success demands we not only meet the day-to-day needs of our patients, but also quality efficiency and valuebased care. These initiatives all require substantial investment in our practices to optimize outcomes. Such an environment compels providers to engage others within their practice to ensure these programs and requirements are met.

onciling transition of care medication, and transitioning patients from high cost low-value brand drugs or generic drugs to lower cost agents of equal efficacy. We have used our EMR to identify patients who would benefit from Clinical Pharmacy management. Discharges, high cost drugs, or poorly controlled diabetes trigger a provider consultation for intervention with our Pharmacy team. Such interventions have been highly successful improving diabetic control across our patient population. We are aggressively identifying transition of care medication reconciliation to reduce rehospitalization and drug errors improving post-discharge patient care. These programs led by a Clinical Pharmacy team can benefit the overall community. Our Quality team focuses on HEDIS and STAR outcomes utilizing nursing and ancillary staff to fill deficiencies in our patient panels. Quality outreach has direct communication with patients to promote compliance with Preventive Health screenings and diabetes management measures, working with community radiology and lab service vendors to optimize quality and IPA-based outcomes. We have developed internal reporting with established benchmarks and timelines for specific STAR and HEDIS measures looking at overall Quality performance. The team actively meets with providers and staff to review quality data and assist with practice-based process improvements. This collaboration effectively and efficiently realizes performance goals and enhances patient care delivery.

In this model, primary care physicians work at the highest-level delegating tasks to other providers and teams, promoting more efficient, higher quality care, and improved patient satisfaction.

This environment has ushered in process improvements and changes in daily workloads within our practice environment. Utilization of Pharmacy teams, care coordinators, and Quality practice managers have become crucial to success. In this model, primary care physicians work at the highestlevel delegating tasks to other providers and teams, promoting more efficient, higher quality care, and improved patient satisfaction. General Physician, PC (GPPC) has positioned itself by developing numerous backend programs and processes surrounding Pharmacy, PCMH, HEDIS gaps/STAR measures, and CPC+ allowing providers to meet the changing requirements of today’s health care.

GPPC added a Clinical Pharmacy team focused on improving diabetic control with hemoglobin A1C levels above 9, rec-

A dedicated PCMH team develops protocols, process improvements, and documentation to support the medical home and individualized patient care treatment plans. Frequent meetings with providers and staff ensure compliance with the many re-


quirements to maintain PCMH. Quality Standards are driving true transformation at the practice and organizational level. New guidelines in the 2017 PCMH Annual Renewal process necessitate we maintain standards and documentation and are prepared for NCQA audits.

and strategies to identify those patients at highest risk who would benefit from more aggressive involvement of providers and a care management team. Utilizing our technology resources and nursing teams to implement CPC+, we can improve patient outcomes.

Our Revenue Cycle team plays a critical role with Quality in focusing on coding to identify the most commonly missed high complexity codes and coding for diabetes, heart failure, vascular disease etc. As our monthly revenue per member depends on accuracy, we have increased utilization of tools like VATICA to identify appropriate high complexity codes and understand those commonly missed by providers. Proactively evaluating providers’ use of high complexity codes can maximize reimbursement increasing revenue for other programs.

As primary care has transformed so has our organization, integrating practices with different processes and procedures. Communication and provider interaction have been crucial to our success. Engaging support of our ancillary services, providers, and teams improves efficiency, patient care and outcomes. EMR data analytics and thoughtful positioning of team resources has also maximized our improvements while minimizing impact on day-to-day clinical practice. As pressures on primary care continue to mount, our programs need to be nimble to meet these challenges. We must continuously evaluate processes. Our approach is working and could be adapted successfully by similar organizations. General Physician, PC strives to be a leader in maximizing resources in a value-based environment to provide patient-centered care that meets the needs of our patients and the requirements of care in 2019 and beyond.

CPC+ is another GPPC primary care program that involves the integration of Nurse Care Managers into comprehensive patient-focused care to support the management of high-risk patients with chronic diseases. We have established protocols

Helping You Live Your Best Life Ranked 3rd Largest Medical Group in 2018 by Buffalo Business First

Providing comprehensive health care for you and your family. Convenient locations all across Western New York PRIMARY CARE Richard Charles, MD Buffalo 716.248.1420 Maritza Baez, MD Buffalo 716.248.1420 Thomas Cumbo, MD Ashley Kremer, DO Kierann Toth, MD Williamsville 716.631.8400 Thomas Dilamarter, MD Jennifer Yerke-McNamera, MD Orchard Park 716.260.1593

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Leia Ince-Mercer, MD Nicholas Masyga, DO Hamburg 716.646.2590

Thomas Madejski, MD Medina 585.798.3345 Albion 585.589.1322

Eugene Kalmuk, MD West Seneca 716.608.6116

Esfandiar Mafi, MD Williamsville 716.932.7776

Kathleen King, MD Marcy Masyga, DO Springville 716.592.3600

Ripple Marfatia, MD Castile 585.493.9230 Attica 585.591.2186

Christian Lates, MD Ritu Sood, MD Elma 716.626.5840

Allyn Norman, DO Adam Norman, MD Williamsville 716.204.4532

Tat Sum Lee, MD Richard Milazzo, MD Dunkirk 716.363.6960

James Panzarella, DO Tonawanda 716.833.2200

Anthony Perna, MD Buffalo 716.874.4060 Jennifer Ruh, MD Orchard Park 716.508.4040 Nisha Sharma, MD Lauren Steinmetz, MD Hamburg 716.646.5500 PEDIATRICS Rohini Thodge, MD Dunkirk 716.363.6960

12/7/18 12:36 PM


E-Cigarette Users Have Lower Exposure to Toxicants — As Long as They Don’t Smoke Combustible Cigarettes Too Dual cigarette/e-cigarette users may be exposed to even higher levels of carcinogens than cigarette-only smokers The largest study to date to compare exposure to toxicants among users of electronic cigarettes, smokers and nonsmokers has been completed, suggesting possible benefits for smokers who switch completely to electronic cigarettes. The research team, led by Maciej Goniewicz, PhD, PharmD, and Andrew Hyland, PhD, of Roswell Park Comprehensive Cancer Center in collaboration with scientists from Westat, the National Institute on Drug Abuse (NIDA), the U.S. Food and Drug Administration (FDA) and other academic centers, saw clear evidence that e-cigarette users, while exposed to more toxicants than people who do not use any form of tobacco, evidence significantly lower levels of toxicants than those who smoke cigarettes. The findings, which were based on the largest prospective U.S. study of tobacco use, were published by the journal JAMA Network Open. Using data from 5,000 of the U.S. adults participating in the federally funded Population Assessment of Tobacco and Health (PATH) Study, between 2013 and 2014, the research team analyzed their use of tobacco, testing urine samples from these participants for key biomarkers of exposure to harmful chemicals. The authors report two new findings that expand our understanding of the widespread impact of both tobacco and e-cigarettes among U.S. adults: Exclusive users of e-cigarettes who do not smoke combustible cigarettes were exposed to toxicants associated with tobacco use, but at significantly lower levels than smokers. Dual users, or people who both smoke cigarettes and use ecigarettes, had toxicant exposures that were similar to or even higher than exposures for those who used cigarettes alone. Dr. Maciej Goniewicz, lead author of new research suggesting a benefit for smokers who completely switch to electronic cigarettes. “Our goal was to give the public reliable information about the actual impacts that smoking and vaping have on individual users,” says Dr. Goniewicz, the study’s first author, who is Associate Professor of Oncology in the Department of Health Behavior at Roswell Park. “The findings are striking, because we now have solid evidence that e-cigarettes — while they still expose users to some toxicants — appear to significantly reduce this exposure compared to combustible cigarettes. But

that reduction in exposure did not extend to dual users. This is important information for any e-cigarette users who continue to smoke tobacco cigarettes. Our data suggest that potential harm reduction can only be achieved if smokers switch completely to e-cigarettes and discontinue use of deadly combustible tobacco products.” The scientists tested study participants for levels of 50 biomarkers of exposure to nicotine and other known tobacco product toxicants, breaking them down into four groups: current, exclusive users of e-cigarettes; exclusive users of combustible tobacco cigarettes; dual users of combustible and electronic cigarettes; and never-users of any tobacco products, including e-cigarettes. They found that e-cigarette-only users had statistically significantly greater concentrations of biomarkers of nicotine, tobacco-specific nitrosamines (TSNAs), volatile organic compounds (VOCs) and metals compared to those who never used tobacco products. However, these concentrations were significantly lower than the levels detected among current, exclusive cigarette smokers and dual users of both products.

Other noteworthy findings: Nearly all e-cigarette-only users — 93% — previously used cigarettes Among all e-cigarette-only users, 56% used e-cigarettes daily, compared to 20% of dual users who used e-cigarettes daily Cigarette consumption was similar between cigarette-only smokers and dual users — approximately 15 cigarettes per day “We know that quitting cigarettes improves health dramatically, but we don’t know much about possible risks from smoking and vaping together,” adds Dr. Hyland, the Chair of Health Behavior at Roswell Park, Director of the New York State Smoker’ Quitline, scientific lead on the PATH Study and senior author on this new research. “These data are clear that cigarette smoking is the primary factor responsible for exposure to the toxicants measured in this study. Stopping smoking completely is the best thing a smoker can do for their health.”



Menopause As most women experience menopause between the ages of 40 and 58 (the average age for menopause is 51 years old) it is highly likely that our practices contain a fair number of women who are postmenopausal. These patients, in addition to the myriad of signs, symptoms, and conditions that all of our mid-life patients present with, have a set of unique issues that require at least a rudimentary knowledge of and a sensitivity for this estrogen-reduced state.

What is menopause?

After approximately four decades of menstruation, the permanent “pause in menstruation” is unavoidable. Estrogen levels, previously cyclically waxing and waning, gradually diminish to a static low level as the ovaries slow down its production. This signals the end of menstruation and fertility and the beginning of another phase in a woman’s life. Technically, the diagnosis is made retrospectively, requiring one year of amenorrhea due to a decline in ovarian estrogen production. An FSH or Estradiol blood test is generally not needed for diagnosis. Not infrequently, menopause can be brought on suddenly (due to a bilateral oophorectomy), early (premature menopause less than 40 years old; smoking; genetic, metabolic, autoimmune disorders; infection), temporarily (due to chemotherapy or a life altering event), or later in years (obesity).

What is perimenopause?

Generally there are a number of physical and hormonal changes that occur over the approximately 4 to 8 years that eventually herald the onset of menopause. During this transition, women frequently experience intermittent vasomotor symptoms (VMS - hot flashes) and irregular, unpredictable light to heavy menstrual cycles. Perimenopause begins when changes in the intermenstrual interval are first observed and ends one year after the final menstrual period. Despite what many of our patients believe, contraception is still necessary during the bulk of this phase.

What symptoms are generally experienced by our patients?

The direct result of a diminished estrogen level, vasomotor symptoms are the most widely recognized complaint of menopausal women. Experienced by more than 75%


David I. Kurss, MD, FACOG, NCMP

of patients, they vary in frequency, severity, and duration. Some women will note twenty VMS per day and night - interfering with their sleep, productivity, mood and tolerance levels, and cognitive abilities, while others may glide through this phase without much ado. While many women will be symptomatic for two to five years, some studies have indicated that women may experience VMS for up to twenty years. Later symptoms of menopause include diminished libido, vaginal dryness and dyspareunia. Accelerated bone loss and heightened coronary heart disease risk follow as the protective effects of estrogen become even more remote.

What are some recommended treatment options for our menopausal patients?

Now is the time for our patients to embark on a new path (if not already on it) - exploring the many verified practices of a healthy lifestyle - including a nutrient-rich and calorie-conscious diet, weight bearing exercises, cardio training, yoga- meditation and stretching, adequate water intake, family and community involvement, appropriate supplementation, and regular visits for preventive and disease-focused care to their primary care and speciality physicians and extenders. Many typical menopausal symptoms can be prevented or blunted with simple lifestyle changes. Additionally, highly effective and well tolerated menopausal hormone therapy (MHT) is truly a blessing for many of our symptomatic patients. Tailoring the regimen to the lowest effective dose for the shortest duration needed is an oft mentioned adage in todays lexicon. While there is definite truth to this approach, blind adherence to this shouldn’t interfere with our goal of making our patients comfortable both symptomatically and with adhering to our prescription recommendations. Systemic estrogen therapy is the mainstay option to address

VMS. Progestogen therapy is added to protect the uterus (if present) from malignant change potentially induced from unopposed systemic estrogen therapy. There are nonhormonal options, as well. Vaginal dryness and dyspareunia (part of the genitourinary syndrome of menopause - GSM), while aided by systemic menopausal hormonal therapy, can be addressed by administering local vaginal or certain oral therapies alone, if VMS aren’t an issue. Another benefit of systemic menopausal hormone therapy is protection from osteoporosis of the hip and spine.

What about the safety of menopausal hormone therapy?

Menopause hormone therapy is both safe and effective. Women were experiencing the significant benefits of MHT for two decades before the first Women’s Health Initiative (WHI) study (a large, groundbreaking, and much-needed prospective randomized clinical trial) was published in 2002. Shortly thereafter, rushed interpretations impugning its use caused needless suffering and bone loss. MHT use plummeted. Much of this was due to physician hesitancy in prescribing MHT and patient’s reluctance to continue their prescribed regimens. Unfortunately, this mindset has persisted even today. Questions arose whether it was sound to manage our young newly-symptomatic patients based on the WHI findings. Enrollees were accepted until age 79. 83% of the WHI participants were more than 5 years from the onset of menopause - beyond when most present with VMS. Only 3.45% of participants in the Estrogen plus Progestin arm were between the ages of 50 and 54 years old - the range during which many women initiate MHT. Fortunately, eventually published WHI analyses stratified the enrollees by age as opposed to viewing all enrollees as one homogeneous group. Conclusions could now be aligned with the population that we were treating. A different and lower risk was noted when comparing a healthy, newly menopausal, VMS-suffering patient at age 51 to the largely asymptomatic average aged enrollee in the WHI, at 63 - 64 years old. When counseling our patients, several key points should be kept in mind. Level I evidence supports a favorable benefit-risk ratio for symptomatic women who

initiate MHT when younger than 60 years old or are within 10 years of menopause onset. Estrogen therapy alone (in hysterectomized women) has an even more favorable benefit-risk ratio. There is no good data showing a definite causative relationship between menopausal hormone therapy and breast cancer. Estrogen therapy alone actually showed a non-statistically significant reduction in breast cancer risk. The real concern about hormone safety is with long-term usage of systemic MHT. Many patients can safely continue MHT beyond age 60. Treatment should be individualized and periodically reevaluated. In the absence of VMS, discontinuing systemic MHT in favor of local vaginal or other therapy for GSM or bisphosphonates for osteoporosis prevention is prudent.

Take Home Message

Menopause is simultaneously a challenging time and an opportunity for women to embrace change and incorporate new activities into their life. As physicians and extenders, being mindful of this transformation, above and beyond the aging process, will better enable us to offer our menopausal patients a compassionate ear and a truly comprehensive approach to this universally experienced chapter of a women’s life.

Dr. Kurss is a nationally recognized, board-certified, Obstetrician-Gynecologist. He received his MD, with honors, in 1982, from SUNY at Buffalo School of Medicine, became a Diplomate in the American Board of Obstetrics and Gynecology in 1991, a Fellow in the American College of Obstetricians and Gynecologists in 1993 and is recognized as a Nationally Certified Menopause Practitioner by the North American Menopause Society. In 1993, Dr. Kurss founded the Women’s Wellness Center of Western New York and Suburban Obstetrics and Gynecology, the area’s first physicianassociated wellness center. Here, Dr. Kurss offers a myriad of health promoting programs to his female patients and to their families.


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Area Healthcare

TRINITY MEDICAL Trinity Medical WNY Welcomes New Physicians Group expands practice in Cardiology, Nephrology and Endocrinology Trinity Medical WNY is pleased to announce the newest members of its physician team, expanding the group’s specialty practices in the areas of cardiology, nephrology, and endocrinology. Operating in conjunction with Catholic Health, Trinity Medical continues to develop community based specialty and primary care practices to serve the needs of families throughout Western New York. Joining Trinity Medical Cardiology’s Buffalo office at 3435 Bailey Avenue, Nawfal Al-Khafaji, MD, received

Bachelor of Medicine and Bachelor of Surgery degrees from the University of Baghdad College of Medicine. Board certified in Internal Medicine, he completed Internal Medicine residencies at Jordan Hospital and Chicago Medical School. He completed a fellowship in Cardiovascular Disease at Creighton University School of Medicine and is a member of the American College of Cardiology, American Society of Echocardiography, and American Society of Nuclear Cardiology. Trinity Medical Multi-Specialty at 5320 Military Road in Lewiston welcomes Jyotsna Bhatnagar, MD. A Clinical Assistant Professor in the

Department of Nephrology at SUNY Buffalo, Dr. Bhatnagar received degrees in Medicine and Surgery from Lady Hardinge Medical College. Board certified in Internal Medicine and Nephrology, she completed an Internal Medicine residency and Nephrology fellowship at SUNY Buffalo. She also completed a Physiology residency at Maulana Azad Medical College. She is an associate member of the American College of Physicians and a member of American Society of Nephrology. Deepthi Kunduru, MD, has joined Trinity Medical Endocrinology Cheektowaga at 2625 Harlem Road. Dr. Kunduru completed her


medical education in India receiving her Bachelor of Medicine and Bachelor of Surgery degrees from J.N. Medical College and a post-graduate degree in Obstetrics & Gynecology from J.J.M. Medical College. Board certified in Internal Medicine, she completed an Internal Medicine residency at Bronx Lebanon Hospital Medical Center and a fellowship in Endocrinology from SUNY Buffalo. She is a member of the American Association of Clinical Endocrinologists. Toni Murphy, DO, is pleased to join the Trinity family, introducing Trinity Medical Endocrinology West Seneca, at 600 Harlem Road. A diplomate of the American Osteopathic Board of Internal Medicine, with a subspecialty in Endocrinology, Dr. Murphy graduated from the New York College of Osteopathic Medicine. She completed a residency in Internal Medicine from Delaware Valley Medical Center and a fellowship in Endocrinology and Metabolic Diseases at Nassau County Medical Center. She serves as Chief of Endocrinology at Mercy Hospital of Buffalo. She is also a member of the American Osteopathic Association, the New York State Osteopathic Medical Society, the American Diabetes Association, the Endocrine Society, and the American Association of Clinical Endocrinologists, where she serves on the Board of the Directors of the upstate New York Chapter. 26 I VOLUME 6 I 2018 WNYPHYSICIAN.COM

John Michael Nayda, MD, has joined Trinity Medical Cardiology’s Orchard Park Office at 310 Sterling Drive. Board certified in Cardiology and Internal Medicine, Dr. Nayda received his medical degree from Georgetown University School of Medicine. He completed an internship and residency in Internal Medicine at MedStar Georgetown University Hospital. Specializing in Cardiology and Interventional Cardiology, he completed fellowships in Cardiovascular Disease and Interventional Cardiology at the University of Rochester Medical Center.

MERCY Dr. Edward Cosgrove Named Medical Director of Emergency Department Buffalo, NY—Edward Cosgrove, MD, has been named Medical Director of the Emergency Department at Mercy Hospital of Buffalo. He is a member physician of TEAMHealth, Northeast Division, which services the hospital. Dr. Cosgrove, who has over 20 years of experience in emergency medicine, previously served as the Assistant Medical Director of Mercy Hospital’s Emergency Department since 2016. A graduate of the University of Notre Dame, he received his medical degree from the University of Buffalo (UB) School of Medicine and Biomedical Sciences. While completing his residency in Internal Medicine, Dr. Cosgrove

also attended law school at UB and was admitted to the New York State Bar after graduating from UB School of Law in 2000. Dr. Cosgrove began his career in emergency medicine at the Emergency Department of Sisters of Charity Hospital. He became a partner in Buffalo Emergency Associates and the Exigence Group two years later. While contributing to the growth of the practice, he has worked at numerous facilities throughout the area including the facilities of the Catholic Health System of WNY, Bradford (PA) Regional Medical, Olean (NY) General Hospital, Lourdes Hospital of Binghamton (NY), and UPMC Chautauqua/WCA Hospital in Jamestown, NY. Dr. Cosgrove was also closely involved in the development of WNY Immediate Care for the Exigence Group. Beginning in 2005, he assumed the role of medical director for the alpha site and acted as director of quality assurance for the urgent care division of Exigence. While working in urgent care, he was involved in personnel recruitment and retention, practice standardization, patient satisfaction initiatives, and EMR customization among other duties. During his time at urgent care, he continued to work in the emergency departments staffed by the Exigence Group. Dr. Cosgrove joined TEAMHealth in 2012.


The Cost of

“Compassionate Care” Since New York’s first dispensaries opened in January 2016, patients have faced numerous challenges accessing medical marijuana in this state.1 The “Compassionate Care Act” (“Act”), signed by Governor Cuomo in July 2014, legalizes the use of medical marijuana for qualifying conditions and provides the State Department of Health (“DOH”) authority to grant medical marijuana dispensary licenses for the provision of medical marijuana products to patients. The Act’s intent is to provide patients with debilitating conditions access to alternative forms of treatment while maintaining public health and safety.2 Under the Act, licensed dispensaries may manufacture and sell pharmaceutical oils, capsules, tinctures, ointments and patches containing a variety of combinations of THC and CBD, the principal drugs in cannabis.3 The program started small with only 150 physicians certified to suggest medical marijuana as treatment, and an even smaller number of patients approved to purchase marijuana products.4 In order to receive a registration ID to purchase medical marijuana, prospective patients require a referral from a state certified physician based upon presenting one of the DOH preapproved conditions or chronic symptoms. A patient may then submit his or her referral to DOH, and upon approval, DOH will provide the patient a medical marijuana ID card. Patients may present the ID at dispensaries to demonstrate their registration with the program. Patients pay anywhere from $300$1,200 per month for medical marijuana, and must pay in cash. Dispensaries cannot utilize credit card financing due to federal restrictions that designate marijuana as a Schedule 1 Controlled Substance – the same class of illegal substances as heroin.5 In addition, virtually no New York State insurers currently provide coverage for medical marijuana. Although, recent decisions of the State’s Workers’ Compensation Board do provide for reimbursement of the cost of medical marijuana if certain established criteria are met.6 Despite these restrictions, participation in the program has grown rapidly. In an attempt to expand patient access, DOH rules now allow nurse practitioners and physician assistants to write medical marijuana referrals. From 2017 to 2018, the number of certified health care providers increased to over 1,700,7 and there are now over 60,000 active registered patients – a number that is nearly doubling every quarter.8 One cause of the

Brandan Ray, Esq.

William P. Keefer, Esq.

rapid increase in patients is likely DOH’s expansion of treatable conditions to include chronic pain, ALS, Parkinson’s, neuropathy and PTSD.9 Currently, dispensaries are primarily concentrated in and around New York City. As of July 2018, the ratio of certified practitioners to patients remains significantly lower outside the State’s larger metro areas.10 So while the aggregate number of certified physicians and registered patients in the program is increasing, access is still limited. This has naturally resulted in higher costs for those in less populated regions.11 The unwillingness of practitioners in these areas to be DOH certified may be related to marijuana’s stigma as a controlled substance and the lack of research-backed clinical guidelines for its use. Moreover, while providers have the option of being included on DOH’s public list of providers who can write medical marijuana referrals, it is estimated only 32 percent of certified participants choose to be listed.12 Providers only certify patients to obtain medical marijuana registration. Dispensaries actually write and fill prescriptions based on the information they receive from patients’ medical marijuana ID cards. As such, providers cannot be certain what type and dosage of medical marijuana their patients receive. At the end of its biannual report, DOH made several recommendations for how it seeks to expand the program. These included certifying all health care providers who may prescribe controlled substances to authorize patients to participate in the medical marijuana program, developing a pilot study to dem-


Kassie Parisi, Medical Marijuana Dispensary to Open in Halfmoon, The Daily Gazette, November onstrate the effects on consumption and costs in registered pa 22, 2018, < 13 in-halfmoon>. tients, and educating the public and providers on medical use. New York State Department of Health, Medical Use of Marijuana Under the Compassionate Care Act: Two Year Report, July 2018, < While the program continues to grow, the high cost of medi two_year_report_2016-2018.pdf>. cal marijuana apparently has encouraged some patients to Chris Simunek, The New York State of Kind: Everything You Need to Know About Weed in NYC, Thrillist, April 19, 2018, < choose lower-cost, lower-grade illegal marijuana to self-pre weed#>. Matthew Hamilton, Medical Marijuana Goes on Sale in New York, But Few Were Buying, Times Union, scribe and self-medicate.14 Self-prescribing exposes patients to January 8, 2016, <( sale-in-New-York-but-6744405.php>. improper dosing, undesirable side effects, less therapeutic efId. New York State Department of Health, Two Year Report. fect and criminal penalties. Changes in the current regulations Id. Id. on the state and federal level to decriminalize marijuana could Parisi. New York State Department of Health, Two Year Report. have a number of positive effects, including facilitating new Simunek. Claire Hughes, N.Y. Health Department Releases Medical Marijuana Provider List, Times Union, laws to regulate and tax recreational use of marijuana – thereby May 7, 2017, < medical-marijuana-11128431.php>. providing a funding source to lower the patient cost of medical New York State Department of Health, Two Year Report. Id. marijuana, destigmatizing the clinical use of medical marijuana to increase insurance coverage for medical marijuana, and allowing for clinical trials to provide research to improve the quality and efficacy of prescribing medical marijuana. Until further legal reforms provide avenues for wider availability, lower patient cost and significant clinical research, the current high price point will continue to significantly limit the number of New Yorkers able to obtain the compassionate care the Act promises. William P. Keefer is a partner with Phillips Lytle LLP and leader of the firm’s Health Care Law Practice Team. He counsels hospitals, physician groups and other health care clients on a broad array of issues, including fraud and abuse, corporate The experts at the Vascular & Endovascular Center of Western New York compliance, transactional arprovide minimally invasive surgical care and superb diagnostic testing utilizing state-of-the-art technology. rangements, payer audits and agency actions. Mr. Keefer can • Five board-certified vascular surgeons be reached at wkeefer@phil• Minimally Invasive Vein Care in both Buffalo and Niagara Falls • Seamless care coordination with specialty providers or (716) 847-5488. • Top 3% nationally-ranked vascular surgery practice Brandan Ray is an associate with Phillips Lytle LLP, where Affiliations with Catholic Health, Kalieda Health and Catholic Medical Partners he concentrates his practice in the area of corporate law. He can be reached at bray@phillipslytle. com or (518) 618-1211. 1









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