Western New York
PHYSICIAN the regional voice of practice management and the business of medicine
VOLUME 4 / 2021
Genetic Testing for Hereditary Cancers with Primary Providers
Reveals Opportunities to Prevent and Manage Cancer Risk
SPECIALT Y PROFILE
Palliative Care: A Team-Guided Path for Illness Management & Comfort
RRH Harnesses Stem Cells’ Potential to Treat Cancers
WESTERN NEW YORK PHYSICIAN I VOLUME 4 I 2021
Medical Research 28 URMC Part of Collaboration Awarded $10M for Pediatric Concussion Research
26 Roswell Park Experts Share Insights on Diagnosis and Treatment of Head & Neck Cancers at AHNS 2021
26 Roswell Park Team Shows Dendritic-Cell Vaccines Can Be Paired with Standard Therapy for Breast Cancer
21 Researchers Mobilize at Hospital’s
Genetic Testing for Hereditary Cancers with Primary Providers Reveals Opportunities to Prevent and Manage Cancer Risk
“Front Door” to Expand Cancer Screenings
Prevention is key in the battle to cure cancer. With greater understanding of a patient’s genetic risk for developing cancer, physicians and patients have an extraordinary opportunity towards prevention. Recommended by both ACOG and the US Preventive Services Task Force, genetic screening and testing should be a routine part of care at the primary level. SPECIALT Y PROFILES
RRH Harnesses Stem Cells’ Potential to Treat Cancers 13 WellNow Urgent Care Offers Allergy Testing and Treatment
23 Roswell Park Researchers Identify Key Link Between Stress and Cancer 17
Regional News 16 Roswell Park Comprehensive Cancer Center and Oishei Children’s Hospital Launch First Edition City of Buffalo MONOPOLY to Benefit Pediatric Cancer Patients
Keeping Tabs on Tax Changes
Palliative Care: A Team-Guided Path
for Illness Management & Comfort
Researchers Aim to Prevent Lung
Cancer With Latest CIMAvax-EGF
Building on Prior Research, Wilmot
Makes Progress on Vexing Liver Cancer
Is Remote Patient Monitoring
Right for Your Practice?
Responding to Online Reviews and
Social Media Posts
Risk Management Tip: Managing
Negative Online Reviews
WNYPHYSICIAN.COM VOLUME 4 I 2021 I 1
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Welcome to the latest issue of Western New York Physician – where you will find informative stories and articles about and for physicians in western NY.
Andrea Sperry creative director
Lisa Mauro writers
Welcome to the Oncology Issue. No sooner did the healthcare system begin to recover from the relentless heights of the pandemic, we enter the flu season and a burgeoning resurgence of Covid-19 and its mutations. While medical experts continue to support precautions for safe distancing, families have slowly re-emerged to gather, albeit in smaller groups or outside locations. Practicing safe distancing, getting vaccinated, masking up, sanitizing hands and surfaces, these are all the steps taken to manage our risk, to avoid infection, to protect our families, to survive what researchers at John Hopkins claim is the deadliest American pandemic surpassing the Flu of 1918. Our cover story focuses on why it is vital that cancer risk screening and genetic testing be available to patients at their primary point of care with their PCP or OB/ GYN. Recommended and supported by the US Preventative Services Task Force and the American College of Obstetricians and Gynecologists, understanding the risks for cancer are similar to the precautions we have all taken to avert Covid-19. Empowered with insight, physicians and their patients can navigate best paths forward in care – to avoid or prevent cancer, to protect our family members, to survive the waters ahead. Discover how seamlessly genetic screening and testing can fold into your practice workflow. Our next issue focuses on Aging and • Enhancing Care & Patient Experience • Improving Financial Performance • Managing Chronic Care • Advances in Lung Cancer New column in 2022 – Physician-to-Physician an opportunity for medical experts to share with their colleagues the important innovations in their area of practice. Suggest a topic or expert for an upcoming discussion. More info to come. As always, we thank each of our supporting advertisers— your partnership and support ensure that all physicians continue to enjoy this regionally-based resource and benefit from the collaborative sharing of information. Wishing you a safe holiday season!
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medical advisory board
Joseph L. Carbone, DPM John Garneau, MD Thomas Hughes, MD Chuck Lannon Johann Piquion, MD, MPH, FACOG Catherine C. Tan, MD Michael Silber, MD James E. Szalados, MD, MBA, Esq. John R. Valvo, MD, FACS contributors
Brigid M. Maloney, Esq. Richard Castaldo, MD Manning & Napier Advisors Leslie Orr URMC Roswell Park Cancer Institute Rochester Regional contact us
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Palliative Care: A Team-Guided Path for Illness Management & Comfort Richard Castaldo, MD
In 1974, a pioneering surgical oncologist in Montreal named Dr. Balfour Mount coined the term “palliative care” to create a different connotation than “hospice care.” Over the last four decades, the growth of this type of comfort care in the United States has paralleled that of hospice care, which began in the United States the same year in Connecticut. While most people are familiar with what hospice means, many parts of our population do not know what palliative care entails in delivering relief to patients on the late-stage illness spectrum. Palliative care and hospice care share a similar focus, however palliative care is initiated earlier in the illness process, rather than just at end of life, and patients can still receive chemotherapy or dialysis. According to the Center to Advance Palliative Care (CAPC), there are six million people in the United States with a serious illness who could benefit from palliative care. Based on that ratio, that translates to more than 15,000 people in the Buffalo Niagara Region who might be eligible. For Western New Yorkers with serious, progressive illnesses, it can be challenging to navigate the health care system. The extensive paperwork and variety of medical decisions can make finding and securing the needed services a difficult time. When a chronic condition impacts quality of life for patients and families, contacting a palliative care provider enables them to receive the comprehensive care and support that fits their needs. Chronic illnesses often lead to patients cycling in and out of the emergency room or hospital. Some examples of diseases for which palliative care proves especially effective include: • • • • •
Cancer Chronic obstructive pulmonary disease Congestive heart failure Dementia Neurological disorders, including ALS & MS
Anyone can make a referral; it does not have to be a health care professional. When doctors refer patients to palliative care, they are not relinquishing their primary care of that patient, rather, they are receiving a supplemental team of experts that implements additional services and resources. They collaborate with primary care physicians and specialists to create a care plan to keep patients independent at home. They serve as an
extra set of eyes and hands to lighten a practice’s workload and can give doctors alerts for any condition changes. When patients enroll in palliative care, which is often covered by health insurance, they receive case management to reduce discomfort and hospitalizations. The primary goal is to alleviate distress associated with advanced illnesses. A crossfunctional team develops a care plan for the patient’s home or long-term care facilities to prevent trips to the emergency room or hospital admissions and mitigate symptoms such as: • • • • •
Pain Shortness of breath Loss of appetite Constipation Emotional needs and spiritual concerns
The services address mental, emotional, social and spiritual issues. A medical director performs consultations to review a patient’s stage in the disease process and medical needs. Registered nurses make monthly visits in the home or assisted living facility to assess what is bothering them while anticipating needs and ensuring appropriate medications are available. Patients also have access to a social worker who will assist them with accessing necessary resources, applying for Medicaid and obtaining personal care aide services and social or medical transportation. Social workers also help prepare advance directives while guiding families and connecting them to community resources, personal care aides and medical or social transportation. Spiritual counselors can discuss one’s values and beliefs, the search for purpose and meaning, and how serious illness can make it difficult to find acceptance and peace. The ultimate goal is to adopt coping strategies to ease stress from the illness and its related symptoms. Sorting through the landscape of health care organizations can be overwhelming for individuals to find the proper assistance they need. Chronic illness educators spend extensive time counseling patients, answering questions and responding to concerns regarding the illness and its prognosis. They take pride in teaching patients and families about the disease process and treatment options. Another benefit is that staff can visit patients after they are discharged from the hospital
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to help avoid additional hospitalizations. Nurses help patients avoid exacerbating conditions related to the illness as part of a post-acute care model. Many programs now offer remote patient monitoring through telehealth kits that equip clinical staff with real-time monitoring and evaluation, enabling a rapid response whenever the situation demands it. There are many organizations that oversee palliative and hospice care, enabling a streamlined approach for clinical staff to be cross-trained in patient evaluation and admissions for both programs. Many patients eventually are referred from palliative care to hospice in a continuum of care that emphasizes comfort and quality of life for everyone involved for as long as possible. Whether a patient is discharged from the program or continues to hospice care, the clinical team aims to meet the patient’s goals for comfort and dignity. The medical directors, nurses and social workers always strive to alleviate any burden in the family through dedicated, specialized care and thorough guidance at every step of the illness. Dr. Richard Castaldo, the Medical Director of Niagara Hospice and Pathways Palliative Care in Niagara County, hopes this information will be helpful to health care providers and comforting to patients and families.
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Genetic Testing for Hereditary Cancers with Primary Providers Reveals Opportunities to Prevent and Manage Cancer Risk
Doctors have long known that inherited gene mutations can significantly increase a patient’s lifetime risk for developing cancer. Since prevention is the first line of defense, the US Preventative Services Task Force recommends that primary care physicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer. The American College of Obstetrics and
Gynecology’s Committee on Genetics makes essentially the same recommendation: “A hereditary cancer risk assessment is key to identifying patients and families who may be at increased risk of developing certain types of cancer. This assessment should be performed by obstetrician–gynecologists or other gynecologic care providers and should be updated regularly."
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While testing for genetic mutations used to be either nonexistent and/or cost prohibitive, advances in genetic research now make it easier to identify and understand how these mutations correlate to other cancer syndromes. Since 2014, insurance companies have been required to cover all costs, including out of pocket, for genetic counseling and BRCA testing to patients who meet certain personal or family history criteria. Medicare, however, still only pays for patients who already have been diagnosed with cancer. “It’s more cost-effective to prevent cancer than to treat it,” notes Sarah Geno, a physician assistant at Rochester Clinical Research who consults with physician practices on risk assessment and genetic testing and shares best practices for implementing hereditary cancer screening programs. She understands how critical this information is in providing optimal medical management based on patients' individual risk; having worked with genetic laboratories, Geno finds Natera accessible, affordable, and easy to integrate into a practice’s existing screening program. Earlier this year, the Breast Cancer Research Foundation published the results of a large, multi-center study in the NEJM. Lead investigator, Fergus Couch, PhD, a pathologist at the Mayo Clinic, wanted to improve the accuracy of breast cancer risk assessment for women without a family history. "While the risk of developing breast cancer is generally lower for women without a family history, this study showed that 30 to 50 percent of breast cancer mutations occur in women who have traditionally not been considered high risk.” Because of this, Geno adds, “Natera offers a low cash price for these patients and a sliding scale for patients whose need meets financial guidelines. This level of support for my patients was an important part of choosing Natera’s testing lab.”
“Evaluating a patient’s risk of hereditary breast and ovarian cancer should be a routine part of obstetric and gynecologic practice” American College of Obstetricians and Gynecologists practice bulletin 182 2017 (reaffirmed 2019)
Test panels for differing needs Well known for Panorama, the top NIPT in the US, and its combination NIPT/Carrier Screen kit, Natera also offers Empower, developed in partnership with Baylor Genetics, which analyzes genes associated with an increased risk for hereditary cancers. Geno considers Natera’s laboratories “the most accurate” in detecting genetic abnormalities. Natera’s full multi-cancer panel expands up to 53 genes and test results include National Comprehensive Cancer Network (NCCN) guidelines for recommended medical management changes to mitigate risk. For tests that produce “variants of uncertain significance” (VUS), Natera-developed RNA testing delivers another layer of functional evidence that may move a variant into the positive or negative category. Using a single tube of patient blood, Empower with RNA improves detection and classification of some variants that may fall within splice site regions and automatically provides an updated report within two weeks, reclassifying the variant if RNA analysis produces a different result. Natera’s comprehensive breast cancer risk assessment uses the Tyrer-Cuzick evaluation, recommended for patients who may have an increased cancer risk even without a gene mutation. This risk may involve the family’s cancer history and the patient’s own estrogen exposure throughout her lifetime. “This looks at all the other risk factors that may be there, like age of menses, how many births, hormonal exposures, smoking, tissue density, premenopausal, or postmenopausal,” said Geno. If Tyrer-Cuzick shows a risk of >=20%, the patient is eligible for a breast MRI in addition to a mammogram and two clinical breast exams per year—all covered by insurance.
Who is eligible, and why Genetic testing can be used with patients who have a family history of cancer to prevent disease before it develops—but according to research published in Genetics in Medicine in 2015, up to 80 percent of women at high risk for hereditary breast or ovarian cancer have never been tested, or even discussed testing with their health care providers. Among patients at risk for Lynch syndrome, as many as 69 percent told researchers they were never advised to seek genetic screening by their providers.
“Family history should be reviewed annually; it’s considered standard of care,” said Geno. “You want the best care for your patients…but you also want to be sure that you are not delaying care. If this information is not acted on and a patient is later diagnosed with a cancer, the provider is opening themselves up for litigation.”
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“I’ve been in the medical legal field for over 20 years, and this is the greatest malpractice threat I’ve ever seen. Fortunately, it is also the most readily solvable. All it requires is for us to take a family history, recommend genetic testing to those patients who meet criteria, and document our efforts” Victor Cotton, MD, Esq.
“I’ve been in the medical legal field for over 20 years, and this is the greatest malpractice threat I’ve ever seen. Fortunately, it is also the most readily solvable. All it requires is for us to take a family history, recommend genetic testing to those patients who meet criteria, and document our efforts,” says Victor Cotton, MD, Esq. Using the BRCA gene as an example, we know that approximately 1/400 women possesses a pathogenic BRCA mutation. In the US, that equates to about 500,000 women. Each woman faces a lifetime risk of breast cancer of up to 85% and a risk of ovarian cancer of up to 60%. Because of the near certainly that these patients will develop cancer, numerous entities, including the American College of Obstetrics and Gynecology and the US Preventive Services Task Force, have issued recommendations for identifying these women, including screening when the patient’s family history is reviewed. If positive for certain patterns of cancer, genetic testing should be recommended; and, if the patient tests positive for a pathogenic mutation, medical and surgical options for reducing cancer risk should be explored. “In terms of impacting these patients’ lives in a positive way, this is enormously beneficial. We’re able to prevent cancers that are almost certain to occur.” While any individual may develop cancer in their lifetime, inheriting a gene mutation can increase the risk by 30 to 50 percent—and some genes increase the risk to as much as 90 percent.
Statistics show that 1 in 4 patients meet medical guidelines for hereditary cancer testing with routine risk assessment.
Although accepted guidelines and recommendations have been out for almost 10 years, only about 15 percent of patients who meet criteria have been tested, which means that most women who harbor a pathogenic mutation have not been identified.
Inforrmed Care Patients with an increased risk may be eligible for earlier, more frequent screenings and recommended for screenings with different modalities. Family members need this information so they can be appropriately managed according to their individual risk. Preventative care may include regular blood tests; imaging, including CT or MRI scans; or in high-risk cases, surgery to prevent a cancer diagnosis. This is particularly important in younger women with a family history of breast and/or uterine cancer who have not yet started their own families. “Through genetic testing I have helped many patients mitigate their risk,” said Geno. “Patients with mutations putting them at higher risk for HBOC or Lynch syndrome were able to make informed decisions relative to their ongoing healthcare. When they have testing and know the results, they can get the family counseling they need. For instance, if they are at a high risk for uterine, breast or ovarian cancer, they may decide to put family before career, or maybe they will decide that childbearing is not for them and opt to remove their ovaries, uterus, or get a double mastectomy. For women in their 30s, if they know they have a 50 percent chance of developing cancer, they can take action.” Taking steps to prevent cancer does not necessarily require major surgery, she added, citing holistic approaches and things like oral contraception, which reduces the risk of ovarian cancer. “Having the knowledge and the diagnosis, they can get treatment to prevent the cancer from ever being there.” Understanding a woman’s hereditary cancer risk can dramatically affect medical management to prevent or delay cancer occurrence and inform cancer treatment.
The Patient Experience In her years at three different medical practices in the Rochester, New York area, Alisa Lukas, MSN, APRN, Women’s Health Practitioner- BC, provided genetic cancer screening to as many as 1,000 patients. When COVID hit, however, risk screening was “put on hold,” so Lucas began regularly screening patients for genetic cancer risk at the Canandaigua Medical Group OBGYN where she worked. “I screened two to three patients a day for genetic cancer risk.”
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Understanding a woman’s hereditary cancer risk can dramatically affect medical management to prevent or delay cancer occurrence and inform cancer treatment. intact rather than put some of their premenopausal patients into early menopause.” Lucas explained.
Power of Knowing
Sarah Geno, PA
In addition to her routine nurse practitioner duties, Lukas used appointment slots to explain to patients what the screening could reveal about their genetic predisposition to cancers. Lukas noted that 95 percent of her patients chose to have their blood drawn on the spot. “I saw patients as young as their early 20s, whose mothers had had ovarian and breast cancer,” she said. “I also had patients in their late 80s who wanted to be screened—not just for themselves, but for their family members.” She would always emphasize that “only 10 percent of cancers are genetic—the other 90 percent just happen. But if we know someone has a particular gene associated with a specific cancer, we can do closer surveillance for early detection of the cancer for better survival.” Lukas reviewed detailed lab results with patients and offered referrals to appropriate cancer centers, oncologists or diagnostic facilities for those with positive gene mutations. Results also were documented within the patient’s electronic health record. Genetic cancer risk screenings also assist surgeons evaluating patients for gynecological procedures such as hysterectomies. “If providers referred patients to me for genetic cancer screening testing preoperatively, and results showed they had a positive gene mutation for ovarian cancer, the OB/GYN surgeon would likely remove the ovaries—and if they did not have that positive gene, the surgeon might leave the ovaries 8 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
Although the testing procedure is simple and relatively painless, some patients still resist the opportunity to find out about their genetic risk for cancer. “Some people fear positive results,” said Lukas. “It's all about how the information is presented to the patient. If they understand that, as their provider, you need that information to determine appropriate screenings and surgeries going forward, they will see the importance in stratifying their risk.” Higher-risk patients can start early detection screenings and can inform family members interested in preventative care. Patients at risk for certain hereditary cancer syndromes can be referred to specialists who will follow them for those increased risks. “These are all measures we can implement to improve patient outcomes,” said Geno. “Isn't that what we want as providers—to do our best for our patients?” The greater objection, however, has to do with cost. Many health insurers cover genetic testing for people with one or more risk factors: family history, previous diagnosis of cancer, or specific ethnicity with a higher incidence of a particular cancer (women of Ashkenazi Jewish descent are at greater risk for breast cancer, for example). Lukas and Geno both noted that their decision to go with Natera tests had to do, in part, with the company’s work with insurance companies to make sure that patients’ screening tests would be covered. “I always told patients that they would be notified prior to the test being performed at the laboratory if they were not fully covered by their insurance, so they could decide if they wanted to cover the additional cost or decline testing,” said Lukas. “Natera does a good job getting the genetic cancer screening test covered.”
Getting Started with Genetic Testing “The lab I use works with offices from start to finish. They make patient identification, test ordering, billing and followup care easy and helped us seamlessly incorporate it into our
current workflow. They also offer free genetic information sessions for patients and providers,” says Geno. Patients whose healthcare providers don’t actively screen and/or test can utilize a free screening and eligibility program offered through Rochester Clinical Research at www.rcrclinical.com/hereditary-cancer-screening/ “Most of the time it’s covered by insurance,” Geno notes. While many practices now see the value in offering genetic cancer risk testing to patients, others still require education about the benefits testing can provide to all patients at risk for cancer. Education is key to making this testing a norm throughout OB/GYN practices. “My goal is to educate family nurse practitioners, undergraduate nursing students, and physician assistant students about
My goal is to educate family nurse practitioners, undergraduate nursing students, and physician assistant students about genetic cancer risk screening. genetic cancer risk screening,” Lucas said. “It’s important that we incorporate this into the curriculum, so future providers know what can be done and how it can benefit patients. Genetic cancer risk screening is a powerful tool to detect cancer in early stages, giving patients a better chance at survival.”
Hereditary cancer testing simplified Designed with your practice in mind Empower panels include genes associated with increased risk of common hereditary cancers, with options to suit your preferred screening strategy.
BRCA1 & BRCA2
BRCA1 & BRCA2
Genes BRCA1, BRCA2
Breast, Ovarian, Endometrial cancers and Lynch Syndrome genes
Additional Genes ATM, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, NBN, NF1, PALB2, PMS2, PTEN, RAD51C, RAD51D, STK11, TP53
Most commonly screened-for hereditary cancer genes across 8 cancer types
Additional Genes APC, AXIN2, BAP1, BARD1, BMPR1A, CDK4, CDKN2A, GALNT12, GREM1, HOXB13, MEN1, MITF, MSH3, MUTYH, NTHL1, POLD1, POLE, RNF43, RPS20, SMAD4, VHL
Includes multi-cancer panel plus additional genes with emerging evidence of elevated cancer risks
Additional Genes CTNNA1, DICER1, KIT, MRE11, PDGFRA, RAD50, SDHA, SDHB, SDHC, SDHD, SMARCA4, TSC1, TSC2
*Breast STAT panel available with 11 breast cancer genes reported within 5-7 calendar days + 29 additional genes reported within 2 weeks. Breast STAT genes include ATM, BARD1, BRCA1, BRCA2, CDH1, CHEK2, NBN, PALB2, PTEN, STK11 and TP53.
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Vital testing made affordable
SPECIALT Y PROFILE
RRH Harnesses Stem Cells’ Potential to Treat Cancers Randi Minetor
If you have been waiting for decades to see if stem cells turn out to be the new frontier of disease treatment, we now have the answer. It’s a resounding yes, said Anne Renteria, MD, Rochester Regional Health’s Medical Director of the Acute Leukemia & Stem Cell Transplant and Cellular Therapy programs at the Lipson Cancer Institute. “I always tell my kids that I live in a sci-fi world,” she said. “It is very complex and very specialized, but what we are doing is bringing Rochester Regional Health (RRH) very community-based access to cell therapies and bone marrow transplants.” Stem cells, produced by the bone marrow, have the ability to turn into all three of the types of blood cells that the human body requires to function. This capability can be lifesaving to people with one of several kinds of blood cancer, such as acute leukemia or lymphoma, and also those who have undergone high-dose chemotherapy. “Some of the chemo is so strong that it will bring the blood counts all the way down to zero,” said Dr. Renteria. “If you leave it like that, there’s a good chance the counts will never recover. So we infuse back their own stem cells after they receive high-dose chemo.” There are two modalities of stem cell transplant—and in either case, the patient’s cancer should be in remission before the transplant. An allogenic transplant involves finding a donor who is a perfect or near-perfect match for the patient, so that they can donate stem cells from their own bone marrow to restore the patient’s immune system. “We have to identify someone who is perfectly matched, and those stem cells are infused in the patient,” said Dr. Renteria. “So we need to first treat the cancer, then administer a conditioning chemo followed by immunosuppressive therapy to make sure that the patient can accept and allow the buildup of the new and foreign stem cells in their body. These new and foreign stem cells have the mission to build a new immune system.” An autologous transplant, also called high-dose chemo followed by stem cell rescue, involves collecting the patient’s 10 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
Dr. Renteria is the Medical Director of our Acute Leukemia & Stem Cell Transplant and Cellular Therapy Programs.
own stem cells after the patient has been treated with chemotherapy, when, for example, the multiple myeloma has been defeated and the patient’s bone marrow is close to free of cancer. Even though the disease has been arrested, the bone marrow after receiving a high-dose chemo may be so suppressed that it will be unable to generate the blood cells the body needs for a healthy recovery. “The patient’s stem cells are typically collected four to six weeks ahead of the transplant procedure, then preserved in liquid nitrogen,” said Dr. Renteria. “They are therefore ready to use when we proceed with the transplant procedure.”
Autologous transplant provides important advantages over an allogeneic transplant, which relies on donor stem cells. The collected stem cells are ready for use at exactly the right time, eliminating the time-consuming process of finding a relative or other donor who is a perfect or nearperfect match to the patient. Even more important, a patient whose immune system is already depleted does not need to worry about rejecting the donor’s stem cells, so no harsh immunosuppression therapy is required.
Creating a stem cell program at RRH “There are many new transplant centers growing in the country right now,” said Dr. Renteria. “Everywhere you go, there’s a transplant center coming to life.” She had deep background in this new treatment modality before coming to Rochester, as the leader of acute lymphoblastic leukemia research and clinical service and assistant professor of medicine at the Icahn School of Medicine at the Mount Sinai Hospital system in New York City. She completed a fellowship in Blood and Marrow Transplantation at the Mount Sinai School of Medicine, and she served in the department of hematology oncology at Boston University School of Medicine before taking the position at Mount Sinai. Most recently, Dr. Renteria was the Medical Director of Medical Affairs at ICON PLC, a clinical research organization conducting clinical trials in hematology oncology as well as cellular and gene therapies. “I had been approached by several different companies,” she said, “but I chose RRH because of the support that they were offering. They had just built the Sands-Constellation Center for Critical Care, with a dedicated Oncology inpatient floor with 36 private rooms, 18 of them being positive pressure rooms,” rooms that maintain a higher air pressure than their surrounding environment. Positive pressure rooms allow air to leave the room without recirculating back in, keeping contaminants from entering the room and protecting patients with compromised immune systems from airborne infections. Some of these rooms at the new center can be converted to negative pressure rooms, which keep infectious bacteria and viruses from leaving the patient’s room, isolating the patient and their illness. “They had already started investing in this crucial infrastructure,” she said, “so they were committed to treating this population of patients.” Before building the Sands-Constellation Center, RRH had general oncologists on staff who took care of patients with many different kinds of cancers. When it came to acute leukemias, however, they most of the time referred patients to specialized centers like the Wilmot Cancer Center at the University of Rochester Medical Center, or Roswell Park
Cancer Center in Buffalo. “Those centers had the systems to support the patient through a very, very intense and specialized treatment,” said Dr. Renteria. “So in starting a program, we had to increase the complexity of the therapy we can offer the patients, and then build the system to support that.” Even with the investment in new facilities, however, adding the ability to treat acute leukemia and lymphoma patients required much more. “How do we get a center that does this kind of thing up and running?” said Dr. Renteria. “The nurses, the APPs, and the doctors all needed to be trained for that. We needed a very efficient and strong support system for patients, so we needed social workers, a clinical navigator, a bone marrow transplant coordinator. It takes a village.” Many staff members are bilingual in Spanish—Dr. Renteria herself speaks four languages—and they are mindful of the situations patients may be in at home, and how they can help bridge the gaps they may encounter as they undergo treatment. For example, “We have a very strong representation of patients that are farmers,” she said. “One of our APPs is a farmer herself. She understands the needs of the population, the gaps that must be bridged. Our staff at RGH really understands what patients are going through socially as well as medically.” Dr. Renteria arrived in late November 2020, and started assembling the team immediately. “At that time, Rochester General Hospital was seeing and managing approximately one patient with acute leukemia per month and since I joined at the end of November last year, this number has already significantly increased. And all our patients are being treated in-house.” With the team in place and their specialized training completed, RRH is working toward performing its first autologous stem cell transplant procedure at the end of October. “We are already treating our patients with the indicated and very, very complex modalities of regimens,” she said. “The clinic is opening more days per week, and extending its hours. We are in continuous communication with different specialties, including blood bank and pathology, to make sure we have the transfusion management doctor to collect the stem cells. We have involved the National Marrow Donor Program. It’s another level of care and coordination.”
On the horizon Dr. Renteria and her staff are already looking ahead to additional therapies that this highly specialized team can offer patients. One of these, chimeric antigen receptor (CAR) T-cell therapy, alters the genes inside of immune cells known as T cells to attack cancer cells and destroy them. The CAR
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is a manufactured receptor that helps the T cell identify the targeted cancer cells. This innovation can help treat some cancers even when chemotherapy hasn’t been effective. This technology requires collection of white blood cells, which contain the T cells, and separating the T cells from these white cells. A laboratory then adds the CAR, turning these T cell into CAR T cells. The cells remain in the lab for several weeks to multiply enough cells for the therapy to be effective. The patient then undergoes mild chemotherapy to lower the number of immune cells in their body before receiving the CAR T cells. Once the patient receives them, the cells go to work binding with cancer cells and killing them, while multiplying further to disable even more of the cancer. As the cells multiply, however, they may release chemicals into the blood called cytokines. These chemicals can boost the immune system into high gear, causing a number of symptoms that mimic a serious infection. When these symptoms become severe, they require treatment in the intensive care unit, where specialists trained in treating cytokine release syndrome (CRS) work to bring it under control.
“It’s another layer and level of training,” said Dr. Renteria. “We need to get everyone on the team aligned, have mock sessions with mock patients, make sure we are all coordinated and on the same page. We need to train people in the ED, so they can recognize CRS, know what is going on, and who to call as well. The ICU needs to be on board, because CRS has to be treated in the ICU. It’s 100 percent reversible with the proper care.” The first CAR T cell procedures could take place as soon as early 2022. “Rochester General Hospital is really an amazing place,” she added. “Six months after I got here, look at where we are. A lot of my colleagues said, ‘You’re crazy, this is never going to take off, you need a full commitment from the leadership. You have to set up everything.’ I discussed this with the leadership here prior to my coming. I wanted to be able to come to a place that would support what I do, and they are completely on board and invested in supporting our community in their most diverse needs.” Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019) and is a freelance journalist based in Rochester.
Oncology patient room in our new critical care center where the program is housed 12 I VOLUME 4 3 I 2021 2020 WNYPHYSICIAN.COM
SPECIALT Y PROFILE
WellNow Urgent Care Offers Allergy Testing and Treatment Randi Minetor
When Jeanne Lomas, DO, was the associate program director for the University of Rochester’s allergy and immunology fellowship program, she discovered a disturbing trend that would eventually limit services to patients. “I attended a national meeting for allergy fellowship leadership,” she said. “Many programs had empty slots— which is crazy, because subspecialty fellowships are highly competitive. Allergists are retiring faster than new ones are being trained. Many areas of the country just cannot recruit allergists.” Meanwhile, more people have allergies than ever in recorded history. The American Academy of Allergy, Asthma and Immunology (AAAAI) reports that the number of people with allergic diseases has risen steadily in the industrialized world for more than 50 years. At least 40 percent of schoolchildren worldwide have a sensitivity to
“The numbers of patients with access to treatment is decreasing, while the prevalence of allergic diseases is increasing” one or more common allergens, and about 13 percent of people in the US over the age of 18 have sinusitis, an allergyaggravated chronic condition. The Asthma and Allergy Foundation of America (AAFA) and the American College of Allergy, Asthma and immunology (ACAAI) tell us that allergies are the sixth leading cause of chronic illness in America, with 19.2 million adults and 5.2 million children diagnosed with allergic
Jeanne Lomas, DO
rhinitis (hay fever) alone. A remarkable 9.2 million American children had skin allergies (rash or hives) in 2018, with Black children dominating these numbers. As high as the numbers are for respiratory and skin allergies, the impact of food allergies is even higher. About 32 million people in the US are allergic to one of the eight foods that cause most reactions: eggs, fish, milk, peanuts, shellfish, soy, tree nuts, and wheat. Anaphylaxis, the most severe and life-threating reaction to a specific food, produces 30,000 emergency room visits annually, according to FoodSafety.gov.
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“The numbers of patients with access to treatment is decreasing, while the prevalence of allergic diseases is increasing,” said Dr. Lomas. She saw an opportunity to do something about this when she joined the staff of WellNow Urgent Care, taking the role of Director of Allergy and Immunology Services. Here she developed a program to provide quality allergy services to patients, expanding their access to quality care. Patients come to a WellNow Urgent Care clinic for allergy testing and treatment—but they do not need to be in an emergent situation to visit this clinic. “We’re set up as a pilot program in our Clarence facility with a separate clinic area from the urgent care so people aren’t coming into the urgent care side,” Dr. Lomas explained. Patients can schedule a clinic appointment online and come in for a full allergy workup, including environmental skin testing. Once their allergies have been defined, they can go to any WellNow clinic for allergy shots or other therapies. “Allergy shots are meant to desensitize you to allergens like cat dander and pollens,” she said. “You build up a tolerance to these allergens, so they don’t give you the same symptoms when you’re exposed. It works really, really well—we can potentially cure people of their environmental allergies—and it’s safe, even for young children and most pregnant women!” The barrier to treatment, however, is that patients who are
“We’re set up as a pilot program in our Clarence facility with a separate clinic area from the urgent care so people aren’t coming into the urgent care side”
seen by an allergist in private practice or a hospital-based clinic can only receive allergy shots when the clinic is open. “So for people who are in school or working, it’s hard,” she said. WellNow clinics are open during the evenings and on weekends. “Typically, allergy shots are given once per week for the first few months,” she said. “It’s a big time commitment. WellNow bridges this gap with more flexible hours, so we can offer this service to more people who would otherwise not be able to commit to the therapy.” 14 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
Dr. Lomas noted that patients who could not make this kind of commitment to their own wellness—whether because of work schedules or family obligations—often try to minimize their discomfort. “Sometimes people think their allergy symptoms are not that big a problem,” she said. “But I see all of the time that we can relate their allergies to other things—sinus infections, or asthma attacks, even poor sleep. Their symptoms may be worse than they realize. The allergies are a chronic disease that they’ve been fighting their whole lives. When you offer them a treatment that works, it changes everything.” The new program began in July 2021, and it already sees a full roster of patients on clinic days. “We are hiring and have more providers starting, so that we can meet the demand,” she said. WellNow Allergy currently offers full allergy evaluations including environmental skin testing, spirometry (pulmonary function testing), and patch testing, as well as blood draws. Dr. Lomas is planning on expanding services to food and venom skin testing within the next 6 months. One of the most common misdiagnoses is a penicillin allergy, Dr. Lomas noted. “About 95 percent or more of patients who report a history of penicillin allergy can actually tolerate the drug,” she said. “There are many studies showing that if you are listed as penicillin-allergic, you are more likely to be prescribed alternative antibiotics, which are most costly and have more side effects. So we can evaluate for that and help these patients take it off their allergy list.” A graduate of the University at Buffalo and Lake Erie College of Osteopathic Medicine, Dr. Lomas served as chief resident in pediatrics at the University of Rochester Medical Center (URMC), and went on to complete a fellowship at URMC in Allergy & Immunology. She then served on faculty as an assistant professor of Allergy and Immunology at URMC for nearly six years before arriving at WellNow. “I completed a pediatrics residency prior to allergy & immunology training—we treat little kids to adults and elderly patients, and the span of ages is really attractive to me,” she said. “There are very few specialties in medicine where you can provide as much relief for patients as you can by treating their allergies. I say to my patients, ‘I’m so excited for you because you are going to feel so much better.’” Relieving and curing allergies has the added benefit of improving patients’ quality of life for the long term, she added. “Patients are super-appreciative. It’s a very rewarding field.” Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019) and is a freelance journalist based in Rochester.
Responding to Online Reviews and Social Media Posts
Authored by Martin Kaiser, a MLMIC Risk Management Consultant, and Edward Krause, a Claims Assistant Vice President with MLMIC It goes without saying that social media is a huge part of our lives today. A Pew Research study reported that 69% of adults in America use social media on a regular basis, including 27% of people over age 55. Many “baby boomers” rely on the internet to obtain their healthcare information, including provider reviews. Most hospitals use social media for their marketing efforts, as well as customer outreach and engagement. It is also estimated that over 90% of healthcare providers use social media for personal activities and over 65% of providers use this medium for professional reasons, including providing organizational news and details of services provided, offering patient education, and detailing the availability of community events and wellness programs. A significant amount of interaction by the public on social media sites includes individuals looking for healthcare advice and recommendations for care, as well as information from those who have had personal experience with specific providers. These social media platforms include such familiar names as Facebook, Twitter, Angi, and Yelp, as well as healthcare-specific sites such as WebMD, VITALS, and RATEMD, with new sites seemingly appearing every day. It should be noted that while 90% of all online reviews about the patient experience and provider care are positive, some negative reviews will be posted. What follows will help to identify and address negative comments appearing on social media websites. Problematic Aspects of the Use of Social Media by Patients Unfortunately, when patients and/or their families use social media platforms to voice negative comments about the provision of their healthcare, there may be problems associated with their posted messages. These may include the quality and credibility of information posted by the individual; the posting of information that may be misconstrued or taken out of context by those present on the social media site; and even the posting of inappropriate or discriminatory personal comments about you or your staff. Such posts may become a distraction to those providers who frequently visit social media sites, or even the comment section of their own website, to see what is being written about them and their practice. This “web surfing” may result in poor care or medical error. Reacting to negative comments that are posted on a social media site may present several problems for the provider. First, a direct response via the social media platform to the author of the negative comment may confirm that the individual is a patient of the provider, thus breaching the patient’s privacy. Further, a comment in response to a negative post may be perceived as unprofessional by the patient or their family, or to prospective patients who are vetting the provider to see if they wish to become his or her patient. It should always be remembered that the internet is truly “worldwide,” and it must be understood that any advice or information that you post on the social media platform may be read by out-of-state patients, potentially raising licensing issues if it appears that medical advice was provided in a state where the provider is not licensed. Addressing Negative Online Reviews Unfortunately, you cannot prevent negative posts from being written about you or your practice, and it is often difficult to have them taken down. The best practice is to continue to provide optimum care to your patients, and to respond in an appropriate manner. Most importantly, resist the urge to ignore the negative review or to retaliate. Do not engage in online arguments with the individual, as this is a direct violation of your professional boundaries. The negative concern expressed should
be reviewed by you and your staff to verify if it is accurate, and then corrective actions should be taken, if applicable. If the author of the post can be determined, you may contact that person offline to address the stated concerns. When contact is made, be sure to document the entire conversation in the patient’s medical record. A patient portal may be employed to facilitate the proper documentation of this conversation. If it becomes apparent that there is some basis for the negative comment and corrective action has taken place, the patient should be contacted and thanked for bringing their concern to the practice’s attention. You may even let them know how their concern helped the practice improve. This may even improve the patient’s image of the practice. In the event the posted concern pertains to an untoward outcome, or if you suspect legal action is being threatened, contact the MLMIC Claims department as soon as possible. Always print and retain all patient social media posts, as patients may choose to delete their comments from the social media platform. Risk Management Strategies for Negative Online Reviews The development of a formal social media policy is the first step in instituting a plan to help guide you and your staff if a negative review about your practice is posted online. The following Items should be addressed in a practice’s social media plan: • Assign a staff member to review social media sites on a regular basis for posts about your practice, and to constantly address evolving social media and technology. If your practice includes separate locations, these reviews should be conducted for each location. • Designate a person to communicate on behalf of the practice. This person is often the risk or corporate compliance manager, practice administrator, or, in solo practices, the actual provider. • Reiterate to staff the need to maintain the same patient confidentiality online as they would in any other environment, as well as maintain appropriate boundaries in the physician-patient relationship. Never “friend” a patient in an online setting. • If you feel you are being pressured into responding on a social media platform, limit your response to a standardized response such as one of the following: “According to state and privacy laws, we are precluded from commenting on patient treatment. However, we are always available to discuss concerns with our patients. Patients are welcome to contact us directly.” “In order to protect our patients’ privacy, all patient concerns and complaints are resolved directly by [name of practice] and not through social media.” “At [name of practice], we strive for the highest levels of patient satisfaction. However, we cannot discuss specific situations due to patient privacy regulations. We encourage those with questions or concerns to contact us directly at our office.” • All staff should be alerted to immediately report negative social media comments to practice leadership. • Link your social media policy to other organizational policies, such as an employment agreement. A confidentiality agreement should be signed by your staff members, and they should receive documented education in patient privacy and HIPAA. A well-intentioned social media post by a staff member may trigger HIPAA concerns. Reprinted with permission from www.MLMIC.com. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.
WNYPHYSICIAN.COM VOLUME 4 I 2021 I 15
Roswell Park Comprehensive Cancer Center and Oishei Children’s Hospital Launch First Edition City of Buffalo MONOPOLY to Benefit Pediatric Cancer Patients 100% of game sales support Roswell Park Oishei Children's Cancer and Blood Disorders Program
Roswell Park Comprehensive Cancer Center and John R. Oishei Children’s Hospital have launched the First Edition City of Buffalo MONOPOLY® game, officially licensed by Hasbro, to benefit the Roswell Park Oishei Children’s Cancer and Blood Disorders Program for pediatric cancer patients. One hundred percent of the proceeds from the sale of the game will have long-term benefit to the program, helping ensure that children and their families facing childhood cancer and blood disorders can remain in Western New York to receive the very best care. “The funds raised through the sale of this game will specifically fund a critical position on our Roswell Park Oishei Children’s Cancer and Blood Disorders Program care team - a Bone Marrow Transplant Coordinator,” said Kara Kelly, MD, the Waldemar J. Kaminski Endowed Chair of Pediatrics at Roswell Park and Chair of the Roswell Park Oishei Children’s Cancer and Blood Disorders Program. “Our joint program has helped us to nearly triple the number of bone marrow transplants that we perform, allowing families facing a pediatric cancer diagnosis to stay right here in our community to receive care. Having a dedicated Bone Marrow Transplant Coordinator, funded by the sales of the City of Buffalo MONOPOLY game, will help to ensure that there is seamless support for the care delivered across both Roswell Park and Oishei Children’s Hospital.” Each year, Hasbro selects a limited number of custom MONOPOLY games to produce, and this year Buffalo was on that short list. The First Edition City of Buffalo MONOPOLY game features iconic hometown brands and corporations across Buffalo, bringing to life an 16 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
authentic snapshot of what makes this community so special. The game can be purchased for $50 exclusively at participating Tops Friendly Markets locations while supplies last. “As part of our Neighbors Helping Neighbors philosophy, we have supported both the Roswell Park Comprehensive Cancer Center and Oishei Children’s Hospital programming for many years, but this is a unique and exciting fundraiser for both charities,” said John Persons, president and COO. “We truly believe in the work of both agencies as they align nicely with our philanthropic mission and we hope everyone enjoys this Western New York version of the game.”
Keeping Tabs on the Tax Changes
The tax code has been through a whirlwind these past
few years. We’d forgive our readers if they have a hard
Financial planning best practices are continuing to
evolve in today’s quickly shifting landscape. For those
time keeping it all straight.
interested in peering around the corner, highlighted be-
with the passage of the SECURE Act, which changed
for the rest of 2021.
To briefly recap, the changes started at the end of 2019
a number of rules relating to IRAs and retirement plans.
low are a few of the key proposals we have on our radar
Then, in early 2020 when the pandemic was beginning,
The Next Shoe to Drop
CARES Act, and the multitude of changes they brought.
infrastructure bill passed the Senate in early August. The
pursued by the Biden Administration and its Congres-
vote on the bill in late September.
Trump’s signature Tax Cuts and Jobs Act of just a few
spending, the bill makes use of several non-tax offsets.
various COVID-relief bills were put in place, such as the
And most recently, there are the ambitious ideas being
sional allies. And all of that doesn’t even count President
Months and months in the making, a $1 trillion
most recent indications are that the House has agreed to Rather than including any tax increases along with the
In addition, the $1 trillion number includes pre-authori-
WNYPHYSICIAN.COM VOLUME 4 I 2021 I 17
zation for 5 years of typical transportation maintenance
Corporate Taxes: There still appears to be a strong
spending. This spending is not really ‘additional spend-
push to raise the corporate tax rate, which was previ-
structure thrust and lessening the political pressure to
of the Tax Cuts and Jobs Act. Numbers have ranged
ing’, further bringing down the real size of the infraraise offsetting revenues.
Meanwhile, the House and Senate also approved a
2022 budget resolution that provides reconciliation
instructions for a $3.5 trillion spending package. Reconciliation allows for budget-related bills to pass filibuster
proof with only a simple majority, meaning that a larger spending bill could potentially pass later this year with-
out any Republican support.
It’s possible for the full package to pass, but we think
ously lowered from 35% down to 21% in 2017 as part between 25% to 28%, with the higher number remain-
ing the preferred figure. The Democratic party has
declared, however, that they will not raise taxes on small businesses (e.g., family farms).
Investment Taxes: Proposals remain intact to treat
long-term capital gains and qualified dividends as ordi-
nary income for taxpayers with taxable income above $1 million. If enacted, this would result in a top marginal
capital gains tax rate of 43.4%, when including a new
that is unlikely. With the Senate evenly divided 50-50,
top marginal rate of 39.6% and the 3.8% net investment
united. They literally would not be able to lose a single
Estate Taxes: This may seem like the most cut and dry
this route requires the Democrats to stay completely
Senate vote. Such a razor thin majority means that we
of impacted areas, although nothing in trust and estate
think compromise is likely on many of the key provi-
tax law is ever that simple. Nevertheless, current plans
limitations of the budget reconciliation process, bills
above $1 million for individual and $2 million for joint
sions of President Biden’s agenda. Additionally, due to
call for capital gains taxes at death on unrealized gains
must be ‘revenue neutral,’ meaning Congress cannot fi-
all, of the proposals will require a variety of tax increases,
social security payroll tax on wages above $400,000, to
nance the package via the deficit. Paying for most, if not predominately impacting high income individuals and corporations.
The Art of Compromise Due to the slim majorities, Democrats have already
begun to compromise on a couple of President Biden’s
initial tax proposals. Here is a summary of where things stand currently on key tax issues, as well as on a few
items that seem to already be on hold:
Individual Taxes: Democrats have consistently stated
their intention is to avoid raising taxes on families
making less than $400,000. Current proposals remain
for raising the top marginal income tax rate from 37%
to 39.6%, which would apply to income over $452,700
for single and head of household filers and $509,300 for
18 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
A Few Items on Hold: Original plans to apply the
restore the 2009 federal estate and gift tax levels ($3.5 million federal exemption and $1 million lifetime gift
limit at a 45% maximum tax rate), and to place a cap
itemized deductions for higher earners all appear to be on thin ice at the moment.
As always, we will continue to closely monitor the
evolving situation in DC for potential impacts on your
financial plan. As these plans come into greater focus,
we may make recommendations on a proactive basis to
help clients get in front of any potential issues that can
impact specific planning goals. Please feel free to schedule a call with a Financial Consultant if you have any
questions, and in the meantime, subscribe to our Finan-
cial Planning blog for updates on these issues and more. Please consult with an attorney or a tax or financial
advisor regarding your specific legal, tax, estate planning,
or financial situation. The information in this article is
not intended as legal or tax advice.
Is Remote Patient Monitoring Right for Your Practice?
Brigid M. Maloney, Esq.
In the past three years, the Centers for Medicare
In the meantime, physicians who are treating patients
and Medicaid Services (CMS) significantly expanded
with chronic or acute conditions may elect to initiate
utilize remote patient monitoring with qualifying
CPT codes 99453, 99454, 99457, 99458, and 99091, as
remote physiologic monitoring, involves the use of digital
99453 - Device set-up and training. This code reflects
reimbursement opportunities for physicians who properly patients. Remote patient monitoring, also referred to as
technology to monitor and report medical data from
patients with chronic and/or acute health conditions and electronically transmitting such information to healthcare
remote patient monitoring for reimbursement using
staff time that includes instructing a patient or caregiver
about using one or more medical devices for remote
monitoring. This code can only be billed once per device.
providers for assessment. Common digital equipment
Reimbursement in Upstate New York is approximately
monitors, digital weight scales, blood pressure monitors,
99454 - Daily collection and monitoring of patient
used for remote patient monitoring include blood glucose
and pulse oximeters.
physiological data. To qualify, data must be transmitted
Remote patient monitoring reimbursement is based on
to the provider at least 16 or more days in each 30-day
data, combined with increased communications with
required number of monthly reporting days is reduced
the premise that additional monitoring of patient health patients and adjustments to treatment plans based on
period. During the COVID public health emergency, the
from 16 days to two days. Reimbursement in Upstate
such data will result in healthier patients, better clinical
New York is approximately $60.00 per patient, per 30-
published in JAMA demonstrates how remote patient
99457 – Treatment management, 20 minutes per month
outcomes, and lower health care costs. A 2013 study
monitoring has the potential to significantly increase
of review, including live, interactive communication with
blood pressure control. A 2020 study published in JAMA
the patient, by a physician clinical staff member under the
a remote monitoring program resulted in a reduction
also includes time spent furnishing care management
approximately $50.00 per patient, per calendar month.
reimbursement policies that are presently in place as
or more beyond the 20 minutes provided under 99457
found that in a randomized clinical trial of 242 patients, in rehospitalizations of patients following hip and knee
CMS will likely continue to refine the broad
more data become available and the benefits and overall
clinical effectiveness of specific devices and diseases are studied more closely.
general supervision of the ordering physician. This code
services. Reimbursement in Upstate New York is
99458 – Treatment management, additional 20 minutes
Reimbursement in Upstate New York is approximately $40.00 per patient, per calendar month.
WNYPHYSICIAN.COM VOLUME 4 I 2021 I 19
99091 – Review of patient data by physician or qualified
Remote patient monitoring poses a broad opportunity
healthcare provider. Reimbursement in Upstate New York
for physicians to generate additional revenue under the
When considering whether remote patient monitoring
patient monitoring is somewhat limited, and the practice
a number of factors into consideration: each patient must
effective and worthwhile strategy for care management
is approximately $55.00 per patient, per 30-day period.
is right for a healthcare practice, a physician should take
appropriate circumstances. Although evidence for remote
does involve some risks, many physicians believe it is an
be an active and willing participant who, with training,
in certain patient populations.
the ordering physician should specify ranges in which
Brigid M. Maloney, Esq. is aA Partner at the law firm Lippes
a patient-by-patient basis (one size does not fit every
as Co-Leader of the firm's Health Law Practice, providing
understands how to use the monitoring equipment;
alerts should be filtered, responded to, and escalated on
patient); documentation must be in place supporting
Mathias in Buffalo, NY, Brigid M. Maloney, Esq. serves counsel to health care clients, including national digital health
each code that is billed; a trusted, HIPAA-compliant
innovators, telehealth providers, remote patient monitoring
track, and report the remote patient data; and only
PCs, single and multi-specialty medical practices, hospitals,
be selected. Some physicians choose to use a full-service
medical call centers, physicians, dentists, and other licensed
the non-clinical aspects of the remote patient monitoring
issues related to corporate formations, mergers, acquisitions,
technology service should be implemented to receive, monitoring devices that are proven to be reliable should
remote patient monitoring vendor program to handle services in order to streamline the process.
20 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
companies, management services organizations and friendly
behavioral health providers, human services agencies, med spas,
practitioners on structural, regulatory and reimbursement
joint ventures, complex contractual arrangements and other affiliations and collaborative efforts.
Researchers Mobilize at Hospital’s “Front Door” to Expand Cancer Screenings To find people who are behind on cancer screenings and then motivate them to follow through, an innovative team is leveraging the emergency department at Strong Memorial Hospital and other regional UR Medicine sites for a research project. The project is especially important for the Rochester David Adler, M.D., M.P.H. area, where cancer rates are higher than in New York state and nationally. According to data from the University of Rochester’s Wilmot Cancer Institute, if the 27-county region from which Wilmot draws patients were its own state, it would have the second highest cancer incidence in the U.S. behind Kentucky. The researchers’ goal is to identify participants for studies that evaluate whether a text-message reminder tool is more effective than a standard referral for prompting individuals to get screened for cancer. Researchers are directing their attention to underserved people who visit the emergency room for any type of illness, using the wait time as an opportunity for education about cancer screenings. In 2020, the same research team started its National Cancer Institute-funded project by identifying urban and rural women who were in need of screening for cervical cancer, a preventable disease. At the time, researchers said they planned to expand their project — and this year they’ve included colon and lung cancer, two common malignancies for which screening can improve survival.
Why the emergency department? “The ER takes care of people from all walks of life, from the most fortunate to the least,” said David Adler, M.D., M.P.H., professor of Emergency Medicine and Public Health Sciences at the University of Rochester Medical Center, and a Wilmot Cancer Institute investigator who co-leads the projects. “It’s a place to reach the uninsured, the underinsured, and people who generally have little or no access to health care, including people of color, recent immigrants, and those with language barriers,” he said. Co-investigator Beau Abar, PhD, noted that the emergency department is a hospital’s “front door,” as more than 70 percent of patients needing inpatient hospital care come through the emergency room. “Our project is also timely, given that the COVID-19 pandemic has resulted in dramatic increases in missed cancer screenings,” said Abar, an associate professor of Emergency Medicine, Public Health Sciences, and Psychiatry.
Routine cancer screening Adhering to scientific guidelines for cancer screening can lead to early detection of the disease, making it more treatable. Receiving accurate information from health care providers can also ease fears and debunk myths. For example, Abar said, a colonoscopy is not the only way to screen for colorectal cancer. Other options include the less invasive sigmoidoscopy or annual stool tests. It’s important that individuals find the best option by consulting a physician. • The colon cancer study involves referring qualified individuals to a physician to coordinate the screening test and sending text messages to encourage follow-up. • The lung cancer screening study is similar: researchers engage people who are eligible for a low-dose CT scan to screen for lung cancer and then will evaluate which method works best to encourage patients to complete the process. Through UR Medicine’s Lung Cancer Screening Program, patients can get screened
WNYPHYSICIAN.COM VOLUME 4 I 2021 I 21
in Rochester and in the region, including Brockport, Canandaigua, Dansville, and Hornell. • Early data from the cervical cancer study show that the percentage of women who lack adequate screening is higher in the Rochester region than national averages, demonstrating a great need for cancer prevention services, education, and research, Adler said. Most cases of cervical cancer and related deaths occur in women who have not been screened with routine pap tests. Adler, Abar, and their team recently received a University of Rochester Research Award to gather pilot data for colon screening and a URMFG Healthcare Innovation two-year pilot award for the lung cancer study. Nancy Wood, MPA., MS, is the project manager. The team collaborates with Wilmot’s Cancer Prevention and Control research program and its Community Outreach and Engagement office.
Screening for Colon Cancer • Colon cancer is becoming more common and deadly. It is the third most common cancer in the U.S., and the third leading cause of cancer deaths. • Colon cancer almost always develops from precancerous colorectal polyps, which, in many cases, can
be detected and removed before they turn into cancer. • Adults ages 45 to 75 should be screened for colon cancer, but millions of people in the U.S. do not adhere to this recommendation. • Checking for cancer when a person has no symptoms is best. If cancer is found at this stage, it is often easier to treat.
Screening for Lung Cancer • Lung cancer is the number one cause of cancer deaths in the U.S. • Individuals are eligible for a low-dose chest CT to screen for cancer if they are 50 to 80 years old, have smoked a pack a day for 20 years or two packs a day for 10 years (or more), and either still smoke or have quit within the last 15 years. • The guidelines were developed by the U.S. Preventive Services Task Force (USPTF), which has also called for prioritizing lung cancer screening for vulnerable, underserved people. • Studies show that lung cancer screening and early detection can lead to better outcomes for patients.
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1 Reduce Costs & Increase Savings 2 Strategic Partnerships with Other Providers 3 Increase Retention & Acquisition of Patients 4 More Control Over Patient’s Care 5 Access to More Advanced Technologies Phone: (716) 247-5282 GBUACO Main Oﬃce: 564 Niagara Street, Building 2 Buﬀalo, NY 14201 22 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
Roswell Park Researchers Identify Key Link Between Stress and Cancer Stress pathway involving beta-adrenergic receptors fuels tumor growth Elizabeth Repasky, PhD Stress can have a significant negative effect on health, but our understanding of how stress impacts the development and progression of cancer is just beginning. A team from Roswell Park Comprehensive Cancer Center has identified an important mechanism by which chronic stress weakens immunity and promotes tumor growth. Their findings, just published in Cell Reports, point to the beta-adrenergic receptor (B-AR) as a driver of immune suppression and cancer growth in response to stress, opening the possibility of targeting this receptor in cancer therapy and prevention. Using a preclinical model of triple-negative breast cancer, a research team led by Hemn Mohammadpour, PhD, DVM, a postdoctoral research affiliate in the lab of Elizabeth Repasky, PhD, and Dr. Repasky, who is Co-Leader of the Cell Stress and Biophysical Therapies Program and the Dr. William Huebsch Professor in Immunology at Roswell Park, found that as tumors grow, they become more sensitive to stress signals coming from the nervous system. Specifically, the researchers discovered that a population of immune cells known as myeloid derived suppressor cells (MDSCs) show an increase in the expression of B-AR, a molecule that controls the function of key immune cells. Elizabeth Repasky, PhD, left, and Hemn Mohammadpour, PhD, DVM, immunology researchers from Roswell Park, report new findings about the role certain immune cells play in affecting response to cancer treatment. The findings will help researchers better understand why prolonged exposure to stress often makes our immune system less effective, and build on Roswell Park’s pioneering research into the relationship between stress and cancer. “This increase in B-AR expression on myeloid-derived suppressor cells allows these cells to be stimulated by the stress hormone norepinephrine, which fosters an immunosuppressed environment that promotes tumor growth by increasing MDSC’s ability to generate and process energy and suppress anti-tumor immune response,” says Dr. Mohammadpour, the paper’s first author. “This study provides some very important clues that help explain the specific mechanisms by which
Hemn Mohammadpour, PhD, DVM
prolonged stress stimulates tumor growth and decreases lifespan.” While there has been a longstanding recognition that long periods of stress, or chronic activation of nerves, are harmful to overall health, details about how this occurs are unclear, especially in the setting of cancer. A better understanding of the specific ways in which stress influences cancer, particularly in terms of lowering immunity against tumor cells, could be used to design new drugs or therapies that can help to minimize negative effects of chronic stress and boost cancer immunotherapy. Based on these findings, Dr. Repasky’s team is planning new clinical and laboratory studies to identify therapies — including existing therapies already approved for other applications — that can block these harmful stress signals and stop the negative cycle of cancer growth and metastasis. “This is especially important for cancer patients, who frequently endure greatly increased levels of stress after their diagnosis, including anxiety, depression and worry about factors like finances and family interactions,” adds Dr. Mohammadpour.
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Researchers Aim to Prevent Lung Cancer With Latest CIMAvax-EGF Clinical Trial Prevention study is recruiting lung cancer survivors as well as those at high risk due to smoking history
A groundbreaking international collaboration brought an innovative lung cancer immunotherapy from Cuba —CIMAvaxEGF— to Roswell Park Comprehensive Cancer Center. Now researchers at the Buffalo-based center are now examining whether this immunotherapy developed to treat lung cancer might prove to be an effective tool for preventing the often-deadly disease. Led by Mary Reid, MSPH, PhD, the interventional earlyphase clinical trial is currently recruiting for participants who fall into two groups, or cohorts — middle-aged individuals who currently smoke or have quit smoking within 15 years and carry other lung cancer risk factors like COPD, family history of the disease or have high-risk occupational exposures but have not been diagnosed with cancer AND lung cancer survivors who have completed treatment. “If you’ve had lung cancer and survived it, your biggest fear is that the tumor is going to come back, and we’d like to do anything we can to prevent that,” said Dr. Reid, who is also the Chief of Screening, Survivorship and Mentorship at Roswell Park. “I think CIMAvax has shows great potential to help this group as well as individuals who are past or current smokers at risk for lung cancer.” This immunotherapy works by blocking a protein known as epidermal growth factor (EGF), which lung cancer cells 24 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
need to grow. CIMAvax produces antibodies against EGF, mounting an immune response, capturing the protein so that it no longer circulates in the blood and no longer reaches the cancer cells. The cells end up “starved,” as the protein cannot connect to its receptor, known as EGFR, on the cell and cancer growth is inhibited. Previous studies have shown that EGFR has been found in the airways of cancer-free subjects as well as people diagnosed with cancer. Dr. Reid and team are looking to learn whether the antibodies created by CIMAvax may drive down the risk for developing lung cancer. “No one deserves to get lung cancer,” says Dr. Reid. “We need to offer people something to reverse damage done by smoking exposure. If we could have an easy-to-administer medication someone can get on an outpatient basis that could prevent them from progressing to cancer — that would be a quality-of-life game-changer. So we’re exploring whether CIMAvax has that potential.” CIMAvax-EGF has been developed over the course of more than 25 years by researchers at the Center for Molecular Immunology (CIM) in Havana, Cuba. The CIM is currently conducting an identical prevention study in their country. For full study and enrollment details, please visit the CIMAvax page on the Roswell Park website or call 1-800-ROSWELL (1-800-767-9355).
Building on Prior Research, Wilmot Makes Progress on Vexing Liver Cancer Individuals diagnosed with intrahepatic cholangiocarcinoma (iCCA), a type of liver cancer, face a five-year survival rate of less than 10 percent. But a Wilmot Cancer Institute team that also investigates pancreatic cancer, which has similarly poor survival statistics, discovered factors that both aggressive cancers have in common. Scientists believe the new data provide a roadmap for targeting the tumors David Linehan, M.D with immune therapies. In a recent publication in the journal Gut, the team showed that iCCA tumors are comprised of a dense network of cells that are non-cancerous and yet help to create an environment that’s ripe for cancer’s growth and spread. Called TAMs (tumorassociated macrophages), these same cells also play a sinister role in pancreatic cancer. The TAMs create an inflammatory barrier around cancer cells that block the body’s natural disease fighters (such as T cells) from destroying the cancer. Patients with iCCA whose tumors are infiltrated with TAMs have a poorer prognosis, the paper stated. First author is Luis Ruffolo, M.D., a surgical resident at URMC. This image shows how the green cancer cells are protected by the red TAMs. Researchers also developed new laboratory methods to advance the studies, which
are led by David Linehan, M.D., chief of clinical operations at Wilmot and the Seymour I Schwartz Professor and chair of Surgery at the University of Rochester Medical Center. Linehan and collaborators have been investigating TAMs for many years and are working on combinations of therapies that can break through the juggernaut of resistance. The latest paper lays out how TAMs are recruited to the tumor site; it also demonstrates in mice that blocking those recruitment pathways depletes TAMs and allows T cells to activate against iCCA. Intrahepatic cholangiocarcinoma arises in the bile ducts inside the liver and usually occurs in adults ages 50 to 70. It is part of a group of biliary tract cancers (gallbladder, for example) and is often treated with chemotherapy. More recently, scientists have discovered that iCCA is a diverse genomic disease with the potential for new, targeted immunotherapy options.
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Photo: Matt Wittmeyer
By Leslie Orr
ROSWELL PARK Roswell Park Experts Share Insights on Diagnosis and Treatment of Head & Neck Cancers at AHNS 2021 Team outlines strategies to improve treatment of oral and thyroid cancers at American Head & Neck Society meeting With the international community of experts in headand-neck cancers gathering virtually to share new ideas and treatment strategies at the American Head & Neck Society (AHNS) 10th International Conference on Head and Neck Cancer, underway now, Roswell Park Comprehensive Cancer Center teams are presenting new research on both the basic science supporting new treatments as well as opportunities to improve the early and accurate diagnosis of thyroid cancer and other head/neck malignancies. Among the 17 presentations of new research led by Roswell Park’s head/neck cancer experts, representing several
Our latest work presented at AHNS identifies several opportunities to apply nextgeneration insights, and we’re proud to help shape these conversations and advance the care of cancer patients everywhere. disciplines and expertise in both clinical and laboratory research, are three studies that may lead to development of new and more effective drugs and treatments for oral-cavity cancers and another trio of studies focused on improving the diagnosis and treatment of thyroid cancers. “This is an exciting time for all of us who are working to improve the care and outcomes of patients with cancers of the head and neck, because we’re able to take advantage not only of improvements in diagnostics and traditional therapies but the incredibly detailed understanding we now have of processes at the molecular level,” says Wesley Hicks Jr., MD, FACS, Chair of Head & Neck/Plastic & Reconstructive Surgery at Roswell Park. “Our latest work presented at AHNS identifies several opportunities to apply next-generation insights, and we’re proud to help shape these conversations and advance the care of cancer patients everywhere.” To support their studies in oral cancer, the team applied two distinct approaches to advance the understanding of activity in the microenvironment of oral-cavity tumors:
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• The team used immunohistochemical analyses to (1) characterize a type of regulatory T cell that supports tumor growth and impedes immunotherapy and (2) analyze tumor expression of the NY-ESO-1 antigen in oral cavity dysplasia and carcinoma, showing that presence of this protein increased during tumor development. (Abstract P020 and Abstract P038) • For another study, the team examined the role that exosomes — small vesicles secreted by tumor cells — play in interfering with chemotherapy and immunotherapies, demonstrating that they increase in abundance as cancer progresses. (Abstract P031) In three separate projects addressing thyroid cancer incidence, detection and diagnosis, Roswell Park researchers report that: • Core needle biopsy, the diagnostic tool used most frequently in Roswell Park’s head/neck cancer practice, correctly diagnosed thyroid cancer and identified an especially aggressive subtype, tall cell variant (TCV) papillary thyroid carcinoma, more frequently than an alternative diagnostic approach, fine needle aspiration (FNAC). (Abstract P203) • TCV papillary thyroid carcinoma has been diagnosed more frequently among patients seen at Roswell Park, compared to national incidence rates, and this aggressive subtype requires close post-treatment surveillance. (Abstract P172) • Lectins, naturally occurring proteins present in many plant-based foods, represent a promising biomarker candidate that may be able to help distinguish different subtypes of thyroid cancer to support the most appropriate and personalized treatment strategies for each individual patient. (Abstract P136) “We’re seeing increasing numbers of aggressive thyroid cancers in our practice at Roswell Park,” says Vishal Gupta, MD, Assistant Professor of Oncology and Otolaryngology in the Department of Head & Neck/Plastic & Reconstructive Surgery at Roswell Park. “Through this trio of studies, we’re working to quickly identify, characterize and address this apparent trend to help guide treatment and follow-up for patients with especially aggressive or hard-to-diagnose thyroid tumors.”
Roswell Park Team Shows Dendritic-Cell Vaccines Can Be Paired with Standard Therapy for Breast Cancer iPSC-derived dendritic cells can work synergistically with radiation therapy to control both local and distant tumors A research team led by Fumito Ito, MD, PhD, FACS, of Roswell Park Comprehensive Cancer Center reports new data on the promise of combining standard treatment for breast cancer with a particular form of cancer immmunotherapy — dendritic-cell (DC) treatment vaccines. This study, published in the Journal for ImmunoTherapy of Cancer, is the first to demonstrate that in situ dendritic-cell vaccines can improve the effectiveness of radiation therapy for some aggressive and treatment-resistant forms of breast cancer. “Although immunotherapy with primary conventional dendritic cells is a promising approach, obtaining a sufficient
Fumito Ito, MD, PhD, and colleagues have shown that dendritic-cell treatment vaccines can be combined with radiation therapy as a potential treatment for some breast cancers.
ficking of intratumorally injected iPSC-DCs to the tumordraining lymph nodes and augmented the activation of tumor-specific T cells. Their work shows that this multimodal intralesional therapy can control growth of distant tumors and render some breast cancers responsive to anti-PD-L1 therapy “While our work to develop this strategy is at an early stage and will need to be studied further, we show that these two approaches, radiotherapy and intratumoral iPSC-DC administration, can work synergistically to control not only local tumor growth but also distant tumors. And we saw evidence of systemic tumor-specific immunological memory, suggesting a potential for long-term tumor control,” says Dr. Ito. This study sheds light on the antitumor efficacy of in situ administration of iPSC-DCs when integrated with radiotherapy against poorly immunogenic tumors. These findings align with another study from Dr. Ito and his team, recently published in Nature Communications, that showed potent systemic antitumor immunity caused by combinational multimodal intralesional therapy. “Currently, efficacy of immunotherapy against breast cancer is limited,” adds Dr. Ito. “Our hope is to improve clinical outcomes for patients with advanced unresectable and metastatic breast cancer.”
number of circulating conventional dendritic cells has proved difficult,” says Dr. Ito, who is Associate Professor of Surgical Oncology at Roswell Park. Use of induced pluripotent stem cells (iPSCs) has been proposed to overcome that limitation, but the feasibility of this approach had not previously been demonstrated. To better understand the potential Building Healthcare Practices, Together of this approach, Dr. Ito and colFor Doctors, Dentists and Veterinarians leagues conducted laboratory studies to assess the antitumor efficacy of intratumoral injection of iPSC-DCs, or dendritic cells derived from iPSCs, and radiotherapy in models of triplenegative breast cancer that have shown Healthcare professionals are crucial to the strength resistance to anti-PD-L1 checkpoint of our communities. When planning your financial inhibition immunotherapy. strategy, consider the difference Tompkins Bank of Castile The team’s results show that intracan provide as you work toward building your practice. tumoral administration of iPSC-DCs significantly enhanced antitumor efficacy of local irradiation, which is commonly incorporated into treatment plans for patients with breast cancer. The researchers demonstrate that radiation therapy increased the trafBankofCastile.com
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URMC URMC Part of Collaboration Awarded $10M for Pediatric Concussion Research National trial will study biomarkers that predict delayed recovery in children, teens Researchers at the University of Rochester Medical Center are part of a new collaborative project, led by the University of California, Los Angeles, to study concussions in children and teens. The project, which was awarded $10 million from the National Institute of Neurological Disorders and Stroke, will test ways to predict which kids will develop persistent symptoms after a concussion, so researchers can study how to help them recover faster. The grant to the Four Corners Youth Consortium, a group of academic medical centers studying pediatric concussions, will support Concussion Assessment, Research and Education for Kids, or CARE4Kids, a multisite study that will enroll more than 1,300 children and teens nationwide, including an estimated 240 in the Rochester area. Every year, more than 3 million people in the U.S. are diagnosed with concussions. Symptoms continue to plague 30 percent of patients three months after injury and adolescents face an even higher risk of delayed recovery. Chronic migraine headaches, learning and memory problems, exercise intolerance, sleep disturbances, anxiety and depressed mood are common. The pre-teen and teen years are critical for psychosocial and brain development and researchers fear what long-lasting concussion symptoms could mean for the developing brain. “Prolonged concussion recovery can have an enormous impact on the lives of teens and pre-teens, often setting the stage for academic difficulties, persisting mood disorders, and chronic pain,” said Jeffrey Bazarian, MD, MPH, professor of Emergency Medicine at URMC, who will lead the Rochester study site. “Early evaluation and treatment for kids at high risk for prolonged recovery is our best hope for preventing an acute injury from becoming chronic.” The study, which focuses on children between the ages of 11 and 18, will unfold in two phases. The first part will evaluate children with concussions to identify a set of biomarkers — including those related to 28 I VOLUME 4 I 2021 WNYPHYSICIAN.COM
changes in blood pressure, heart rate and pupil reactivity — that could predict which kids will develop persistent symptoms after a concussion. The next will seek to confirm that these biomarkers accurately predict prolonged symptoms in a second group of children diagnosed with concussions. Ultimately, the team hopes to develop an algorithm to help healthcare providers diagnose and treat concussed kids and to enable the future development of therapies that could help kids recover from concussions faster. “Discovering objective biomarkers for persistent post-concussion symptoms will permit earlier intervention and future use of specific treatments for these patients,” said national project leader Christopher Giza, MD. director of the UCLA Steve Tisch BrainSPORT Program and professor of Pediatrics and Neurosurgery at UCLA’s David Geffen School of Medicine and Mattel Children’s Hospital. “Our big goal is to alleviate suffering and promote maximal recovery.”
Risk Management Tip: Managing Negative Online Reviews The Risk Healthcare providers recognize that along with their practice websites, public websites such as Yelp, Healthgrades, and Rate MDs, and social media sites like Facebook and Twitter, can be used as marketing tools to inform the public of their services. The online community, however, is then afforded an opportunity to respond, rate, and, at times, complain about those services. These statements and reviews are readily accessible to anyone with an internet-ready device to open and read. While there is a basic instinct to immediately respond to negative online reviews, healthcare providers must remember that privacy rules make a complete response via social media inappropriate, and responding directly to an online post puts the healthcare provider at risk of disclosing protected health information (PHI). Your response may not contain any identifying statements, but the mere recognition of a patient-provider relationship is a potential HIPAA violation. The following tips will help you successfully and appropriately respond to negative online reviews:
Recommendations 1. Critically review all social media posts for accuracy and authenticity. While some negative statements regarding the performance of you or your staff may be difficult to read, evaluate these reviews to determine if there is any opportunity for learning or process change. 2. Do not become engaged in online arguments or retaliation—especially if the comments made are particularly negative and potentially detrimental to the reputation of the facility or physician. 3. According to federal and state confidentiality and privacy laws, providers are precluded from identifying patients on social media. In order to protect patient privacy, all patient concerns and complaints should be resolved by the practice by contacting the patient directly and not through social media. 4. If you do choose to respond via social media, use a standard response that also serves as a marketing opportunity for your practice. Some examples include: • “[Insert name] Medical Group is proud to have been providing comprehensive and compassionate care in the community since [insert year] and takes our treatment of its patients and their privacy seriously. Because federal privacy laws govern patients’ protected health information, it is not the policy of [insert name] Medical Group to substantively respond to negative reviews on “ratings” websites, even if they provide misleading, unfair or inaccurate information. We welcome all our patients and their families to address any concerns/requests or information about their care with us directly, as we strive to continue to provide individualized care in our community.” • “At our medical practice, we strive for patient satisfaction. However, we cannot discuss specific situations due to patient privacy regulations. We encourage those with questions or concerns to contact us directly at [insert phone number].” 5. If you feel the patient’s complaint has disrupted the physician-patient relationship, consider discharging the patient from your practice. This action may be viewed as retaliatory by the patient and may set off a new series of negative posts. Attorneys at Fager Amsler Keller & Schoppmann, LLP are available to assist you to make this decision. 6. Notify your local authorities if you feel at any time that your safety, the safety of your staff or your family is threatened or at risk. Reprinted with permission from www.MLMIC.com. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC. WNYPHYSICIAN.COM VOLUME 4 I 2021 I 29