CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
USING LIFESTYLE CHANGES TO TREAT CARDIOVASCULAR DISEASE CARING FOR ADVANCED COMPLEX ILLNESSES THE IMPACT OF INSURANCE CHANGES ON PATIENTS AND PHYSICIANS
chesphysician.com VOLUME 5: ISSUE 1 JAN/FEB 2015
Maryland/DC/Virginia
Contents 20
VOLUME 5: ISSUE 1 JAN/FEB 2015
10
F E AT U R E S
10 Using Lifestyle Practices to Treat Cardiovascular Disease 16 Caring for Advanced Complex Illnesses
D E PA R T M E N T S
Cases
| 7 | 30 Years of Progress in Treating Cardiovascular Disease
Solutions HIT
| 8 | PAs Expand Their Reach and Their Roles
| 20 | The Impact of Insurance Changes on Patients and Physicians
Policy
| 24 | Michael Busch: 11 Years as Maryland’s House Speaker
Compliance Living
| 27 | False Claims Investigations: Ten Best Practices for Complying with DOJ Subpoenas
| 28 | Chesapeake Culture, Chesapeake Life
On the Cover: Vinay Satwah, DO, medical director, Center for Vascular Medicine
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CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
Maryland/DC/Virginia www.chesphysician.com
JACQUIE COHEN ROTH FOUNDER/PUBLISHER/EXECUTIVE EDITOR jroth@chesphysician.com LINDA HARDER, MANAGING EDITOR lharder@chesphysician.com
One year ago, I wrote a publisher’s letter stating that the year ahead in healthcare would be rich with challenges and innovation, requiring physicians and healthcare leaders to be especially adaptable to change. Little did I know my words were foreshadowing what lay ahead for my own business. With this issue, I’m pleased to unveil Chesapeake Physician – Your practice. Your life. This new name represents the expansion and re-branding of Maryland Physician Magazine – Your practice. Your life. as we welcome new physicians in Northern Virginia and Washington, D.C. to our readership. With the advent of the Patient Protection and Affordable Care Act (ACA) in 2010, I recognized that there was a void in the Maryland healthcare marketplace for a print and online connection among Maryland-based physicians and healthcare stakeholders. I launched Maryland Physician’s inaugural issue in May/June 2011 to create a multi-media platform that spotlighted leading-edge healthcare diagnostic and treatment protocols as well as all aspects of practicing medicine. Our founding mission was to grow a physician and healthcare stakeholder network with a commitment to achieving the highest standards of quality and efficient patient care. Thanks to the development and support of a dedicated team of writers, artists, advisors, contributors and advertisers over three-plus short, very busy and very exciting years, I've grown Maryland Physician to fill that void, becoming a renowned and well-regarded resource for Maryland-focused healthcare industry news. Over the last part of 2014, I launched an online reader poll, met with my Advisory Board and asked healthcare policy influencers and makers if it made sense for us to expand our network to encompass the broader Chesapeake region. The answer was a clear and resounding ‘yes!’ My mission remains constant, but with an expanded scope that includes the healthcare industry in the District of Columbia and Northern Virginia (NOVA). With the name Chesapeake, there is the opportunity for future growth from Cooperstown, New York, through Hampton Roads, Virginia (see Living, page 28). For now, though, we focus on Maryland, D.C., and NOVA. As I wrote back in May 2011, every medical practice today, no matter the size or specialty, is challenged by ever-increasing complexities that impact the art and science of practicing medicine. It’s my passion and my goal to keep you informed, intrigued and inspired with content and events focused on leading-edge treatments and practical advice for managing a clinical practice. Now, it’s my distinct honor to extend our reach beyond Maryland’s borders and into other areas of the Chesapeake Bay, inclusive of providers, healthcare stakeholders, patients and their families. To life!
Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician
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JACKIE KINSELLA, MANAGER OPERATIONS, SOCIAL & DIGITAL MEDIA jkinsella@mojomedia.biz CONTRIBUTING WRITER Anne K. Sessions COPY EDITOR Ellen Kinsella LISA WOLFINGTON, BUSINESS DEVELOPMENT lwolfington@mojomedia.biz PHOTOGRAPHY Tracey Brown, Papercamera Photography Chesapeake Physician – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Chesapeake Physician is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email jkinsella@ mojomedia.biz. Chesapeake Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, MD, FACS KURE Pain Management MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center DANILO ESPINOLA, MD Advanced Radiology GENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, DO, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine-free paper
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CASES
30 Years of Progress in Treating Cardiovascular Disease
I
FIRST MET ‘FRED’ WHEN HE WAS 32 years old, with his first inferior myocardial infarct (MI). We treated him with streptokinase within two hours of chest pain onset. His ejection fraction (EF) remained intact. However, this tale really started many years before that MI. Fred remembers going to the National Institutes of Health (NIH) when he was 10 years old and being told that he, his mother and other siblings had a unusual familial hyperlipidemia that would promote premature cardiovascular disease. He vividly remembers coming home from school to find the paramedics doing CPR on his 37-year-old mother on the front porch. She died of a massive heart attack. Science had little to treat lipid problems in the 1960s. While Fred never smoked and was not diabetic, his other risk factors indicated that it was only a matter of time before he also developed heart disease. When he had his first heart attack, he had a one-year-old son and a brilliant career in sales. Over the next 12 years, we valiantly worked to control his high lipids with diet, exercise and every novel therapy that existed, including first-generation statins, but only achieved modest success. During that time Fred continued to work in sales and enjoyed his wonderful family. Then disease and tragedy struck. They say bad things come in threes. When Fred was barely 42, his only son died of a brain tumor, his marriage failed, and he had another massive anterior heart attack. He was rushed to the catheterization lab within 30 minutes of the onset of chest pain, and the proximal LAD was found to be completely occluded. It was successfully opened
By Nisha Chandra Strobos MD, FAHA
using RheoPro® and two TRISTAR overlapping stents, which were state-ofthe-art therapy at the time. The heart muscle damage was mitigated, but sadly, not aborted. His EF was now 20%. Fred returned to work, but his heart function remained low. At the age of 44, he developed short, three-to-five beats, of non-sustained ventricular tachycardia (VT) presenting as dizzy spells. As luck would have it, the MADIT 2 study had just demonstrated that patients such as Fred lived longer with an automatic implantable cardioverter defibrillator (AICD). We implanted an AICD that just a few days later shocked him in the middle of the night, terminating VT. Without the device, he would have likely died.
he was suffering from severe Class 3 congestive heart failure. Cardiac resynchronization therapy (CRT) had emerged as a proven, effective strategy of care for patients with severe heart failure and QRS prolongation. Such patients often had cardiac dyssyncrony; e.g., the right and the left ventricle did not contract simultaneously. CRT requires the placement of an additional coronary sinus lead in the heart and can be lifechanging in select patients. We placed a CRT device in Fred’s heart, and his improvement was nearly miraculous. He began exercising again, and today he runs a yearly charity golf tournament that raises money for children with brain cancer. His lipids are as good as they
While Fred never smoked and was not diabetic, his other risk factors indicated that it was only a matter of time before he also developed heart disease. It was evident that Fred was not out of the woods. His ischemic cardiomyopathy produced short bursts of VT that the AICD treated with overdrive pacing. However, these frequent episodes were worsening his condition. Guided by his team of doctors, Fred faced the difficult decision of going on amiodarone, an effective yet problematic medicine with many side effects – for the rest of his life – or receiving ventricular tachycardia ablation, a high-risk procedure that might prove highly successful. Fred chose the ablation, and thankfully his arrhythmia improved. However, the arrhythmia had worsened his EF. Despite maximal medications, Fred struggled to work or perform many of his typical daily activities. At age 53,
have ever been on triple therapy that includes rusuvastatin. Fred is now 24 years out from his first heart attack. He can walk for an hour at four miles/hour on a steep incline. Indeed, bad things happened in threes to Fred many years ago. He could have died. However, medical science came to his rescue. He received a primary stent, an implantable cardiovertor-defibrillator, an ablation and a CRT device. He is now more than “OK.” Good things and science also happen in threes… or more. Dr. Strobos is chief of Cardiology, Johns Hopkins Bayview Medical Center, and professor of Medicine, Johns Hopkins University School of Medicine. She can be reached at nchandra@jhmi.edu.
JANUARY/FEBRUARY 2015
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SOLUTIONS
PAs Expand Their Reach and Their Roles
P
By Theresa Neumann, PA-C
HYSICIAN ASSISTANTS (PAs) have long been on the frontlines of healthcare, serving as trusted medical professionals to patients in areas where healthcare providers are in short supply. Legislation that took effect this past fall will further increase access to these practitioners in rural areas of Maryland. House Bill (HB) 459 recently extended the Maryland Loan Assistance Repayment Program for Physicians (MLARP) to include PAs. Approved by the Maryland General Assembly in its 2014 session, it took effect October 2014. As is true for similar legislation passed by states throughout the nation, the law is expected to increase the number of PAs practicing in underserved areas by offering them an education loan repayment program. With the passage of this legislation, Maryland joined Washington, D.C., Virginia and 45 other states that have made legislative or regulatory improvements for PAs. These loan repayment programs, which award up to $25,000 per year for a two-year obligation, usually require a few years of service in exchange for reimbursing loans that PAs have accrued throughout their education. In Virginia, 2014 legislation allowed qualified PAs to testify as expert witnesses on matters within their scope of practice, administer topical fluoride to children’s teeth and be considered healthcare providers for the purpose of medical malpractice. PA Training and Scope of Practice
PAs receive graduate-level training in an intense medical program that teaches them to diagnose, treat and prescribe medication. In addition to many medical procedures, PAs perform physical examinations, order and interpret lab tests, assist at surgery, provide patient education and counseling, and make 8|
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rounds in hospitals and nursing homes. PAs must graduate from a nationally accredited ARC-PA program and pass the national certification exam. The PA profession has never been stronger and is projected to grow 38% from 2012 to 2022. Over the years, many of the original barriers to their scope of practice have been eliminated – including legal, regulatory and employer-based restrictions. That has allowed them to practice at the top of their education. The incentive program allows a wider range of students to consider becoming PAs, further establishing them as a viable and trusted option for medical care.
practices, PAs have become an integral part of healthcare, both in primary care practices and in specialty practices. More than 6,000 new PAs enter the workforce each year. Data from the National Commission on Certification of Physician Assistants (NCCPA) shows unprecedented levels of demand for PAs upon graduation. Some 78% of recent graduates receive multiple job offers, and 52% entertain three or more. As the number of patients increases, due to an aging population and the newly insured, there will be an increased demand for providers of high-quality, patient-centered care. PAs have the medical training and background that
93% of patients who have interacted with a PA in the last year agree that they will be part of the solution to address the shortage of healthcare providers. By design, PAs and physicians practice as a team and have practice agreements and scopes that embrace the strengths of each provider. Studies have shown that teams of PAs and physicians can allow a practice to see more patients, improve patient outcomes, decrease wait times and improve patient satisfaction. Survey Data
A recent Harris Poll commissioned by the American Academy of Physician Assistants (AAPA) found that 93% of patients who have interacted with a PA in the last year agree that they will be part of the solution to address the shortage of healthcare providers. Additionally, 91% agree that PAs improve health outcomes for patients. Given the high patient satisfaction rates documented for PAs in every aspect of medicine, and the value of the physician-PA relationship in numerous
enables them to care for these patients. According to the poll, only 24% of U.S. adults say they have found a primary healthcare provider whom they like and trust. These findings suggest that PAs are needed to help fill the gaps. The generalist medical knowledge that PAs possess lends itself well to rural environments, where healthcare providers who have knowledge of primary care, as well as surgery and other specialties, are crucial for populations that continue to have limited access to care. PAs are an established and highly trusted part of a collaborative healthcare team that depends on collaboration and communication among all parties involved, with an emphasis on what’s best for the patient. Theresa Neumann, PA-C, is the legislative chair and director-at-large of the Maryland Academy of Physician Assistants. Learn more about Maryland PAs at mdapa.org.
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Using Lifestyle Factors
TO TREAT CARDIOVASCULAR DISEASE BY LI NDA H A RDER • PH OTO GRA PHS BY TRAC EY B ROW N
Western medicine has tended to emphasize medication and procedure-based approaches to treat cardiovascular disease. A growing number of physicians, however, are successfully using lifestyle changes that include nutrition and Transcendental Meditation (TM) to prevent disease or serve as a treatment adjunct.
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REVERSING WESTERN ‘MALNUTRITION’ Most doctors in practice today have received little or no nutrition training, and many have limited knowledge of how to use diet to prevent or treat the disease. Monica Aggarwal, MD, a cardiologist and director of echocardiography at Mercy Medical Center, was one such physician until she got sick following the birth of her third child. She recalls, “I met a nutritionist who felt that dietary changes could help me. I dismissed her comments at first, but she persisted. She taught me that I knew very little about nutrition and how important it is. Today, I use my own experience to help my patients through better nutrition, and I’ve seen it produce amazing results”
Inflammation “Certain factors trigger plaque formation, such as high cholesterol, diabetes, high blood pressure and smoking,” says Dr. Aggarwal. “Those plaques grow and build over time.
We don’t know, though, which of those plaques will rupture and create heart attacks. We do know that if patients’ inflammatory markers are high, they are at higher risks for events. So I focus on decreasing inflammation by modifying risk factors and aggressively modifying diet. The transition to a whole-grain, plant-based diet that is low in processed foods is key to decreasing that inflammation.” The American Heart Association recommends that CRP tests be limited to those with a 10-20% (moderate) risk of a myocardial infarct in the next 10 years. Of course, clinicians must consider that inflammation elsewhere in the body can cause an elevated CRP. Marsha Seidelman, MD, an internist with a practice based in Silver Spring, Maryland, is another physician who takes nutrition seriously. While she also believes that some foods can increase inflammation, she does not monitor CRP levels. “One of the reasons I don't check them,” she says, “is that we have no specific treatment for inflammation.
Monica Aggarwal, MD, cardiologist and director of Echocardiography at Mercy Medical Center
If someone has cardiovascular risk factors, I will use the usual preventive measures such as aspirin and statins.” “Nutrition has not been extensively studied because there’s no money in it, as there is in pharmaceuticals,” explains Dr. Aggarwal. “I am doing small retrospective studies on how plant-based diet affects inflammation in chronic illness.” Dr. Seidelman agrees that nutrition research is limited. “There are so many confounding issues and variables – how much exercise the person got, how the food was prepared, etc. – that I take everything I read with a grain of salt,” she says. “That said, a Mediterraneanstyle diet emphasizing whole grains, fruits and vegetables is really important. I encourage physicians not to get overwhelmed by all the conflicting data in the journals. Just have a general roadmap – such as increasing vegetables, healthy oils and unprocessed foods – since these recommendations haven’t changed much for years, and there is more data to support them.”
Guide Nutrition Choices Dr. Seidelman continues, “Patients don’t understand that what they eat affects their long-term health. But physicians can’t just say ‘lose weight.’ That’s not very helpful. For example, many people don’t realize that a white hamburger bun is a processed food. You have to explain what it is. “I review nutrition in every yearly physical, trying to shift people away from red meat,” she adds. “If they’re trying to lose weight, I focus on portion control, eating slowly and drinking water before the meal. Overly restrictive diets can backfire, especially over the long run. I encourage people to do what works for them. If patients can make no other changes, however, I encourage them to add more vegetables to their diet. Even losing five to 10 pounds can start to make a difference in risk factors and outlook.”
The Evidence for Eating Your Vegetables While research remains limited, often
with conflicting results, it’s hard to deny the evidence for eating more vegetables. An April 2013 study published in the New England Journal of Medicine found that those consuming Mediterranean diets supplemented with nuts or extravirgin olive oil had a 3% lower death rate after 4.8 years than those on a low-fat diet. Like Dr. McDougall, Caldwell Esselstyn, Jr., MD, a former surgeon at the Cleveland Clinic, believes that conventional cardiology has failed patients by developing treatments that focus on the symptoms of heart disease, not the cause. He advocates for a plantoriented diet without added oils to prevent and even reverse heart disease. A study he published in the July 2014 issue of The Journal of Family Practice found that nearly 200 people with established heart disease who adhered to a vegan diet for three years had a low recurrence of cardiovascular events (0.6%). Dr. Esselstyn hypothesizes that a plant-based diet prevents the creation of trimethylamine oxide (TMAO), an JANUARY/FEBRUARY 2015
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Marsha Seidelman, MD, internist in Silver Spring, Md.
atherogenic compound produced only by omnivores who eat animal products. “Red meat contains carnitine which, when digested, is turned into TMAO by our gut bacteria,” Dr. Aggarwal notes. “And TMAO has been found to increase atherosclerosis. Eating fish increases urinary TMAO, which means you’re excreting more of it. Gut bacteria is an exciting field of study and it may turn out to be more important than saturated fats.” She adds, “A meat diet is catching up to us. I recommend completely eliminating red meat and strongly advise eliminating dairy and processed foods. Because we pasteurize milk, we destroy all of the enzymes, and our microbiome can’t deal with it. Studies have shown that consuming dairy doesn’t decrease our osteoporosis risk, and greens provide significant calcium. I tell all of my patients that I can treat their heart disease with medications, but why not try a plant-oriented diet?” A meta analysis of studies involving a total of 900,000 people, published in the South American Journal of Epidemiology in September 2014, found that increased fiber from cereal and, to a lesser extent, vegetable sources, 12 |
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decreased the risk of several chronic diseases, including cardiovascular disease and diabetes.
Potential Benefits from Spices “I believe that spices, such as pomegranates, turmeric and cinnamon, can be beneficial,” Dr. Aggarwal states. “Pomegranates today are available in powder form, juice, seeds, or whole in most grocery stores. Turmeric is one of the most potent anti-inflammatories and anti-bacterials. Raw turmeric is hard to use, so powder is okay. I buy it from an Asian grocery store because it’s fresher. Including ground black pepper with the turmeric allows your body to absorb the spice.” The National Institutes of Health (NIH) reports that data on the value of pomegranates in heart disease prevention is mixed. Some studies have shown that it may lower cholesterol and systolic blood pressure, while others have shown no value. Likewise, the evidence for curcumin, the active ingredient in turmeric that prevents platelets from clumping together, to improve cholesterol levels, is inconclusive. Clearly, more research would be invaluable in helping physicians guide their patients.
TM REDUCES CV RISK FACTORS Developed by Maharishi Mahesh Yogi and brought to this country in the 1960s, Transcendental Meditation (TM) is one of many meditation approaches available to help people achieve a state of relaxed awareness. Its proponents point out that it is the most clinically studied form of meditation, with more than 380 peer-reviewed published studies documenting its health benefits, including a significant impact on cardiovascular health. Norman Rosenthal, MD, clinical professor of psychiatry at Georgetown University School of Medicine, is a well-known physician who espouses and practices TM. He explains, “All meditation practices are different. It’s understandable that people try to lump them together, but it’s like saying that all antibiotics are the same. TM involves sitting in a comfortable position, closing one’s eyes and thinking of the mantra that has been given to you by your teacher. It’s easy to learn but is a subtle process that helps to clear thoughts and distractions. You learn to let thoughts come and go, and to let the mantra come to you rather than working to go back to it.”
Stuart Rothenberg, MD, FAAFP, national director, TM Health Professionals Program, and teacher of continuing education in Ayurvedic Medicine at the University of Maryland Center for Integrative Medicine, adds, “The hallmark of TM is ‘transcending,’ which means the mind automatically settles down to quieter and quieter levels and ultimately goes beyond thought altogether. TM is not mindfulness, which prevents the mind from transcending. Instead, TM is experienced as a state of complete relaxation that’s even deeper than sleep. Patients tend to stick with it because it’s easy to do and pleasant.” Like Dr. Rosenthal, Dr. Rothenberg practices TM and has experienced its benefits first hand, both personally and in his medical practice. “I was my own first case study,” he recalls. “TM immediately helped me feel less stressed and need less sleep. And shortly after I began prescribing it to patients, a young man found it helped him to quit smoking in six weeks, after other approaches had failed. Later, an 82-year-old male significantly reduced his blood pressure after only two weeks of TM.”
Extensive Research Documents TM’s Benefits Nine randomized clinical trials have demonstrated that TM has a significant impact on hypertension, and concluded that anti-hypertension medications can be decreased on average by 25% with this practice over a one-year period. In a June 2014 issue of Hypertension, the AHA stated that TM was the only documented meditation practice for lowering hypertension, and endorses its consideration for use in clinical practice. Additionally, a series of NIHsponsored clinical trials and metaanalyses found that TM significantly reduced insulin resistance, smoking and alcohol abuse, carotid intima-media thickness and left ventricular hypertrophy. More importantly, a five-year randomized controlled study published November 2012 in Circulation found a nearly 50% decrease in death, heart attack and stroke in those who practiced TM, compared to the control group.
MD Referrals Cut Costs, Improve Compliance Dr. Rosenthal acknowledges, “There’s real data from controlled studies of TM. But unless the physician really flags TM as helpful, patients won’t pursue it. You can’t just lump it in generally with other
recommendations like ‘exercise more.’ You also can’t just give patients a pamphlet – it must be taught. Physicians should refer patients to a qualified center.”1 Contributes Dr. Rothenberg, “Patients receive a discount if referred by a doctor, and free introductory sessions are offered to help patients learn more. The fee can be paid in installments and there’s a sliding scale for those with financial needs.” “Practitioners should check in with their TM teacher regularly,” Dr. Rosenthal adds. “There’s no extra charge, and the influence of the group reinforces the practice. For those who claim they don’t have time, I say that keeping healthy takes time – you can spend that time in cardiac rehab after you have a heart attack, or in TM beforehand.” “You might think that I’ve just ‘drunk the Kool-Aid,’” he laughs, “but I’ve been repaid many times over. You have to do TM regularly or it does no good. But slowly, good things start to happen, and
THERE’S REAL DATA FROM CONTROLLED STUDIES OF TM. BUT UNLESS THE PHYSICIAN REALLY FLAGS TM AS HELPFUL, PATIENTS WON’T PURSUE IT. - Norman Rosenthal, MD
thanks to TM, small stressors during the day bounce off my shoulders. I would no more think of skipping it than I would skip brushing my teeth. Your brain is different – ‘lightened’ – afterwards. TM is like a surge protector for life’s daily stresses.” Dr. Rothenberg concludes, “TM creates a state of transcendence. It’s effortless and a delight to learn and practice.” Surely no patient ever felt that way about a pill they were taking.
OPTIMAL MANAGEMENT OF PAD Patients with coronary artery disease are also at higher risk for peripheral artery disease (PAD). As with cardiovascular disease, it’s critical for patients to comply with long-term lifestyle changes as part of PAD management. Vinay Satwah, DO, medical director at the Center for Vascular Medicine (CVM), notes, “PAD risk factors are similar to cardiovascular risk factors – smoking, poor diet and lifestyle leading to diabetes, high blood pressure and cholesterol, and increased age. Atherosclerosis begins in the coronary arteries and migrates to the peripheral vessels eventually.” Patients may present with a variety of symptoms, including buttock or leg pain, cramping, or tightness that worsens with activity and alleviates with rest. He adds, “The disease process can be asymptomatic starting in one’s 30s and 40s, and manifest itself later on in life in the 60s or 70s. Patients will tell me that they’ve been good with diet, but they don’t realize that the disease has accumulated over years and that it may take years of lifestyle changes to halt the progression of PAD.”
Diagnosis Starts with Non-invasive Measures Diagnosing PAD starts with a simple Ankle Brachial Index test (ABI), a blood pressure ratio that can performed in the primary care office. However, Dr. Satwah cautions physicians, “When determining the ratio of blood pressure in the arm to that in the ankle, make sure that the higher brachial number is used as the denominator for both measurements, regardless of which side of the body it was on. “The gold standard is a ratio of 1, with 0.6 to 0.7 indicating a definite case of PAD; under 0.6 indicating a severe case and under 0.5 denoting critical limb ischemia, in which case it must be treated quickly,” he continues. ”If you get a reading above 1.2, it could indicate a diabetic with non-compressable vessels that have hardened so much we cannot get an accurate reading. In those cases, ABI is not a good predictor of PAD and we may need to obtain toe pressures.” The next test is pulse volume recording, a physiological study that looks at changes in blood-vessel volume from the proximal leg down through the distal thigh and into the calf, and translates it into waveforms. Dr. Satwah notes, “If the waveforms are high in the JANUARY/FEBRUARY 2015
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Vinay Satwah, DO, interventional cardiologist and medical director, Center for Vascular Medicine
proximal thigh but drop significantly at the calf, it’s likely hemodynamically significant disease between the two segments. Those patients should be referred to a vascular center.” Arterial duplex ultrasound is another useful tool used to evaluate blood flow in the leg. “Only a specialized vascular ultrasound technologist should perform this study,” cautions Dr. Satwah. “Increased velocity is suspicious for PAD, but not foolproof. Patients who are obese, have significant gas or edematous legs may not have accurate results.”
...IT MAY TAKE YEARS OF LIFESTYLE CHANGES TO HALT PROGRESSION OF PAD. - Vinay Satwah, DO
complete obstructions to help plan our interventional treatment strategy,” explains Dr. Satwah. “If we find a lesion, my preference is usually to fix it in the same setting, unless, in rare cases, the patient requires open bypass surgery or has a renal issue.”
Conservative Treatment The first ‘prescription’ for PAD is 30 to 45 minutes of continuous aerobic activity at least five times a week. According to Dr. Satwah, “As long as the heart rate increases to our target rate (about 220 minus the patient’s age) for that time frame, whatever activity the patient prefers is fine. Patients who have intolerable pain should discontinue exercise, but pain from mild PAD often diminishes with continuing activity.” Other conservative approaches involve switching to a low-cholesterol, low-fat diet that will also help keep the patient’s blood glucose levels under control, and smoking cessation. Dr. Satwah says “We typically try these approaches for three months in patients with mild to moderate PAD. If they have pain at rest or a non-healing leg ulcer, however, we bypass conservative measures, since this typically indicates very advanced PAD with tissue threat. These patients should be referred for a PAD workup by a vascular physician immediately.”
Invasive Testing
Atherectomy and Bypass
Angiograms remain the gold standard for evaluation of patients who have abnormal non-invasive test findings. “We look for the anatomical location, degree of narrowing and presence of
When the plaque is eccentric and bulky, an atherectomy can be performed to ‘shave off’ some of the plaque before performing balloon angioplasty. Dr. Satwah points out, “Studies that have
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compared angioplasty alone with angioplasty plus atherectomy found that the rate of restenosis is higher with angioplasty alone. There are a variety of modalities we can choose from, depending on the patient’s anatomy, plaque location and amount of calcification. All entail a small risk of embolization, but heparinization during the case, and new technologies have greatly reduced that risk. For very high-risk patients with chronic total occlusions (CTOs), we can insert a distal protection device that catches debris before it can lodge into a tiny vessel.” In Dr. Satwah’s experience, interventional treatment can last many years in a compliant patient, but less than six months in someone that is non-compliant. Bypass surgery can be efficacious over the long term in the absence of multiple comorbidities.
The Future Today in the U.S., stents for PAD are nitinol based (bare metal), but Dr. Satwah believes that drug-coated balloons, which are currently in use in Europe, will be widely available here soon. “I think FDA approval is coming within the next year, and it’s available now in clinical trials. The physician will inflate the balloon, let the medicine coat the arterial wall, then deflate the balloon,” he explains. “The medicine helps control the amount of plaque recoil.” “It’s a privilege that patients entrust their bodies to my vascular care,” he concludes. 1
Visit www.tm.org for a listing of area TM centers.
Monica Aggarwal, MD, a cardiologist and director of Echocardiography, Mercy Medical Center Marsha Seidelman, MD, an internist in Silver Spring, Md. Norman Rosenthal, MD, clinical professor of psychiatry at Georgetown University School of Medicine and author of Transcendence: Healing and Transformation Through Transcendental Meditation Stuart Rothenberg, MD, national director, TM Health Professionals Program Vinay Satwah, DO, interventional cardiologist and medical director, Center for Vascular Medicine
BOND WITH US
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Caring For
{ADVANCED} COMPLEX ILLNESSES BY LINDA HARDER
Life expectancy in the U.S. has increased, but life without disability has not. This means physicians are treating more patients with advanced complex illnesses (ACI). Three Maryland physicians discuss how they provide compassionate, anticipatory care for patients and caregivers. 16 |
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MOST PROTOCOLS AND GUIDELINES ARE written for a single disease that is amenable to treatment. Yet the number of frail patients with multiple diseases continues to increase. These patients aren’t dying, but they are in the final stage of life. Finding the balance that will help them live well with illness is one of our greatest challenges. While a growing number of physicians understand this trajectory, recognizing the point at which aggressive care may be detrimental is not easy, and the task of getting patients and caregivers on the same page can be daunting.
WHAT IS ACI? Lou Lukas, MD, director of Chesapeake Palliative Medicine, uses the term Advanced Complex Illness, or ACI, to describe the syndrome of failing physiology that is common to many late-stage illnesses. ACI patients have high, though unpredictable, mortality, complex bio-psycho-social symptoms and frequent or intense healthcare utilization. The hospital has become a regular part of their treatment. “It’s the point at which the risk/benefit ratio of treatment is
skewed permanently toward risk, and the burdens of treatment may outweigh the benefits,” she explains. “It doesn’t mean you throw in the towel, but you make very selective treatment choices.” ACI typically involves one of three trajectories, each with its own pattern of decline: z z z
End organ damage such as CHF and COPD Metastatic or highly aggressive malignancies Medical frailty and/or advanced dementia
like to have an end-of-life conversation with their doctors, only 8% have actually done so, according to 2012 data. Dr. Lukas says, “All doctors who have treated frail patients have been surprised by how long some patients live and how unexpectedly some patients die. That uncertainty keeps us from having conversations with patients who are experiencing a downward trajectory.”
PHOTO COURTESY OF AAMC
Patricia Czapp, MD, a primary care physician and chair of Clinical Integration at Anne Arundel Medical Center (AAMC), notes, “ACI is progressive, regardless of what we do. I ask patients if the standard treatment they’ve received has helped them maintain or improve their quality of life or regain lost functionality. If not, they likely have ACI and it’s time to have a different type of treatment discussion.”
PRACTICE ANTICIPATORY GUIDANCE When a patient has ACI, physicians should shift into anticipatory guidance mode. Dr. Lukas explains, “Physicians have to use the knowledge and experience we have gained about advanced illness and use it to help patients understand the road ahead. We need to be honest in helping them understand that their condition is progressive, and will have exacerbations and decline, but that we can improve both the quality and length of life by taking a twopronged approach to planning. We need ‘Plan A’ to avoid complications and maintain function, and ‘Plan B’ for what we do we do when things get worse.” She goes on to say, “If we focus on ‘end of life’ we get caught up in conversations about code status and ventilators. Instead the conversations we should be encouraging are those about what makes life worth living and how to get more of that into the time they have. Then we can help them decide which medical treatment will support their goals and which treatment exposes them to more risk than benefit.” Aimee Yu, MD, FCCP, a pulmonologist and intensivist at AAMC, says, “I explain that the body has a budget of energy. Treatments such as chemotherapy can zap that energy store without benefit and sometimes even cause harm. For example, it’s not widely known that inserting a feeding tube will actually hasten death in patients with dementia. The American Thoracic Society has issued new guidelines that contraindicate feeding tubes for these patients.”
THE PROBLEM WITH “END OF LIFE” CONVERSATIONS The Institute of Medicine released a report in the fall of 2014 entitled, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” that urges clinicians to have frequent conversations with their patients about end-of-life care. Yet, while 80% of patients would
Aimee Yu, MD, FCCP, a pulmonologist and intensivist at AAMC and Patricia Czapp, MD, a primary care physician and chair of Clinical Integration at Anne Arundel Medical Center.
“Ideally, physicians should make this conversation routine so it’s part of the history and physical,” Dr. Yu advises. “Ask patients what their wishes are before they’re in crisis.” Dr. Czapp adds, “Physicians should ask themselves if they think the patient can ever get back to where he or she was before. If not, is it okay for us to continue solely with this conventional treatment, or is it time to offer treatment that fits with this patient’s unique situation and goals?” A good resource for physicians, patients and caregivers is The Conversation Project (theconversationproject.org), an initiative started by Boston Globe columnist Ellen Goodman and others in 2010. The site contains a ‘conversation starter kit’ in both Spanish and English that can help patients converse with family members and doctors.
TOUGH DECISIONS Sometimes families wait too long to have these conversations. “When a patient can’t speak for herself and the family isn’t sure what to do, I start by asking caregivers to tell me about their Mom,” Dr. Yu explains. “What does she like, how did she grow up? And knowing Mom, what do you think we should do? I make it clear that I care about the person, and tell them up front I’ll be honest with them and let them know how things are going. The family wants to see that you’re making an effort and caring. That approach works across cultures.”
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If families argue among themselves over the appropriate course of care for their loved one, Dr. Czapp suggests, “Physicians can tell patients that it’s not our decision to make. The patient’s body has already made the decision. If a patient or family member says, ‘I’m holding out for a miracle,’ you can say, ‘me, too, and let’s prepare in case that doesn’t happen.’” Dr. Yu describes the situation of one elderly man in the ER who had advanced esophageal cancer. “The family was urging that all possible interventions be used. The patient was weak, but alert. Using all the breath he could muster, he slowly whispered a single word: ‘dig-ni-ty’. That turned the family around immediately.” “Family members who want futile, aggressive treatments may equate these treatments with love,” Dr. Czapp notes. “We need to help them see in cases like these, love can be expressed by providing compassionate care that respects the body’s limitations.”
PALLIATIVE AND HOSPICE CARE By the time a patient has ACI, there are few, if any, truly “curative” treatments. Palliative medicine is an approach to patient care that acknowledges this and emphasizes symptom control and good decisionmaking. It doesn’t place any limits on the patient’s treatment and is appropriate at any point in a serious diagnosis. Hospice can be an appropriate next step for patients with ACI. Unfortunately, both the public and the medical community may have misconceptions about these services. Hospice is a specific benefit that entitles patients and families to team-based services provided in the patient’s home to help them come to terms with circumstances when aggressive treatment doesn’t bring additional benefit. As Dr. Lukas points out, “At the center of hospice and palliative care is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so.”
A BETTER WAY TO WRITE THE PLAN Once a plan is in place, it should be written in a way that will be respected even when the physician is not there to direct care. Living Wills were developed for this purpose, but have been found to suffer from several major limitations. They are conditional, often not available when or where needed, and may not apply to the actual situation because they were written years earlier. They also don’t carry the weight and durability of a medical order. To address these issues, more specific, portable and durable medical order forms have been created by many states. Nationally, these forms are known as Physician Orders for Life Sustaining Treatment (POLST). In Maryland they are called Medical Orders for Life-Sustaining Treatment (MOLST) and
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IS MEDICARE COVERAGE IN SIGHT? Lack of reimbursement has been one barrier to these conversations. At the time of publication, while some Medicare Advantage plans and a few state Medicaid providers reimburse for specific end-of-life conversations, traditional Medicare coverage does not. That may be changing in 2015, if CMS approves coverage of the billing codes for end-of-life conversations submitted by the American Medical Association in 2014. Medicare coverage likely would spur expanded private coverage. While no universal code currently exists for this conversation, physicians can bill for their additional time when counseling and coordinating care using existing E&M codes.
in Virginia, where forms are still in development, they are called POST. MOLST, which became law in 2013, conveys orders for CPR and other life-sustaining treatments. It must be completed for patients entering a nursing home, home healthcare, hospice, dialysis or assisted living, but can be useful for anyone with a serious illness. A physician, physician assistant, nurse practitioner or medical resident can complete MOLST. More information can be found at MarylandMOLST.org. Dr. Czapp points out, “The key to using MOLST is to understand that it can be your friend. Don’t be overwhelmed by it. We all have to fill out page one, which addresses resuscitation status. When it comes to the specific treatment sections on page two, you only need to discuss the options that fit your patient. For example, a congestive heart failure patient should express an opinion about intubation and dialysis.” Dr. Yu concludes by saying that doctors should offer to help people with hard decisions. “Sometimes doctors don’t make recommendations because we were taught to honor patient autonomy and not to be ‘paternalistic.’ Now we understand that, in these situations of deep emotion and complex decisions, patients and families appreciate it when we are ‘parental,’ offering nurturing, informed advice while respecting their need to make up their own minds.”
Lou Lukas, MD, CMO, director of Chesapeake Palliative Medicine Patricia Czapp, MD, chair of Clinical Integration, Anne Arundel Medical Center Aimee Yu, MD, FCCP, pulmonologist and intensivist, Anne Arundel Medical Center
Clinical Features In each issue, Chesapeake Physician interviews some of the region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.
Healthcare IT Chesapeake Physician explores ongoing major healthcare IT developments and the new care delivery models that depend on them, from interoperability issues to the latest on Meaningful Use, ACOs, Medical Homes, mobile health, hospital employment, mega groups, and more. Don't be left behind – read what Chesapeake physicians and healthcare IT experts have to say that keeps you abreast of the latest technology changes in every size and type of medical practice.
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HEALTHCARE IT
The Impact of Insurance Changes on Patients and Physicians
Daniel Levy, MD, owner of The Child and Teen Wellness Center, a pediatric group practice in Owings Mills, Md.
BY LI NDA H A RD ER • PHOTO GRA PHS BY TRAC EY B ROW N
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Healthcare has long been paid for in the U.S. via a byzantine set of policies and structures. As costs have risen, patients are paying a higher share out of their own pockets. Our experts examine the latest trends and their impact on your practice.
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S HEALTHCARE COSTS rose far faster than inflation in the past decades, employers and insurers alike looked for strategies to rein in their expenses. With the average cost of insuring a family in excess of $17,000 per year, they are shifting costs onto the end user in the form of higher premiums, co-pays, co-insurance and deductibles, plus implementing tiered prescription drug plans, to the point where patients are pinched by higher out-of-pocket costs. In 2013, a Deloitte study found that even employer-sponsored plans had an
average deductible of $1,135, and a Kaiser study determined that the average deductible in a high deductible plan was $2,098 for a single person and $4,037 for a family. The Affordable Care Act (ACA) capped the amount that can be shifted onto patients in its healthcare exchange plans, but even its out-of-pocket limits are higher than the average household can afford - $6,600 for an individual and $13,200 for a family in a bronze plan in 2015. According to a survey of large employers by the National Business Group on Health, nearly one-third will offer only high deductible plans in 2015, up from 10% in 2010. Slightly more than 80% of these companies offer such plans as one option of several, up from 53% in 2010. Drowning in Medical Debt
Karen Pollitz, senior fellow at the Kaiser Family Foundation, says, “Nearly all exchange plans have high deductibles. A study conducted by the Federal Reserve this summer found that most households couldn’t handle an emergency of $400, let alone thousands of dollars. Providers usually want to be paid within 90 days, but people don’t keep much in reserve, and medical debt has become a huge problem, even among those with health insurance.” In fact, NerdWallet reports that medical debt is the chief cause of personal bankruptcy and responsible for more collections efforts than credit cards. An astonishing 40% of Americans are being pursued by collection agencies for unpaid medical bills. Growth in Consumer-Directed Health Plans
Even as healthcare cost increases have been moderating – estimated to grow 6.5% in 2015 – employers continue to look for innovative approaches to reduce costs. Consumer-directed health plans seek to reduce healthcare spending by exposing consumers to the financial implications of their treatment decisions. However, that approach doesn’t work well for major medical emergencies.
Do Patients Know What They’re Buying?
“The biggest issue is that so many issues haven’t been adequately explained to the public,” says Daniel Levy, MD, owner of The Child and Teen Wellness Center, a pediatric group practice in Owings Mills, Md. “We have to explain the insurance parameters to patients – they don’t know what they’re buying. People are then angry when we ask to be paid for our services. The medical industry office is the only place where people are shocked when asked to pay at the time of service.” However, Carolyn O’Conor, MD, a family practitioner at Spectrum Family Medicine in Rockville, Md., has found that her patients are fairly cost conscious. She notes, “We have a large, internationally-diverse practice. People are more aware of what things cost. My patients are very aware of when they’ve met their deductible. As a result, they get a lot of their care at the end of the year. The flip side is that many plans now provide a wellness visit at no charge, so it has had a positive impact on physicals.” Dr. O’Conor has also seen a positive impact from the ACA’s provision that allows children to stay on their parents’ plan until age 26. “Previously, that group was often uninsured. We try to help patients work through the issues to help them. We also see the impact with our own employees – we used to cover the entire medical bill, but now they pay a small percentage. And we have gradually gone to a higher deductible plan, but we have done our best to keep them insured.” New Tactics to Curb Medication Costs
Another tactic, the creation of specialty tiers with graduated copays for expensive medications, has required many patients to pay 20 to 40% of their annual prescription costs until their deductible is met. According to a December 2013 study by Avalere Health, a private research company, 91% of plans sold through the healthcare exchanges in 2014 had four or more ‘tiers,’ for medications and diseases. JANUARY/FEBRUARY 2015
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Crohn’s disease, rheumatoid arthritis, MS and some cancers were all in the highest tier. HR 490, federal legislation, first introduced in 2011 and slated to be reintroduced in 2015, attempts to address this issue. However, its passage is far from certain. In addition to specialty tiers, socalled ‘step therapy,’ the practice of requiring patients to try less costly drugs before using more expensive specialty medications, is on the rise. These policies can have dire consequences for some patients, such as those with primary immune disorders, where switching medications or being required to get sick before they can receive appropriate treatment, has a high cost to their health. Dr. O’Conor says, “I encourage patients to call us if something we have prescribed is costly, as there may be another way to go. I never want to prescribe something unnecessarily expensive.” Prior Authorizations
Another approach to control costs requires doctors to obtain prior authorization for some medications. Dr. Levy notes he now spends considerable time obtaining prior authorization for medications that his patients have used for years, noting, “It boggles the mind. These children have had ADHD or other chronic disorders for years, yet suddenly we need authorization. Once we arrive at a good homeostasis, we want to maintain, not jeopardize that.”
Debbie Redd, CEO of Capital Women’s Care
throughout Maryland, notes that their specialty presents a unique challenge. “We treat our obstetric patients for nine months without getting paid. That makes it very important for us to know up front what insurance they have. We do a lot of pre-authorization work after they call to make an appointment and we collect a deposit and copays up front even if we have to later refund the patient some money. We do a good job on that. As a result, we haven’t seen an increase in our bad debt.” Redd acknowledges that it may be
My impression is that, overall, the ACA is a good thing. It’s the history of the way health insurance is set up in this country that’s the problem. – Carolyn O’Conor, MD
He adds, “Less than 10% of medical care dollars are spent on children, yet those dollars have been shown to be some of the most worthwhile dollars we could spend. A dollar spent now on a child’s care is worth hundreds or thousands of dollars later, preserving his or her ability to thrive.” Debbie Redd, CEO of Capital Women’s Care, a group of about 160 OB/GYNs in multiple locations 22 | CHESPHYSICIAN.COM
harder for smaller practices to verify eligibility. “Our large size allows us to put more processes in place. The system automatically goes out to verify eligibility with all of the payers the patient provided. We outsource this service to a billing company, and this service is part of their fee. We then verify their insurance again after the second and third trimester, as it can change.” She adds that many women who are
planning to get pregnant select a lower deductible plan if they have the option. Insurer-Hospital Partnerships, Narrow Networks
Another insurance trend affecting physicians are partnerships between hospital systems and insurers. Redd cites Innovation Health, a joint venture between Aetna and Inova in Virginia that initially covered Inova’s employees but that has expanded to cover many residents of Northern Virginia. “Our group is no longer a Tier 1 provider, so people have to pay more to see our obstetricians. Ironically, that will cost the healthcare system more in the long run because it’s cheaper for us to provide care than it is for OB/GYNs employed by the hospitals.” A NBGH survey found that about 25% of employers now offer a ‘narrow network’ plan among their options to workers. These plans lower the premium cost but offer a narrower choice of participating providers. A McKinsey & Co. survey found that nearly half of ACA plans offered narrow networks in 2014. Care provided outside of the networks receives little or no coverage. Surprisingly, however, a study by the Robert Wood Johnson Foundation of the ACA implementation in six states, including Maryland and Virginia, found few consumer complaints about these narrow
networks. A greater issue for patients was the inaccuracy of many listings of participating providers. Implementation of Strong Verification and Collections Systems
Pollitz advises doctors to evaluate their collections practices to see how much time patients have to pay their bills. When patients’ bills go to a collection agency, they may no longer be able to get auto or other types of loans, and if they start charging up their credit cards they could be paying double-digit interest rates. She notes that what they owe is a pressing issue on many patients’ minds, even if they don’t bring it up with their doctors. A recent Gallup poll found that the steady climb in those delaying care due to costs had reached its highest levels yet – some 33% of respondents – since the question was first asked in 2001. At the same time, Dr. Levy laments the growth in his practice’s accounts receivables. “People don’t understand they are partners in helping to pay for their care.“ To address the problem, he has retrained his front office staff. “As soon as people walk in and we’ve welcomed them, we verify their insurance. If a patient owes us money from a prior visit, we trained our staff to say, ‘You have an outstanding bill, how would you like to pay?’ If the patient is unable to pay, and has a routine or longstanding complaint rather than an urgent medical problem, we tell them we have to reschedule their appointment and ask that they bring payment next time.” While acknowledging that the ACA isn’t perfect, Dr. O’Conor views it as an improvement. “I’m here to help my patients with their health issues. My impression is that, overall, the ACA is a good thing. It’s the history of the way health insurance is set up in this country that’s the problem. I think the ACA will be seen as an incredible legacy for President Obama.”
Karen Pollitz, senior fellow at the Kaiser Family Foundation Daniel Levy, MD, pediatrician, owner of The Child and Teen Wellness Center Carolyn O’Conor, MD, family practitioner at Spectrum Family Medicine Debbie Redd, CEO, Capital Women’s Care
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POLICY
Michael Busch: 11 Years as Maryland’s House Speaker
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BY LI NDA H A RD ER • PH OTOGRA PH BY TRAC EY B ROW N
ESPITE HIS 28 YEARS IN the Maryland state legislature, Speaker Michael Busch has never taken the splendor of the House chamber for granted. With its soaring, ornately fluted columns and curving rows of plush tufted chairs, the chamber is an inspirational setting for the years of legislative wrangling that have taken place within its walls. In addition to having a Republican Governor, for the first time in years, Maryland’s General Assembly will include four physicians. Newcomers Terri Hill, MD, Jay Jalisi, MD, and Clarence Lam, MD, were elected to serve along with incumbent Dan Morhaim, MD. A fourth physician running this past year, Dr. Tim Robinson, lost to Jim Brochin.
Q:
and if they kept costs down, the physicians would get it back. Physicians kept the costs down but never got the other $2. We did away with that and passed the Patients’ Bill of Rights.
been part of the House for 28 years. I tell people that I was only elected for a four-year term but stayed for 28. I was here as chair of the committee that handled health insurance in 1995 when we passed the Patient Access Act, which required insurers to offer a point-ofservice plan in addition to a closed-panel HMO, so that individual patients could get to the doctor they had a relationship with. That model was duplicated elsewhere around the country. It was a big battle and a significant piece of legislation. We had to battle the insurers over it. We also eliminated withholds. The insurers promised primary care physicians they would give them a pool of patients and withhold, say, $2 per member per month
: What do you think about that new waiver? The new waiver is going
You’ve had a long tenure as Speaker of the House (since 2003). Looking back, what healthcare accomplishments are you most proud of? What were the biggest challenges you faced in the healthcare arena? I’ve
24 | CHESPHYSICIAN.COM
Q
to cause some constraints and move some people out of the traditional hospital setting into primary care and ambulatory care groups. So, I think it will be a challenge initially for hospitals to make their numbers, but hope that the ultimate result will be better overall health outcomes for patients. If you removed the all-payer system or the waiver, you’d have tremendous instability in the marketplace, with hospital closings all over the state.
Q:
What are the challenges facing you in the upcoming Maryland legislative session? I think the greatest
challenge we’ll face is finding a health secretary to head what is a very cumbersome agency with a lot of moving parts. You have the physician review board and all of the professional boards to oversee. [Secretary of the Department of Health and Mental Hygiene] Dr. Joshua Sharfstein and [Chairman of the Health Services Cost Review Commission] John Colmers are both talented guys who have been tremendous public servants. Colmers had served on the transition of CareFirst and headed the HSCRC. There was a tremendous amount of pressure on both men. The greatest undertaking is to find a health secretary that understands the complex delivery system in the state, and then to deal with the federal mandates of both Medicare for the dual eligibles and Medicaid. I’ve had a conversation with Governor-elect Hogan, who has to get a budget secretary first and has a lot on his plate, but then health and transportation have to be next. The Department of Health and Mental Hygiene has one of
the largest budgets in the state, and on top of that is charged with the care of some of our most vulnerable citizens. Physicians have had it tough because their reimbursement has gone down at the same time that costs are rising and their medical malpractice has gone up. In an all-payer system, the hospitals get paid but the physicians don’t. Many hospitals have a dwindling physician base in certain specialties, such as OB/GYNs that are supplemented by the hospitals they serve or solely owned by the institution. At one point, we didn’t even have an obstetrician in Western Maryland – fewer people are going into that field. After you get done paying malpractice and other administrative expenses you get tail insurance so that if something happens 15 years later, you have to pay for that even when you stop practicing.
medicinal benefits to certain patients can be challenged; the argument is clear that it can be helpful, but how do you navigate its use for medical purposes only, and keep it out of the hands of people who want to use it recreationally?
Q:
There apparently is a long waiting list for people with developmental disabilities to get needed care. What have you done to address this problem? What are the key barriers to care? What future changes do you see coming? When we
passed the alcoholic beverage tax, we dedicated quite a bit of money – about $30 million annually – to developmental disabilities, which includes a wide spectrum of disabilities, with autism being one of the primary ones. Those with severe autism fall under the school
Physicians have had it tough because their reimbursement has gone down at the same time that costs are rising, and their medical malpractice has gone up.
Q:
What can physicians do to increase their influence in the legislative process? My suggestion to
physicians is to let your patients know when they come into your office what’s important, and to suggest that they contact their legislators.
Q
: How do you think the republican majority in the U.S. legislature will impact the Affordable Care Act (ACA)? For all the screaming and yelling, I think they will let the ACA play out. It’s too far down the road to eliminate it now.
Q
: Maryland’s Medical Marijuana Commission continues to struggle to create a viable model for making this accessible to patients. How do you see this process unfolding this year? What you want to do is see whether or not the structure that was set up works. There’s a practical application to how you actually deliver the service without violating the law. Delegate Morhaim worked very hard at that and it was a controversial issue. I don’t think its
system until they’re 18, but once they’re out of school it can be hard for families to deal with them as young adults who can’t function without some level of supervision. We’ve tried to increase the funding of disabilities through this tax. There is a waiting list, but everything comes down to whether there is sufficient money.
Q
to which stakeholder makes the determination of what a medical home is.
Q:
You worked hard to prevent Blue Cross Blue Shield from becoming privatized. Talk about that experience.
At the time, I felt that privatization was a windfall for the members of the board and the executive staff of Blue Cross Blue Shield and a detriment to the healthcare resources in the state. Most of the Blue Cross plans in the country were undervalued when they were sold and then became extraordinarily wealthy organizations. One side said that the fair price for Maryland’s plan was $2 billion and the other side said that was too low. I felt it was very important to keep a nonprofit insurer in the state. At the end of the day we had an established process to go through that worked for us. Candidly, when we stopped the conversion here, it was the last attempted conversion in the country. It was no easy task to convince the national Blue Cross Blue Shield board that they should continue to give use to the ‘mark,’ as they call it. But they couldn’t justify the compensation that was going to go to the individuals. Our fear was that as soon as they became a for-profit, they would be reluctant to take on risk. It’s easy to insure the healthiest people, but it’s not so easy to insure the sicker ones. As someone once said, pre-existing conditions mean you can get healthcare for everything except what you were sick with.
: What was your involvement in promoting the Patient Centered Medical Home (PCMH) concept in Maryland and how do you think it’s working? PCMH is nice in theory and it
Q:
goes back to the primary care physician, obviously, but I would suggest that PCMH is something for which hospitals, physicians and insurers all have a different definition. It’s a great idea but it’s a question of who designed that medical home and who is the gatekeeper – is it the insurance company that pays the physician or the physician group that tries to make sure healthcare is delivered appropriately, or is it the hospital? The two models in the state – CareFirst Blue Cross Blue Shield’s and the state’s model – are vastly different, and it comes down
skepticism around the ACA. In theory, it’s the right way to go, but it’s the practical delivery of that service that people are concerned about. In Maryland, as with other states around the country, we experienced some difficulty in our initial attempts to enroll individuals in coverage. Having made some significant changes to the state exchange, we seem to be on better footing with this second wave of enrollment. Now the question becomes the degree to which we improve accessibility and cost for the individual.
What are your predictions about the healthcare exchange this year and its ability to serve new and reenrolling consumers? There’s still some
JANUARY/FEBRUARY 2015
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COMPLIANCE
False Claims Investigations: Ten Best Practices for Complying with DOJ Subpoenas
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By Ilana Subar
HE OBAMA ADMINISTRATION has made healthcare fraud cases a top priority since for the past five years. In 2009, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius established an interagency task force, the Fraud Prevention and Enforcement Action Team, to increase coordination and optimize civil and criminal enforcement. This coordination has yielded historic results: from January 2009 through the end of the 2014 fiscal year, the Department of Justice (DOJ) used the False Claims Act (FCA) to recover $14.5 billion in federal healthcare dollars. What can physicians and other healthcare providers do to prepare for, and respond to, DOJ subpoenas in the current enforcement climate? Here are 10 tips that can help mitigate the challenges in responding to DOJ subpoenas:
the company of its obligation to preserve documents. If directed to do so by counsel, the company should send out an internal memo notifying anyone who may have responsive documents of their preservation obligation.
z Be Proactive and Prepare In Advance Even before you or your company is served with a subpoena, you should make sure that you have an active compliance plan and policies for responding to subpoenas and government investigations. Such policies should provide for the involvement of inside and/or outside counsel. This will help protect the attorney-client privilege in the company’s assessment and response.
z Review Your Document Production Before you produce documents to DOJ, you should have counsel carefully review your production to ensure subpoena compliance, to adequately protect attorney-client/work product privileges and to identify any areas of risk.
z Engage Legal Counsel and Preserve Documents Immediately after receiving a subpoena, the company should involve counsel. Counsel will work with the company to take necessary steps to preserve potentially responsive documents, including electronic records. Counsel generally needs to issue a “litigation hold” letter, which notifies
z Try to Establish a Good Relationship with DOJ Establishing a good relationship with DOJ (and any U.S. attorney’s office involved in the investigation) is important. It is often the best way to reduce the compliance burden of responding to a subpoena. Recipients, through counsel, should seek to learn whatever details can be shared about the investigation and the company’s status, and to discuss the potential narrowing of the subpoena scope. Having a good relationship with DOJ also will be useful if you ultimately decide to negotiate a settlement of FCA claims.
z Be Prepared for Interview Requests DOJ often asks to interview company personnel in connection with its investigation. These interviews may be conducted under oath. With the help of counsel, you should assess whether company personnel should be represented by separate counsel. z Conduct an Internal Investigation You should conduct an investigation of the relevant facts in order to determine if you need to take corrective/remedial
actions. An early fact assessment also will better prepare you to address any future questions regarding the investigation. z Review Insurance Policies Responding to a DOJ subpoena or investigation can be quite expensive and disruptive. The company should have counsel review its insurance policies to determine whether the company has coverage for legal expenses (or any settlement payment). z Determine If There Are Parallel Proceedings Physicians and healthcare companies should remain aware of the potential risk of “parallel proceedings” – i.e., simultaneous criminal, civil, and/or administrative investigations. You want to avoid the mistake of realizing too late that an investigation is proceeding on more than one track. z Evaluate Your Potential Exposure FCA contains significant penalty provisions. The government is entitled to three times the amount of its loss. Also, it may be entitled to civil penalties of $5,500-$11,000 for each false claim submitted and/or false document used to get a false claim approved for payment. z Remember OIG’s Role. If DOJ agrees to settle its FCA claims against you, remember that the OIG often plays a role. The OIG may require a Corporate Integrity Agreement with you as part of any settlement of FCA claims. The current enforcement environment shows no signs of abating, so it is critical to know what to do if you receive a DOJ subpoena. Ilana Subar, a partner at Whiteford, Taylor & Preston, LLP, has represented healthcare providers facing government investigations. She can be reached at isubar@wtplaw.com JANUARY/FEBRUARY 2015
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LIVING
By Anne K. Sessions
COURTESY OF CHESAPEAKE BAY PROGRAM
Chesapeake Culture, Chesapeake Life
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TARTING AT HAVRE DE Grace, Md., where the Susquehanna River empties its fresh water into the Chesapeake Bay, waters flow 200 miles south to Virginia Beach and the Atlantic Ocean. This is the Chesapeake, a region that’s supported indigenous people, colonizing Europeans, thinkers and leaders who have changed the course of human history. The Bay’s watershed reaches deep into six states: New York, Pennsylvania, Delaware, Maryland, Virginia and West Virginia – and the District of Columbia. While the “Chesapeake Region” gains its name from the Bay, it refers to much more than the body of water. The region incorporates the culture, climate, colonial history, and of course the Bay’s tributaries, watershed, environmental and population health. In short, any discussion of “The Chesapeake” covers a scope of history, nature, and geography (a surface area of 4,479 square miles) that is remarkable, even for a continent as big as North America.
11,684 MILES OF COASTLINE The Bay’s coastline is a cartographer’s nightmare since more than 150 streams and rivers flow directly into it. Total shoreline, including tributaries, is 11,684 miles. In general, the water of the Chesapeake is considered brackish, a mix of oceanic salt water and freshwater from the tributaries. There is higher salinity at the mouth of the Bay where the Atlantic Ocean washes in, and lower salinity at the northern, freshwater fed, end. Salinity varies from year to year depending on rainfall and 28 | CHESPHYSICIAN.COM
snowmelt. This means the Chesapeake supports an ecosystem that thrives in salinity variations, which in turn supports a distinct food chain that “tastes” uniquely like the Chesapeake region – slightly salty, slightly sweet – an identifiable “terroir” or more specifically, “merroir.”
CHESAPEAKE FOOD WEB The scene-stealing rock star of the Chesapeake fish catalog is the rockfish (striper, striped bass) or morone saxatilis. According to the CBF, fishing for rockfish generates roughly $500 million each year in economic activity. If morone saxatilis is the Bay’s “gateway” seafood, consider the food “web” that brings that rockfish to market. A healthy Bay is an ecological balance of nitrogen and carbon. Tucked into the axis of that balance grows and thrives sub-aquatic vegetation like naiads and wild celery. After his 1608 Bay explorations, Captain John Smith described undersea forests
visible in the clear water, likely eel grass in the high-salinity southern Bay. For eons these plants have shaded the shallower water, protecting vulnerable breeding creatures like the blue crab, and free-floating creatures like the common grass shrimp and the lined seahorse. Feeding on nitrogen are algae, which nourish zooplankton (animal larvae, jellyfish and shrimp), which in turn feed the planktivores (menhaden and crustaceans), which support the rockfish. Branching off this web are algae-filtering marine bi-valves like oysters and clams, sustenance for waterfowl such as ducks and herons. The omnivore blue crab with the enigmatic name callinectes sapides (calli=beautiful, nectes=swimmer, sapides=savory) will prey on almost any part of that food web at different stages of development. This simplified web description is the foundation of a commercial seafood industry in Maryland and Virginia that contributes $3.39 billion in sales, $890
BAY HEALTH - PUBLIC HEALTH It would be folly to think that the health of a population who reside within the 64,000 square miles of the watershed is not in a few ways linked to the Bay. In May 2004 Johns Hopkins Bloomberg School of Public Health launched the Chesapeake Bay Health Indicators Project, “to preserve and improve both the human health and the ecological health of populations living in and around the Chesapeake Bay watershed through improved recognition of the linkage between the quality of the environment and the protection of public health.” The landmark 1983 Chesapeake Bay Agreement was the first codified effort to monitor the ecological status of the Bay and develop science-based policy to protect the ecosystem. The JHSPH project sought to mirror those efforts by measuring risks to the human population within the Chesapeake’s ecosystem. Hopkins’ researchers created a matrix for tracking the effect on human health of Bay degradation, looking at three indicators:
drinking water protection; microbial risks in surface waters; and toxic pollutants. Those Environmental Public Health Indicators (EPHI), were selected because they are commonly monitored and can be used to measure complex environment/health relationships. McGee says, “People can see the explicit connections between their health and the health of the Bay: if the water’s not safe for swimming, or there are water-born illnesses, or algae blooms.”
PROTECTING THE BAY The 1983 Chesapeake Bay Agreement codified efforts to protect the health of the Chesapeake Bay, creating an Executive Council with the governors of the six watershed states and the District of Columbia, and the chair of the Chesapeake Bay Commission. The 2009 White House signing of Executive Order 13508 established a Federal Leadership Committee to oversee activities by agencies involved in Bay restoration. The committee is chaired by a representative from the Environmental Protection Agency, and includes senior representatives from the Department of Agriculture, including the Natural Resources Conservation Service and the Forest Service. Also on board are the Departments of Commerce (which includes NOAA), Defense and Homeland Security. Additionally there is the Department of the Interior – bringing with it the United States Geological Service, National Park Service and Fish and Wildlife Service. Beyond these federal efforts are the nonprofit organizations so familiar in the Chesapeake region. The granddaddy of them all is the Chesapeake Bay
Foundation, actively involved at the Executive-Council level as part of the Independent Evaluator team. Also in these leadership groups are Alliance for the Chesapeake Bay, county and city governments, water control boards and universities. These are the groups that reach into local communities to help support riverkeeper programs, stream restoration and water analysis. There are now less than six degrees of separation between the White House and the spats (juvenile oysters) elementary children nurture off docks during environmental science field trips. At the federal, state and local level it’s recognized that the conditions of the Chesapeake Bay directly affect the conditions of a significant population – be it a mater of clean water, commerce or national security. Jeff Corbin of the EPA states, “There are nearly 18 million people in the Chesapeake Bay watershed, and each one of us has an impact on the Bay ecosystem.”
SAVE THE DATE Bay Fundraisers and Celebrations January 29-February 1, 2015 Baltimore Harbor – Baltimore Boat Show April 19, 2015 Leonardtown, Md. – Earth Day on the Square May 2, 2015 Chincoteague Island, Va. – Annual Chincoteague Seafood Festival September 19-20, 2015 Gloucester, Va. – Bluegrass by the Bay Festival October 10, 2015 Chincoteague Island, Va. – Annual Chincoteague island Oyster Festival October 17, 2015 Virginia Beach, Va. – First Landing Fall Festival
COURTESY OF CHESAPEAKE BAY PROGRAM (2)
million in income, and almost 34,000 jobs to the local economy, according to the 2009 Fisheries Economics of the U.S. report by the National Oceanic and Atmospheric Administration (NOAA). Beth McGee, senior water quality scientist with the Chesapeake Bay Foundation states, “The more people we engage in the Bay, who come to love the Bay, the more they’re going to support the Bay and restoration efforts. Chesapeake Bay Foundation (CBF) has award-winning education programs to get kids to know life on the water, exactly for that reason.”
JANUARY/FEBRUARY 2015
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COURTESY OF CHESAPEAKE BAY PROGRAM
LIVING
Seventeen million people live, work and play in the Chesapeake Bay watershed. Home to 3,600 species of plants and animals, the Chesapeake is more than just “the Bay,” it’s considered a national treasure. 30 |
CHESPHYSICIAN.COM
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