CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
GI GAME CHANGERS FOR HEP C, COLON CANCER AND GERD WEARABLES: BEYOND FITNESS TRACKING BARIATRIC SURGERY: UNDERUSED TOOL FOR METABOLIC SYNDROME, OBESITY
chesphysician.com VOLUME 5: ISSUE 2 MARCH/APRIL 2015
Maryland/DC/Virginia
Contents 10
VOLUME 5: ISSUE 2 MARCH/APRIL 2015
16
F E AT U R E S
10 GI Game Changers 16 Bariatric Surgery: An Underutilized Tool for
Fighting Obesity and Metabolic Syndrome D E PA R T M E N T S
Cases
| 7 | Body Contouring Following Bariatric Surgery
Solutions HIT
| 8 | The Impact of the ACA on Private Practice and Physician Happiness
| 20 | Wearables: Beyond Fitness Tracking
Living
| 23 | Travel to Charleston With a Little Help From Apps
Compliance Policy
| 31 | Open Payments/Sunshine Act Year Two: Guidance for Physicians
| 32 | The Challenge of Controlling Healthcare Utilization A Conversation With Jesse Pines, MD, MBA
Our Bay
| 34 | Celebration of the Chesapeake Bay
On the Cover: Andrea Cox, MD, PhD, Johns Hopkins University, associate professor of Medicine, Oncology, and Immunology, and co-director, Viral Hepatitis Center
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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
Computers used to be the size of rooms, now they’re downsizing from smartphones that fit in our pockets to wearables that fit on our wrists. Computers also are becoming game changers personally and professionally – managing our lives and your practices as well as keeping patients healthier. When we first explored mHealth in March 2012, it was challenging to find a physician familiar with mHealth let alone one using it in a medical practice. Today, mHealth is being called the new economy in healthcare and there’s a race to be part of this technological boom. Big players like Nike and Apple are already in the space, while entrepreneurial scientists are partnering with techies, creating products that can manage chronic diseases or promote rehabilitation. While I was scoping out the latest in healthcare tech developments at the 2014 mHealth Summit for this issue’s Healthcare IT feature (see page 20), I met a lead researcher with Hewlett Packard. It’s his job to take HP into the mHealth space. He made the point that one billion people are using HP’s technology in 56 different countries and territories. That’s a lot of opportunity. Game changing is a theme throughout the following pages. Most everyone is aware that obesity is an epidemic in the U.S. Not everyone is aware that bariatric surgery has been validated as a valuable tool in fighting that epidemic. Of course, lifestyle changes that include a healthy diet and exercise should be the first line of defense, but studies support the value of bariatric surgery in maintaining long-term weight loss and managing obesity-related conditions (see page 16). Our cover story spotlights game changers in the diagnosis, treatment and outcomes of GI diseases. Of particular note are the latest treatments for treating hepatitis C. Chronic hep C is estimated to affect close to 2% of baby boomers and is on the rise with millennials due to a heroin epidemic. There’s good news in DNA stool tests for colon cancer as well as new challenges in recognizing GERD – our #1 online trending clinical topic for the last three-plus years (see page 10). Moving away from this issue’s clinical news, spring will be upon us soon, though not soon enough after our especially cold winter. If you’re ready to skip out of town for a long weekend, my recommendation is to visit Charleston, South Carolina. Inspired by the mHealth Summit, I decided to plan and manage an upcoming visit to “Chucktown” with my iPhone and apps. I used apps to book my flight, reserve my Airbnb stay and my rental car, make dinner reservations while there. I even used an app to organize my notes for Living (see page 23). Lastly, a favor to ask of you. Please visit us at chesphysician.com and take our short reader survey. We’d like to make sure we’re writing and presenting the most compelling Chesapeake Region healthcare news we can. If you have more to say than what our survey asks, please shoot us a message. There’s an app for that! To life!
Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician
JACKIE KINSELLA MANAGER OPERATIONS SOCIAL & DIGITAL MEDIA jkinsella@mojomedia.biz CONTRIBUTING WRITER Anne K. Sessions COPY EDITOR Ellen Kinsella BUSINESS DEVELOPMENT Eileen Nonemaker enonemaker@mojomedia.biz Lisa Wolfington 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 licensed and practicing physicians and a select group of healthcare executives and stakeholders in throughout Maryland, Northern Virginia and Washington, DC. 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 Green Spring 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
Body Contouring Following Bariatric Surgery
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WENTY-THREE-YEAR-OLD TJ HAS struggled with his weight throughout his life. TJ tried to diet and exercise but this was not working. He consulted with the team of physicians at the University of Maryland Center for Weight Management and Wellness in Baltimore, and enrolled in their comprehensive program. He eventually underwent a sleeve gastrectomy. After surgery, he began an exercise program and strictly adhered to the program diet. TJ slowly lost 160 pounds, going from 330 to 170 pounds. He walked at first but was then able to jog. He was troubled by the overhanging skin and pannus as he ran. Under the excess abdominal skin, he had rashes and recurrent skin infections, as well as low back pain from the weight of the pannus. The extra skin of his breasts caused chafing and discomfort as he ran. He tried antibiotics, antifungal powders, clothing with wicking and compression garments, but symptoms persisted. Twenty months following bariatric surgery, TJ found that his weight loss stabilized. He consulted a plastic surgeon for treatment of the areas of extra skin that bothered him. His excellent physical and nutritional status made him a good candidate for surgery. TJ was able to look at photographs of the operation and the subsequent scars. He was told about the risks and benefits of surgery. He understood that this was a functional operation and that he would trade scars for contour. TJ is not alone. Nearly 42,000 people underwent a variety of body-contouring procedures after massive weight loss in the United States, according to the most recent statistics from the American Society of Plastic Surgeons, compiled in 2013.
By Rachel Bluebond-Langner, MD
Body contouring removes excess skin and improves the overall body shape. Patients who have lost significant weight will often have multiple areas they would like to address with surgery: the abdomen, back, chest/breasts, arms, thighs and face. Generally the length of surgery is limited to six to eight hours, so patients will prioritize locations and chose two, sometimes three, areas at a time. The length of the procedure also determines whether patients spend one night in the hospital or can go home the same day. Patients are expected to be up and walking right after surgery to prevent blood clots. Depending on the procedure performed, patients return to work within one to three weeks after surgery,
decisions are often made on a caseby-case basis. All insurers require documentation of rashes and skin infection, as well as functional disability. TJ elected to pay for the cosmetic portion of the breast-skin removal. After attaining a stable weight for six months, TJ underwent a panniculectomy and breast-skin reduction. He stayed one night in the hospital and returned home the next day. He was up and walking the day of surgery to prevent blood clots. He had drains in his abdomen, which he emptied several times a day for a couple of weeks. He took some pain medication for the first several days, switching then to acetaminophen. His scars are healing and are expected to lighten and soften over the next year.
Nearly 42,000 people underwent a variety of body-contouring procedures after massive weight loss in the United States... and return to exercise six to eight weeks post surgery. In counseling patients considering body contouring, it is important that their weight is stable and nutrition is optimal. This will improve both the aesthetic result, ensuring that the maximal amount of excess skin is removed, and optimize wound healing. It is important, likewise, that other medical conditions are well controlled, and that the patient is a non-smoker, has realistic goals and is committed to maintaining a healthy lifestyle. For TJ, we submitted the details of the operation to his insurance for precertification and subsequently received approval for a panniculectomy. Not all insurance companies cover body contouring after massive weight loss;
TJ is very happy to have increased mobility and to be able to exercise without discomfort. He no longer gets fungal infections in his skin creases as he sweats, and has an easier time with clothing and hygiene. TJ says he has a renewed sense of self and improved confidence. He has returned to running and is currently training for a marathon. For TJ, this procedure was extremely successful, resulting in a healthier, more active, and more confident young man. Rachel Bluebond-Langner, MD, is an assistant professor of surgery in the Division of Plastic Surgery at the University of Maryland School of Medicine in Baltimore and a plastic surgeon at the University of Maryland Medical Center. She can be reached at RBluebondLangner@smail.umaryland.edu.
MARCH/APRIL 2015
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SOLUTIONS
The Impact of the ACA on Private Practice and Physician Happiness
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By Michelle Stahl
he Wall Street Journal recently featured an editorial highlighting a trend of physicians selling their practices to hospitals. Scott Gottlieb, a physician and resident fellow of the American Enterprise Institute, notes the Affordable Care Act’s proponents “view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare.” On the other hand, some see the consolidation of medical practices as removing the competitive forces that have made our healthcare system one of the most advanced in the world. The regulatory burdens from ICD-10, and incentive bundles from the Physician Quality Reporting System (PQRS) and electronic health medical records, principally favor larger institutions and the government.
happiness. By benchmarking to the top-six best practices used by medical billing companies, physicians are well on the path to improving their cash flow and medical practice profitability:
Physicians Who Move to Private Practice are Happier
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Physicians Practice reports “Doctors moving from employment to selfemployment are happier than those who make the opposite move. In fact, 70% of those who became self-employed said they are happier now.” Naturally, one of the benefits of working for someone else is that you have fewer headaches from administrative tasks. And conversely, self-employed physicians enjoy greater practice autonomy. Doctors moving from employment to self-employment are happier than those who make the opposite move.
If staying in private practice is right for you, the following best practices will help you secure your finances and your 8|
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Prompt Claims Submission: Aim to submit claims within 24 hours to increase your cash flow and reduce bad debt expense. Active Monitoring of Accounts Receivable: Collect at least 75% of your receivables within 30 days. (The average medical practice collects only 42% of receivables within 30 days.) Making this change alone will increase your medical practice’s cash flow by more than 25%. Assign a Dedicated Person to A/R: Someone within your medical practice should monitor medical collections/accounts receivables, and have sole responsibility for that task. Set up EFT: Implement Electronic Funds Transfers from the payers that offer this service.
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medical practice could reduce its expenses by 15% or more. Accept Credit Cards: Consider investing in a credit card payment system (payment automation system) to enable your medical practice to safely store a patient’s debit/credit card information. The result should be increased cash flow and lower collection expenses. Many payment automation systems securely store credit card information by using tokens and only displaying the last four digits to your staff after the credit/debit card information has been entered.
While working for a large medical group or hospital is enticing, physicians are renowned for high achievement, motivation and ability to master complex tasks. On the one hand, the administrative burdens and pace of regulatory change drives them to seek the safe haven of a large employer. On the other hand, their autonomy and achievement motivation is stifled when they work for a large employer. Fundamentally, our healthcare system
The average physician incurs costs of $67,000 or more per medical biller vs. $48,000 for companies that specialize in medical billing and collections. z
Benchmark Your Medical Billing Costs to Outsourced Medical Billing Companies: The average physician incurs costs of $67,000 or more per medical biller (salary, overhead and software) vs. $48,000 for companies that specialize in medical billing and collections. By benchmarking to medical billing companies, your
is at a crossroads; one that relies on market forces to spur innovation, or one that relies on a select few to set policy for the rest of us. Doctors who employ best practices, such as those used by top billing services, should be able to remain in control of their destiny. Michelle Stahl, CPC, is the owner of Physicians Billing Service. She can be reached at michelle@pbsmedicalbilling.com.
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GI GAME CHANGERS BY LI NDA H A RDER • PH OTO GRA PHS BY TRAC EY B ROW N
From exciting new hepatitis C treatments and DNA stool tests for colorectal cancer to the changing face of GERD symptoms, physicians have more tools and challenges to treat common GI disorders than ever before.
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GAME-CHANGING HEPATITIS C TREATMENTS Things have never looked better for those with chronic hepatitis C, which is estimated to affect 1.6% (about 3.2 million) of Americans, especially those born between 1945 and 1965. Due to that high prevalence, the disease has been the primary cause of liver failure and transplant. Since late 2014, three FDA-approved oral treatment regimens have had a greater than 95% cure rate. Even better, a vaccine to prevent hepatitis C altogether may be available in the next few years, assuming current trials demonstrate efficacy. There are seven genotypes of hepatitis C, and some are easier to treat than others. “Genotype 1 is the dominant type in the United States, including in this area,” notes Andrea Cox, MD, PhD, associate professor of Medicine, Johns Hopkins University Viral Hepatitis Center. “It has also been the hardest to treat.”
Targeted Antivirals
She explains, “We used to use antiviral medications that were not specifically targeted to hepatitis C. Basic science first had to characterize the proteins to allow development of these new drugs. Today, companies have designed direct-acting antivirals that specifically target the key proteins in the hepatitis C virus life cycle. Like HIV/AIDS drugs, the combination drugs are from several different classes, so they target different parts of the life cycle, reducing the chances the virus will become resistant.” In late 2014, the FDA approved the following oral combination therapies to treat genotype 1 infection: z Harvoni – a direct-acting antiviral that combines ledipasvir, an NS5A inhibitor, and sofosbuvir, a polymerase inhibitor, in a single tablet z Simeprevir in combination with sofosbuvir provides a direct-acting antiviral combination therapy for genotype 1 patients
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Viekera Pak – ombitasvir, paritaprevir and ritonavir tablets co-packaged with dasabuvir tablets
Dr. Cox is bullish on the new treatment regimens, recalling, “In the past, treatment regimens were challenging for both patients and physicians. They required interferon injections that were hard to tolerate and needed to be taken by most patients for 24 to 48 weeks, with only a 45% response rate for genotype 1 infections. In contrast, the new FDA-approved oral treatment regimens cure the disease in almost all who take them, with some regimens effective against many genotypes while remaining equally effective against genotype 1. These new drugs are miraculous.” Good News Comes at High Cost
The only bad news is the enormous costs of these new drugs, which may limit access to those who can afford them. While costs vary widely, most cost $63,000 to $95,000 per treatment course.
Andrea Cox, MD, PhD, Johns Hopkins University, associate professor of Medicine, Oncology, and Immunology, and co-director, Viral Hepatitis Center
“I hesitate to discuss costs because they’re rapidly in flux,” acknowledges Dr. Cox. “Fortunately, insurance usually covers the medications for the patients who most need them and the drug manufacturers and patient advocate programs have been good to our patients who are not fully covered by their insurance. So, most of our patients who need them have been able to get them. That said, the insurers are limiting access.” Dr. Cox also notes that the cost of the new cures is still lower than the cost of a liver transplant, and that not everyone with the disease needs treatment. “For example, if a patient has had hepatitis C for 30 with no liver damage, you may not want to treat them,” she says. The decision to treat is made on a caseby-case basis. Patients undergoing liver transplantation also may be candidates for these newer treatments. “Interferon wasn’t tolerated by very ill patients, so those preparing for transplant couldn’t use it to prevent infection of the new
transplanted liver. The new regimens are only being used in test cases at present, but may keep hepatitis C from destroying the transplanted liver.” Vaccines: VIP Trial
Along with the University of California, San Francisco, Hopkins is testing a vaccine in a trial called Vaccination is Prevention (VIP). The trial aims to enroll 350 people who are at risk for hepatitis C, with a control group that receives a placebo. “The vaccine has been tested in healthy populations in England, but this is the first time we’ve tested a vaccine in an at-risk population,” notes Dr. Cox, who is heading up the study here. “Enrollees receive extensive counseling and referral to a needle-exchange program, but they’re at risk. Vaccines are less expensive than drugs. We hope to have data from the study in 2016.” Screening Baby Boomers and Other at-Risk Groups
Unlike HIV/AIDs, where about 80%
Julia Korenman, MD, a gastroenterologist with Digestive Disease Associates in Rockville, Md.
of those with the disease in the U.S. know they have it, only about half of those with hepatitis C are aware. That underscores the need for more widespread screening. “Everyone born between 1945 and 1965 should be screened,” Dr. Cox recommends. “The infection is often a silent one until liver disease is severe. With these effective, less onerous treatment options, now is the time to find out if patients have hepatitis C. Multiple studies have shown that many physicians did not screen for hepatitis C in the past, and I don’t 12 |
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blame them because effective, welltolerated treatments weren’t there. But today, we can really save lives with minimal side effects. I urge physicians not to hesitate to screen.”
DNA TESTS: NEW SCREENING FOR COLORECTAL CANCER With one in 20 Americans getting colon cancer, early detection and treatment is critical. It’s the second-most diagnosed cancer in women, though men have a slightly higher risk. While hardly replacing the gold standard of colonoscopy, new DNA stool tests
can be another important tool to detect these cancers earlier. Julia Korenman, MD, a gastroenterologist with the Digestive Disease division of Capital Digestive Care, says, “American College of Gastroenterology (ACG) and American Cancer Society guidelines call for people at average risk to have a colonoscopy every 10 years, starting at age 50. African Americans should start at age 45, and those with a first-degree relative who had colon cancer should start at age 40 or sooner. Many gastroenterologists recommend a second colonoscopy in five to seven years, then every 10 years after two ‘clean’ procedures.” The FIT (fecal immunochemical test), which measures fecal hemoglobin, is a non-invasive screen for colon cancer. “It’s recommended to be done yearly if you’re not getting colonoscopy,” says Dr. Korenman. “Some physicians are uncomfortable with waiting 10 years until the next colonoscopy, so they might recommend FIT in between.” Cologuard, a new multi-target stool DNA test, combined with FIT, has been available since August 2014, as the first stool-based colorectal screening test that detects the presence of red blood cells and DNA mutations. “When Cologuard was approved, the ACG put out a statement emphasizing the difference between detection tests and preventive tests,” Dr. Korenman explains. “Prevention tests, such as colonoscopy, are preferred over detection tests like Cologuard. It recommends colonoscopy every 10 years as a preferred prevention test.” Colonoscopy can prevent colon cancer by removing colon polyps before they become cancerous. Alternatives for screening are an annual FIT test or Cologuard every three years. A study published in the April 2013 issue of the New England Journal of Medicine compared a noninvasive, multi-target stool DNA test with FIT for nearly 10,000 participants at average risk for colorectal cancer. It found that the DNA test detected significantly more cancers in this group than did FIT (92.3% sensitivity compared to 73.8%) but also had more false positive results. Patients should undergo colonoscopy if either the FIT test or Cologuard are positive. “When polyps are found, they are removed and their size and type affects the timing of colonoscopy followup,”
Donald O’Kieffe, MD, FACG, FACP, gastroenterologist with the Metropolitan Gastroenterology Group in Bethesda, Md.
notes Dr. Korenman. “If small polyps are found, we recommend a colonoscopy at five years. When multiple polyps with worrisome features are found, patients should receive a colonoscopy in one or three years. Patients should understand that removing polyps decreases their cancer risk but doesn’t eliminate it. Thus, follow-up colonoscopies are needed.” Any Screening is Better Than None
“It’s important to increase the number of people being screened,” says Dr. Korenman. “If a patient is reluctant to undergo colonoscopy, use another approach. Some people can’t take time off from work, or have difficulty getting a ride to and from the facility. A benefit of using a DNA or FIT test is it’s relatively simple from the patient perspective – they get a kit, take a stool sample, and send it in, with results coming back to their physician.” She continues, “Of course, the preparation for a colonoscopy also makes it challenging. We’re all seeking a prep that tastes okay but we haven’t found that yet. I’ve changed my
preferred preps many times. Some are more palatable than others but most work about the same.” Virtual Colonoscopies
Dr. Korenman doesn’t believe that virtual (CT) colonoscopies have many advantages over a visual colonoscopy. “Patients still need the prep, and the procedure’s not comfortable because air and fluid are blown into the colon. Also, most insurers do not reimburse for this procedure. Yet it can be useful for some patients, such as those whose anatomy prevents us from seeing the entire colon, or in patients at high risk for bleeding or some with cardiac disease. The decision should be made on an individual basis.” If polyps are found on virtual colonoscopy, a colonoscopy is needed to remove them. She urges more physicians to stress the importance of colonoscopies. “PCPs can reinforce the need to get a colonoscopy. Surprisingly, I actually see many patients referred by gynecologists, not PCPs. Hopefully, electronic medical records reminders will increase the likelihood of timely referrals,” she explains.
THE CHANGING FACE OF GERD Gastroesophageal reflux disease (GERD) may be the reason behind some 450,000 physician visits a year. Donald O’Kieffe, MD, FACG, FACP, a gastroenterologist with the Metropolitan Gastroenterology Group in Bethesda, Md., says, “Some 19 million people are affected, and GERD probably accounts for more office visits than the common cold.” Dr. O’Kieffe points out that reflux is a mechanical problem of the lower esophageal sphincter (LES) that allows acid and digestive enzymes to regurgitate back into the esophagus. Medications reduce the acidity, but don’t address the mechanical problem. He notes, “Most people reflux because the lower esophageal sphincter is leaky. Often, this is the result of a hiatal hernia displacing the sphincter from under the diaphragm to above it, decreasing its tone. However, repairing the hiatal hernia may not totally fix the sphincter.” Lifestyle Changes
Dr. O’Kieffe notes that many patients resist one of the most helpful lifestyle changes – elevating the head of the bed. MARCH/APRIL 2015
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“Other helpful lifestyle changes include losing weight, not eating large meals and not reclining for four hours after eating. Certain foods weaken the LES and stimulate acid secretion.” ‘Miracle’ Drugs
Reviewing the history of medications that have been developed in the past few decades, Dr. O’Kieffe notes, “After years and gallons of liquid antacids, Tagamet (cimetidine), an H2 receptor antagonist, was the first pill that reduced gastric acid, and it was viewed as a miracle drug when it came out in the U.S. in 1979. Several other H-2 blockers followed it and all were blockbuster sellers until Prilosec (omeprazole) came out in 1989. This drug was the first in the proton pump inhibitor (PPI) class and these have been the mainstay of GERD management since.” Articles in recent years have raised concerns about PPI safety. Effects on
with special probes can be useful if the trial of treatment result is not clear."
goes away during the day can be a clue that there has been nighttime reflux.”
Complications of GERD – Check for Barrett’s
LPR: the New Face of Reflux
Chronic exposure of the lower esophagus to acid and other digestive enzymes can ulcerate and stricture the esophagus. Barrett’s esophagus is considered a pre-malignant complication of reflux and an important condition to check for. Endoscopy is the best test for assessment of these complications. Alarm or Important Warning Signals
Pain in the chest that persists despite treatment, any evidence of internal bleeding and food sticking in the esophagus while swallowing are all important “alarm” symptoms that need further attention. Dr. O’Kieffe notes that what is perceived as heartburn can be, in fact, a cardiac symptom or sometimes a referred gallbladder symptom.
THE SCARIEST FORM OF REFLUX IS SILENT REFLUX, WHERE PEOPLE HAVE CHRONIC REFLUX BUT DON’T KNOW IT. – Donald O’Kieffe, MD, FACG, FACP
bone density, blood levels of B-1, magnesium and iron, and possible increased risk of GI infections may be long-term consequences, but Dr. O’Kieffe believes they are for the most part safe and effective, and their benefits far outweigh the risks. Testing for GERD
Periodic heartburn can be treated with an initial trial of medical therapy. “When should we carry out endoscopy to look for complications of GERD?” asks Dr. O’Kieffe. “If the heartburn or GERD symptom occurs three times a week, or requires daily medication to control the symptom, I feel an endoscopy is warranted to look for important complications of reflux. Some patients who don’t do well on treatment, or those who are obese or who have diabetes, may need a gastric emptying study as well to see if that is part of their problem.” He adds, “Most physicians use a therapeutic trial of acid suppression to test. If symptoms improve, it is usually GERD. Testing the pH of the esophagus
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Hiatal Hernia Repairs
On occasion, a mechanical solution to a mechanical problem is necessary. Surgical or laparoscopic Nissen fundoplication procedures have been carried out for years with dramatic improvement noted only about 50% of the time. Newer endoscopic and laparoscopic techniques are being utilized, but Dr. O'Kieffe feels the “jury is still out” regarding their longterm effectiveness. A Surprising Impact on Sleep
A study published in the American Journal of Gastroenterology in 2005 is one of several that found those with GERD may suffer from disrupted sleep patterns which, in turn, may impact daytime performance. Women appear to be more affected than men. “Even those with no reflux symptoms but who had sleep issues were put on a proton pump inhibitor and the quality of their sleep improved,” notes Dr. O’Kieffe. “Gastroenterologists agree that nocturnal GERD may have a sleep impact. Waking with a sore throat that
Dr. O’Kieffe comments, “The face of GERD has been changing over the past two decades. For most of the 20th century, the typical symptoms of reflux were heartburn, indigestion and occasional acid in the mouth. However, as we neared the 21st century, GERD began to develop a new face. The GI specialist began being increasingly consulted by ENT, pulmonary specialists and even dentists to see if symptoms in the pharynx, mouth and airway could be related to reflux.” He continues, “This new set of symptoms (hoarseness, sore throat, constant throat clearing, cough, wheezing, recurring pneumonia and even sinus and dental problems) are now felt to be frequently related to reflux of acid high enough in the esophagus to affect these structures. This set of symptoms has been termed laryngo-pharyngeal reflux (LPR). Most GERD remedies are highly effective in relieving lower esophageal symptoms, but the LPR symptoms are harder to diagnose and effectively treat. The standard regimen of once-a-day PPI may not be sufficient to impact them.” Silent Reflux
Dr. O’Kieffe concludes by saying, “The scariest form of reflux is silent reflux, where people have chronic reflux but don’t know it. They are subject to the same set of complications, including Barrett’s esophagus and adenocarcinoma of the esophagus, but never had the symptoms to bring them under medical care. We think today that maybe as many as 15% of reflux patients have silent reflux.”
Andrea Cox, MD, PhD, associate professor of Medicine, Johns Hopkins University Viral Hepatitis Center Julia Korenman, MD, a gastroenterologist with Digestive Disease Associates division of Capital Digestive Care in Rockville, Md. Donald O’Kieffe, MD, FACG, FACP, a gastroenterologist with the Metropolitan Gastroenterology Group in Chevy Chase, Md.
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6535 N. Charles Street, 3rd Floor, Baltimore, MD 21204 410.938.5252 O eatingdisorder.org
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.
In Every Issue and Online Cases xSolutions xCompliance xPolicy
Jacquie Cohen Roth Founder/Publisher/Executive Editor 443.837.6948 xjroth@chesphysician.com chesphysician.com CHESAPEAKE
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BARIATRIC SURGERY AN UNDERUTILIZED TOOL FOR FIGHTING OBESITY AND METABOLIC SYNDROME BY LI NDA H A RDER • PHOTO GRA PH S BY TRAC EY BROW N
Andrew Averbach, MD, director of Bariatric Surgery at Saint Agnes Hospital in Baltimore
What adult doesn’t know that obesity is an epidemic here and in many developed countries? Yet a recent study questions whether primary care physicians are able to sufficiently intervene to promote weight loss in overweight and obese patients.
Primary care physicians (PCPs) have their work cut out for them, with ever-shorter office visits and a growing list of required tasks for each appointment. That may be affecting their ability to talk to obese patients about their weight. A recent study published in BMJ Open, which examined 91,413 primary care electronic health records from 2005 to 2012, found that 90% of overweight patients and 59% of morbidly obese patients had no recorded weightmanagement intervention. Obesity has proven one of the least tractable health issues; only 1% or fewer of those who use traditional medical and lifestyle changes to lose weight are able to keep it off in the long term. In contrast to high recidivism rates with traditional weight-loss approaches, however, studies have found that bariatric surgery achieves much higher long-term weight loss. Perhaps more importantly, long-term studies have demonstrated its value for fighting obesity-related conditions. That’s why Andrew Averbach, MD, director of Bariatric Surgery at Saint Agnes Hospital in Baltimore, and Christina Li, MD, director of Bariatric and Minimally Invasive Surgery at LifeBridge Health, also in Baltimore, encourage PCPs to refer more patients for one of the few effective measures for
long-term weight loss and resultant health improvements in morbidly obese patients – bariatric surgery. “Only 2–5% of patients who are eligible get bariatric surgery,” says Dr. Li. “If doctors had time to encourage it more, patients would listen. Of course, a major barrier physicians face is the lack of time, and some patients avoid surgery due to fear, cost or perceived stigma. Others regard it as ‘the easy way out,’ which it’s not. But if PCPs can just bring it up, we’ll do the rest.” She adds, “We have a tool to make it easy for PCPs – a pamphlet that provides information and allows them to agree to be contacted so they can get their questions answered directly by a bariatric center.” Indications Should Move Beyond BMI The weight loss resulting from bariatric surgery has been shown to decrease blood glucose, hyperlipidemia, joint pain, blood pressure and polycystic ovarian syndrome, while improving fertility rates and testosterone levels. An article published in the June 2014 issue of the Journal of the American Medical Association, based on the long-term Swedish Obese Subjects (SOS) study, found that bariatric surgery was 80% more effective in achieving type-2
diabetes remission than traditional weight-loss methods used in the control group. Considering that the majority of subjects in this study underwent the ‘lap band’ procedure, which is now falling out of favor, bariatric surgery may have even greater potential to impact diabetes and other comorbidities in the future. This study also found that bariatric surgery was associated with a long-term reduction in overall mortality and the incidence of myocardial infarction, stroke and cancer. An April 2012 New England Journal of Medicine study compared the results of bariatric surgery (both bypass and sleeve) plus medical therapy vs. medical therapy alone in 150 patients at the end of 12 months. It found that the use of drugs to lower glucose, lipid, and bloodpressure levels decreased significantly after both surgical procedures, but increased in patients receiving medical therapy only. Dr. Averbach says, “Bariatric surgery provides far more health benefits than weight loss. It affects many metabolic diseases, such as diabetes and fatty liver. Doctors agree that there’s no other treatment that so effectively puts diabetes in remission.” “Every lost pound positively affects blood pressure and blood sugar,” adds Dr. Li. “Even patients who don’t lose a ton of weight get the benefits of better glycemic control.” Dr. Li notes that bariatric surgery is endorsed by the American Heart Association, the American College of Surgeons, the American Medical Association and many other medical groups. “It’s really changed, due to its proven safety and effectiveness,” she says. “The death rate at Centers of Excellence is less than 0.11% – comparable to removing your gallbladder.” She believes that the indications for bariatric surgery should extend beyond body mass index (BMI). Dr. Averbach recommends that bariatric surgery should be offered to patients with BMI 30-34.9 with comorbidities, due to
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provides across-the-board higher weight loss and health benefits.” Dr. Li concurs. “The ‘sleeve’ is definitely a happy medium. It involves less surgery than the bypass but provides more consistent weight loss than the band. The duodenal switch has higher malabsorption and mortality rates, so it’s less common, but each surgical approach has its role, depending on the patient’s needs.” Dr. Averbach adds, “The sleeve procedure is skyrocketing, accounting for half or more of the procedures our center does today. The main advantage is that is doesn’t require significant alteration of the GI tract, so it has a lower rate of metabolic side effects. About 20% of patients, however, may experience reflux. It doesn’t improve metabolic comorbidities as well as bypass does, but otherwise it’s a very good first-line procedure for many people with BMI at or below 60. Bypass will remain an option for those with significant BMI>60, advanced diabetes and significant preoperative GERD.” The surgeons caution PCPs against recommending a particular surgical approach. “When physicians refer patients for bariatric surgery, they tend to recommend a specific procedure,” Dr. Averbach observes. “We prefer that they let the surgeon determine which procedure is ideal for that patient.”
Christina Li, MD, director of Bariatric and Minimally Invasive Surgery at LifeBridge Health in Baltimore
ONLY 2-5% OF PATIENTS THAT ARE ELIGIBLE GET BARIATRIC SURGERY.
– Christina Li, MD
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its proven efficacy and ease of treatment of stage-1 disease. Lap Band Use Diminishing “The laparoscopic gastric banding or ‘lap band’ procedure that was popular from about 2005 to 2008, has fallen out of favor because it provides less weight loss and more long-term side effects than the gastric bypass or the vertical sleeve gastrectomy procedures,” notes Dr. Averbach. “Its revision rate is about 25% and it requires significant followup care and compliance. We’ve found that switching to the sleeve procedure
On the Horizon One of the more promising endoscopic bariatric procedures on the horizon is transoral sleeve gastroplasty, which uses an endoscopic suturing device to mimic surgical sleeve gastrectomy. A small pilot study at the Mayo Clinic, published in the September 2013 issue of Gastrointestinal Endoscopy, found the procedure to be safe and feasible. A second trial was launched to study the metabolic effects of this procedure. Potential advantages of less invasive approaches include reduced cost and the ability to serve those who are overweight but not obese. “Endoscopic sleeve procedures are not yet ready for prime time,” explains Dr. Li. “And intragastric balloon procedures, in which a balloon-like device is placed into the stomach and inflated to decrease the size of the stomach, have the potential to be a bridge to bariatric surgery for short-term weight loss, but would not replace it.”
DOCTORS AGREE THAT THERE’S NO OTHER TREATMENT THAT SO EFFECTIVELY PUTS DIABETES IN REMISSION. – Andrew Averbach, MD
Dr. Averbach agrees. “No endoscopic procedure has been proven effective to date. The gastric balloon has some promise for those in the early stage of obesity, with the potential to drop 1520% of excess weight, but a side effect is nausea.” Patients for a Lifetime “Surgery cannot work alone,” notes Dr. Averbach. “In addition to extensive pre-op education, patients need to be educated and followed for at least a year after the procedure. They need to understand what healthy eating habits are. This was somewhat overlooked in the past, but now we pay far more attention to that and to psychological issues. We do everything we can to help
them adhere to the plan and to maintain their weight loss. It’s easier to intervene when they come back sooner rather than later, which is why we have each patient sign a contract committing to their good health pre- and post-surgery.” Dr. Averbach adds, “Some patients require treatment prior to surgery to stabilize their depression or bipolar disease. Sometimes we see a recurrence of prior substance abuse, which can replace the abuse of food. In about 10% of patients, their alcohol abuse increases after bariatric surgery. Having a strong support network is a critical piece of bariatric surgery” “There’s no doubt that patients can still ‘out-eat’ all of these surgeries,” contributes Dr. Li. “Anecdotally,
education levels don’t correlate with success – what does is persistence. We see some ‘addiction transference’ where people addicted to food transfer their addiction to something else, such as alcohol. They have to be committed to a lifestyle change and work on it every day.” She continues, “The key role PCPs can play is to bring up the topic more often. And they should send the patient back to the bariatric surgeon at least yearly. We take care of their labs and monitor their vitamin levels. These patients should be lifetime patients of their bariatric surgeon. Bariatric surgery can be a life-changing and life-saving measure for patients, yet sadly, we are reaching so few of them today.”
Andrew Averbach, MD, director of Bariatric Surgery at Saint Agnes Hospital in Baltimore Christina Li, MD, director of Bariatric and Minimally Invasive Surgery at LifeBridge Health’s Sinai and Northwest Hospitals in Baltimore
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HEALTHCARE IT
Wearables: Beyond Fitness Tracking BY LI N DA H A RD ER
Wearable fitness devices have been on the market since early in the 21st century. Only recently, however, have wearables begun expanding into exciting other health uses. The 2014 mHealth Summit in National Harbor, D.C., and the 2015 Consumer Electronics Show unveiled some of the latest developments.
A
CCORDING TO ABI Research, a technology market intelligence company, over 90 million wearable devices, including Google Glass, Nike FuelBand and Fitbit Flex, shipped in 2014. While estimates vary significantly among forecasters, ABI predicts wearables will grow to 170 million devices by 2017. Smartwatches are among the newer entrants, with the Apple watch hitting the market in early 2015. But according to a recent PricewaterhouseCoopers Health Research Institute report, the demand for electronic wearables will dip slightly in 2015 as the market suffers from overlapping devices. At the 2014 mHealth Summit held December 2014, Walgreens Chief Medical Officer Harry Lieder, MD, MBA, FACPE, noted the following good news for wearable manufacturers: z z z
Some 21% of U.S. consumers currently own one. The market continues to grow. More than half of survey respondents believe the devices will increase their athletic ability, help them lose weight and increase their lifespan.
Conversely, he indicated that the bad news is: z Good controlled studies about the impact of wearables on health don’t exist. z Less than half of those who own a wearable use it regularly. z Even if the wearable is free and there were incentives to use it, surveys have found that only 68% of consumers say they would use one.
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Improving Wearable Usage Despite the tendency for user ‘fatigue,’ Dr. Lieder believes that wearable use can be increased with gamification, human support and rewards. Walgreens is betting that rewards will yield results – they have created Balance Rewards for Health Choices, which users can redeem for discounts on purchases at their stores; over 155,000 people with wearables already have linked to the program. They eventually will be able to link in claims data to determine if wearables affect health outcomes. Joseph Kvedar, MD, vice president of Connected Health at Partners Healthcare, noted that Microsoft, Samsung and Apple are all betting on smartwatches to take off. However, he remarked that, while people check their cell phones constantly, it is difficult to get them to push a button to upload their blood pressure several times a day. “Participation is far higher if the data is uploaded passively,” he stated. “To succeed, these technologies must ask patients to do less, not more.” Dr. Kvedar further commented that making wearables part of a social activity is helpful, as “no one wants to look like the unhealthy one.” Physicians can play a key role in motivating patients as well, because most don’t want to disappoint their doctor.
Blood Glucose Monitoring Dr. Lieder’s presentation included a mention of a new grassroots wearable solution developed by a group of men whose children have diabetes. Called NightScout, the tool allows diabetic adults to continuously monitor their glucose levels, and permits parents of diabetic children to remotely track their blood sugar levels in real time while they’re at a sleepover or out of town.
Medication Usage Reminders Each year, over half a million Americans are hospitalized because they skipped or took incorrect medication dosages. To improve compliance and safety, MediSafe Project, a company started by two brothers whose diabetic father accidentally took an overdose of insulin, developed MediSafe, a medication management platform that connects patients and health providers. The first mobile app to sync medication reminders between devices of families and
caregivers, it has been downloaded over a million times. The app is installed on a person’s smartphone, tablet or other device, and automatically loads medication reminders onto a smartwatch. Users can quickly record that they’ve taken the dose by swiping and tapping once on the reminder, or by shaking their wrist left to right. If they forget to take a medicine, the app can notify a loved one. Chief Marketing Officer Jon Michaeli notes, “We’re technologically agnostic, and are working on being available via landline phones, the web, etc., so consumers can have access any way they’re most comfortable. We’re doing pilots with physicians now, building interfaces with hospitals, pharmacies, and others, and embarking on independent research.” Michaeli adds, “We also send patients personalized educational content, such as diabetes information, to help them improve their health. There’s a digital pillbox in the app that allows patients to see the shape and color of each pill, and we send positive messages to reinforce adherence.”
Continuously Measuring Vital Signs At the mHealth Summit, Swiss company Sensogram Technologies showed off its new SensoSCAN, a device similar to a pulse oxygen monitor that fits on your finger to monitor blood pressure, oxygen saturation, heart rate and respiration rate using biosensors that transmit data in real time to smartphones or tablets via the cloud. Vahram Mouradian, PhD, founder and CEO, said, “It provides a dynamic picture of these vital signs, rather than just showing a single moment in time. SensoSCAN, which was FDA-approved after years of research and development, does not require separate reimbursement. We also developed a second device for active patients called SensoTRACK. It fits over the ear like a Bluetooth headset and monitors vital signs for wellness, fitness and sport uses.” Dr. Mouradian discussed how SensoSCAN also can save healthcare providers money. “When a patient is monitored at home after a procedure such as cardiac surgery, CMS pays the home monitoring company $2,400 for
their services, whether the patient is monitored for a week or two months. “The monitoring company makes money for the first five days, but then they start losing dollars thereafter,” he said. “Using SensoSCAN can save them 70% over other existing monitoring technologies, while improving care for patients.”
At the mHealth Summit, Swiss company Sensogram Technologies showed off its new SensoSCAN.
Monitoring Falls and Appliance Usage Bill Rom, a managing partner at 151 ADVISORS, a strategic consulting firm that helps fledgling technology companies take advantage of new market opportunities, stated, “The challenge is how to pay for these wearable technologies. They’re gaining traction in hospitals – where remote wireless scales and other monitoring devices are taking off. KIWI is one of the companies we advise. After their CEO fell, he decided to develop a multi-function sensor that detects motion and acceleration, so that users can remotely monitor whether a loved one has used the toilet or opened a refrigerator, for example. It’s based on a platform that can accommodate multiple uses and customized solutions.”
Wearables in Outpatient Rehab Centers Brandon Tudor, assistant VP of access and administrative services at the MedStar Institute for Innovation, discussed their National Rehabilitation Network’s undertaking to use activity trackers in its outpatient physical therapy clinics. Beginning in early 2015, their physicians will ‘prescribe’ home exercises that can be tracked by therapists via a Fitlinxx Pebble. MARCH/APRIL 2015
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Tudor said, ‘We formerly had no way to track whether or not patients were performing their home exercises, and they often overstated their compliance to avoid disappointing their therapists. This will give us accurate data. Data security, ease of use, connectivity with the patient’s electronic health record and cost are all critical in making wearables valuable for practitioners.”
EEG Headsets For ALS Patients with limited movement, such as those who suffer from Amyotrophic Lateral Sclerosis (ALS), may benefit from an emerging wearable technology developed by Fjord, a division of Accenture Interactive. Called Emotive Insight, this wireless EEG headset detects brain commands, emotions and microfacial movements. The development team created a simple, efficient approach that used thought patterns to complete tasks such as making phone calls, sending emails or turning off connected SmartTVs.
2015 Consumer Electronics Show (CES) Wearables The 2015 CES also unveiled new ways to ‘wear’ electronic monitors, from
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Emerging wearable technology developed by Fjord, a division of Accenture Interactive, called Emotive Insight.
smart adhesive “bandages” that monitor an infant’s temperature and send smartphone alerts to parents, to Belty, an automated belt that contains a pedometer and Bluetooth capabilities to monitor waistline trends. Belty was named Best of CES. Another wearable getting attention at CES was the HBox, a secondgeneration device from BlackBerry and NantHealth that uses a genomic signal to “interrogate” blood, cancer or
potential diseases and share data with a patient's physician. The device will be part of an upcoming clinical trial to help 100,000 patients manage pre-hypertension or hypertension. Companies today are getting the message that the key to making wearables ‘sticky’ for patients is to make sure that they are trustworthy and that they simplify or organize an important facet of life. Certainly, that lesson has to apply to the provider side as well.
LIVING
Charleston, South Carolina: With a Little Help From My App By Jacquie Cohen Roth
I
RECENTLY TRAVELED TO Charleston, South Carolina, to visit my dad with my daughter, Lindsay, who joined me from her current home base of New York City. Over the last couple of years, I’ve visited there several times and am truly in love with “Chucktown.” Inspired by the plethora of apps at the mHealth Summit this past December, I decided to let apps do the heavy lifting for my travel plans. I love them. Apps can keep us healthier, they can also help us get a lot done, including getting to places faster, more efficiently and cheaper. My air travel was handily managed by my Southwest Air app. They, like most major carriers, have a smartphone application to help with booking, checkin, changing or cancelling reservations, even car rental. Through this app I accessed my mobile boarding passes, checked flight status and set up alerts. Oh, and I kept checking their weather report. I was making a tee time. At the Charleston International Airport, I pulled up my car reservation and was soon on my way to Wild Dunes Resort, which Golf Digest named one of the best golf destinations in the state. The Links Course and Harbor Course equal 36 holes of South Carolina Famous for its lovingly restored architecture, Charleston will astound you with details like these columns we discovered on our walking tour of the historic district.
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JACQUIE COHEN ROTH
Take a walk and enjoy Charleston's famous restaurants and public murals. Then talk with sweetgrass crafters while art is created right before your eyes.
beauty and challenge, and they are open to the public. OK, no app for that choice – it was recommended by a friend – but if you’re not interested in driving there, or anywhere in Charleston, Uber, the app-accessed car service, is operating in the city, at least until June 2015. Accommodations were an easy choice, hello Airbnb, (for iOS, Android). I booked a great little privately-owned condo, at a very good rate in the Ashley neighborhood just outside the city. My hosts, Ryan and Royce, based in South Dakota, became my private concierges via our conversation hosted on Airbnb. A short walk from the condo brought me to the very welcoming Blue Rose Café. A full breakfast menu was complemented by extensive daily menus heavy on the comfort soups, stews and baked goods of Chef Denis O’Doherty’s Killarney childhood. The owners of the Blue Rose Cafe are also active in community programs, supporting local performance groups, social charities and community environmental goals. This charming place really lives into their proclamation, 24 | CHESPHYSICIAN.COM
Céad mile fáilte – a thousand welcomes. Charleston is a city that mashes African, European, and now Asian influences in a melting cook pot that’s been stirred by the South. The results are groundbreaking food establishments that reflect all this. To my point, nationally acclaimed restaurants feature James Beard Foundation award winners like Low Country specialist Chef
Downtown. It was Restaurant Week and we were fêted like royalty. Using Yelp (for iOS and Android) and Urban Spoon (for iOS and Android) we also found and enjoyed Michael’s on the Alley, Hutson Alley specifically, and Eli’s Table at 129 Meeting Street for a lusty brunch. All this culinary discussion should not detract from the active outdoor life
Charleston is a city that mashes African, European, and now Asian influences in a melting cook pot that's been stirred by the South. Robert Stehling, of Hominy Grill, and Chef Sean Brock, at Husk, which, I discovered, has a wonderful bar as well. Both Bon Appétit and Southern Living declared Husk Best New Restaurant in 2011. Our first night, we decided to go Mediterranean and landed at Sermet’s
Charleston supports, and I strongly recommend trying out some of these options during a visit. I mentioned the golfing, but we also walked the Ravenel Bridge over the Cooper River, in the well-planned bike and pedestrian lane. Each end of the bridge supports parking,
some private, some public. If you’re there in April, register for the annual 10K (6.2 mile) Cooper River Bridge Run, usually held the first weekend. This point-to-point course starts in Mount Pleasant and finishes in downtown Charleston at Marion Square. There are a number of running apps to help you train for that. Yelp can help you find a bike rental and paddle boarding source, and even bowling, if that’s your cup of Southern Comfort. Take advantage of the usually lovely weather and TripAdvisor (for iOS and Android) to hire a walkingtour guide and get an up-close view of the city’s famous window boxes, iconic gates, and historic homes. There’s a robust creative community in Charleston, of which the best-known event is the Spoleto USA Festival. The 17-day festival showcases both established and emerging artists in over 100 arts performances. Imagine wandering from program to program, indoors and outside, enjoying some of the world’s greatest artists. Complementing this is Piccolo Spoleto, which highlights local and regional
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artists. This year it runs from May 22 to June 7. I confess I haven’t found an app for this event, but their website will help you purchase tickets, spoletousa.org. And don’t leave town without purchasing one of the distinctive, hand-woven sweetgrass items sold on street corners, in the City Market, and even hawked, in the form of stemmed roses, by boys in the parks. In Colonial times, shallow, flat, woven baskets were used to separate rice seed from chafe. Today, the bulrush, from the sandy soils of coastal South Carolina, is used to create one of the most prized cultural souvenirs in the nation. During our trip, Lindsay and I decided to venture out of Charleston to explore some of the historical roots of the area. I tasked Lindsay with planning that adventure and she came up with a trip to Drayton Hall, an 18th-century plantation located on the Ashley River about 15 miles northwest of Charleston. Drayton is a preserved plantation, but not restored. This fascinating place resists any glossy gentrification of the antebellum South
and honors the African enslaved community that lived here, as well as the families of European descent. Visit the African-American cemetery for a fascinating guided or self-guided tour and feel the history and heritage of the South. For those who like to shop, Chucktown is nirvana from well-known upscale national stores to unique boutiques. After hours of chatting on our self-guided walking tour of restored magnificent homes, using MapQuest (free for iOS, Android) to guide us, and a couple of hours of some serious window shopping and quick stops into innumerable unique boutiques, I realized I’d misplaced my purse AND my phone. Panic! Where?! I remembered my “Find My iPhone” app, and one of the boutique owners we’d met was on it – she opened up the app on her Mac and we were able to zero in on the exact location of my purse and phone. Relief with retail and libation celebration were in order. On to Yelp and off we were! For more information on visiting Charleston, visit charlestoncvb.com.
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BEFORE Martinez initially was treated for numerous varicose veins in her legs. A few years later, however, she began experiencing pain in her pelvic area. The pain got so intense that she quit her job as a phlebotomist and she had to move from the third floor to the first floor because she could not climb stairs. After performing a thorough history and physical plus a highly specialized pelvic ultrasound, the doctors at CVM discovered an enlarged, compressed pelvic vein on her left side. They subsequently performed a venogram to pinpoint that the problem was located in the left ovarian vein. Minimally invasive treatment (involving an injection of medicine) that closed off the problematic vein relieved the pain for months. The doctors found that a second vein, the common iliac vein, was also severely compressed and would need surgical treatment. “It was excruciating,” Marti-
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CVM RECEIVES VASCULAR TESTING ACCREDITATION BY THE IAC
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ardiovascular diseases are the No. 1 cause of death in the United States. On average, one American dies every 39 seconds of cardiovascular disease – disorders of the heart and blood vessels. Stroke, a disorder of the blood supply to the brain, is the third leading cause of death and the leading cause of disability in the country, with nearly 800,000 new strokes occurring annually. According to the American Heart Association, the total direct and indirect cost of cardiovascular disease and stroke in the U.S. for 2010 was an estimated $503.2 billion. Early detection of life-threatening heart disorders, stroke and other diseases is possible through the use of vascular testing procedures performed within hospitals, outpatient centers and physicians’ offices. While these tests are helpful, there are many facets that contribute to an accurate diagnosis based on vascular testing. The skill of the technologist performing the examination, the type of equipment used, the background and knowledge of the interpreting physician and quality assurance measures are each critical to quality patient testing. Center for Vascular Medicine has been granted a three-year term of accreditation in vascular testing in the areas of Peripheral Arterial Testing by the Intersocietal Accreditation Commission (IAC). Accreditation by the IAC means that Center for Vascular Medicine has undergone a thorough review of its operational and technical components by a panel of experts. The IAC grants accreditation only to those facilities that are found to be providing quality patient care, in compliance with national standards through a comprehensive application process including detailed case study review. IAC accreditation is a “seal of approval” that patients can rely on as an indication that the facility has been carefully critiqued on all aspects of its operations considered relevant by medical experts in the field of vascular testing. When scheduled for a vascular testing procedure, patients are encouraged to inquire as to the accreditation status of the facility where their examination will be performed and can learn more by visiting www.intersocietal. org/vascular/main/patients.htm. IAC accreditation is widely respected within the medical community, as illustrated by the support of the national medical societies related to vascular testing, which include physicians, technologists and sonographers. Vascular testing accreditation is required in some states and regions by the Centers for Medicare and Medicaid Services (CMS) and by some private insurers. However, patients should remain vigilant in making sure that their vascular testing procedures are performed within accredited facilities, because for many it remains a voluntary process.
WELCOME DR. MICHAEL MALONE
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r. Michael Malone joins Center for Vascular Medicine (CVM) with a special interest in complex peripheral interventions, as well as open vascular surgical procedures. Prior to joining CVM, he was clinical assistant professor of surgery at the University of Toledo School of Medicine and the University of Medicine and Dentistry of New Jersey/ Cooper Hospital. Previously, he was an attending vascular surgeon at Blanchard Valley Health System and Mercy Hospital of Tiffin for several years. Dr. Malone complements CVM with a wide breadth of significant surgical knowledge and experience from numerous academic and hospital appointments. His work has been published in several vascular surgery journals and textbooks.
WELCOME JEANNE SANDERS
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eanne brings a varied skill set and wide base of knowledge to Center for Vascular Medicine (CVM), having over 18 years of experience in the healthcare arena of business management and development. Most recently, she served as CEO of Horizon Vascular Specialists in Maryland. Prior to Horizon, Jeanne was a corporate vice president of community care for the Adventist Health Care System and senior vice president of Shady Grove Adventist Hospital. Throughout her career, Jeanne has been instrumental in business planning and development, successfully implementing growth strategies as well as being a key player in decisions involving day to day business practices. Jeanne is an integral part of the daily management of CVM in her multi-faceted role, which includes the oversight of Operations, Finance and Clinical Scheduling. She is a key player in the continued implementation of CVM’s core mission of ‘state of the art vascular care in a compassionate and cost efficient manner.‘ Jeanne has a Bachelor’s Degree in Nursing from Washington Adventist University and a Master’s Degree Nursing/Health Care Administration from Georgetown University. www.cvmus.com
SPECIAL ADVERTISING SECTION
CVM INTRODUCES C02 ANGIOGRAPHY BY VINAY SATWAH, DO
Sanjiv Lakhanpal, MD
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enter for Vascular Medicine (CVM) is pleased to offer an additional modality to increase its efficacy in treating certain patients suffering from lifestyle-limiting Peripheral Artery Disease (PAD). After an abnormal non-invasive diagnostic work-up, the patient may need further invasive evaluation, in the form of an angiogram. This is traditionally performed with fluoroscopy and injection of contrast into the arterial Carbon dioxide guided stent placement of right renal system, likely in the angiography suite by an Intervenartery stenosis. A. CO2 DSA demonstrates orificeal stenosis of right renal artery (arrow). B. DSA with the tional Vascular specialist. injection of CO2 through the sheath demonstrates the However, there exists a subset of patients who have stent in good position (arrow). C. After stent deploysevere allergic reactions to iodinated contrast, in ment, the renal artery is widely patent. which special consideration should be made to avoid exposure. Additionally, in patients who have abnormal baseline kidney function, with elevated blood urea nitrogen (BUN) levels and/or creatinine levels, minimization of contrast administration is important. Some patients may have known Chronic Kidney Disease (CKD), but have not shown the progression of disease to the point where hemodialysis is required. It is critical to be conservative with the amount of contrast usage in these patients as they are at increased risk for contrast-induced nephropathy (CIN). Therefore, in an effort to provide the highest quality of vascular care to all patients, Center for Vascular Medicine (CVM) has incorporated the utilization of carbon dioxide (CO2) in performing invasive diagnostic studies and interventions. When injected into the vascular system, CO2 gas has chemical properties that allow the visualization of vessels under fluoroscopy. This allows an alternative approach to angiography while avoiding contrast exposure. With the availability of high-resolution digital subtraction angiography (DSA) and a reliable gas delivery system, CO2 angiography has become widely used for vascular imaging and guidance during endovascular procedures, including angioplasty and stent placement, transcatheter embolization, and endovascular abdominal aortic aneurysm (AAA) repair. Since CO2 is a colorless and odorless gas, and it cannot be visually distinguished from air, pressurized cylinders are used to contain the gas. Unlimited amounts of CO2 may be used for vascular imaging because the gas is effectively eliminated by means of respiration. Although very useful, the overall quality of CO2 vascular images is slightly less than that obtained with contrast medium. Therefore, routine use is not desirable for complex interventional procedures, requiring precision in imaging quality. It is important to note that incorrect application of technique may result in air contamination, which may cause serious complications. Therefore, a thorough understanding of the unique physical properties of CO2 is necessary for the safe and effective performance of CO2 angiography. The highly skilled and board-certified physicians at Center for Vascular Medicine (CVM) have received specialized training in performing CO2 angiography.
Vinay Satwah, DO
Mike Malone, MD
Gaurav Lakhanpal, MD
Rakesh Wahi, MD
Shekeeb Sufian, MD
REFERENCES:
Moos JM, Ham SW, Han SM, et al. Safety of carbon dioxide digital subtraction angiography. Arch Surg. Dec 2011;146(12):1428-32. Nadolski GJ, Stavropoulos SW. Contrast alternatives for iodinated contrast allergy and renal dysfunction: options and limitations. J Vasc Surg. Feb 2013;57(2):593-8.
Tom Militano, MD
Call today to make a referral:
866-916-9202 www. c vmu s.com
Krutiben Patel, PA-C
I M M ED I AT E APPO I NTM E NTS AVA I L A BLE Annapolis | Glen Burnie | Greenbelt | Prince Frederick | Silver Spring
COMPLIANCE
Open Payments/Sunshine Act Year Two: Guidance for Physicians
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N JUNE 30, 2015, THE Centers for Medicare and Medicaid Services (CMS) will publish the first full-year report of payments to physicians from pharmaceutical and medical device manufacturers. Physicians who want to review their data before publication can register with CMS. These data are being published pursuant to the Sunshine Act portion of the Affordable Care Act, which requires most pharmaceutical and medical device manufacturers to report a wide range of payments to physicians and academic medical centers. In September 2014, CMS, which calls the program “Open Payments,” published the first official report, but it covered data only from the last five months of 2013. The Open Payments program reports a wide range of payments to physicians. Some examples of common payment categories are: z z z z z z z z
Speaking engagements Travel expenses Meals Entertainment Gifts Educational materials such as textbooks or journal reprints Participation in a paid advisory board Royalties, consulting fees, research or other grants, etc.
Pre-publication review of the Open Payment data is important to individual physicians for several reasons. First, the initial set of data contained a large amount of incorrect, mismatched, or otherwise misleading data, which in some cases created the impression that a doctor had received payments that in fact were not made. Second, many hospitals or other physician employers have used the Open Payments site to
By Theodore M. “Ted” Doolittle
validate compliance by employed physicians with the hospital’s own ethics or conflict-of-interest policies. Third, patients and consumer or advocacy groups can access this data easily, which may result in questions to the physician about payments he or she has received. These kinds of questions can only be expected to increase in 2015, because CMS has made considerable refinements and improvements to the website, which will make this information easier for patients and others to access and analyze. The best way to respond to such questions is to know in advance what data is on Open Payments, and better yet, to correct any misleading or incorrect data before it is even published. Fortunately, individual physicians do have the opportunity in advance of publication to review, and if necessary, dispute, any information about them reported by a manufacturer. The so-called “Review and Dispute” period lasts 45 days. During the first program-year, due to the difficulties associated with starting up a new program, CMS announced the various program deadlines on a rolling basis. On February 2, 2015, CMS announced that it anticipated the 45-day Review and Dispute period would start on a date to be determined in April 2015 to accommodate the June 30 publication date. The first step for physicians who wish to review their information before it becomes public, and who also wish to receive notification of important deadlines such as the start of the Review and Dispute period, is to create an account at the CMS Enterprise Portal page at portal.cms.gov/wps/ portal/unauthportal/home/. Further information about the next steps in the
registration process can be found at cms.gov/OpenPayments/ProgramParticipants/Physicians-and-TeachingHospitals/Registration.html. When a physician chooses to dispute any data they find during the Review and Dispute period, the Open Payment system triggers communication between the physician and the relevant manufacturer, and if a mutually agreeable resolution is reached before the date of publication, CMS will publish the corrected data. If a mutually agreeable resolution is not possible before the publication deadline, CMS will not mediate between a physician and a manufacturer. The data will be published as reported by the manufacturer, but marked as “disputed.” As CMS continues to refine the system and make it easier to access and understand the data, physicians should expect an increase in questions stemming from payments they have received from drug and medical device manufacturers. Much as the rise of websites such as Zillow, which contains real estate pricing data, have made it easier for individuals to access house and mortgage information nearly effortlessly, so should doctors now expect that patients, malpractice investigators, potential employers, and even just the idly curious will be able to access a full slate of information regarding payments from drug and medical device manufacturers? Physicians are therefore well advised to make it an annual ritual to visit the Open Payments site prepublication. This will enable the physician to prepare written or oral responses to questions about his or her data, and/or to dispute the content if necessary. Theodore M. “Ted” Doolittle is a partner at LeClairRyan. He can be reached at ted.doolittle@leclairryan.com. MARCH/APRIL 2015
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POLICY
The Challenge of Controlling Healthcare Utilization A conversation with Jesse Pines, MD, MBA, Director of the Office of Clinical Practice Innovation at George Washington University BY LI NDA H A RDER
Jesse Pines, MD, MBA, a board-certified emergency physician, is the director of the Office for Clinical Practice Innovation and a professor of Emergency Medicine and Health Policy at the George Washington University School of Medicine and Health Sciences. He is an authority on the impact of the Affordable Care Act (ACA) on the current acute care system, and cost containment/utilization approaches.
Q
: Can the ACA be dismantled at this point? That would be difficult since many provisions of the ACA have been implemented and would be challenging to undo.
Q
: How has the ACA impacted emergency care? First, emergency care has been affected by the ACA’s insurance reform, which we know is associated with an increase in the use of emergency department (ED), primary care and healthcare services in general. We know that having insurance increases the use of all medical care, including ED use. The problem is that Medicaid patients still face major barriers to care from outpatient doctors because many physicians don’t accept Medicaid. Especially in places like Maryland and D.C., where Medicaid has expanded, we’ve seen an acceleration of ED visits and a growth in the percentage of Medicaid patients. Second, payment reform has 32 | CHESPHYSICIAN.COM
affected emergency care. A key element of the ACA was to create the Centers for Medicaid and Medicare Services (CMS) Innovation Center, which has the ability to change the way physicians and hospitals are paid without going through the congressional rule-making process. We’re seeing a move away from strictly fee-for-service payments to new payment forms, such as those in Accountable Care Organizations (ACOs), episode-based payments and bundled payments. They provide an incentive to deliver care more efficiently. While the impact of these sorts of payment models on how emergency physicians get paid is yet to be determined, we do know that ED visits often result from poor care coordination and that ED discharges also must coordinate care. New incentives for EDs and hospitals will promote this, especially in Maryland, where hospitals essentially receive a fixed payment for hospital-based care, making coordinating care and keeping people
healthy priorities, particularly when they have multiple chronic conditions. In the old model, doctors didn’t talk to each other much and that didn’t benefit patients. In the future, this will change.
Q:
Can more primary care address the issue? Unfortunately, there’s a real
shortage of primary care physicians due to the unfavorable economics. And that doesn’t fundamentally change with the ACA. Very few medical students are electing a primary care path. I recently asked a group of about 25 third-year medical students whether any of them were planning to choose primary care.
Only one hand went up, and that student admitted she was only just thinking about it. The rest were planning to become specialists. To have more primary care, the economics must change.
Q
: Does better care coordination reduce use? In EDs today and in the future, there will be more of a push to coordinate with primary care physicians and multiple specialists outside the ED. It creates more work but may be less costly because hospital admissions are so expensive.
Q
: What impact have global hospital budgets, such as the ones in Maryland, had on the ED? When a hospital is operating under a global budget, as Maryland hospitals are now doing under the waiver, admitting a complex patient becomes a cost driver, not a revenue driver. In the ED, that is manifesting as longer, more complicated work-ups to keep people out of the hospital. I wrote an article on the early experience of the Total Patient Revenue (TPR) hospitals in which we looked at the impact on EDs. A lot of good things resulted – social work and care management services increased, for example – but there were also unintended consequences. At least anecdotally, I heard that hospitals under global budgets would transfer some of the complex patients out to hospitals that were paid under fee-for-service. With all Maryland hospitals now on global budgets, it will be interesting to see how this evolves. One issue with payment reform that we know is that it can set up conflicting incentives between physicians, who are still largely paid on a fee-for-service basis, and hospitals that are paid on a global budget. In the TPR program, many inpatient specialists left to go to non-TPR hospitals. From what I’ve heard, the CMS Innovation Center’s long-term plan is to put everyone on global payments. Until that happens, there will continue to be a push to move care, where possible, into unregulated spaces such as the outpatient setting.
Q
: It seems like urgent care centers are on every corner these days. Doesn’t that help with ED utilization?
Urgent care centers and retail clinics are a great example of unregulated space. The issue is that these tend to be built in suburban areas that have a good case mix, not in poorer areas such as inner cities. The other issue with building more clinics is supply-induced demand. It’s like our traffic problems on the highways. We assume traffic will improve if we add more lanes, but that in turn attracts more drivers to remote suburbs, and traffic gets worse again. In a similar way, building more urgent care capacity attracts more patients, so it could potentially induce more demand for care rather than drawing patients out of EDs. The issue now with urgent care and retail clinics is that some don’t accept Medicaid, and there’s not much regulation of their quality.
cost too much. Several years ago, we examined data from several countries that had a single-payer system, and, with few notable exceptions (including Denmark), they all had ED crowding. ED visits in France, for example, doubled from 1990 to 2010. Just changing the payment system doesn’t solve the delivery-system problem. Delivery-system reform needs to drive payment reform, not the opposite. The other factor to consider is the price of American healthcare. Cost equals volume times price. For some healthcare services, prices in this country are three to five times higher than elsewhere. Even current global payments are based on historical payments, so they aren’t really addressing the price side of the equation. Once we create a
Once we create a more efficient system, we’ll have to address price, or we won’t be able to bring down costs. I previously served as an advisor for the CMS Innovation Center. I remember one of my first meetings. We were talking about decreasing costs and I asked, “Haven’t you been trying to do this for the last 30 to 40 years?” The response was, “Every time we try to decrease healthcare costs, it’s like squeezing a balloon – you push on one end and the other end gets bigger.” New payment models are trying to grab a bigger part of the balloon. If part of the system is unregulated, there’s always a place for the balloon to expand.
Q:
Don’t high-deductible plans discourage ED use? A high deductible
does provide a disincentive to use the ED, but those with Medicaid have no such disincentive. And for those without Medicaid, such as those with “bronze” plans who have low incomes and highdeductibles, it discourages not only ED use, but any healthcare use.
Q:
Would a single-payer approach be a better option to control utilization and costs? Single-payer is
a great idea and works in many other countries, but the question is how we get from here to there. Vermont recently tried to implement a single-payer system, but ultimately did not because it would
more efficient system, we’ll have to address price, or we won’t be able to bring down costs.
Q:
Are there any strategies that will work? On the positive side, with the
ACA, we’re undergoing a major culture change, and physicians increasingly understand that resources are finite. There’s a lot of grassroots change occurring. Six months ago, I was in the trauma bay, and a resident told me that his patient didn’t need a CT scan. When I asked him why he thought that, he cited evidence-based tools. He was right, but it was still shocking to hear him say it. That’s one example of that culture change having a positive impact on costs, though it does increase the risk of patient safety problems. Some healthcare is effective and less costly. The challenge is figuring out what care is most efficient. Jesse Pines, MD, MBA is principal investigator for Urgent Matters (urgentmatters.org), a GW School of Medicine program that disseminates information on best practices in emergency care and has extensive experience in quality improvement, patient safety, operations research and clinical epidemiology. He has served as a senior advisor at the Center for Medicare and Medicaid Services Innovation Center in Baltimore, and a consultant to the National Quality Forum on patient safety and emergency care in Washington, D.C.
MARCH/APRIL 2015
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JACQUIE COHEN ROTH
OUR BAY
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F O R
Pelvic Pain o f Va s c u l a r O r i g i n Call today to make a referral:
866-916-9202 www.StopPelvicPain.com I M M ED I ATE A PPO I NTM E NTS AVA I L A BLE Annapolis | Glen Burnie | Greenbelt | Prince Frederick | Silver Spring