Maryland Physician Magazine March/April 2014 Issue

M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

THE UNMENTIONABLES: INCONTINENCE AND ERECTILE DYSFUNCTION MANAGING THE INFLAMED GUT mHEALTH BEGINS TO HARNESS CARE IMPROVEMENTS

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VOLUME 4: ISSUE 2 MARCH/APRIL 2014

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Contents 12

VOLUME 4: ISSUE 2 MARCH/APRIL 2014

16 F E AT U R E S

12 The Unmentionables: Incontinence and Erectile Dysfunction 16 Managing the Inflamed Gut 22 mHealth Harnesses Care Improvements D E PA R T M E N T S

Cases

| 9 | Morbid Obesity and Gastroesophageal Reflux Disease

Compliance

| 11 | Legal Pitfalls and Hospital Employment Agreements

Policy

| 24 | A New Era: Marylandâ&#x20AC;&#x2122;s Medicare Waiver

Living

| 26 | Asheville, North Carolina: Perfect Mix of Small Town and City Sophistication

Solutions

| 29 | Physician Opportunities in the New Maryland Medicare Waiver

Good Deeds

| 30 | Putting Up the Good MS Fight

On the Cover: Jennifer Bepple, M.D., urologist, Central Maryland Urology Associates

JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com

March 23, 2014,

marks the fourth anniversary of the historic piece of federal legislation, the Patient Protection and Affordable Care Act (ACA). On January 10, 2014, the Centers for Medicare and Medicaid (CMS) and the state of Maryland partnered on a historic piece of healthcare regulation that allows the state to adopt new policies that will, in theory, reduce per-capita hospital expenditures and improve outcomes – goals of the ACA. Many eyes are on Maryland, watching to see if the revisions to Maryland’s already unique all-payer hospital rate regulation system will be successful. Success metrics include the generation of $330 million in Medicare savings over a five-year period, limits on all-payer per-capita hospital cost of care and quality targets designed to promote better care and health for Maryland’s population. Inherent to the shaping of a historic shift in a payment model is that many of Maryland’s healthcare stakeholders believe that government can indeed “do good.” How did we get to this shift and when will we know if it’s working? We sat down with John M. Colmers, Health Services Cost Review Commission Chair, to find out (Policy page 24). The paradigm and face of healthcare delivery are changing. This issue’s cover photo features Jennifer Bepple, M.D., a urologist with Central Maryland Urology Associates, who was just a few weeks away from giving birth when we held our cover photo shoot. We spoke to her as part of our clinical feature on “the unmentionables” – incontinence and erectile dysfunction (page 12). Your patients may be reluctant to speak with you about either disorder, so our experts urge you to have open and frank discussions that offer them options for diagnosis and treatment. We also spotlight intestinal disorders in this issue: Crohn’s disease, colitis and celiac disease. I’ve been guiding one of my 20-something daughters through the journey of identifying which digestive disorder is causing her symptoms. The standard of care for celiac is diet compliance, which is becoming less challenging with a new abundance of gluten-free offerings. More clinical trials, new medications and better diagnostic tools also mean that life for patients with chronic digestive disease is greatly improving (page 16). Mobile health (mHealth) (Healthcare IT page 22) is beginning to have a significant impact on how care is delivered and how patients manage their own health. The FDA has yet to set firm guidelines for the regulation of mHealth apps that function as medical devices, but there are abundant apps to help your patients better manage their chronic diseases. A personal search for managing celiac disease resulted in 46 different apps for a gluten-free life. Of course, the quality of these apps varies, but the point is that patients are becoming engaged staying healthy and that’s the heart of healthcare reform.

To life!

Jacquie Cohen Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag

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MANAGER OF DIGITAL CONTENT & SOCIAL MEDIA BUSINESS DEVELOPMENT Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Tracy Fitzgerald COPY EDITOR Ellen Kinsella PHOTOGRAPHY Tracey Brown, Papercamera Photography DIRECTOR OF FINANCE Kyle Marisa Roth BUSINESS DEVELOPMENT Eileen Nonemaker enonemaker@mdphysicianmag.com Maryland Physician Magazine – 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 www.mojomedia.biz Subscription information: Maryland Physician Magazine 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 $52.00. 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 jroth@ mdphysicianmag.com. Maryland 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 Maryland Physician. Advisory board members include: PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D., FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center Although every precaution is taken to ensure accuracy of published materials, Maryland 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

Morbid Obesity and Gastroesophageal Reflux Disease Elizabeth A. Dovec, M.D.

A 45-year-old morbidly obese female with past medical history significant for hypertension presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past four months. She says these symptoms are worse when she lies down and after meals. She denies difficulty swallowing. The patient has been taking Nexium, a proton pump inhibitor (PPI), regularly over the past 12 weeks, resulting in partial resolution of her symptoms. Her history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. On examination, she is obese with a central fat distribution. She is found to be 5 feet, 3 inches and weighs 280 pounds. Her body mass index (BMI) is 47 kg/m2. She is interested in discussing the best appropriate treatment plan. CASE:

DISCUSSION: Obesity is increasing in epidemic proportions, and qualifies as one of the leading medical conditions among Americans. The adverse health effects associated with obesity may reduce patient quality of life and longevity. The treatment goals of any patient with morbid obesity should be focused on weight loss as well as on the reduction of comorbidities. Surgical weight-loss options, such as the Laparoscopic Roux-En-Y Gastric Bypass and Laparoscopic Vertical Sleeve Gastrectomy, should be considered in patients who have unsuccessfully attempted supervised weight-loss programs by diet, exercise or medications, and fulfill minimum weight criteria that include BMI of 35 to 39.9 kg/m2 with obesity-related comorbidity, or BMI of greater-than 40 kg/m2 without comorbidity. Patients with long-standing gastroesophageal reflux disease (GERD) may develop complications such as peptic strictures or Barrett’s esophagus – which is associated with an increased risk for developing esophageal adenocarcinoma. These patients are also at greater risk for extraesophageal complications due to pharyngeal reflux and silent aspiration (including laryngitis, reactive airway disease, recurrent pneumonia and pulmonary fibrosis). Normal physiologic mechanisms are important in preventing abnormal GE reflux. Abnormalities in the resting pressure, intra-abdominal length or number of relaxations of the lower esophageal sphincter (LES) can contribute to abnormal reflux. There is a correlation between obesity and GERD. The first phase of therapy for symptomatic GERD involves lifestyle modifications aimed at factors that have been shown to increase symptoms and acid exposure in the esophagus. Triggers include spicy foods, fatty foods, drinks

that contain caffeine or alcohol, and certain medicines. Medical therapy includes motility agents, which increase acid clearance, H2-receptor antagonists and proton-pump inhibitors. For the uncomplicated patient with GERD, surgical therapy should not be recommended over PPI therapy. However, patients who are refractory to medications should be considered for anti-reflux operations such as fundoplication and weight-loss surgery. Reflux disease warrants special consideration in the recommendation of operative bariatric choices for patients. Patients with GERD will have significantly greater improvement in symptoms after gastric bypass than after the sleeve gastrectomy or gastric adjustable banding operations. Patients who undergo gastric bypass also have higher symptomatic relief than those who undergo other anti-reflux procedures such as fundoplication for GERD. Those who are referred for surgical fundoplication with a BMI of greater than 35 should be offered the option of having a gastric bypass as an alternative to a laparoscopic fundoplication. Gastric bypass will treat the patient’s reflux symptoms as well as improve their physical and medical issues related to severe obesity. Elizabeth Dovec, M.D., serves as a bariatric surgeon at Greater Baltimore Medical Center’s Comprehensive Obesity Management Program. Dr. Dovec may be reached at 443-849-3779 or bariatrics@gbmc.org. Frezza EE, Ikramuddin S, Gourash WF, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2002;16:1027–1031. Weiss HG, Nehoda H, Labeck B, et al. Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility. Am J Surg. 2000;180:479–482. Madalosso CA, Gurski RR, Callegari-Jacques SM, et al. The impact of gastric bypass on gastroesophageal reflux in patients with morbid obesity: a prospective study based on the Montreal Consensus. Ann Surg. 2010;25:244–248. Thodiyil PA, Mattar SA, Schauer PR. Gastroesophageal reflux disease in the bariatric surgery patient. In: Schauer PR, Schirmer BD, Brethauer SA, eds. Minimally Invasive Bariatric Surgery. New York, NY: Springer; 2007:441–442.

MARCH/APRIL 2014

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Compliance

How to Avoid Legal Pitfalls in Hospital Employment Agreements By James S. Jacobs, Esq.

N MARYLAND AND ELSEWHERE in the U.S., health reform and other factors are fueling the trend toward hospital employment of physicians. A 2013 survey by Jackson Healthcare found that 40% of physicians reported being a hospital employee or in a hospital-owned practice. If you are among those considering the sale of your practice to a hospital, think about the following issues before and during negotiations. Assets, Goodwill and Accounts Receivable

Hospitals typically acquire your practice’s assets, and not the legal entity you own. Generally, the acquisition is for a nominal fair market value of the furniture and equipment acquired, which is determined by an independent appraiser. Hospitals no longer regularly purchase the goodwill of the practice with a large cash payment. Although goodwill payments may still be negotiated, they must be justified in the context of the total compensation, since all parties want to be inoculated from a government claim that any payments are being made for referrals. Your accounts receivable generally are not included in the sale; you are responsible for collecting and retaining them. Unless there is an outside, thirdparty collection agency, you must contract with the hospital to collect the receivables on your behalf, negotiating a fee for this service, because the hospital now employs your former employees and owns your computer equipment. Compensation

Most agreements provide a base salary with specified productivity thresholds. Incentive compensation also is based on

productivity. Compensation determined by a formula that uses work relative value units (wRVU), not cash collections, is becoming more prevalent. wRVUs address concerns about reduction of payment rates by Medicare and other third-party payers, and about the efficiency of hospital billing and collections. If compensation is based on cash collections, be wary of whether the agreement specifies cash or accrual accounting. Cash accounting entails an initial lag in receipts, and the first year of employment includes only approximately 10 months of collections. Regardless of the accounting method used, be careful about how the compensation is structured in your initial year of employment. You may ask that the hospital build in relief during the transition period, to make up for lower productivity resulting from practice changes that they’ve required. The contract also should prorate the compensation formula upon termination. Avoid provisions that require you to be employed on the last day of the year in order to receive incentive compensation. Also consider requiring the compensation formula to address periods of disability. Malpractice

Sometimes hospitals permit you to retain the existing malpractice policy, and agree to pay those premiums during hospital employment, especially when you are nearing retirement and are eligible for a free reporting endorsement (“tail”). If you’re not close to retirement and you retain your prior policy, be sure to specify who will have the responsibility for the payment of the tail

upon the termination of employment. This is a heavily negotiated item. In many cases, you are required to be insured under the hospital’s malpractice coverage. When the hospital provides coverage under its policy, specify that this is an “occurrence” policy, and no tail coverage is required. If a tail is necessary, it should be paid by the hospital. Negotiating Restrictions

Negotiate employment agreement provisions that restrict where you can practice if the agreement is terminated. For example, hospitals should agree not to restrict your ability to continue to practice if they terminate the agreement without cause, or fail to renew it. Hospitals may also allow you to continue to practice within the same geographic area if you do not affiliate with or accept benefits from a competitor. You may be able to negotiate a release from the restriction upon payment of a specified cash amount when the agreement ends. Group Practices

A group practice purchase can provide more leverage to physicians. A group can maintain its identity, making the change appear seamless to patients. In a group, physicians can pool their compensation and determine how it will be allocated to each physician, subject to the reasonable approval of the hospital. This allows pre-existing compensation arrangements to be maintained and may allow the practice to be managed semi-autonomously from the hospital. James S. Jacobs is a principal in the Maryland law firm of Jacobs & Dembert, P.A. He can be reached at jjacobs@jdlaw.com.

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Jennifer Bepple, M.D., urologist, Central Maryland Urology Associates

THE UNMENTIONABLES Incontinence and Erectile Dysfunction While American society has become more open about health issues, many of your patients may still be reluctant to mention that they have incontinence or erectile dysfunction. Thatâ&#x20AC;&#x2122;s why our experts advise that physicians ask about these common disorders. 12 | WWW.MDPHYSICIANMAG.COM

“Primary care physicians should be sure to ask every patient, whether via the health survey or during the visit, about [incontinence.]” — Jennifer Bepple, M.D.

Despite the growing acceptance of countless formerly taboo topics in our culture, many patients remain reluctant to tell their physician about incontinence. Jennifer Bepple, M.D., a urologist with Central Maryland Urology Associates, says, “There’s still an unfortunate stigma associated with incontinence. Primary care physicians should be sure to ask every patient, whether via the health survey or during the visit, about this issue. And they should educate patients that it’s not a normal part of aging, and there are multiple treatment options available.”

STRESS INCONTINENCE

INCONTINENCE The prevalence of incontinence increases with age. In a large U.S. survey of nonpregnant women, moderate or severe urinary incontinence was reported to affect 7% of women ages 20 to 39, 17% ages 40 to 59, 23% ages 60 to 79, and 32% over 80 years. Stress and urge incontinence are the most common types in females. While age, menopause, weight, number of children and prior pelvic surgery or radiation are risk factors, studies have shown that even college athletes can suffer from one or both of these types of incontinence.

Stress incontinence refers to the inability to prevent leakage of urine when stress is placed on the abdominal muscles. Caused by weakened pelvic muscles or a deficient urethral sphincter, stress incontinence has two main types urethral hypermobility and intrinsic sphincter deficiency. “When assessing patients and determining their options, we are sure to identify which type they have,” Dr. Bepple reports. “We do this based upon their physical exam and urodynamic studies.” Anything that increases intraabdominal pressure, such as smoking, a chronic cough, obesity or constipation, can worsen stress incontinence. Because it is essentially an anatomical issue, no medications are indicated. The first line of treatment is conservative. Dr. Bepple recommends referring patients to a qualified pelvic floor physical therapist who can provide biofeedback and a

personalized exercise regimen. Home biofeedback devices can also be useful to ensure that patients are performing the exercises correctly. Surprisingly, Dr. Bepple notes that many people do the wrong variety of exercises or perform them incorrectly. She says, “It’s like the gym. If you haven’t worked out in five years, you can’t just go and bench press 150 pounds immediately. And you need a guide as to what exercises are appropriate.” She adds, “I’m a strong advocate for women to try these conservative approaches because there are no side effects.” If these conservative approaches fail, women may need one of two surgical options. The first option is a mid-urethral sling, performed as an outpatient procedure under sedation to address urethral hypermobility issues. While it enjoys a success rate greater than 80%, many women continue to mistakenly believe that the polypropylene mesh used in the sling procedure is what the FDA once cautioned users about, despite clarifications issued in 2011 and 2013. “The FDA warning excludes mid-urethral slings, but many women are still nervous about this procedure,” Dr. Bepple comments. “The American Urogynecological Society issued a position statement supporting the sling as the worldwide standard of care. However, it’s contraindicated for women who are, or are considering becoming, pregnant, and those with compromised immune systems, bleeding or some pelvic disorders.” MARCH/APRIL 2014

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Andrew Kramer, M.D., associate professor of Surgery/Urology at University of Maryland Medical School

The second surgical option involves the injection of a urethral bulking agent to address intrinsic sphincter deficiency (ISD). This procedure is performed on an outpatient basis under mild sedation. While it’s a viable option for those who can’t tolerate a sling or who only need their sphincter deficiency addressed, it has the drawback that some 30% of patients may need a repeat injection. The bulking agents, which can be injected via a transurethral or periurethral approach, can be made of synthetics, bovine collagen or autologous substances. Stem cells also show promise as future bulking agents. They work by coapting the submucosal tissues of the bladder neck and urethral wall and resisting urinary flow.

URGE INCONTINENCE Urge incontinence, or overactive bladder (OAB), is the need to urinate urgently and often. While more common in women, especially in older women, it is also seen in men. “What patients eat and drink influences this condition,” Dr. Bepple states. “Coffee, teas, sodas, 14 |

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acidic fruit such as tomatoes or oranges, alcohol and spicy food contribute to the problem. Even decaffeinated products can worsens symptoms, because it’s the acidity, in addition to the caffeine, that contributes.” Even when patients follow a strict diet, they may still need medications. Anticholinergics, such as Ditropan or Vesicare, are the oldest class of these medications. Their potential side effects, including dry eyes, dry mouth and constipation, can dissuade patients from using them, and they’re contraindicated in those with narrow-angle glaucoma, urinary retention and some gastrointestinal diseases. The tricyclic antidepressant imipramine hydrochloride may be used to relax the smooth muscle of the bladder, and may also contract the muscles at the bladder neck. A newer class of drugs, the beta-3 adrenoceptor agonists such as Myrbetriq (mirabegron), targets beta-3 receptors, decreasing the frequency of rhythmic bladder contractions during the filling phase. This increases bladder capacity

and improves symptoms in patients with OAB. It is contraindicated in those with poorly controlled hypertension. Dr. Bepple says, “Many primary care physicians have a ‘go-to’ medication. If that medication fails, they often refer to a urologist, where further evaluation can be performed. We make sure patients are emptying their bladders well by checking a post-void residual, and can perform cystoscopies, urodynamic studies, uroflow evaluations and a urine culture or microscopic analysis as indicated. We also sometimes ask patients to keep a voiding diary that records what and how much they drank, and when and how much they voided. “When patients fail medications, we may use medications in combination,” she continues. “Other options include BOTOX®, initially approved for the neurogenic bladder, but now FDAapproved for idiopathic overactive bladder. Side effects may include infection or retention, however, and it must be repeated every six to 10 months.” Second-line treatments also include InterStim®, a sacral neuromodulator -

essentially a bladder pacemaker. It treats urinary frequency, urgency and non-obstructive urinary retention by regulating the signals the sacral nerves send to the brain. Percutaneous tibial nerve stimulation employs a similar concept, involving the placement of a tiny needle behind the ankle to stimulate the nerves that control pelvic floor function. Patients initially have weekly treatments in the urology office for 12 weeks, then every two weeks thereafter, trying to then stretch this to monthly treatments. “Thankfully, it’s rare today to have patients need bladder augments or open procedures,” Dr. Bepple concludes.

Erectile Dysfunction, Not Impotence Andrew Kramer, M.D., associate professor of Surgery/Urology at University of Maryland Medical School, and director of Sexual Medicine at the medical center, often hears his patients with erectile dysfunction (ED) say, “I don’t know how to say this… I’m embarrassed.” He says, “I reassure them that sex is a basic human right, and that ED is just a medical condition like any other. The term I don’t like to use is impotence. That implies weakness or powerlessness – and it’s not. ED affects about half of men over age 50 in some form - not getting an erection, not sustaining it, etc. “ED is a window into a man’s health,” Dr. Kramer continues. “Men may not seek help for a health condition until they get ED, which mimics the degree of many medical problems, including hypertension, heart disease and

there. It’s good to address the other medical issues, but not fair to expect patients to wait to address their ED.

DIAGNOSIS “The key to a diagnosis is putting together the picture from the history and symptoms,” Dr. Kramer explains. “I find out whether the man can experience orgasm, has sensation or has issues with firmness. I also ask about morning erections. I don’t typically need an EKG or angiography. There’s not much benefit to digging into the causes – it’s almost always a combination of age, small-vessel disease and nerve disease. Many men can get an erection when they masturbate – it’s only the stress of performing that gives rise to ED. I tell them the brain is the biggest sex organ. Emotional attachment is important.” He continues, “Age is an independent risk factor – some men mistakenly expect their performance to be the same at 50 as it was at 18. Other risk factors are bloodvessel disease and anything that affects on-demand blood flow. Smoking causes vasospasms and small-vessel disease. Exercise and big fatty meals also affect blood flow. For an erection, you need rapid, on-demand diversion of blood flow within 30 seconds.”

PENILE IMPLANTS TREATMENT OPTIONS Treatment has changed dramatically since 1997, when medications to treat ED came onto the scene. Sildenafil (Viagra), vardenafil (Levitra or Staxyn) and tadalafil (Cialis) reverse erectile dysfunction by increasing nitric oxide, which opens and relaxes blood vessels in the penis,

“The term I don’t like to use is impotence. That implies weakness or powerlessness – and ED is not that.” — Andrew Kramer, M.D.

endothelial dysfunction. If a patient has vessel disease or diabetes, their physician should ask if they’re experiencing ED.” Dr. Kramer urges primary care physicians to ask their male patients if they have any erectile issues. “If they indicate any problems, you can either suggest medication, or tell them you can refer them to an expert who can help,” he says. “We’re capturing so little ED now – only about 5% of what’s out

hyper- or hypotension, heart or liver disease or prior stroke.” Even at about $10 a pill, Dr. Kramer feels that insurance coverage is appropriate, stating, “Sexuality is a normal human function, not involving vanity or greed.” If pills don’t work, the next step is often injections of alprostadil (Caverject or Trimix). These also are vasoactive, drawing blood into the penis. Men inject the medication into the penis about five minutes before sex, and they work regardless of mental stimuli. While the injections involve essentially no pain, many men are queasy about injecting themselves, and the drop-out rate is high. Inserting suppositories like MUSE into the urethra have an effect similar to the injections, though their use has decreased since Viagra was introduced. Vacuum devices are a fourth option. Dr. Kramer notes, “Vacuum devices, which trap blood in the penis, have been around for 100 years. Today, we use a vacuum erection device with a handpowered or battery-powered pump to create a vacuum that pulls blood into the penis. After getting an erection, patients slip a tension ring around the base of the penis to keep it firm.”

helping men get and keep an erection. “The medications are similar, except that Cialis is long-acting and Viagra and Levitra are short-acting,” Dr. Kramer comments.” Each is vasoactive and about 92 to 93% effective, though it should be noted that placebos are over 40% effective. All of them may cause a stuffy nose or other minor side effects. Contraindications include those taking nitrates or anticoagulants, those with

When less-invasive methods fail, penile implants are a viable option. “Costing about $12,000 and covered by most insurances, implants provide a terrific cost-benefit ratio, with little risk of infection or injury,” Dr. Kramer exclaims. “In a 30-minute outpatient procedure involving general anesthesia, the surgeon inserts a pump in the scrotum and a cylinder in the penis. The sensation and orgasm are the same as a natural erection. It’s very effective. Even men who have not had an erection for 10 years can quickly return to erections following an implant.”

Jennifer Bepple, M.D., urologist at Central Maryland Urology Associates Andrew Kramer, M.D., associate professor of Surgery/Urology at University of Maryland Medical School, and director of Sexual Medicine at University of Maryland Medical Center

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MANAGING THE INFLAMED

GUT

CROHN’S DISEASE, CELIAC DISEASE AND PREGNANCY WITH IBD

BY L INDA H ARDER • PH OTOG RA PH Y BY TRA CEY BROWN

Michael Epstein, M.D., FACG, AGAF, founder of Annapolis-based Digestive Disorders Associates

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Maryland gastroenterologists explain how to better manage the inﬂammation in Crohn’s and celiac disease, and how to help women with inﬂammatory bowel disease through pregnancy and childbirth.

THE CHALLENGE OF CROHN’S DISEASE Crohn’s disease, which affects an estimated 500,000 to 700,000 Americans, is a chronic inflammatory bowel disease (IBD) that can involve any part of the intestinal tract, from the mouth to the anus. However, the ileum and cecum are most commonly involved. Crohn’s may also affect the eyes, skin and joints, and cause inflammation in other organs. Its primary symptoms are pain, weight loss, loss of appetite and abdominal fullness or mass. Some patients exhibit symptoms of colitis, with diarrhea or constipation. They may also have fevers, fatigue and a feeling of malaise. In contrast to the other type of IBD, ulcerative colitis, which only affects the inner lining of the colon or ileum, Crohn’s is transmural, potentially affecting the entire thickness of the bowel wall. Another common feature unique to Crohn’s is ‘skip’ lesions – unaffected areas sandwiched between affected areas. More severe cases may result in fistulas that occur between two loops of the bowel, between the bowel and rectum or anus, or enterocutaneous fistulas between the bowel and skin. Patients also may demonstrate ‘crops’

of aphthous ulcers on the mucous membranes lining the mouth. Michael Epstein, M.D., FACG, AGAF, founder of Annapolis-based Digestive Disorders Associates, says, “The manifestations of Crohn’s are protean, and symptoms overlap with those of other illnesses. They may be mild or severe, and they may relapse or remit in irregular intervals or be chronic.”

ETIOLOGY While Ashkenazi Jews, caucasians, teens and young adults are at higher risk; Dr. Epstein notes that the incidence in blacks and in older people is on the rise, perhaps due to better detection and diagnosis. Crohn’s is believed to be caused by a dysregulated proinflammatory response to commensal gut bacteria. Due to mutations, some mucosal defense mechanisms are disrupted, including the presence of mucus-coated epithelium with tight junctions, IgA secretion, and defensins (naturally-occurring antibiotics that are produced by Paneth cells to maintain sterility of the crypt). Mutations in the NOD2/CARD15 gene and the autophagy gene,

ATG16L1, are associated with Crohn’s disease. The NOD2 gene is involved with recognition of bacterial peptidoglycans, and mutations in the gene cause a decrease in defensin production and secretion. Mutations in the ATG16L1 gene lead to a decrease in the exocytosis of secretory granules in Paneth cells, thereby decreasing concentrations in the crypt of defensins, lysozyme and phospholipase A2. When defense mechanisms are depressed, uncontrolled microbial proliferation can occur, and certain genes are stimulated to produce proinflammatory cytokines like tumor necrosis factor-α (TNF-α ), interleukin-1 (IL-1), IL-6, and the chemokine IL-8. Cytokine and chemokines attract T-cell infiltration (primarily Th-1 cells in Crohn’s disease) that in turn amplifies the inflammatory response. “Certain triggers, such as bacterial infection of the gut, C. difficile, E. coli infection or other stressors may set off the disease,” Dr. Epstein explains. “Some medications, such as Advil or Motrin, also can cause a flare-up. We avoid aspirin, Aleve and the like because they may exacerbate the illness.”

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Mary Harris, M.D., medical director, The Center for Inflammatory Bowel and Colorectal Diseases at Mercy Medical Center

DIAGNOSIS While Crohn’s symptoms can mimic those of other gastro-intestinal diseases, Dr. Epstein states, “We have very good imaging procedures like CT or MR enterography, balloonassisted enteroscopy, colonoscopy and ileoscopy, as well as blood tests to aid in making an accurate diagnosis.”

MEDICATIONS Biologics such as anti-TNF-α therapy have emerged as secondline therapies for those who have failed conventional therapies. It has been supported by several large, randomized controlled trials. “Medications have evolved from a primary reliance on steroids and mesalamine to control inflammation, to a greater use of immunologics, such as Imuran® and Purinethol®, and biologic therapies such as Humira or Remicade,” notes Dr. Epstein. “Biologics, developed over the past decade, are the biggest boon to care since prednisone. Nonetheless, some 40 to 45% of patients don’t respond to them.” Disease-related factors and co-infection should be ruled out, however, before determining that nonresponse is drug-related.

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The SONIC (Study of Biologic and Immunomodulator Naive Patients In Crohn’s Disease) study, published in the New England Journal of Medicine in 2010, found that for patients with early disease, combining infliximab and azathioprine was superior to using either drug alone for patients whose disease was refractory to mesalamine, budesonide or prednisone. Digestive Disorders Associates is participating in several global clinical trials to assess the efficacy of treatment regimens that involve drugs in the interleukin class, plus multiple antibiotics. “DNA from tuberculosis(TB) like organisms is present in those with Crohn’s. The theory is that bacteria similar to TB cause some of the cases of Crohn’s.”

SURGICAL OPTIONS About 15% of patients with Crohn’s will be affected by strictures in the small intestine. Less invasive alternatives to bowel resection include strictureplasty, in which the narrowed section of bowel is opened without removing bowel tissue, and endoscopic balloon dilation, in which physicians dilate the stenosed section with a balloon introduced during endoscopy. Perianal fistulas, the most common fistulas to present in Crohn’s, can be treated surgically if antibiotics plus anti-TNF-α drugs fail. “In the past, about half of patients ended up with surgery at some point,” says Dr. Epstein. “However, with today’s medications and alternative therapies, that percentage is decreasing.”

MICROBIOME While fecal microbial transplants are being eyed for Crohn’s, only one small study has indicated they may have value, and gastroenterologists generally are skeptical of their potential. According to Dr. Epstein, “The microbiome is the next big area, but we have lots of theory and very limited data. Some 90% of bacteria in the gut are unknown. We don’t yet know the optimal dose, amount or number to give people. Well-done studies found that the ovum of pork tapeworm was not effective in

treating Crohn’s, and it remains to be seen if microbiologic therapy can alter the course of the disease.”

PATIENT EDUCATION Dr. Epstein advocates, “The most important thing with Crohn’s is to educate patients so they can be in control of their health. The Crohn’s and Colitis Foundation website (www.ccfa.org) is an excellent online resource. No two patients are alike, so no two have the same needs. It takes lots of compassion and patience to deal with patients with this disorder – it can be exhausting, but also very rewarding.”

CELIAC DISEASE: UNDERDIAGNOSED GI DISORDER Celiac disease is a disorder in which those with a genetic predisposition cannot tolerate gluten, a protein found in wheat and some other grains. Gluten triggers an autoimmune response that engenders an inflammatory cascade inside and outside the gastrointestinal (GI) tract. Gliadin, the toxic component of gluten, binds to the intestinal receptor CXCR3, which releases the protein zonulin. Zonulin makes the intestine more permeable to large molecules. This triggers an autoimmune response in which a celiac patient's immune system identifies gluten as an intruder, and responds by attacking the intestine instead of the intruder. Despite growing awareness of the potential impact of gluten on many digestive systems, celiac disease remains a vastly underdiagnosed disorder, especially in the U.S. “It’s estimated that more than 1% of Americans, or about three million people, have celiac disease, yet only about 60,000 have been diagnosed,” says David Doman, M.D., FACP, FACG, clinical professor of Medicine, George Washington University School of Medicine, and founding partner, Montgomery Gastroenterology in Silver Spring. That is likely due in part to the wide spectrum of clinical manifestations, age of onset and severity of symptoms in celiac disease. Children are more likely to exhibit malnourishment,

“If a 30year-old patIent has osteoporosIs, physICIans should ConsIder undIagnosed CelIaC dIsease as a possIble CulprIt.” – David Doman, M.D., FACP, FACG

weight loss and diarrhea, while adults commonly have symptoms that manifest outside the GI tract. An adult’s only symptoms may be migraines, depression, ADHD, recurring miscarriages or infertility, or skin disorders such as unexplained hives, uticaria or dermatitis herpetiformis. Many people have genetic susceptibility to celiac but never get the disease. According to Dr. Doman, “It’s still unclear what the trigger is and why some patients get celiac as children while others are affected as adults. It’s likely that some mutations are more aggressive than others.” Malabsorption of Vitamin D, folic acid and other nutrients can cause osteoporosis at a young age. “If a 30-year-old patient has osteoporosis, physicians should consider undiagnosed celiac disease as a possible culprit,” he advises.

issue when the patient has adhered to a gluten-free diet or is taking immunosuppressants.” He also warns physicians against interpreting positive genetic test results as indicative of celiac. “A positive test only means that the individual is at higher risk for celiac. It’s only helpful in ruling out celiac when the test finds the patient to be free of celiac-related mutations.” Dr. Doman adds, “The gold standard in diagnosing celiac disease continues to be the small bowel biopsy. The endoscopic procedure takes about half a dozen random biopsies, and histologic changes can range from mild with lymphocytic infiltration, to complete villus atrophy. The patient can have a complete absence of villi in the most extreme cases.”

TREATMENT In 2014, the standard of care is a lifelong gluten-free diet. While many patients find this diet provides compliance challenges, gluten-free food is far more readily available at most supermarkets or online today than in the past. Phase 2 and Phase 3 clinical trials are currently underway on a number of fronts to develop new treatment approaches, including the following:

in pregnancy and IBD. Mary Harris, M.D., medical director, The Center for Inflammatory Bowel and Colorectal Diseases at Mercy Medical Center, is one of the few. “I became an expert by default because other colleagues didn’t want to deal with this issue,” she says. “Crohn’s and colitis are almost invariably diagnosed in people of childbearing years, and it takes careful planning for these patients to have a successful pregnancy and birth.” Fortunately, with good care and planning, it’s entirely possible for most women with IBD to conceive. “However, patient education and planning is a requisite,” Dr. Harris emphasizes. “Patients must be in remission for at least three months before getting pregnant, and folic acid prior to conception is even more important for this group than for the general population.” “These patients have high anxiety levels,” Dr. Harris explains. “And David Doman, M.D., FACP, FACG, clinical professor of Medicine, George Washington University School of Medicine

z New types of genetically engineered wheat that will not cause the inflammatory cascade z Therapeutic probiotics that can metabolize gliadin z A therapeutic vaccine that can induce gluten oral tolerance z Transglutaminase inhibitors for targeted immune suppression z Antizonulin therapy to restore small bowel cellular junction integrity

DIAGNOSIS Diagnostic tests can include serologic testing, malabsorption screening, genetic testing, radiographic evaluation, wireless capsule endoscopy and small bowel biopsy. Dr. Doman cautions, “No single laboratory test can completely establish a diagnosis of celiac disease. Antibody testing is only 90 to 95% reliable, and false negatives are an

Today, a strict gluten-free diet is mandatory for successful treatment, but these new clinical trials present hope for other options in the future,” Dr. Doman concludes.

PREGNANCY AND IBD Given the thousands of gastroenterologists in the country, perhaps it’s surprising that only a handful specialize

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“I assure theM that wIth Careful ManageMent, they usually Can have a suCCessful pregnanCy and delIvery.” – Mary Harris, M.D.

management of IBD during pregnancy. Remicade and Humira can be taken up to 32 weeks of pregnancy, while Cimzia® can be continued throughout pregnancy.” Cimzia blocks the action of TNF, a substance produced by cells of the immune system to induce inflammation. It’s the first and only PEGylated biologic treatment for Crohn’s disease, which refers to the process by which the drug’s proteins are covalently joined with polyethylene glycol (PEG), an FDA-approved polymer, providing enhanced therapeutic capability. Because of that, it’s too large to pass through the placenta.

DELIVERY AND BREASTFEEDING they can tell a physician’s level of discomfort. They come to me with a list of questions that often includes, ‘Am I healthy enough to enjoy sex?’ and ‘Will I have impaired fertility?’” Active disease can affect fertility because it can cause inflammation in the ovaries (particularly the right ovary) and the fallopian tubes. Transmural inflammation can potentiate a tubal pregnancy, and scar tissue from a prior surgery can also impact fertility. She notes, “Those who have had a colectomy have their fertility cut in half. That makes it critical for physicians to discuss the potential issues before performing an elective colectomy on a young woman.”

MANAGING PREGNANCY Good nutrition is critical for patients with IBD during pregnancy, and low maternal weight gain has been associated with a lag in fetal growth. Active disease also is associated with prematurity and low fetal weight. Dr. Harris comments, “Pregnancy and the postpartum period can worsen IBD, so patients generally should be seen once each trimester, as well as fourto-six weeks post-partum. If they have a flare-up, they should see their specialist immediately. Active disease in the first trimester can lead to spontaneous abortion or congenital malformation. It’s critical that physicians and patients understand that the risk from active disease is greater than the risk of taking medications to treat the disease.” She notes, “Biologic therapy, including Remicade®, Humira and others, has greatly improved the medical 20 |

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Dr. Harris notes, “If the disease is refractory even with medications, in-vitro or other fertilization techniques present a viable alternative for many women with IBD.” Perhaps surprisingly, most women with IBD can safely deliver vaginally. The two exceptions are patients with an ileal pouch, which can be torn during delivery, and patients with Crohn’s disease who have perirectal fistulas or abscesses. The C-section rate, which approaches 30 to 35% in this population, is lower than might be expected. “I personally believe no patient should breastfeed while taking biologics,” Dr. Harris exclaims. “However, some medications, such as mesalamine, in low doses, may be safe to take while breastfeeding.” “These patients should be seen by an expert,” she concludes. “I see the relief on patients’ faces when they know that I’m not intimidated. But I assure them that, with careful management, they usually can have a successful pregnancy and delivery.”

Mary Harris, M.D., medical director, The Center for Inflammatory Bowel and Colorectal Diseases at Mercy Medical Center David Doman, FACP, FACG, clinical professor of Medicine, George Washington University School of Medicine and founding partner, Montgomery Gastroenterology Michael Epstein, M.D., FACG, AGAF, founder of Digestive Disorders Associates, Annapolis

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Healthcare IT

mHealth HARNESSES CARE IMPROVEMENTS BY LI N DA H A RD ER

T THE FIFTH ANNUAL mHealth Summit in December 2013, keynote speaker Rick Valencia, senior VP and general manager of QualComm Life, predicted, “By 2020, we’ll need 1,000 times the bandwidth we have now, and everywhere we go we’ll be connected. With 6.8 billion mobile connections, mobile is more prevalent than electricity or running water.” Valencia’s comments are in line with the many mind-boggling statistics on mobile technology, including:

‰ More than 80 billion apps were downloaded in 2012 ‰ The number of mobile devices will exceed the number of people on the planet in 2014 ‰ The wearable device market will hit $1.5 billion this year ‰ The mHealth market will be worth $30 to $60 billion by 2015

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What’s more impressive, however, is the fact that mHealth is beginning to move beyond big numbers, gimmicky devices and interesting apps to make an impact on health and healthcare delivery. At the summit, the focus was slowly shifting to applying mobile devices to improve patient and population health, though data on results is in its infancy. “There has never been a more exciting time to be an entrepreneur or investor in the mobile health and wellness space,” said Rich Scarfo, VP, Events at HIMSS Media, and director of the mHealth Summit. Another key-noter, Steve Case, CEO of Revolution and former CEO of AOL, observed, “What’s happening here is health, not healthcare. It’s happening outside healthcare’s walls.” Esther Dyson, considered the most active healthcare angel investor, added, “mHealth is creating a new industry, not transforming an existing one.” Partnerships Provide Remote Monitoring of High-Risk Patients

To use mobile devices to transform health, new partnerships between technology companies, insurers, health providers, universities and government agencies are forming. In one example, the American Heart Association has teamed up with Qualcomm Life on a

Connected Heart Health initiative that uses wireless technologies and evidence-based care plans to improve post-acute outcomes for patients with cardiovascular disease. Another example of a healthcarefocused technology company that has joined with physicians and patients is Alere™ Connect. They have partnered with the George Washington Hospital to secure a $1.9-million Innovation Grant from the Centers for Medicare and Medicaid (CMS) that funds research led by Susie Lew, M.D., medical director for the Acute Hemodialysis Unit. Dr. Lew’s project investigates how video and real-time, continuous remote monitoring may improve patient access to care, treatment adherence and health outcomes for patients on peritoneal dialysis, a home-treatment option for renal failure. In this program, Alere Connect’s remote monitoring technology will help identify dialysis patients who are having issues in near-real-time, to permit early intervention rather than waiting for them to be in crisis. The team predicts the new model will reduce overall hospital days and save approximately $1.7 million. The cloud makes much of this remote connectivity possible. Alere Connect’s CEO, Kent Dicks, said, “Our goal is a

total solution. We develop remote health-monitoring devices that securely and automatically transmit health information from patient homes to our CloudCare platform, where the data is downloaded to provider EMRs.” Alere Connect also has partnered with over 10,000 physicians to provide home International Normalizing Ratio (INR) monitoring services to 100,000 patients taking warfarin, providing a real-time option that is safer and more convenient than monthly monitoring in a clinic. Another model that uses mobile devices to remotely monitor and manage high-risk patients was developed at CHRISTUS St. Michael Health System in Texarkana, Texas. In 2010, it launched a Care Transition intervention program to reduce hospital readmissions of high-risk patients (e.g., diabetes, hypertension, myocardial infarct and pneumonia), whose readmission rates are higher than average. Luke Webster, M.D., chief medical information officer, noted in his presentation, “Patients are able to learn and apply new self-care skills to help them assert a more active role during care transitions.” The pilot program decreased per-patient costs from $13,000

Improving Patient Engagement in the Hospital

Hospitals also are using mobile devices within their walls to better inform and guide patients. David Cook, M.D., anesthesiologist at Mayo Clinic, described how his team piloted the use of tablets and an app called “MyCare” in post-surgical care to improve patient communication and health. Patients recovering from cardiac surgery and other procedures received a tablet loaded with an instructional video and a personalized care plan. The plan included both educational modules on what to expect and daily ‘homework,’ such as how much to walk each day. Cook’s team coupled patient feedback with data from FitBit to monitor pain levels and progress in daily activities. Establishing protocols allowed ancillary staff to take appropriate interventions without requiring physician input. The program reduced hospital stays for some patients, and patients liked knowing what to expect and being able to track their progress. Surprisingly, the 80-year-olds mastered the devices as well as younger patients did. PatientPoint® and Miami Children's Hospital® (MCH) won Microsoft’s

“With 6.8 billion mobile connections, mobile is more prevalent than electricity or running water.” — Rick Valencia to $1,200, and average readmission rates from 1.43 to 0.20. The health system plans to expand this program in 2014 and begin using telehealth to reduce patient transfers from smaller hospitals to tertiary centers. MedStar Institute for Innovation’s Virtual Visit solution provides a similar program, offering remote monitoring and management of high-risk patients with chronic diseases using QualComm’s 2net Platform and Hub. The platform can capture and deliver medical device data to integrated portals or databases from nearly any wireless medical device, for storage in a secure, interoperable system.

“Innovation in Patient Engagement” prize based on MCH’s use of the PatientPoint Care Coordination Platform 2.0. The program integrated data from tablets used at more than 40 check-in points across the hospital with the MCH Admissions-Discharge-Transfer (ADT) systems to reduce waiting times and to provide educational information. Following on this success, MCH is focusing on population health and care coordination. It takes data from health plans, EMRs and patient self-reporting to create a more robust health record. Using tablets, secure messaging, mobile apps and interactive voice response (IVR), MCH can reach out to

noncompliant patients before they arrive in the physician’s office, and automate followup to increase medication and care-plan compliance. Far-Flung Partnerships

In a partnership that spans the seas, German company Boehringer Ingelheim, United BioSource Corporation (a subsidiary of Express Scripts) and Healthrageous launched a SMART Study involving employees at more than 10 major U.S. corporations. This Institutional Review Board-approved research project is testing a digital diabetes self-management program. Participants received a personalized action plan with health behavior improvement goals, a wireless glucose meter transmitting data to clinical monitors, and HbA1c at-home test kits. The impact will be measured through medical claims data and self-reported biometric health measures. Physician, Pharmacy and Insurer Partnerships

In January 2014 Baltimore-based WellDoc received $20 million in funding from Merck GHI Fund to continue commercializing its FDA-cleared mobile application and program for Type II diabetes, called BlueStar. The company will stop marketing its first major product, DiabetesManager (see Maryland Physician March/April 2011 issue). BlueStar must be prescribed by a physician and purchased through a pharmacy. The app links to WellDoc’s Automated Expert Analytics System to deliver various motivational, educational and action-oriented messages to the patient’s mobile device at the same time that it provides physicians with regular updates and clinical decision support tools. With the new funding, WellDoc can market BlueStar to a growing number of payers, pharmacy benefits managers and physicians. The technology is covered by participating insurers. mHealth clearly is only at the beginning of its maturation process. But it has moved beyond early mobile app use to support an ecosystem of providers, payers, health technology firms and health information systems that are connecting to improve patient care.

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Policy

A New Era: Maryland’s Medicare Waiver

Aer almost 40 years under the existing Medicare waiver, and with healthcare reform underway nationally, Maryland healthcare policy leaders agreed to revise current incentives in favor of a populationbased approach. Maryland Physician spoke with Health Services Cost Review Commission (HSCRC) Chairman John M. Colmers to learn why.

The new Medicare waiver has been referred to as the boldest costcontainment plan ever attempted, transitioning most Maryland hospitals from case-based to population-based reimbursement. What spurred the HSCRC to take this leap rather than make more incremental changes? The

existing waiver, which had been in place since 1977, could continue if we passed two tests: First, one demonstrating that our system remains all-payer, which we were able to do; and second, keeping the rate of increase in Medicare payments per-admission below the national rate of increase, which was becoming increasingly difficult to do. As Maryland 24 |

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TRACEY BROWN

An Interview with John M. Colmers

hospitals decreased readmissions and eliminated ambulatory-sensitive cases, what was left were the more expensive cases, so the average cost-per-case was increasing faster than the national average. Thus, by doing the right thing by our patients, we found ourselves in an increasingly untenable position. The challenge was to design a new system that was acceptable to all parties in the state, and then convince the federal government that it was in their interest to accept it. I give enormous credit to Dr. Sharfstein, secretary of the Department of Health and Mental Hygiene (DHMH), and to the hospitals and payers for agreeing to move from a system based on volume to a system based on value. Changing a $15.5-billion industry is challenging, but we could see that losing the waiver would be incredibly disruptive. Nonetheless, it’s remarkable that the public and private leadership in the state is committed to this change. Our

ultimate goal is to hit the ‘triple aim’ – a better experience of care, better population health and lower per-capita costs.

It sounds like hospitals under the Total Patient Revenue (TPR) program have fared well over time. But how can hospitals with overlapping service areas manage under population-based health?

We have some experience in global budgeting with 10 TPR hospitals. They still charge each patient individually, but they are guaranteed a set yearly revenue. Under TPR, they have fundamentally changed the way they view their role. In Hagerstown, for example, Meritus Health took over the school health program so they could keep children with asthma healthier and out of the ED. Under global budgets, hospitals begin to think differently. In Cumberland, for example, the Western Maryland Health System is doing innovative work with

nursing homes and emergency departments – having patients complete a follow-up program so they don’t need to be readmitted. And we know that, in aggregate, the TPR hospitals have done a better job in controlling readmissions. Now we want to encourage collaboration among hospitals with overlapping service areas. For example, perhaps two hospitals that serve Baltimore City could work collaboratively on some programs for shared populations. Hospitals will need to develop innovative programs to provide more care to patients in their homes, such as Hopkins’ Hospital at Home, a program that provides hospital-level services to patients at home with certain diagnoses.

How will the new waiver impact Maryland physicians? Much

of the new demonstration waiver is consistent with current outcome-based models and the state’s Patient Centered Medical Homes program. To be successful, physicians must have electronic medical record systems and decision-support mechanisms. They have to think differently about the way care is rendered in the community – their role as patient managers is essential. They need to make sure that their patients are directed to the most appropriate settings for receiving optimum care as they move throughout the system.

implement policy at the ground level. For example, I’ve participated in setting policies on readmissions, but when I came here, I could see that it literally takes hundreds of people to implement those policies – physicians, nurses, administrators, and others.

What are your key responsibilities and goals at Hopkins? My ‘day job’

is to develop a strategic plan for Johns Hopkins Medicine as a whole, and to encourage strategic planning in each entity. We not only have multiple academic and community hospitals in our system, but also a premier medical school and research enterprise, the

What are some of the biggest challenges ahead for the waiver?

We have lots of technical issues to solve. For example, how we account for changes in market share and how to create an infrastructure that can efficiently support the care-management work of hospitals, physicians and other care providers, are high-priority matters. As noted above, we seek to create an environment that encourages appropriate collaboration, not unproductive competition. We have settled on an overall per-capita growth rate of 3.58%, but we have to see if that’s the right number in the long run. Finally, there must be a strong focus on creating Medicare savings.

What makes Maryland likely to be successful in implementing the new waiver? Our relatively small size helps –

everyone knows one another. I also think Marylanders have a willingness to believe that government can help with the solution. Finally, our track record has been impressive. The HSCRC has done an excellent job over four decades. It’s pretty amazing that it operates with only about 30 employees and a $7-million budget. This model may not work in many other states, but it might provide lessons that other states can adopt. Similarly, we’ll take lessons from their experience. Massachusetts, Vermont and Oregon are on comparable trajectories, though they will take different approaches.

“Our ultimate goal is to hit the ‘triple aim’ – a better experience of care, better population health and lower per-capita costs.” – John Colmers

I think we’ll see an increase in advanced-practice nurses and a decrease in very small physician practices. We need to think of ways to provide the infrastructure to help physicians manage patients’ needs optimally.

When will you know whether the new waiver is working or not? I

think we’ll know early on, though true transformation won’t happen overnight. By year three, I hope we are promoting gain-sharing arrangements. The Commission is increasing its monthly monitoring of performance to be sure we remain on track. Better healthcare coverage under the Affordable Care Act should help us keep people healthier and reduce uncompensated care somewhat.

After a long tenure in healthrelated government positions at DHMH, the Maryland Health Care Commission and the HSCRC, how have you found the transition to the private sector? I have a stronger

appreciation of what it takes to

largest primary-care group practice in the state – Johns Hopkins Community Physicians – a significant managed-care company with over 300,000 covered lives, All Children’s Hospital in St. Petersburg, Florida, and a substantial international presence. I’m not a planner by training, but with leadership from Dr. Paul Rothman and lots of help from my colleagues, we built processes that encouraged the development of strategic priorities through a robust bottom-up and a thoughtful top-down approach. We identified six strategic priorities, assigned accountable leaders to each, and developed goals, metrics, tactics and strategies for each priority. My role is to serve as a champion and cheerleader, then once the plan is in place and the metrics of success established, it’s best to get out of the way of the very smart and innovative people here who are in the midst of implementation. John M. Colmers is chairman, Maryland HSCRC, VP, Health Care Transformation and Strategic Planning, Johns Hopkins Medicine, and former secretary of the Department of Health and Mental Hygiene.

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Living

Asheville, North Carolina A Perfect Mix of Small Town Friendliness and Big City Sophistication By Jacquie Cohen Roth

S SOMEONE WHO is typically drawn to active vacation destinations focused on beach or outdoor sports, Asheville, North Carolina, was not on my radar as a potential vacation spot. However, I’d heard so many great things about it so I followed my inclination to jump at new opportunities for adventure and programmed my GPS to North Carolina. My travel research enticed me with promises of eclectic shopping and a phenomenal vista, in a region rich with history. Once I learned about a unique bookstore that doubles as a champagne bar, the deal was sealed – reservations were made, and off I went. The Best of the Brews

My travels included a stop in WinstonSalem, where an impressively knowledgeable and “tatted-up” bartender claimed, “Asheville is the biggest beer town this side of the Mississippi.” I was intrigued. It turns out, that claim is absolutely true, with more operating breweries per- capita in Asheville than in any other U.S. city. The area’s 11 breweries offer a selection of 50 locally produced beers. Asheville brewery tours allow you to treat yourself to a taste of it all – meet the brew masters, sample their selections and learn about beer making in the delightful historic district. Good Reads + Champagne = Win, Win

Asheville’s Battery Park Book Exchange Champagne Bar is the marriage of two of my very favorite things in life: good reads and Champagne. Positioned in the historic Grove Arcade district known for its rich history, exemplary urban-renewal architecture and locally owned shops,

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Asheville's Grove Arcade district is home to a variety of unique restaurants and cafes, many of which feature locally grown produce and al-fresco dining.

Battery Park has any title you could dream of finding within its ever-changing selection of new and used books. The store is renowned for “trading books by the thousands and wines by the glass.” I spent a lovely, lazy afternoon perusing and wandering through aisles packed with more than 22,000 books, sipping ice-cold Veuve, and settling into one of the incredibly comfortable leather chairs scattered about the store. The Biltmore – A Must See

A visit to Asheville wouldn't be complete without a visit to the famous, privately owned Biltmore Estate, a Chateauesquestyle, 178,926-square-foot mansion, recognized for its exquisite architecture and stunning gardens, in addition to its massive size. I suggest some time to touring the interior of the house with an audio guide, which will spotlight the must-see treasures in each room of the home, and then wrap it up with some time outdoors. Bike, carriage and horseback riding, Segway tours and riverboat excursions are just a few of the activities to take advantage of on the estate’s 8,000-acre grounds. Eat Well

There are many fantastic restaurants and cafés in Asheville to note them all,

but I will mention a few of my personal favorites. For breakfast, you can’t go wrong with Sunny Point Café which makes everything from scratch using locally grown produce. Also you can dine al fresco, which I always prefer. I found myself wandering back to the Grove Arcade area, to explore lunch and dinner options, including casual to high-end venues, and everything in-between. Some of the district’s specialty restaurants include Burger Worx, Chorizo Latin Fare or Thai Tara, just to name a few, or a personal favorite, Carmel’s Kitchen & Bar. A True Best-of-Both-Worlds Kind of Place

As my trip to Asheville was nearing its end, I found myself in yet another bookstore with a singular name: Malaprop’s Bookstore/Café. While there, I chatted with a newly transplanted resident to better understand the “Berkeley meets East Coast Mountain Town” vibe. She explained she lives in Asheville because it’s a place that has all of the friendliness of a small town but the sophistication of outdoor adventures, of which there are plenty! You can learn more about Asheville and begin planning your own journey by visiting ExploreAsheville.com.

' % & ) = D H E > 8 :

Honoring the

Ta t e F a m i l y

March 29, 2014 6 pm - Midnight HILTON BALTIMORE BWI HOTEL

For more information on sponsorships or tickets, please visit www.hospicechesapeake.org or contact Chris Wilson at 443-837-1530 or cwilson@hospicechesapeake.org.

MARCH/APRIL 2014

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ONLINE www.mdphysicianmag.com

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Jacquie Cohen Roth Publisher/Executive Editor 443.837.6948 jroth@mdphysicianmag.com

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Solutions

Physician Opportunities in the New Maryland Medicare Waiver

By Scott Rifkin, M.D.

ARYLAND’S NEW Medicare waiver is bringing a needed sea change to healthcare in this state, and also presents a host of new challenges and opportunities for providers. The original intention of the Maryland waiver was to set hospital rates that all patients would be required to pay. This all-payer system prevented cost shifting from privately insured patients to government-insured patients. The waiver also sought to recognize social costs, such as uncompensated care and teaching costs, as part of the rate-setting system. The old system was based on case rates. Now, to control overall costs, the system is transitioning to an all-payer global budget for hospitals, to encourage reductions in volume as well as cost per case. Essentially, if hospitals decrease their volume, they will now keep the savings. If volume increases, they may not receive more dollars. Global budgets provide incentives for hospitals to keep patients healthy and out of the hospital. They also seek to reduce costs by improving quality and reducing unnecessary admissions, especially for Medicare fee-for-service, which has not invested in care coordination, as have commercial and other payers. For the first time, economic incentives for good population-based preventive care exist. Gone are the days of hospitals encouraging (or turning a blind eye to) overuse of the ER, OR, or cath lab. Physician Opportunities

Physicians have numerous business opportunities under the new waiver. Those who help design and implement programs that keep patients healthier and prevent hospitalizations will thrive. Research at the Centers for Medicare

and Medicaid Services has identified billions annually in preventable admissions. Hospital use is the single most controllable part of the healthcare cost structure. Post-Acute Care

Hospitals now have incentives to extend their services into post-acute care, and develop programs that reduce ‘avoidable’ readmissions by encouraging medication compliance, preventive followup, etc. The skilled nursing facilities (SNFs) in our network, for example, have developed Step Up™ units that can provide a higher acuity of care for patients with flare-ups in their chronic conditions. They have also developed tighter coordination with home care companies. National Post-Acute Healthcare (NPH), a company that provides government contracting and post-acute network creation for hospitals and SNFs, is working with our SNFs not only to provide enhanced clinical capabilities at the nursing facility, but also to provide coordinated patient flow procedures, transition protocols, electronic data mining and analysis, and negotiated gain-sharing incentives. Using this approach in Pennsylvania, we reduced hospital usage by 50% and accessed new revenue streams that we share with our primary care physicians and hospital partners. Similar programs can be structured in Maryland.

days before going to a SNF. The company also negotiates a share in those savings for the physicians who help to keep patients healthier and, therefore, using fewer hospital days. My colleagues and I developed this pilot program to allow emergency room physicians and case managers to seamlessly transition appropriate patients to a nearby SNF that has agreed to meet certain standards of quality medical care, data integration, and oversight responsibility. This model aligns incentives and provides gain-sharing opportunities. An example is an Alzheimer’s patient that hits the ER with dehydration, confusion and a urinary tract infection, but can be stabilized in the ER and transferred directly to a contracted SNF. Outpatient Surgical Centers

Direct Admissions

Surgeons can prevent unnecessary admissions through better population health management, encouraging more outpatient cases and surgical alternatives. Hospitals may be willing to fund programs that reduce surgical volumes, even ones that divert patients to your outpatient surgery center, as long as you are committed to lowering total costs. For the first time, the talk about preventive care will be supported by the system’s incentives. We chose to be physicians to help our patients become healthier. This change offers tremendous promise for Maryland to be a national leader in improving quality and reducing hospitalizations and costs.

Physicians also can partner with hospitals to keep appropriate patients from being admitted in the first place. Direct Admissions, an NPH program, will seek an exemption from the threeday hospital stay rule, which artificially keeps patients in the hospital for three

Scott Rifkin, M.D. practiced internal medicine for 20 years, and now owns Mid-Atlantic Health Care, which owns and operates 16 skilled nursing facilities with a total of 3,000 beds. Dr. Rifkin is also a partner/investor in NPH and several other companies. He can be reached at scottrifkinmd@gmail.com.

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Good Deeds

Putting Up the Good MS Fight By Tracy M. Fitzgerald

HROUGHOUT APRIL AND May, thousands of Marylanders will walk in one of 11 local 5K events planned and sponsored by the National Multiple Sclerosis Foundation’s Maryland Chapter. Collectively, their efforts will raise thousands of dollars to support research and the continuous search for a cure to a disease that impacts approximately 400,000 Americans – multiple sclerosis, or MS. “We have been doing the walks for 25 years. They are the chapter’s largest program, fundraiser and gathering of patients and people who have been touched by MS,” said Mark Roeder, chapter president. “They create a tremendous opportunity for people with MS to interact with others who face similar challenges, and also for us to bring communities of people together who want to help.” Multiple sclerosis is diagnosed when a person’s immune system attacks the brain, spinal cord and optic nerves,

their individual medical challenges. While some turn to the organization for financial support or assistance with securing and utilizing medical equipment, others take advantage of the chapter’s educational and social programs, or join advocacy efforts to justify the need for funding. “More than $48 million was invested into MS research, allowing for 350 investigations and clinical trials, in 2013,” said Roeder. “Every dollar we raise supports these efforts, as well as our ability to hold programs here in Maryland to help our local patients and their families.” One such program is the Maryland Chapter’s annual “Discovery Weekend,” held in Ocean City and offering a series of interactive, high-energy workshops to help patients and their families learn new techniques to cope with symptoms of the disease, stress, medication issues and everything in between. The program’s agenda is intentionally constructed with

“More than $48 million was invested into MS research, allowing for 350 investigations and clinical trials in 2013.” – Mark Roeder, president, NMSS, Maryland Chapter

resulting in symptoms ranging from numbness, weakness and fatigue to loss of muscle control, vision and balance. It is typically detected in early adulthood and is slightly more prevalent in women. Like each of the 40 other chapters of the National MS Society, the Maryland Chapter’s key priorities center around driving research for a cure and addressing the issues that patients face, providing guidance to help each maximize their quality of life despite 30 | WWW.MDPHYSICIANMAG.COM

many periods of downtime to give families an opportunity to talk, connect and share stories and ideas. The chapter also facilitates an annual research symposium each fall, in partnership with clinicians from Johns Hopkins Hospital and the University of Maryland Medical Center, to discuss current research projects, diagnosis and treatment protocols and advancements in care. The symposium is open to physicians and the general public.

The Bike MS Chesapeake Challenge offers a variety of course lengths all along the scenic waterfront of Maryland's Talbot County.

“Things happen and change so quickly in the MS world; the emerging information is constant,” said Roeder. “The research symposium is a way we can keep physicians and their patients abreast of our latest findings, and make them aware of new medications, therapies and environmental factors that affect people with the disease.” Also on the calendar of upcoming fundraising events for the chapter is the Bike MS Chesapeake Challenge, scheduled for the weekend of May 31, with several course options available ranging from 30 to 100 miles throughout the scenic waterfront communities of Talbot County. For further information about Walk MS or Bike MS, or to learn more about the resources and programs offered by MS Maryland, visit nmss-md.org.

Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at news@mdphysicianmag.com.