Maryland Physician Magazine May/June 2014 Issue

M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

VOLUME 4: ISSUE 3 MAY/JUNE 2014

BLAZING A TRAIL: WOMEN HEALTHCARE LEADERS WOMEN'S HEALTH UPDATE: PROPHYLACTIC OOPHORECTOMY; DIABETIC PREGNANCIES THE ILLNESS OF SECRETS: EATING DISORDERS

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Contents 12

VOLUME 4: ISSUE 3 MAY/JUNE 2014

16 F E AT U R E S

12 Eating Disorders: The Illness of Secrets 16 Maryland Women Healthcare Trailblazers 24 Women’s Health Update D E PA R T M E N T S

Cases

| 7 | Hernia Repair in a Liver Transplant Candidate

Compliance HIT

| 11 | When Must You Report Suspected Child Abuse?

| 26 | How Will the Physician Payments Sunshine Act Impact You?

Policy

| 28 | Therese M. Goldsmith, Maryland Insurance Commissioner, Speaks Out

Living

| 30 | A Getaway for Golf

Solutions

| 33 | ICD-10: The Good News

Good Deeds

| 34 | Starting the Journey of Motherhood Off Right

On the Cover: Sheri Rowen, M.D., director of the Eye and Cosmetic Surgery Center at Mercy Medical Center

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JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com JACKIE KINSELLA, MANAGER OPERATIONS, SOCIAL & DIGITAL MEDIA jkinsella@mdphysicianmag.com CONTRIBUTING WRITER Tracy Fitzgerald COPY EDITOR Ellen Kinsella

Inspire…innovate…breathe.

While in Switzerland a few years ago, I took an opportunity to ski a black diamond. At the time, I wasn’t a black diamond skier (still am not) but when else would I get that chance? With my skis pointed down the run and with every intention of being on my feet at the bottom, I pushed off. The run was just as I anticipated – a thrill with a safe landing.

Three years ago, I launched Maryland Physician Magazine with a goal to inspire you and your healthcare peers here in Maryland. With the help of Managing Editor Linda Harder, our mission has been dedicated to building a Maryland-based physician and healthcare stakeholder network with a commitment to achieving the highest standards of quality patient care. For on-going motivation, I use the imagery of that same black-diamond run sign. The feeling has been the same – when else would I get the chance and the goal has been the same – be upright upon landing.

While on this thrilling run, I’ve learned quite a lot and I’ve learned when to breathe. I’ve had the ongoing privilege of meeting, speaking and working with some of the smartest, most innovative, most inspiring and kindest people. All share a common focus: to deliver the highest level of care for patients here in Maryland.

Some of them you’ll get to “meet” while you read this third anniversary issue.

Over the last three years, our online readership has exploded with the help of social and digital media along with events we hosted in October 2013. Your e-mails, letters and messages across all platforms let us know that that we’re realizing our mission. When I’ve met many of you, it’s been a distinct pleasure to learn we agree that information delivered digitally is informative and supportive, but there’s nothing like holding a well-written and beautifully designed glossy magazine. That end result comes from an incredible team I’ve built over the last three years.

We continue to stay focused on keeping you abreast of current clinical and practice management information during some of the most dynamic times in healthcare delivery. The Maryland Physician Magazine Advisory Board has helped guide our content development and our advertisers have enabled us to get that content out to you.

Thank you for bringing us into your practice, no matter the size. It’s an honor.

To life!

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

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PHOTOGRAPHY Tracey Brown, Papercamera Photography 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.

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Cases

Hernia Repair in a Liver Transplant Candidate Hien T. Nguyen, M.D.

A 40-year-old woman is on the liver transplant list for Laennec’s cirrhosis with a MELD (Model for End-stage Liver Disease) score of 9.

She presented to the hernia clinic with multiple recurrent abdominal wall hernias, resulting from prior operations. Her transplant team and I have followed her for a number of months, with the plan of repairing the hernias at the same time that she gets her liver transplant.

However, she complains of worsening pain over the enlarging hernias with worrisome obstructive symptoms of nausea and vomiting. A CT scan of her abdomen shows intestine incarcerated within one of the hernias, as well as contracted and fibrotic rectus muscles.

Despite the higher risks of surgery and subsequent hernias due to her cirrhosis, the patient wanted the hernia fixed as soon as possible due to intense pain.

CASE:

DISCUSSION: The MELD score originally was used to predict threemonth mortality after a transjugular intrahepatic portosystemic shunt (TIPS) procedure. TIPS was used to decrease portal hypertension from liver cirrhosis in an effort to decrease complications such as ascites, encephalopathy, and varices within the esophagus, stomach and anorectum. MELD currently is used by the United Network for Organ Sharing (UNOS) to prioritize patients for liver transplants. It is determined by serum bilirubin, INR and creatinine.

Higher scores indicate a higher mortality; a score of 9 to 12 correlates with a mortality of 5 to 10%.

Surgery leads to a transient decrease in perfusion to the liver, a worrisome condition for a patient with cirrhosis.

Certain anesthetic agents in surgery can decrease hepatic blood flow by 30%.

Further, intraoperative hypertension can occur due to vasoactive drugs, intermittent positive pressure ventilation, and splanchnic vasodilation triggered by retraction of abdominal viscera.

In addition, a cirrhotic liver does not metabolize effectively, and leads to an increase in the volume of distribution for administered medications. Given the complex and recurrent nature of the hernia, the operation typically takes at least three hours to complete.

Coordination with multiple teams is necessary to undertake such an operation, including anesthesia, critical care, gastrointestinal medicine and the transplant team.

A physician performing this type of hernia operation for this patient must take into consideration her current medical conditions and future medical and surgical issues. The surgeon’s repair must give her the best chance of healing without recurrence, while minimizing the risk of worsening her medical conditions and anticipating potential future sequelae of her disease. For example, a future transplant operation will require an

incision through the abdominal wall, thereby dividing the hernia repair. Due to the multitude of surgical challenges, including the size of the hernia, the number of defects, and the scar tissue from prior operations, a posterior component separation was used to reconstruct her abdominal wall. This required division of the transversus abdominus muscles on both sides, which allowed the contracted rectus muscles to be brought back to midline, and closure of the hernia defects. When divided, the transversus abdominus muscles, corsetlike muscles that lie posterior to the obliques, allow the rectus muscles to be mobilized medially and the hernia defects to be closed with minimal tension.

Mesh is also necessary to decrease the risk of recurrence, while also off-loading the tension on the repair of the defect.

In this case, a large piece of biologic mesh was chosen to reinforce the repair. This mesh is designed to incorporate into the abdominal wall musculature, and withstands infection better than synthetic mesh. In a patient with cirrhosis, poor wound healing and future worsening ascites and overall metabolic function are likely, which can lead to further infection risks. Also, incorporation of the biologic mesh into the musculature allows future operations such as a liver transplant to be performed with the lower risk of hernia recurrence.

The operation was performed in less than three hours, and the patient was admitted to the surgical ICU to monitor for signs of hepatic decompensation.

Postoperatively, her MELD score increased to 12, but she remained stable after surgery, and tolerated a diet on post-operative day 2. She was sent home on postoperative day 4 with close follow-up by her medical and surgical team, and continues to do well.

Hien T. Nguyen, M.D., FACS, is director, Comprehensive Hernia Center, Johns Hopkins Bayview Medical Center. He can be reached at hnguye51@jhmi.edu.

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Profile

SPONSORED CONTENT

Miles G. Harrison, Jr., M.D., FACS, division head of General Surgery at UMMC Midtown Campus and Dimitrios V. Mavrophilipos, M.D., Ph.D., a general surgeon and member of the Center’s team.

When a Patient’s Wound Won’t Heal The UMMC Midtown Campus Wound Healing Center

BY SU SA N WA LKER

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W

OUNDS THAT DO NOT heal within four weeks are a bigger problem than many physicians may realize and the issue is projected to grow significantly as the population of patients with diabetes increases. According to statistics, approximately 6.5 million patients are living with non-healing wounds in the U.S. These wounds require the specialized care offered at the University of Maryland Medical Center (UMMC) JCAHOcertified Wound Healing Center. Located on the system’s Midtown Campus, the outpatient, hospital-based Center provides a multi-sub-specialty, collaborative approach to the treatment of non-healing wounds, especially complex and difficult cases. These wound can be caused by a range of conditions, including:

z z z z z z z z z z z z

peripheral artery disease diabetic foot ulcers venous stasis ulcers osteomyelitis trauma pressure ulcers soft tissue radionecrosis burns chronic edema renal disease necrotizing infections surgical wounds

The Wound Healing Center brings together physicians from a number of specialties. The panel includes general surgeons, internal medicine physicians, infectious disease specialists, plastic surgeons, podiatrists and vascular surgeons who meet on a regular basis to review cases and treatment plans.

“Having physicians from a range of specialties provides a broader perspective than having only surgeons on the panel,” explains Miles G. Harrison, Jr., M.D., FACS, division head of general surgery at UMMC Midtown Campus. “In addition, the Center’s nurses and our clinical care coordinator all possess a high level of expertise, which benefits patients both clinically and in terms of the ability to link patients with support services such as transportation, nutrition and help with insurance issues.”

Advanced Treatment options

All patients treated in the Wound Healing Center have a dedicated physician and nurse who provide care and case management. At the first appointment, a nurse evaluates them and characterizes the wound in terms of size, duration, location and potential cause. A physician then assesses the wound and consults with other specialists as needed. The team develops a detailed treatment plan that is based on the specifics of the patient’s condition and includes the appropriate evidence-based protocols.

“It’s important to know what is causing the wound — diabetes, venous insufficiency or an injury. That information focuses the treatment that we provide to the patient,” adds Dr. Harrison.

The Center offers the full spectrum of wound healing treatments, including bio-engineered skin substitutes, growth factor therapies, advanced dressings and wraps, debridement, negative pressure wound therapy and hyperbaric oxygen

therapy in the Center’s two mono-place chambers. But beyond leading-edge treatments, the key to treatment is the consistent, frequent monitoring of each patient’s condition.

“Our multi-factoral approach to wound healing improves outcomes,” notes Dimitrios V. Mavrophilipos, M.D., Ph.D., a general surgeon and member of the Center’s team. “We ensure that every patient has access to the care and support they need. Members of the treatment team communicate frequently and we can easily refer patients to other physicians to UMMC, one of the nation’s best tertiary care Centers.”

Positive Outcomes Change Patients’ Lives

The Wound Healing Center treated 326 patients in 2013 and is on track to treat even more patients this year. Outcomes for the first quarter of 2014 stand at 89% healed in 14 weeks, above the national average. Those statistics are notable for a number of reasons. The majority of patients that the Center treats have complex wounds complicated by unmanaged chronic disease and other factors like IV drug abuse. Many patients have been living with the pain and complications caused by their wounds for years. Some have become so debilitated they are unable to work or even walk.

One patient had been receiving care for wounds caused by chronic venous insufficiency at another hospital with little or no improvement. His physician referred him to the UMMC Midtown Campus Wound Healing Center as a last hope. “The patient had severe lower extremity ulcers that had not responded to treatment,” says Dr. Harrison. “With 9 months of starting multimodality therapy at our Center, the ulcers were completely healed.”

Another patient who had undergone treatment for bladder cancer came to the Center suffering from severe radiation-induced cystitis. He was unable to urinate, had frequent blood leakage and pain. After two weeks of treatment in the Center’s hyperbaric oxygen chambers, urinary function was fully restored and his pain was eliminated.

Treatment at the Wound Healing Center also transformed the life of a patient who had suffered with chronic venous ulcers on both legs for 13 years.

His pain grew to be so significant that he could no longer work or walk and was taking several doses of pain relievers a

day with no effect. The Wound Center team performed debridement on both legs and the application of twice-a-week compression therapy to promote blood flow. Within six months of starting treatment, the patient was able to return to work as a chef for a catering company.

Even though his job requires long hours on his feet, he no longer suffers the debilitating pain that had once made a normal life impossible.

Dr. Mavrophilipos recalls another patient, a young female whose case was particularly difficult. “She had been an IV drug user and had chronic wounds on both legs as a result of her drug abuse,” he explains. “She was homeless and not in contact with her family. We provided aggressive wound treatment including surgery and within a short period, her wounds healed completely. Her chronic pain was gone. She no longer needed the pain relief opiates had provided. She completed drug rehab, got a place to live and reconnected with her family. She was a different person.”

A Complete Resource For Care

As the awareness that there are effective options for treating non-healing wounds grows among both physicians and patients, the Center is experiencing an increase in the number of patients seeking care.

“Even though our volumes are increasing, we are still able to provide patients with an appointment within 24 to 72 hours after they contact the Center,” adds Dr. Harrison “In addition, the Center offers truly comprehensive care and services. There is a vascular lab within the Center. If we discover that a patient has other medical needs, we can quickly refer them to a physician within the University of Maryland system with one call. If patient needs transportation to the Center, we can arrange that.”

If Your Patient Needs Wound Care

In addition to physician referrals, patients can also self-refer to the UMMC Midtown Campus Wound Healing Center. Most insurance plans cover care for chronic wounds and the Center’s care coordinator will work with patients to find out what their plan covers.

For more information on the UMMC Midtown Campus Wound Healing Center or to refer a patient, call 1-855-866-HEAL or 410-225-8600.

MAY/JUNE 2014

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Compliance

When Must You Report Suspected Child Abuse?

By Marc Cohen and Sarah C.J. Nadiv

D

O YOU UNDERSTAND YOUR reporting duties when you suspect that child abuse has occurred? This article provides a simplified overview of the reporting requirements for physicians and other health practitioners.

The Health Insurance Portability and Accountability Act (HIPAA), Maryland’s Medical Records Confidentiality Act, and professional ethics all require that healthcare practitioners keep medical information, including psychological information, about a patient confidential.

However, these laws have exceptions.

HIPAA, while perhaps this nation’s most comprehensive effort to ensure confidentiality of protected health information (PHI), excuses providers from its confidentiality requirements when the provider is otherwise “required by law” to make a report.

In addition, HIPAA expressly states that a healthcare provider may disclose PHI in order to comply with any state law requiring the reporting of child abuse (See 45 CFR 164.512).

Maryland’s Confidentiality of Medical Records Act, a predecessor and close analog to HIPAA, similarly protects a patient’s medical information from disclosure but does not limit child abuse reporting requirements.

Family Law Article

Maryland’s Family Law Article, Title 5, Subtitle 7, directs any healthcare practitioner to report child abuse to the local Social Services Administration or the appropriate law enforcement agency. The healthcare practitioner must make an oral report to the local department or law enforcement agency as soon as they have “reason to believe” abuse has occurred.

Additionally, the practitioner has 48 hours to file a written report with the local department of social services and provide a copy to the local state’s attorney. These forms are available on the Maryland Department of Human Resources website: dhr.state.md.us.

Healthcare practitioners, police officers, educators and human service workers are required to report suspected child abuse or neglect even if the event occurred in the past, and even if the alleged victim is an adult when the incident comes to light. Reporting is required even if the suspected abuser is believed to be deceased.

Beware the Definition of Abuse and Neglect

However, beware of a potential pitfall in the definition of abuse found in section 5-704 of the Family Law Article.

For reporting purposes, it defines abuse, including sexual abuse, as that which is caused by “any parent or other person who has permanent or temporary care or custody or responsibility for supervision of a child, or by any household or family member…”

As a result, whether the abuse is a physical or mental injury or sexual abuse, to be subject to reporting it must be perpetrated by a parent or other person who fits the above description.

Child neglect has the same reporting limitations as described above for abuse. Providers should only break confidentiality and report the incident if the act was perpetrated by a parent, guardian, custodian, person who has permanent or temporary care or custody, or a household or family member.

State law does not require the victim’s permission to file a report. However, any disclosure other than as authorized

under Maryland Family Law Section 5-704 requires the express agreement of the patient.

These requirements apply even if the suspected abuse or neglect is alleged to have occurred outside Maryland or if the victim lives outside of the state.

In these circumstances, the abuse or neglect needs to be reported to any local department, which must forward the report to the appropriate agency outside this state.

When in doubt, without identifying the patient, it may be wise to contact the local Maryland Department of Social Services to discuss the incident and obtain guidance.

The Bottom Line

Regardless of state and federal confidentiality laws, physicians must report all physical or mental injury or sexual abuse when the act has been perpetrated by a parent or other person who has custody or responsibility for the child or lives in the same house as the child.

Marc Cohen is a principal in Ober|Kaler’s Health Law Group. Mr. Cohen's practice focuses on regulatory compliance and professional discipline.He may be reached at mkcohen@ober.com. Sarah C.J. Nadiv, LCPC, is the early childhood research supervisor, Institute for Innovation and Implementation, University of Maryland, Baltimore. She may be reached at snadiv@ssw.umaryland.edu.

For local Maryland Departments of Social Services, visit msa.maryland.gov.

This article is only intended as a review of basic facts and law. Its purpose is to help spot issues for discussion and further inquiry and is not a substitute for obtaining advice from your legal counsel or the government officials responsible for administering these laws. The reader is advised that laws, regulations and especially published policies of state and federal agencies are constantly subject to amendment and changes in interpretation. Finally, reliance on this article in setting practice protocols or as a defense to government action is further limited in that audit and enforcement actions are always, to some degree, subject to the discretion of government officials.

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EATING DISORDERS: THE ILLNESS OF SECRETS Young Children Are Increasingly Affected Maryland eating disorder experts explain why this serious group of disorders is trending younger and how treatment approaches have evolved.

BY LI N DA HA RD ER

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TYPES OF EATING DISORDERS While anorexia nervosa and bulimia nervosa are the most well known and difficult to treat of the various types of eating disorders, binge eating is becoming more common. In fact, it recently was given its own category in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

Avoidant Restrictive Food Intake Disorder (ARFID), a new addition to DSM5, should decrease the vast numbers of individuals in Eating Disorders Not Otherwise Specified (EDNOS), a category for patients who don’t fit neatly into other diagnostic categories. “Most of these individuals restrict their intake for a reason other than fear of becoming fat. They may have a discomfort with food textures or a fear of choking,” Steven Crawford, M.D. the co-director of the Center, observes. “They are the individuals historically categorized as selective eaters. We treat it like we would any phobia by developing a hierarchy of fear foods and a plan for exposure.”

RISK FACTORS Eating disorders often are tied to painful underlying emotions, issues with selfesteem and feelings of loss of control,

not just a preoccupation with weight and food. Controlling food intake or binging/purging cycles can represent a way to take some control back.

Dr. Brandt says, “While there’s a wide variation in how much of a trigger is needed, and multiple gene interaction is likely involved, mutations in Chromosome 1 and Chromosome 11, as well as serotonin receptor abnormalities, have been identified to date.”

A study of two extended families published in the Journal of Clinical Investigation in 2013 linked EstrogenRelated Receptor Alpha (ESRRA) and HDAC4 mutations, which suppress the expression of other genes to increase the risk of an eating disorder. The two genes are involved in metabolic pathways in muscle and fat tissue and are regulated by exercise. In addition to dieting, the personality traits of perfectionism and harm avoidance are two risk factors for eating disorders.

Because eating disorders originally were far more prevalent in girls and women, boys are less likely to be diagnosed and more likely to be misdiagnosed. “The number of boys presenting for treatment is dramatically increasing – with the full spectrum of diagnoses from anorexia to body dysmorphia,” comments Dr. Crawford.

It is now estimated that one in eight people with an eating disorder is male.

THE IMPORTANCE OF SCREENING Drs. Brandt and Crawford emphasize that primary care physicians should screen children and adolescents for eating disorders. Thankfully, a fivequestion screening tool called SCOFF has proven highly effective (see sidebar).

This tool, developed by a team of British physicians and researchers in 1999, captures 100% of eating disorders, with some false positives.

“It’s important to ask questions, as individuals may struggle to be forthcoming with their symptoms,” says Dr. Crawford.

While the clinical history from the parents and child and a physical exam are important, “The most accurate predictor of an eating disorder is the parent’s report,” adds Dr. Crawford.

“If they express concerns, you need to follow up on them.”

By age six, children develop body awareness. Dr. Brandt comments, “It’s

PHOTO COURTESY OF SHEPPARD PRATT

IT IS ESTIMATED THAT MILLIONS of Americans have an eating disorder, a serious constellation of conditions that entail extreme attitudes and behaviors related to food and weight. Aptly considered an illness of secrets, they are occurring along a broader spectrum than ever. Today, those in middle age are more likely to develop an eating disorder than in the past, and children ages eight to 12 are the fastest growing inpatient population.

Why are younger children increasingly affected? Harry Brandt, M.D., co-director of the Center for Eating Disorders at Sheppard Pratt, explains, “While genetics play a key role, the triggers of more dieting at younger ages and a greater emphasis on health can make a biologically vulnerable individual more susceptible to developing an eating disorder. The war on obesity has resulted in the unanticipated consequence of more children and parents pursuing dieting at earlier ages. Dieting is the most common preceding behavior to onset of an eating disorder.”

Harry Brandt, M.D., co-director, Center for Eating Disorders at Sheppard Pratt

The SCOFF questions*

D Do you make yourself Sick because you feel uncomfortably full?

D Do you worry you have lost Control over how much you eat?

D Have you recently lost more than One stone in a three-month period?1 D Do you believe yourself to be Fat when others say you are too thin?

D Would you say that Food dominates your life?

*One point for every “yes;” a score of ≥2 indicates a likely case of anorexia nervosa or bulimia 1

One stone equals 14 pounds

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PHOTO COURTESY OF SHEPPARD PRATT

an important time to support kids in their body image, and it’s a sensitive subject. Many physicians don’t know enough about weight and nutrition.

You don’t want to encourage a healthy child to diet who doesn’t need to. There is a bell curve of appropriate weights and you don’t want to shame the child or make him or her self-conscious.

A guiding principle is to focus on the child’s lifestyle, not on the scale.”

Both doctors stress that the earlier an eating disorder is identified and treated, the more likely a patient is to recover.

MORE COLLABORATIVE CARE

Steven Crawford, M.D., co-director, Center for Eating Disorders at Sheppard Pratt

THE MOST ACCURATE PREDICTOR OF AN EATING DISORDER IS THE PARENT’S REPORT. IF THEY EXPRESS CONCERNS, YOU NEED TO FOLLOW UP ON THEM. — Steven Crawford, M.D.

Treatment of eating disorders typically involves psychotherapy coupled with nutrition counseling, medical care and medication where appropriate. Research has provided new evidence-based approaches. “Treatments have really changed,” notes Dr. Brandt. “They have become much less restrictive and involve far more collaboration with families.

We also have more data validating their effectiveness.”

One such treatment approach, Family Behavioral Therapy (FBT), promotes a highly involved role for parents in the treatment process, encouraging them to become the experts, and coaching them to be relentless in their support early on when the child is not eating. With this approach, the child’s intense resistance typically lessens over time.

Dr. Crawford explains, “The approach involves empowering parents with the therapist serving as a supportive coach.

The illness is personified and the parents align with the child to fight against the eating disorder.”

For young children with intact families, this treatment entails three phases: z Parents assume responsibility for the child’s eating until the child has reached a healthy weight. z The child gradually takes back control of his or her eating; parents oversee that the child is continuing to eat adequately and is not resuming disordered eating patterns. z The child resumes activities that have been missed, such as reintegrating with friends, while working to put into place structures to prevent relapse.

Dr. Brandt adds, “It’s a very structured program that has been available for

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about a decade, but research evidence of its effectiveness has emerged in the last few years. You have a good sense by the fifth treatment session how well this approach will work for the child.”

An older but also effective approach is Family Systems Therapy. This approach is based on Murray Bowen’s family systems theory, which emphasizes that individuals are inseparable from their network of relationships.

“Both approaches are quite effective.

Today, we help families understand how the disorder happened, while putting weight on the child,” Dr. Brandt explains. “We offer a Collaborative Care Workshop where families learn therapeutic communication, and gain a greater understanding of the illness and confidence in their ability to support the recovery process.”

Medications are useful for some patients. Studies now show that antidepressants can be helpful in treating anorexia once the patient has regained weight. Some bulimic patients can also be helped through effective use of medications.

SPECIALIZED INTENSIVE PROGRAMS While the goal is to treat the illness on an outpatient basis, inpatient care is necessary for those whose eating disorder has led to serious or even lifethreatening physical problems, or when it is associated with severe psychological or behavioral problems. Once admitted to this level of care, patients typically step down to partial hospitalization, then to intensive outpatient as they improve, and eventually back to traditional outpatient care. With the rise in younger patients, the Center for Eating Disorders just opened a specialized inpatient and day treatment program for children ages eight to 15.

The National Eating Disorders Association is an excellent resource for physicians and patients at NationalEatingDisorders.org. A second resource is a series of books on healthy eating for children by Ellyn Satter (ellynsatterinstitute.org).

Harry Brandt, M.D., co-director, Center for Eating Disorders at Sheppard Pratt Steven Crawford, M.D., co-director, Center for Eating Disorders at Sheppard Pratt

Catherine DeAngelis, M.D., MPH, University Distinguished Service Professor, Emerita, professor of Pediatrics, Emerita at Johns Hopkins University School of Medicine and professor of Health Policy and Management at Johns Hopkins University School of Public Health

Maryland Women Healthcare Trailblazers Four amazing women. Four different career paths. Their stories underscore the fact that the state has more than its share of outstanding leaders who just happen to be women.

BY LIN D A HA RDER • PH OTOG RA PH Y BY TRA CEY BROWN

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My advice for everyone is to follow your heart.

If you choose a specialty based on how much the salary is, you probably won’t be happy.

—Catherine DeAngelis, M.D.

JAMA Mama At age 74, Catherine DeAngelis, M.D., MPH, University Distinguished Service Professor, Emerita, professor of Pediatrics, Emerita at Johns Hopkins University School of Medicine and professor of Health Policy and Management at Johns Hopkins University School of Public Health, has hardly slowed down. This year, in addition to teaching nationally and internationally, she is writing her memoir, which she jokingly calls “JAMA Mama” in a reference to her tenure as the first female editor of the Journal of the American Medical Association (JAMA).

The daughter of two Italian Americans who didn’t get past the eighth grade, Dr. DeAngelis knew she wanted to be a doctor since she was four years old. “By the time I was nine, I thought I was going to be a medical missionary. But at age 20, my father said he’d never sign for me to become a nun, and my high school advisors told me I had to be a nurse before I could be a doctor, so I pursued nursing.”

Thanks to a series of scholarships and a chemistry teacher who helped her get accepted to Wilkes College, Dr. DeAngelis was able to go to medical school. Ironically, Hopkins initially rejected her for medical school. “When I was a child, I thought I couldn’t be a doctor anywhere except Hopkins. Later, I knew I would not be accepted there, but I applied anyway. They sent me a ‘sorry, hon’ letter that I wish I had kept!”

As one of only seven women in a medical school class of 112 at the

University of Pittsburgh, Dr. DeAngelis later was accepted at Hopkins for her residency – where she was the sole female.

From Transplants to Pediatrics Dr. DeAngelis initially planned to pursue a transplant surgery residency at Pittsburgh. “But an incident in my second year, while working at a free clinic on Greenmount Avenue a few days a week, convinced me that, for every surgical procedure, there were thousands of patients who could benefit from primary care. A sick child was brought to the clinic burning with fever from pneumonia. I took him to Hopkins’ ER, where he received a shot of penicillin, and by the next morning, he was tearing up the place. They came to the clinic because an ER sign required a dollar to sign in, and they didn’t have it. I took that sign down.”

Ever a trailblazer, Dr. DeAngelis became a Hopkins professor in 1985 – only the 12th female professor in nearly 100 years, and one of even fewer women who weren’t basic scientists. “I worked to get women promoted and to improve their salaries,” she recollects. “During my tenure as vice dean from 1990 to 2000, 67% of all Hopkins women professors were promoted to be a professor, and today, more than 160 of us are full professors.”

She reflects, “I’ve never chosen a profession based on what it would pay.

People told me I was throwing my career away to turn to general pediatrics. But my advice for everyone is to follow your heart. If you choose a specialty based on how much the salary is, you probably

won’t be happy.”

Early on, Dr. DeAngelis was an advocate for nurses and nurse practitioners. She states, “Lots of medical care can be handled by a nurse practitioner.

It takes a team to care for a patient. The right nurse practitioner can augment a physician’s practice hugely. Only about one-quarter of patients who come for health maintenance need a physician’s input, so they can augment care.

The Four T’s of Leadership To be a leader, Dr. DeAngelis advises people that they need the “Four T’s” – being Tough-minded (but not tough), Tenacious, Tenderhearted and Thickskinned.” In more than a decade as the editor-in-chief of JAMA, she certainly needed those characteristics to fight pharmaceutical companies and to ensure JAMA’s scientific integrity. She was the first to require that an independent academic statistician review industrysponsored clinical trials before the article could be accepted, and she more than doubled the journal’s impact factor.

Claiming that she’s dyslexic and is therefore really only 47, “Dr. De” has a lot of life left to live, and many more people to help through medicine.

Overhauling the Medicare Waiver Minnesota is a long way from Maryland, but after Carmela Coyle, now president and CEO of the Maryland Hospital Association (MHA), finished her undergraduate degree at Carleton College, she was determine to move east. It took

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Carmela Coyle, president and CEO of the Maryland Hospital Association

persistent pestering to get an internship with the Congressional Budget Office, but once she did, her long career as a policymaker was launched. “I fell in love with healthcare issues,” she says, “and the American Hospital Association (AHA) had the best reputation on Capitol Hill.”

After spending 20 years in increasingly responsible positions with the AHA, including working under CEO Dick Davidson, who had been MHA’s first president, Coyle decided to throw her hat into the ring when Cal Pierson announced his retirement as MHA’s second CEO. “I knew that the MHA position would allow me to stretch myself, especially since it was clear the Medicare waiver would have to be revised,” she recalls.

MHA: Tackling Multiple Challenges Shortly after Coyle took the helm at MHA in 2008, the stock market collapsed. “We needed to focus on our core mission of policy development and advocacy, so we downsized and sold two for-profit companies,” she comments.

She also tackled the long-simmering debate over the False Claims Act. Working with Lt. Governor Anthony Brown, Health Services Cost Review Commission Director John Colmers (see Maryland Physician March/April 2014) and others, she helped craft a compromise that lessened the financial risk for hospitals and physicians when they made an honest mistake in filing claims.

Another challenge Coyle faced was the nursing shortage. “We learned that one of the major issues was student retention. In 2009, we raised $17 million to support 18 |

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training programs for nurses, much of which was focused on addressing retention issues – many nursing students dropped out before completing their training. Even when the recession made it look like we had fixed the nursing shortage, we realized there was still a structural deficit we had to tackle as baby boomers neared retirement.”

When Coyle was appointed CEO, only one woman sat on MHA’s board of trustees, and men dominated the leadership team. Today, seven of the 24 board members are women, and the leadership team consists of more women than men. “It’s important to have a balance, because women think and work differently than men,” she says. “The waiver required open mindedness and good listening skills, at which women typically excel.” Coyle also purposely increased minority representation in the MHA board.

At the Top of the Roller Coaster Clearly, Coyle’s greatest challenge was in helping to structure and implement the new Medicare waiver. “We enjoyed 40 years under the old waiver, but as we moved more patients to outpatient observation, the old rules made it look like we were failing,” she says.

“In the future, we won’t be as focused on the four walls of the acute care hospital,” Coyle continues. “I’m pleased we could come to an agreement about the new waiver, but the first step was really just to put a policy framework in place. Now, we have to work on how we get there. Hospitals have to rethink how they serve the community, and we have to help them build new skill sets to

manage care and pull out unnecessary services. We have to focus on prevention in more than a token way, and we can no longer wave goodbye at the door.

And after discharge, we have to create clear pathways that require nurses and care managers to practice at the top of their license.”

Coyle likens the journey ahead to being at the top of a roller coaster – with excitement that is combined with a fear of the unknown.

A personal challenge that Coyle faced in 2011 has contributed to her compassion for patients today. “Both my husband and I were diagnosed with cancer 10 days apart. We underwent surgery, chemotherapy and radiation at the same time. Stories of others who came through to the other side were very helpful to us. It was a transformative experience that reminded me why we healthcare providers are here.”

A Progressive Solo Practitioner No one can accuse Holly Dahlman, M.D., founder of Green Spring Internal Medicine, of not persevering through hardship. Born with a number of congenital birth anomalies, Dr. Dahlman underwent more than 30 reconstructive surgeries in her youth. She recalls an early experience with her Chicago pediatrician, “When he asked me what I wanted to be when I grew up, I told him, ‘A doctor!’ Soon, I knew that was the right answer. This was one of my earliest memories. Medicine has been a lot of sacrifice, but I believe it is worth it for those who are called to it.”

Making up a large percentage of the primary care field, women doctors are underpaid relative to their male counterparts, even up to the level of department chairperson, research shows.

“Women physicians should have ‘equal pay for equal work,’ but payment inequities are still a major problem,” notes Dr. Dahlman.

She believes that medical schools’ historic Socratic method of teaching, where questions are fired at students, favored male students. Today, that is changing. “I was at the top of my class at Mt. Holyoke, but at Johns Hopkins I was happy to graduate in the middle of my class. Most of my colleagues were heavy on the scientific end of the

temperament scale, whereas I was more on the creative/intuitive end, but when I found primary care, I knew it was a good fit for me.”

Her first job was with a group practice of seven primary care physicians. “I was young and inexperienced,” Dr. Dahlman recalls. “When you start out in medical school, you don’t know what you’re getting into as far as the business of medicine. I struggled in the early years at the practice. When half of the practice converted to concierge medicine, I had a huge ethical conflict. Fortunately, I was able to depart without controversy since the concierge doctors had downsized their panels and were not upset that I was leaving with my own patients. I decided that starting my own practice

Women physicians should have ‘equal pay for equal work,’ but payment inequities are still a major problem.

—Holly Dahlman, M.D.

would be the best way for me to implement electronic medical records and practice according to my values.”

Dr. Dahlman notes, “While it’s a huge amount of work, today I am able to set my own schedule. In a group, the office manager called many of the shots – here I call all of them. I don’t always love supervising people, but if I hire the right staff, then it works out.”

As if her early experience with repeated surgeries wasn’t enough for one person to bear, in 2009 Dr. Dahlman underwent chemo, radiation and surgery for breast cancer, and then tore her ACL at the end of the year. Because of the electronic medical record, she was able to get through these hardships as a solo practitioner.

Dr. Dahlman is one of the pioneers of electronic medical record implementation in our area and one of the first to adopt the Patient Centered Medical Home (PCMH) model. She opened her practice in 2006 with an EMR, and was invited to participate in the state pilot PCMH

Holly Dahlman, M.D., founder of Green Spring Internal Medicine

program despite being a solo practitioner.

Perhaps even more impressive is that her practice achieved Level III NCQA certification in the first year. “In 2011, we pushed ourselves to achieve Level III and also to attest to Meaningful Use,” she proudly states.

“PCMH is a model in progress,” Dr. Dahlman continues. “It’s a lot of work, but it changes the nature of work for the entire practice. Everyone is working at the top of his or her license. Today, the care manager gets the hospital on the

phone, which used to be on my shoulders. I’ve become the leader of the team, which is very satisfying for me as a physician. I’m doing more creative work, focusing more on sick patients and spending more time with them.”

She adds, “Primary care physicians are on the front lines. We’re the monitors for the healthcare system. We can provide key pieces of information that affect patient care when they are admitted.”

Dr. Dahlman advises other female physicians to have a business mentor and MAY/JUNE 2014

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Sheri Rowen, M.D., director of the Eye and Cosmetic Surgery Center at Mercy Medical Center and owner, Baltimore LASIK, Cataract and Cosmetic Center

consult an attorney when negotiating contracts with a group or hospital. “Join a practice whose vision and values you share. Interview your employer at the same time that they interview you. Ask how you’ll be compensated and what standards will be used to evaluate your performance. Take care of your own health by following the advice you would give to your patients.”

The Entrepreneur Sheri Rowen, M.D., director of the Eye and Cosmetic Surgery Center at Mercy Medical Center and owner, Baltimore LASIK, Cataract and Cosmetic Center, didn’t take a direct path to becoming a physician. She originally hated science and wanted to be a psychologist, but then fell in love with zoology and science in her first year at the University of Maryland College Park. “At first, I thought of becoming a nurse, because I never thought I could be a physician – my brother was slated to be the brilliant doctor in the family,” she recalls.

At College Park, though, “A male friend told me that I had the capability to become a doctor. I still wasn’t convinced, but a week before I had planned to start a PhD program in psychology, I realized I wanted to achieve my own dream, and went for it.”

Dr. Rowen worked for four years at the pediatric oncology department at National Institutes of Health (NIH).

“It was so meaningful to take care of people, and I knew I wanted to be of service. I originally thought I would be a pediatrician, as many women did, but later found the challenges of correcting 20 | WWW.MDPHYSICIANMAG.COM

vision and restoring eyesight to be amazingly interesting and rewarding.”

Few Women on the Lecture Circuit Like Dr. DeAngelis, Dr. Rowen had a limited number of female colleagues in her medical school class and at first, as a young female ophthalmologist on the national lecture circuit, she was one of only two women in the country on the podium. Today, she remains nationally renowned as an educator of her peers.

“We’re looking to create programs for mentoring women. We want to help take the next generation of women ophthalmologists and pave the way for them through meetings and mentoring relationships. Ophthalmology has been a man’s world, and now that the percent of women in the field is increasing, it’s time for more women to come to the forefront.”

primary care doctors coming out of training today want to be employed,” she exclaims. They want a work/life balance, which I understand, but the entrepreneurial spirit is being lost. The hospital can’t make the practice for you – you still have to go out and build it.”

Dr. Rowen is also known for introducing innovative cataract procedures, and in early 2014, she became one of only a few ophthalmologists to perform laser cataract surgery, which uses a 3-D imaging system to map the cornea and customize treatment. The device allows the surgeon to create precise cuts in the cornea, to enter the eye and also to correct astigmatism. “It’s the biggest technology breakthrough in cataract surgery in years. The laser softens the lens, so you use less energy and it’s safer for the cornea.”

Dr. Rowen had family support to help her care for their two now-grown children. She says, “You can’t raise a family and be a physician without support. Women have a lot of other responsibilities, and you need help.

Those of us who went through what we did became stronger. Female ophthalmologists today are grateful that we paved the way.”

What does Dr. Rowen advise for becoming an entrepreneur and bucking the employment trend? “Determine what would make you happy. If you really want to make your own rules, go for it.

Perhaps first work with a small practice, then work to become a partner or owner.

Don’t be afraid of hard work – it will be a very rewarding career in the end.”

Entrepreneurial Spirit Dr. Rowen also is the rare woman ophthalmologist to set up a laser vision correction and aesthetic business, which she opened in a mall store in 2000.

“LASIK has been a tough road,” she acknowledges. “Even before 2008, the market started to change. People became fearful after 9/11, and to this day, many are fearful that LASIK might negatively affect their vision, even though the equipment and techniques continue to significantly improve. I inform them that all-laser LASIK is really safe.”

In 2000, she incorporated skin care and aesthetics into her practice, giving her additional experience with the self-pay side of medicine. That entrepreneurial spirit is less typical of today’s medical residents. “Most

Catherine DeAngelis, M.D., MPH, University Distinguished Service Professor, Emerita, professor of Pediatrics, Emerita at Johns Hopkins University School of Medicine and professor of Health Policy and Management at Johns Hopkins University School of Public Health Carmela Coyle, president and CEO, Maryland Hospital Association Holly Dahlman, M.D., internist and founder, Green Spring Internal Medicine Sheri Rowen, M.D., director of the Eye and Cosmetic Surgery Center at Mercy Medical Center, owner, Baltimore LASIK, Cataract and Cosmetic Center, and clinical assistant professor, University of Maryland

Profile

SPONSORED CONTENT

Sullivan Integrated Aesthetic Center A Patient-Centered Approach to Plastic Surgery

DAVID HARTCORN

services to those living with cancer. (annapoliswellnesshouse.org) The Sullivan Integrated Aesthetic Center also offers a full range of medical spa services, including a supervised weight-loss program. The Ambulatory Surgery Center, medical spa and surgical consult spaces are located in the same facility, which promotes a fully comprehensive and integrated approach to patient health and beauty.

A Collaborative Team

KELLY SULLIVAN, M.D., FACS, understands the patient experience from both the physician and patient perspective. As a child, she was attacked by a dog and required plastic surgery.

The skill and compassion of her surgeon inspired her to become a plastic surgeon and shaped her approach to treating her patients.

“Our practice provides a personal, patient-centered experience,” Dr. Sullivan explains. “Our focus is not on treating a high volume of patients, but on providing the highest quality care. While our new Medicare and AAAASF-certified Ambulatory Surgery Center and our fully equipped medical spa offer state-of-the-art technology, we also work hard to ensure that the patient experience is positive and productive, from the first phone call to the final visit. Because of the excellent care and compassion our patients receive, many will join our spa membership and become long -term 22 |

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patients with our practice, and many return with other friends or family members who are seeking the same kind of healthcare experience.”

Skill and Expertise

Certified by the American Board of Plastic Surgery, and a Fellow in the American College of Surgeons, Dr. Kelly Sullivan received her B.S. from M.I.T. and her M.D. from Harvard Medical School. She completed her general surgery residency and her three-year fellowship in plastic and reconstructive surgery at Emory University.

In her Annapolis practice, she performs the full range of rejuvenation and enhancement treatments for face, body and breast. In addition, she has special expertise in breast reconstruction.

Dr. Sullivan’s commitment to helping cancer patients led her to become the founder and board president of Annapolis Wellness House – a nonprofit organization providing support

Dr. Sullivan’s treatment team includes registered nurses, licensed medical aestheticians and board-certified anesthesiologists.

“We have a collaborative approach to patient care,” Dr. Sullivan says.

“By working together as a team, we are able to provide the full complement of skin and body treatments that help our patients achieve excellent results that can be maintained for a lifetime.”

In terms of insurance reimbursement, while most cosmetic and aesthetic services are not covered, some procedures may be. The staff helps patients determine insurance eligibility and handles all paperwork. Dr. Sullivan is also a Medicare participating provider.

High Patient Satisfaction

The Sullivan Integrated Aesthetic Center surveys patients after every surgical and OR experience, and the patient surveys reveal a high level of satisfaction.

“We take a lot of time and care when treating patients,” adds Dr. Sullivan.

“Our goal is to build long-lasting relationships with patients by not only providing the highest quality care, but also by delivering a warm, supportive experience for every patient.”

For more information on Kelly Sullivan, M.D., FACS, or to refer a patient to the Sullivan Integrated Aesthetic Center, please visit ksullivanmd.com or call 410-571-1280.

WOMEN’S HEALTH update PRECONCEPTION PLANNING FOR DIABETIC WOMEN, GROWING DATA ON THE VALUE OF PROPHYLACTIC OOPHORECTOMIES AND A POSSIBLE ALTERNATIVE TO THE PAP TEST ARE FEATURED IN THIS ISSUE’S HEALTH UPDATE. By Linda Harder

When to Consider Prophylactic Oophorectomy When assessing a patient’s risk of gynecologic malignancy, Teresa Diaz-Montes, M.D., gynecologic oncologist at Mercy Medical Center, who also sees patients at Anne Arundel Medical Center, recommends starting with a detailed family history. “I think that it’s important to take a comprehensive family history of first-degree relatives for ovarian, uterine, breast and colon cancer,” she says. “For example, families that carried a genetic predisposition for colon cancer are at higher risk of uterine cancer. When I explore the family history, I ask about all of these.”

Family Colon Cancer History Increases Risk

As many as one million Americans may have Lynch syndrome, an under-

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diagnosed hereditary disorder in which a mutation in a mismatch repair gene (MMR) can cause colon cancer in up to 85% of those affected. Lynch Syndrome is also the cause of other cancers, including uterine, ovarian and breast cancer, though at lower rates. These patients are also at risk for getting malignancies at a younger age.

Dr. Diaz-Montes states, “I ask patients about their family history every time I see them to determine if there’s any change in family history since I last saw them. A family history of male breast cancer is very suggestive of BRCA2, and these patients should be referred to a specialist. One of my patients had multiple family members diagnosed with colon cancer, including a father and brother both dying from the disease.

She was also diagnosed with colon cancer at a young age. When she came to me, she was already diagnosed with

uterine cancer. This is indicative of the type of patient who should receive genetic counseling and testing, and who may be a candidate for a prophylactic hysterectomy and oophorectomy.”

A Canadian study of more than 5,000 women published in early 2014 in the Journal of Clinical Oncology found that prophylactic oophorectomy reduced all-cause mortality by 77% among women who carry a BRCA1 or BRCA2 genetic mutation. Mortality was cut chiefly by reducing the risk of ovarian, tubal or peritoneal cancers, but also by reducing the risk of breast cancer.

Tailor Treatment to the Individual

While the investigators in this study recommended that women undergo oophorectomy by age 35, Dr. Diaz-Montes prefers to tailor treatment to the individual’s situation. “I don’t believe in pushing all women to hysterectomy

by a specific age,” she says. “You have to individualize your recommendations depending on the patient’s needs. If a 35-year-old woman wants to have children, you need to take that into account when considering the risks and benefits of a procedure.”

Dr. Diaz-Montes further points out that the age at which a young woman is at risk depends at least in part on the affected family member’s age at diagnosis. If a mother had ovarian cancer early, such as at age 41, her daughter is at increased risk for that cancer a decade sooner (e.g., age 31).

Ovarian Cancer

A common blood test for ovarian cancer is useful, but results must be interpreted with caution. Dr. Diaz-Montes says, “Elevated levels of CA 125 are not diagnostic of cancer, but are good indicators of response to therapy. This protein can be elevated due to a number of other factors, such as pregnancy or a menstrual cycle. I see elevated CA 125 in my office every day and reassure younger women that it usually isn’t cancer. However, in post menopausal women, it’s often diagnostic.”

WILL DNA TEST REPLACE THE PAP TEST? In April 2014, the FDA approved Roche’s Cobas HPV DNA test as a primary screening tool for women ages 25 and older. Presently, the DNA test is chiefly used in conjunction with the Pap test. Current U.S. guidelines recommend that women ages 30-65 undergo either co-testing with both HPV and Pap every five years, or Pap testing alone every three years.

Women ages 21-30 are recommended to have Pap testing every three years.

The DNA test has been found to have greater sensitivity in detecting pre-cancerous lesions than the Pap test. It is also considered to be more objective, as it does not rely on interpretation of slides under microscopic examination.

Treatment

According to Dr. Diaz-Montes, prophylactic oophorectomy can be performed using minimally invasive approaches, including laparoscopic or robotic surgery. “We now have solid evidence that this procedure significantly decreases the risk of ovarian cancer and also decreases the risk of breast cancer in women with BRCA1 and BRCA2 genetic mutations,” she concludes.

Pre-Gestational Diabetics Should Plan Ahead Diabetes affects about 6-7% of pregnancies, with 10% of those caused by pre-gestational diabetes. Alice Cootauco, M.D., perinatologist at the Perinatal Center at the University of Maryland St. Joseph Medical Center, is hoping to reduce the incidence of birth defects and pregnancy complications by getting diabetic women to improve their glycemic control before they get pregnant.

“We like to have their hemoglobin A1c levels at less than 6% before they conceive,” she says. “Women with pre-gestational diabetes below these rates have similar rates of congenital anomalies to the general population, at about 2-3%. But if their A1c levels are near 10%, they have a 20-25% risk of birth defects. Most of that risk occurs in the first eight weeks of gestation.

We would love to have them see their primary care physician, then come in for a consult with a perinatologist before getting pregnant.“ Dr. Cootauco adds, “When a pregestational diabetic woman presents, she should be tested for underlying vascular complications, including retinopathy, nephropathy and cardiovascular disease, as these women have a higher risk of pregnancy complications. They need an ophthalmologic screening, a 24-hour urine collection to evaluate total protein and creatinine clearance, and a baseline EKG and thyroid function test, since they are also at higher risk for thyroid disease. They should be started on folic acid, at least 400 micrograms per day, and they ideally also would consult with a nutritionist.”

Diabetic patients also have a higher risk of preeclampsia, hydramnios (an

increase in amniotic fluid that can lead to pre-term delivery) and fetal growth abnormalities, including growth restriction and macrosomia (large baby), which increases the likelihood of a cesarean section. Other risks to the fetus include hypoglycemia, hypocalcemia, cardiac hypertrophy and hyperbilirubinemia.

When to Screen

“Patients with a body mass index (BMI) above 30, a family history of diabetes or a personal history of gestational diabetes should be screened in their first trimester,” Dr. Cootauco advises.

“Those expecting multiples or those at advanced maternal age are at higher risk of becoming diabetic, but don’t need to be screened early. They can be screened at the routine time; 24-28 weeks gestational age.”

Treatment

“The treatment hasn’t changed much in the past few years,” notes Dr. Cootauco.

“Diet modifications and exercise are always the first line of defense. The most commonly used oral hypoglycemic agents are glyburide and metformin.

While not FDA-approved specifically for pregnancy, studies have shown that they don’t cross the placenta, so they can be prescribed for most women.”

Type I diabetics and women who cannot achieve control with an oral agent require insulin therapy with a combination of short- and long-acting insulins. Women on insulin pumps can continue their pumps.

Many hypertensive medications, such as ACE-inhibitors and ARBs, are contraindicated during pregnancy.

Those with a history of being safe for pregnant women include nifedipine, labetalol and methyldopa. Dr. Cootauco stresses, “Most diabetic women can have a successful pregnancy if they have optimal glucose control before they become pregnant.”

Teresa Diaz-Montes, M.D., gynecologic oncologist, Mercy Medical Center and Anne Arundel Medical Center Alice Cootauco, M.D., perinatologist at the Perinatal Center at the University of Maryland St. Joseph Medical Center

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Healthcare IT

HOW WILL THE PHYSICIAN PAYMENTS SUNSHINE ACT IMPACT YOU?

In September 2014, new information about physicians will be available to the public as part of the Physician Payments Sunshine Act, but you should start preparing now.

Physicians can take action to stay informed about what will be reported, when it will be reported and, most importantly, how to review the data before it is made available to the public.

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WHAT IS THE PHYSICIAN PAYMENTS SUNSHINE ACT? The Physician Payments Sunshine Act is a provision of the Affordable Care Act that requires biopharmaceutical and medical technology companies to publicly report data and transfers of value paid or given to physicians and teaching hospitals. The Centers for Medicare and Medicaid Services (CMS) runs this program, also referred to as the Open Payments program. CMS is in charge of collecting the data and publishing the public website.

This information will be released to the public and to the media via an online database known as the Open Payments database in September 2014. By preparing now, you will be able to confidently discuss your interactions and the benefits they bring to your patients.

HOW WILL THE ACT AFFECT YOU? For many years, patients have been able to look up consumer ratings of their physician online. Through the Sunshine Act, patients will have access to even more information about their doctor, including his or her interactions with companies.

It is imperative that patients and members of the media understand that physician work with industry professionals to improve patient care.

Physicians collaborate with companies on research and clinical trials to provide feedback on new medicines or develop new surgical tools, and to allow companies to talk with leading experts in the field about new developments.

You may be asked about these interactions by a patient, and it’s important to be prepared to respond.

DATA REPORTED ABOUT YOU

By August 1, 2014, CMS will open registration for physicians and teaching hospitals. Physicians must register with the Open Payments database in order to review any data that is reported about them before it is available to the public.

If physicians feel that data is inaccurate, they will be able to work with companies to correct it.

Due to delays from CMS, physicians have a smaller than anticipated window to register, review and correct data. It is imperative that physicians stay upto-date so they are aware of when

registration opens. A coalition called Partners for Healthy Dialogues, is working to help educate physicians about this.

WHAT IS BEING REPORTED? Any payment or transfer of value from a manufacturer operating in the U.S. to a physician must be reported as part of the Sunshine Act, unless the payment falls into a category that is exempt from reporting. Even if the physician did not request the payment, or the payment has no value to the physician but might be of value to someone else, it must be reported.

Items reported include, but are not limited to: z Consulting fees z Honoraria z Gifts z Food & beverage z Travel & lodging z Education z Research z Grants z Education materials Drug samples/coupons/vouchers intended for patient use, grants to a CME provider and, patient education materials are some of the items that do not need to be reported.

Last fall, members of Congress and dozens of professional societies submitted letters to CMS expressing concern over medical journals and textbooks being reported under the Sunshine Act. In February, CMS clarified that these items must be reported.

VALUE OF INTERACTIONS Relationships and collaborations between physicians and companies benefit patient care and help to create and improve therapies. But some newsreporting tends to overlook this value, instead focusing on dollar amounts and insinuations that these relationships are untoward. In addition to being inaccurate, such reporting is detrimental to future research, medical innovations

and reputations of dedicated physicians.

In addition to seeing patients and performing surgeries, physicians spend countless hours keeping up with the latest innovations and treatment options.

Interactions, in part, provide an important environment in which physicians learn from their peers about how different therapies are working in the clinical environment, and give physicians the ability to provide important feedback to manufacturers that helps improve therapies.

ABOUT PARTNERS FOR HEALTHY DIALOGUES As the Physician Payments Sunshine Act continues to be implemented throughout the remainder of 2014, Partners for Healthy Dialogues was founded in order to provide information and updates to patients, healthcare professionals, physicians and biopharmaceutical and med-tech professionals.

Partners for Healthy Dialogues is a collaboration between healthcare provider groups and biopharmaceutical and medical technology organizations, committed to demonstrating the value of interactions between physicians and biopharmaceutical and med-tech companies, from to ensure better patient care and to advance medical innovation.

Current healthcare collaborators include: American Academy of Dermatology, Advanced Medical Technology Association, American Association of Neurological Surgeons, American College of Preventive Medicine, American Osteopathic Association, American Urological Association, Association of Black Cardiologists, Biotechnology Industry Organization, Congress of Neurological Surgeons, National Council of Asian Pacific Islander Physicians, Pharmaceutical Research and Manufacturers of America and the Society of Pharmaceutical and Biotech Trainers.

Visit HealthyDialogues.org and cms.gov for more information on Partners for Healthy Dialogues and the Physicians Payments Sunshine Act along with cms.gov.

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Policy

Challenges, Successes, Priorities and Issues TRACEY BROWN

Therese M. Goldsmith, Maryland Insurance Commissioner, Speaks Out

In spite of the challenges of the new healthcare exchange in Maryland, Insurance Commissioner Goldsmith finds much to celebrate.

Maryland Physician Magazine: What are the greatest challenges you have faced over the past three years in regulating healthcare insurance in the state?

Insurance Commissioner Goldsmith: Implementation of the Affordable Care Act (ACA) has been a major focus of healthcare insurance regulation over the past three years. The Maryland Insurance Administration (MIA) has drafted several bills, passed by the General Assembly and signed by Governor O’Malley, that align Maryland law with ACA requirements. We have issued dozens of bulletins and other guidance to insurance carriers on ACA-related matters ranging from rate and policy form-filing requirements, to early policy renewal options, to provider networks for substance use disorder services, to healthcare insurance coverage for transgender individuals.

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of community events across the state to help make consumers more aware of ACA reforms and their options in Maryland’s individual and small group healthcare insurance markets.

grant funds to enhance its rate review process. For 2014, Maryland’s healthcare insurance premium rates are among the most competitive in the country.

MPM: What have been some of the successes to date?

ICG: In 2011, the Center for Consumer

MPM: What have been the major impacts of the ACA on your agency’s work?

ICG: New requirements and open

Information and Insurance Oversight (CCIIO), a part of the Centers for Medicare and Medicaid Services (CMS) within the U.S. Department of Health and Human Services (HHS), determined that the MIA’s review and approval process for healthcare insurance premium rates satisfied criteria established in new federal regulations, which meant that CCIIO would defer to the MIA’s decisions regarding the reasonableness of healthcare insurance premium rate increases in Maryland’s individual and small group healthcare insurance markets. The MIA was awarded nearly $5 million in federal

enrollment periods under federal and state law have required MIA staff to review and issue determinations on unprecedented volumes of premium rate and policy form filings within a compressed time period. The MIA also has reviewed and approved training programs for new consumer assistance workers in the healthcare insurance marketplace, including navigators, certified application counselors, and consolidated service center employees assisting consumers with plans sold through Maryland’s new healthcare insurance marketplace, Maryland

Healthcare Connection. I’m proud of our knowledgeable and dedicated staff that met these challenges.

MPM: How will healthcare in Maryland be different going forward as a result of the ACA? ICG: In Maryland, we see the value of

the ACA every day. Individuals and families now can purchase a healthcare benefit plan without the risk of being turned down or paying higher premiums because of a pre-existing condition.

Non-grandfathered healthcare benefit plans issued or renewed in the individual and small-group markets must include a core set of benefits – known as essential healthcare benefits – and may not impose annual or lifetime limits on those benefits.

The ACA has saved seniors millions of dollars in prescription drug costs, made tax credits for insurance available to eligible small businesses, and allowed young adults to remain on their parents’ coverage until age 26. Advance premium tax credits and cost-sharing subsidies have put private healthcare insurance within the financial reach of many Marylanders who previously could not afford it.

MPM: What are your healthcare insurance priorities for 2014?

ICG: The MIA has incorporated a

30-day public comment period in our rate review process, and we post all healthcare insurance rate decisions on our website. In 2014, we are working to enhance the process for public comment and to make our premium-rate decision documents more consumer-friendly. We also are focusing on our responsibility to enforce all new ACA-related laws and regulations applicable to insurance carriers, producers, navigators and other consumer assistance workers for whom we have regulatory oversight authority.

MPM: Describe key issues involving payment denials related to medical necessity, and what steps you take to help consumers or physicians who have received those denials.

ICG: Each complaint that the MIA

receives from consumers or providers relating to the medical necessity of a service is unique because it is based on whether the service is medically

necessary, appropriate and efficient for that particular covered person.

Unless the complaint is an emergency case and the service has not yet been provided, the complainant must first file an “internal appeal” to the insurance carrier. If the carrier upholds its denial, a complaint may be filed “externally” with the MIA. At that point, the MIA staff gathers all the medical records that are provided by the complainant, the carrier and the healthcare provider regarding the condition and the denial, including the determinations by the carrier, and sends them to an independent review organization (IRO) for an independent, unbiased review. The cost of the review is paid by the carrier.

A physician who is board-certified in the specialty of the case that is being considered must review the case.

The IRO is asked to opine on whether the particular service is medically necessary, appropriate and efficient for the particular covered person. It also is asked to determine whether the medical criteria that the carrier used were objective, clinically valid, compatible with established principles of healthcare and flexible enough to allow deviations from norms when justified on a case-by-case basis.

If the IRO determines that the care was medically necessary for the individual, the carrier is required to pay the benefits under the contract.

Generally, the carrier will pay for the benefits without requiring an Order of the Commissioner. If the medical criteria are not acceptable, the carrier is ordered to file new criteria and use them going forward.

A detailed analysis of the medical necessity complaints investigated by the MIA is provided in the annual Appeals and Grievance report that is available on the MIA’s website at mdinsurance.state. md.us/sa/consumer/appeals-andgrievances-reports.html. Generally, it is well worth the effort to appeal a medical necessity denial. The 2012 Appeals and Grievance Report shows that carriers, on appeal, overturn their initial denials 52.3% of the time and modify denials another 4.3% of the time. For medical necessity complaints that are filed with the MIA, 63.1% of the denials were overturned during the MIA’s investigation process in 2012.

MPM: How can the MIA and Maryland physicians work together to benefit patients?

ICG: Physicians and other healthcare

providers can file complaints with the MIA on their patients’ behalf regarding carrier coverage decisions, and can file complaints on their own behalf regarding carrier business practices that do not comply with state law. Physicians should be prepared to provide specific facts – broad allegations of carrier misconduct, without more, generally do not provide an adequate basis on which to conduct a meaningful investigation.

It also is helpful to hear physicians’ perspectives on areas in which insurance carriers or others may need additional regulatory guidance.

MPM: Describe how the MIA helps physicians select medical malpractice insurance.

ICG: Each year, the MIA produces a

medical malpractice insurance rate comparison guide to help medical professionals find the plans best suited to their needs. The guide includes tips on how to shop for coverage and suggestions for other types of coverage medical professionals might want to consider. The guide is available at no cost at mdinsurance.state.md.us.

MPM: You have been both a certified speech-language pathologist and former litigator focused on healthcare fraud and abuse – a very unique professional background. What mentors have helped develop the skills you use as commissioner?

ICG: I am privileged to have worked

with at least two people I would consider mentors: one a speechlanguage pathologist, the other an attorney. From the attorney I learned to assume nothing. Through his example, he taught me to be a more critical and analytical thinker and to examine an issue from multiple perspectives. From the speech-language pathologist I learned the importance of service. One of his favorite quotes, from Albert Schweitzer, is this: “I don’t know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve.”

MAY/JUNE 2014

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Living

A Getaway for Golf Learning to Play and Learning to Breathe

T

HE STEREOTYPE OF THE physician-golfer teeing it up at a posh country club several afternoons every week has certainly died hard. Truth is, many time-starved physicians wish they could make room in their schedules to play and practice. Moreover, many medical professionals don’t even know how to play at all. It’s a safe bet that many of your colleagues privately yearn for the chance to get a taste of what this great game is all about.

My situation isn’t much different.

I’ve dabbled in golf over the course of my adult life and have led the Annual Hospice of the Chesapeake Tournament for over a decade, but was never too serious about improving or playing more. My inspiration to step things up came from trailing my daughter from tournament to tournament throughout her high school and college golf career.

Watching her inspired to me to play more and really give it a shot. One thing I’ve learned to love about the game, is that I cannot think of anything else to have a decent round – not an easy task for me but a very necessary one.”

The Right Credentials

For me to get serious about golf, I knew a destination golf school was the approach I wanted to take. An escape from my daily routine and wired lifestyle was needed so I could immerse myself in a focused educative program that offered plenty of time for instruction, practice and play.

Online research and recommendations 30 | WWW.MDPHYSICIANMAG.COM

COURTESY OF INNISBROOK GOLF RESORT

By Jacquie Cohen Roth

Golf is a true lifetime sport affording players the opportunity to be surrounded by beautiful settings.

from friends and acquaintances led me to the Innisbrook Golf Academy in Tampa Bay, Florida. I registered for a late winter session at The Golf Institute at Innisbrook, a four-day school led by Dawn Mercer, PGA. Dawn’s credentials were impressive, as she has been a golf instructor for nearly two decades and was named one of the Top 50 Female Instructors in the U.S. by Golf for Women Magazine.

In addition to a team of world-class instructors, Innisbrook boasts four championship courses and an expansive practice facility. The resort also plays host to the Valspar Championship, a PGA TOUR event held each March.

My late winter booking proved fortuitous. I left Baltimore just ahead of

one of this winter’s numerous storms and headed south, with the promise of warmer weather and a rebirth of my golf game.

Sizing Me Up

Thanks to travel delays, I arrived at Innisbrook just in time to miss my scheduled 1 p.m. tee time at the infamous Copperhead course. I rationalized that playing a round at a challenging course named after a venomous reptile was not the best way to start, anyway. Margaritas and pool time won out as I took a moment to decompress before I was to meet Dawn and my fellow “campers” for an evening reception. Because of the storm, I was to be the only student. My disappointment in not having the chance to spend four

days lasted about 30 seconds – I was going to have four days of private instruction. Yay! Upon meeting Dawn that evening, I was impressed with her desire to get to know me. She wanted to learn my motivations for picking the game back up and to see how dedicated I was.

We bonded over both having lost a sister to breast cancer and got to know each other on a personal level.

I didn’t realize it at the time, but Dawn used that time to size me up and identify what teaching strategies she would employ to help me construct my golf game from the ground up.

Things got serious early the next morning when I met Dawn at the Innisbrook driving range. We started learning the fundamentals of the stance and backswing, a strategy that gives new golfers a strong foundation upon which to build.

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more self-aware of when its time to step back and just breathe.

For physicians and other busy professionals, it’s never too late to pick up the game of golf. However, simply buying clubs and hitting the driving range is not the best approach. You really can’t do it alone. Like anything else we decide to learn, it demands dedication and time. If you learn to play along with a focused, professional instructor, you can get started enjoying golf, which truly is a game for a lifetime.

JACQUIE COHEN ROTH

Various drills helped drive home the importance of the address position and essential elements of a sound swing.

As the fundamentals fell into place, I was making solid contact consistently, and learned to savor the satisfaction of a well-struck golf shot.

Intensive instruction each morning gave way to a round of golf each afternoon with Dawn by my side. We played and chatted throughout, but she was right there to correct mistakes and offer advice when needed.

The curriculum included classroom learning, video swing analysis and lots of range time that focused on the technical aspects of the swing. Dawn takes a holistic approach to golf, preaching balance and calm concentration – lessons that also translate to the game of life. She found ways to help me re-focus through breathing exercises and taught me to ignore mild distractions.

These practices not only improved my golf performance, but also are proving to be a help in everyday life!

For more information about Innisbrook, visit innisbrookgolfresort.com and save Thursday, October 2, 2014, for the 12th Annual Hospice of the Chesapeake Golf Tournament.

Local Learning Opportunities If a week-long golf school won’t fit your schedule or budget, there are plenty of golf learning opportunities in Central Maryland. Nearly every course offers certified PGA instructors for individual or group instruction. Baltimore County Golf, a group of five courses in the area, has partnered with the PGA of America to offer a new Get Golf Ready program that is ideal for adults who are new to the game.

A series of five clinics will teach you all aspects of the game, from making a tee time, to basics of the stance, swing and short game, to golf etiquette and more. There’s no equipment required.

Everything is provided for you and classes are offered throughout the spring and summer. For more information visit baltimoregolfing.com MAY/JUNE 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

ICD-10: The Good News Tracey Goessel, M.D.

By Joel Moorhead, M.D., PhD

T

HE ARRIVAL OF ICD-10 ON October 1, 2015, (note the year; the Senate just voted a one-year delay) presents a wealth of opportunities for forward-looking physicians.

Reimbursement for physician services is to some degree a zero-sum game.

The federal budget allocates a fairly fixed number of dollars to fund healthcare for all of us. Physicians who are prepared for ICD-10 will almost certainly fare better than those who are not. Here’s how to get there.

Tune-up on CPT Coding

Evaluation and Management (E/M) services and physician charges for procedures will continue to be reimbursed under CPT even after October 1, 2015. If you currently have a coder, ask him or her to give you a crash course in the coding of common diagnoses and procedures in your practice. This is an excellent way to assure that you are being reimbursed appropriately for your services, both now and after ICD-10 begins. From a coding standpoint, you may find your documentation significantly improved.

Help Hospitals Help You

In the past, physician compensation has been separate from hospital compensation for an episode of care.

Federal and state payers may be poised to change that. CMS Pub 100-18, Transmittal 505 (February 5, 2014) states that physician and facility services can be considered “related.” If an inpatient claim is denied as not medically necessary, all “related” physician claims could be denied at the same time. Also, bundled payments have been proposed, with a single payment for both facility and physician services. The shared

ICD-10 Helps Physicians Document Quality Care

actually are. One inpatient quality measure is the relative Length of Stay (LOS), which is the sum of LOSs for patients admitted/the sum of case weights. This is often reported and compared by individual physicians.

ICD-10 also offers a new data element that may be very useful – the concept of underdosing, as when a patient takes less than the prescribed dose of medication. Think of the seizure patient not taking the prescribed dose of anticonvulsants, or the deep vein thrombosis patient who was noncompliant with Coumadin.

Documenting this can help. Take the example of a Congestive Heart Failure (CHF) patient readmitted within a week of discharge. You could run afoul of a “readmission within a week of discharge for the same diagnosis” quality measure. However, if the patient quit his meds because he didn’t like the frequent voiding, and you document the patient’s underdosing, an adverse quality event is unlikely to be assigned to you or to the hospital.

There also may be longer-term benefits to this documentation. Some future researcher may access the ICD-10 data on underdosing and find an alarming incidence of CHF admissions with underdosing codes. Institutions may respond to this finding by developing low-cost measures to monitor patient adherence to Lasix therapy at home, such as purchasing a bathroom scale for CHF patients and asking them to report their weights daily. With data comes knowledge, and that knowledge can strengthen our power to heal.

Severity-of-illness measures are important to physicians as well. High case weights translate to SOI, telling the government how sick your patients

Tracey Goessel, M.D., is president of FairCode Associates. Joel Moorhead, M.D., Ph.D, is clinical director of FairCode Associates.

For more information, visit faircode.net

interests of hospitals and physicians will depend increasingly upon detailed documentation.

Detailed physician documentation will become even more critical to accurate coding of hospital admissions under ICD-10, which has a greater number of combination codes than ICD-9. These combination codes can include up to five different elements; for example: S52.531xM Colle’s fracture right radius, open, Type I or II, with non-union K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding K71.51 Toxic liver disease with chronic active hepatitis and ascites

Detailed physician documentation of all elements of a complex combination code permits coders to assign codes with the highest degree of accuracy and specificity.

Codes with greater specificity are generally assigned higher case weights (CWs). A hospital’s base compensation rate depends on its Case Mix Index (CMI), which is the sum of CWs for all admissions divided by the number of admissions.

Accurate and specific physician documentation allows a hospital to demonstrate to the government the relative Severity of Illness (SOI) of its patients.

MAY/JUNE 2014

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Good Deeds

Starting the Journey of Motherhood Off Right

By Tracy M. Fitzgerald

E

ACH YEAR, APPROXIMATELY 52,000 women experience a lifethreatening medical condition related to pregnancy or childbirth – not in a thirdworld country that lacks access to medical care, but instead, right here in the United States. In fact, while global statistics show a steady decline in maternal mortality rates over the past two decades, the U.S. is the only country in the industrialized world reporting rates on the rise.

Merck for Mothers is on a mission to change that. This 10-year-old, $500-million-dollar initiative strives to increase access to quality prenatal, postpartum and primary care for women who are preparing for motherhood.

Women with high-risk health conditions such as obesity, diabetes or hypertension, as well as those who represent underserved populations where rates of maternal death and complications are especially high, are targeted. According to Priya Agrawal, M.D., executive director of Merck for Mothers, the majority of maternal deaths that occur in the U.S. are preventable.

“We bring these women help them develop a life hope.” – Alma Roberts “No woman should die bringing life into this world,” she said. “Merck for Mothers is working very hard to get the right care to the right women at the right time, every time. We are reviewing data to better understand why maternal deaths are occurring. A key goal is to standardize care protocols and create new systems to connect high-risk women to care providers before, during and after pregnancy, which may decrease the occurrence rate of preventable conditions.”

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Merck for Mothers has established partnerships with organizations across the country that share a common mission. Locally, they are collaborating with Baltimore Healthy Start, a 22-year-old nonprofit that focuses on the reduction of infant mortality rates, with primary emphasis on the African American and Latin American populations.

An expectant mother meets with a healthcare provider at one of Baltimore Healthy Start’s three Centers.

Baltimore Healthy Start offers a number of facilities, both organizations stress that despite programs and resources, all geared their dual focus on the underserved toward improving the health of populations, maternal health complications mother-to-be or new mother, and baby. can happen to women of all ages, races “Our primary focus is on reducing and socio-economic statuses. infant mortality rates, and to do that, “Physicians are also regular members we have to also take a look at the health of the public, that people want to listen of the mothers and how this relates,” to,” said Dr. Agrawal. “They need to said Alma Roberts, CEO of Baltimore know and understand these statistics, Healthy Start. “We provide food as they can really impact our efforts pantries and laundry facilities to meet positively by encouraging their patients the basic needs of new moms and their to take good care of themselves before babies, but there is so much more for and during pregnancy. This is about them to take advantage of. We offer empowering women to be active yoga and stress reduction courses, participants in their own care.”

Physicians in Maryland who are out of isolation and caring for high-risk patients or those plan. We give them who require social support or access to health and wellness programs to stay on track before, during and after pregnancy are encouraged to send parenting classes and breastfeeding referrals to Baltimore Healthy Start guidance. Women can come to us for by calling 410-396-7318. More help in enrolling in the Affordable Care information is also available by visiting Act. We can arrange transportation for baltimorehealthystart.org. those who need help getting to and from doctor’s appointments. We bring these women out of isolation and help them develop a life plan. We give them hope.”

Maryland Physician would like to Together, as Merck for Mothers and hear about your “Good Deeds.”

Please share your ideas with us at Baltimore Healthy Start work to educate news@mdphysicianmag.com. patients and physicians about the leading causes of infant and maternal mortality,