M A RY L A N D
Physician YOUR PRACTICE. YOUR LIFE.
WHY A DEMENTIA DIAGNOSIS MATTERS HALTING 3 KEY INFECTIOUS DISEASES ACCOUNTABLE CARE EXPANSION
www.mdphysicianmag.com
VOLUME 3: ISSUE 6 NOV/DEC 2013
More Convenient. Most Preferred.
MARYLAND’S PREMIER IMAGING PROVIDER NOW HAS OVER 30 LOCATIONS. Advanced Radiology is pleased to offer over 30 multi-modality locations providing state-of-the-art imaging for the convenience of you and your patients. Experienced, board-certified radiologists combine accurate, precise reporting with responsive service and fast turnaround. Same-day appointments provide convenience and quick access for your imaging needs.
Trusted by more doctors, preferred by more patients.
t %ÚáÚĄùß .ùýýÿáĂùĀøĉ t .3* t %ÚáÚĄùß 9 3ùĉ t $5 t 1&5 $5 t /ąóßþùĂ .þôÚóÚÞþ t 6ĂźÄ„Ä‚ĂąÄƒĂżÄ…ĂžĂ´ t %&9" t 'ĂźÄ…ĂżÄ‚ĂżÄƒĂłĂżÄ€Ä‰
To schedule an appointment at any one of our locations, call 1-888-972-9700 or visit www.advancedradiology.com
Contents 10
VOLUME 3: ISSUE 6 NOV/DEC 2013
16 F E AT U R E S
10 Diagnosing Dementias: Why it Matters 16 Stopping Infectious Diseases 20 Accountable Care Expands With or Without an ACO D E PA R T M E N T S
Cases
| 9 | Dementia Case Study and Discussion
Policy
| 24 | Medical Marijuana Commission is Launched
Living
| 26 | Sites to See and Explore Across Brandywine Valley
Solutions
| 29 | Five Ways the Taxpayer Relief Act Could Affect Your 2013 Taxes
Good Deeds
| 30 | Thinking (and Working) Outside of the Medicine Box
On the Cover: Katherine Coerver, M.D., Ph.D., neurologist at The Neurology Center in Chevy Chase
30
JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com
When my dad first
recognized his memory “slips,” he would chuckle and say, “I’m losing my marbles.” He became very clever at heading off what he grasped as memory lapses, coyly steering the conversation away from a topic of recent history. Throughout this time, his capacity to pull detailed memories from his days as an infantryman in WWII or his house call days as an internist in the Jewish ghettos of Milwaukee was incredible. Now, seemingly quite quickly, his dementia has caused the mind of a once brilliant man and renowned pathologist to become a shadow of itself. Yes, it’s sad not be able to share with him my sweet memories of my childhood or of my mom, who passed away several years ago. And he no longer recalls the names of his children and six grandchildren. Yet, my dad’s dementia has managed to provide treasured moments. One time, I commented on how nice he’d become since he’d “lost his marbles” and he replied, “I’d sure hate to run into my old self!” I’d heard an NPR piece about how powerful music can be for dementia patients and decided that it was worth a try. I downloaded a few songs from musicals that my parents listened to. I pushed play, Richard Harris’ baritone came booming through my iPhone and my dad and I enjoyed a few karaoke sessions of Camelot, ending with a resounding rendition of “I've Been Working on the Railroad”. Our cover story on dementia (page 10) spotlights why a diagnosis is important, discusses the limitations of treatments and underscores the impact of the disease on your patient’s family as well as your patient. There’s hope for treating a disease that now impacts almost 5 million people in the United States – and surely, that number will be escalating. In our 2012 November/December issue, Managing Editor Linda Harder surveyed the status of Accountable Care Organizations (ACO). At that time, there were 154 Medicare ACOs in 37 states (“Accountable Care Organizations – Can They Work for You?”). That article has been one of our top-read articles since Maryland Physician launched – clearly a hot topic. As this issue goes to press, there are more than 250 Medicare ACOs in operation, as well as a growing number of commercial models. In this issue, Linda revisits how accountable care is growing with or without an ACO model, and why some providers choose to participate while others pass (page 20). We’re entering a time of family gatherings and holiday rejoicing. With social media and other influences, time seems to be speeding up and keeping us in the present, often causing us to neglect the rich history and stories from our parents and elder loved ones. Relish the time you have away from your practice and take some time to really listen to someone else’s memories. With that, I wish you and yours a joyful and peaceful holiday season. To life!
Jacquie Cohen Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag #mdphysicianmagEvents
4 | WWW.MDPHYSICIANMAG.COM
MANAGER OF DIGITAL CONTENT & SOCIAL MEDIA BUSINESS DEVELOPMENT Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Tracy Fitzgerald PROOFREADER Ellen Kinsella PHOTOGRAPHY Tracey Brown, Papercamera Photography Melissa Grimes-Guy, Location Photography, Inc. Kevin J. Parks, Mercy Medical Center Randy Sager, Randy Sager Photography, Inc. 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 MedChi CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine free paper
ADVERTISEMENT
Introducing the perfect way to
YOURSELF Trusted medical professional liability coverage from Coverys Over 25,000 physicians, dentists and allied healthcare professionals and hundreds of hospitals, health centers and clinics cover themselves with Coverys. You should too. Our rock VROLG ÂżQDQFLDO VWUHQJWK XQPDWFKHG H[SHULHQFH DJJUHVVLYH FODLP GHIHQVH DQG FXWWLQJ HGJH ULVN PDQDJHPHQW VHUYLFHV PDNH XV WKH LQWHOOLJHQW FKRLFH Nobody covers you like Coverys.
www.coverys.com 800.225.6168 ProSelect Insurance Company
Cases
Dementia Case Study and Discussion By Rebecca Elon, MD, MPH AGSF
CASE: Mrs. Jones was a successful business-woman. After retirement at the age of 65, she remained active with local volunteer groups. After her 79th birthday, her husband became concerned because she had dropped out of most of her usual activities. She had always been a very outgoing person, but had become quiet and reserved. She started asking repetitive questions. She always enjoyed cooking, but recently had trouble getting the meals prepared. When a fire started on the stovetop, she did not know what to do to extinguish it. When they had gone together on a recent vacation cruise, Mrs. Jones got up in the middle of the night and was totally befuddled and frightened. Now, even at home, she wants to be with her husband all of the time. Mr. Jones dropped out of several of his activities, due to his wife’s needs. The latest challenge is that Mrs. Jones no longer wants to take a bath. She has become incontinent of urine and doesn’t seem to be aware when she needs to change her clothes. Their three children all live out of state and there is no other family nearby. Mr. Jones is experiencing physical and emotional exhaustion. He is very worried about the future. He asked his primary care physician what he should do.
DISCUSSION: Family members may not recognize that a loved one is suffering from cognitive impairment until the symptoms are quite advanced. Couples will often compensate for one another’s deficits quite naturally, until the signs and symptoms of impairment are pronounced. Likewise, if a formal test of mental functioning is not performed during the primary care office visit, the physician may miss the signs of early dementia. Medicare recently approved payment to primary care physicians for an annual wellness exam. This exam must include a formal test of cognitive function for the physician to obtain Medicare payment. Once impairment is discovered on the cognitive screening test, the physician will look for potentially reversible causes. A complete medical history and physical examination, including a detailed neurological exam, should be performed. Questions to investigate the possibility of depression should be asked. People who are experiencing early dementia may develop depression in response to the realization they are experiencing deficits. The depression may cause an accentuation of the cognitive impairment, so a trial of antidepressant medication may be given. The physician will look for medical problems that might cause cognitive impairment, including hypothyroidism or certain vitamin deficiencies. Profound anemia or renal failure could cause reversible cognitive impairment. Certain prescribed medications (such as tranquilizers, sleeping pills, pain pills and others) can cause cognitive impairment. Alcohol or prescription drug abuse can present as cognitive impairment. The primary care physician may refer the patient to a neurologist to help make the diagnosis of dementia, and determine the specific type of dementia.
Although Alzheimer’s disease is the most common form of dementia, other dementia syndromes are recognized, including Lewy body dementia, dementia associated with Parkinson’s disease, vascular dementia, primary progressive aphasia, frontal lobe dementia, Cruzfeldt-Jakob disease, normal pressure hydrocephalus, dementia pugilistica and others. A referral to a neuro-psychologist may help to clarify the person’s abilities in various realms of mental function through a battery of cognitive tests. The person with dementia should be advised not to operate a motor vehicle any longer. Referrals to elder law attorneys may be advised to establish a financial plan for future care needs. Advance directives should be made. The use of medications to try to improve cognition is generally recommended, but controversy exists about their cost versus effectiveness. Caregivers must be supported in their efforts to provide care and keep the loved one in the home environment as long as is safe and feasible. The Alzheimer's Association website provides resources for caregivers at www.alz.org. City and county health departments and the Office on Aging (www.aging.maryland .gov) are also sources for caregiver information. Participation in a medical adult day care program can help relieve the burden of family members. When the loved one’s needs exceed the caregiver’s capacity, many assisted living or nursing facility options exist. Caregivers must be able to protect their own health and spend more quality social time with the loved one by enlisting others. It truly takes a village. Rebecca Elon, MD, MPH AGSF serves as chief medical officer of FutureCare Health and Management Corporation. She may be reached at elonr@futurecare.com.
NOVEMBER/DECEMBER 2013
|9
Diagnosing dementias WHY IT MATTERS
IS THERE HOPE FOR THOSE WITH DEMENTIA? While treatments are limited, Maryland neurologists and psychiatrists discuss the importance of a good history and exam, plus optimal supportive care.
10 | WWW.MDPHYSICIANMAG.COM
BY L IN D A H ARDER • PHOTOG RA PH Y BY TRACEY BROWN
A
LZHEIMER’S disease (AD) and other dementias affect a growing percent of our aging population. About 60 to 80% of dementias are due to AD, affecting more than five million Americans. But the impact of the disease spreads well beyond those affected, as over 15 million family members are caring for someone with AD at home, and the average cost of caring for a patient with dementia in a long-term care facility approaches $50,000 per year. In Maryland alone, some 80,000 people are believed to have the disease.
Differentiating Dementias Jerold Fleishman, M.D., LAc, section chief, department of neurology at MedStar Franklin Square Medical Center, notes, “Dementia is characterized by impairment of memory and at least one other cognitive sphere, such as aphasia, apraxia, agnosia or impairment of executive function, that affects normal activities of daily living. Memory issues alone do not define dementia.” He continues, “In AD, the typical trajectory is for short-term or recent memory to be affected first, then longterm memory. Spatial orientation and reasoning often are next. Family members typically observe a slow, progressive decline. In teaching our residents, I use the acronym JOMAC – which stands for judgment, orientation, memory, affect and cognition – to describe the typical functions affected in dementia.” “There is a strong association with depression in those afflicted with dementia,” says Dr. Fleishman. “However, in turn, major depression can behave similarly to dementia, which is important to differentiate because treatment and outcomes are significantly different.”
While AD is the most common dementia in our population, other recognized dementias include vascular or multi-infarct, frontotemporal (FTD) or Lewy body dementia (DLB). Most cases have a mixture of pathologies in the brain. “Vascular dementias, a common form, tend to follow a more step-wise progression, rather than a linear one,” says Dr. Fleishman. “One should think of this diagnosis in patients with a history of multiple strokes, known uncontrolled hypertensions or diabetes that may lead to multiple small-vessel bilateral lacunar ischemic strokes. Over time, these tiny strokes may lead to impaired cognitive function if not controlled.” DLB is increasingly recognized as another common type of dementia. It is characterized by early impairment in attention and executive and visuospatial function, with memory affected later in the disease course. Visual hallucinations can be an early sign of DLB and can be helpful in distinguishing it from AD, where hallucinations tend to be seen later in the disease. FTD, usually seen in those aged 40 to 70, has several variants – including behavioral variant (bvFTD), primary progressive aphasia (PPA) and motor neuron disease (FTD-MND). The more common behavioral variant may be suspected if the patient has ritualized behaviors or abnormal social behaviors, loss of executive function and problemsolving issues.
A Team Approach to Dementia Constantine Lyketsos, M.D., MHS, FAPM, DFAPA, director of the Johns Hopkins Memory and Alzheimer’s Treatment Center on the Johns Hopkins Bayview campus, provides cutting edge treatment and conducts research and
education about dementia. The center sees about 1,000 new patients a year – a large volume, though only a small percent of them are Maryland residents with dementia. About half of the center’s referrals are from physicians, with the other half referred by self or family. An interdisciplinary group of 12 neurologists, geriatricians and psychologists staff the program. “The first visit can be with any of our physicians,” notes Dr. Lyketsos, “but then we triage as appropriate to the physician who is the best match for the patient’s presentation. We meet weekly as a team, and we have three RNs who are experienced with memory care, and work closely with other experts in the area such as occupational therapists and neuropsychologists.”
Good Exam Critical to Accurate Diagnosis Whether in a private physician’s office or a specialized center, our experts agree that the key to dementia diagnosis and treatment is a comprehensive history and physical. “It’s easier to predict outcomes when we have the best diagnosis,” Katherine Coerver, M.D., Ph.D., neurologist at The Neurology Center in Chevy Chase, says. “In my workup, I first take a careful history, perform a physical exam and neurological exam, including completion of a cognitive screen. When appropriate, neuropsychological testing should also be completed to help develop a functional portrait of the brain.” Dr. Fleishman concurs. “History taking is so important and should include asking about medications, overthe-counter supplements, any recent changes in medications, increased physical or emotional stressors and a sleep history, which are all imperative.”
NOVEMBER/DECEMBER 2013
| 11
Constantine Lyketsos, M.D., MHS, FAPM, DFAPA, director of the Johns Hopkins Memory and Alzheimer's Treatment Center
“You’d be surprised how many people we see that have been started on a drug for dementia without having a diagnosis. Diagnosis should be the first step.” – Constantine Lyketsos, M.D., MHS, FAPM, DFAPA
“You’d be surprised how many people we see that have been started on a drug for dementia without having a diagnosis,” Dr. Lyketsos exclaims. “Diagnosis should be the first step.” Dr. Coerver contributes, “As part of the history and physical, I try to determine if a person has language problems or difficulties with attention or processing information. With this knowledge, I am able to start determining if the dementia is due to Alzheimer’s disease or frontotemporal dementia, which tends to manifest itself in language and behavior issues.” “The truth is that biologic tests are not that useful, but we’re good at diagnosing with a rigorous clinical exam,” comments Dr. Lyketsos. “We also employ a cognitive battery that includes such tools as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MOCA). “These are comparable to getting a chest x-ray in that it allows you to rule in or rule out dementia, but not determine what causes it,” he continues. “That’s where tests become useful. Where appropriate, we use neuropsychological testing, which is more like a chest CT.”
Additional Testing “I also order an EEG to detect possible subclinical seizures,” states Dr. Coerver. “I order a basic metabolic panel and liver function, B-12 levels and methylmalonic acid (MMA) levels, because a high level can mask a B12 deficiency. I also check thyroid function and homocysteine levels, which are 12 | WWW.MDPHYSICIANMAG.COM
associated with B12 deficiencies and can cause atherosclerosis, blood clots and possibly Alzheimer’s disease.” She continues, “Next, when appropriate, I get a structural view of the head with MRI, or CT if MRI is not an option, to rule out slow-growing tumors or small strokes. I also look for evidence of atrophy on the scan.” “Focal symptoms in the setting of a dementia, such as falling, may indicate some other process,” notes Dr. Fleishman. “In those patients, I’m more aggressive in pursuing a baseline non-contrast CT or MRI, as recommended by the American Academy of Neurology (AAN).” Dr. Lyketsos says, “Many people can be diagnosed without needing imaging – in fact, we can in some cases conclude with 90% confidence that it is Alzheimer’s without MRI – but we use imaging where appropriate. What matters is the pattern of the entire picture.”
Biomarkers for Dementia While no validated biomarkers for AD currently are available, several are on the horizon, including those for cerebrospinal fluid proteins, blood proteins, brain imaging and genetic risk profiling. Dr. Coerver comments, “While a lumbar puncture is not something I routinely order, research shows there is a good correlation between Alzheimer’s and lower levels of beta amyloid and higher levels of Tau protein biomarkers in the spinal fluid. I will use this test if I believe that there may be an underlying infection or inflammatory changes contributing to a person’s cognitive dysfunction.” She continues, “Is testing worthwhile when effective treatments are limited? Yes, because you never know what you’ll find. Vascular dementia has a better prognosis, and treatment is available for brain tumors or subclinical seizures. Atrial fibrillation increases the risk for vascular dementia because, even with Coumadin, it can release numerous tiny blood clots into the system.” Molecular imaging technologies, involving PET/CT and radioactive tracers, show promise, but are not yet covered by most insurers and can not yet definitively diagnose AD. A study published in JAMA on January 19th, 2011 showed nearperfect correlation between Amyvid (florbetapir F-18) detection of betaamyloid and amyloid levels on autopsy.
“If the first round of tests doesn’t provide enough information,” says Dr. Coerver, “I may order a FDG-PET scan to differentiate Alzheimer’s from frontotemporal disease. Medicare will pay for this test, though private insurers may not.” “Molecular imaging such as PET/CT is nonspecific but helpful in about 10 to 15% of patients,” says Dr. Lyketsos. “Amyvid-PET can help to rule out Alzheimer’s, but Medicare won’t pay for it as a diagnostic tool, so it’s expensive for patients.”
Katherine Coerver, M.D., Ph.D., neurologist at The Neurology Center in Chevy Chase
Treatment Treatment options for those with AD are admittedly limited, and no breakthrough drug is on the immediate horizon. Most FDA-approved Alzheimer's medications – donepezil, rivastigmine and galantamine – function by inhibiting the action of acetylcholinesterase, the enzyme responsible for the breakdown of acetylcholine, a key neurotransmitter. By contrast, memantine, (Namenda), an N-methyl-D-aspartate receptor antagonist, work by limiting the potentially toxic effects of glutamate. Response to these medications varies. “Some people tolerate one of the acetylcholinesterase inhibitors better than another, but they are similar,” Dr. Coerver observes. “Namenda can be used at all stages of dementia. While it has few side effects, some patients experience dizziness, and a small number of my patients have experienced increased confusion. An extended-release form is now available, which improves compliance.” Dr. Fleishman is also an acupuncturist who practices a more complementary approach with his patients. “Since the 1990s, I’ve believed that low-grade inflammation may play a role in dementia and in other medical conditions. Supplements such as curcumin, Omega III fatty acids and Coenzyme Q10 may help. I also believe that lowering homocysteine levels if elevated, with a combination of B6, B12 and folic acid may be helpful.” Dr. Coerver has tried Axona, a prescription nutritional supplement that may increase brain metabolism. “I also advocate a healthy diet, exercise for 30 minutes three to four times a week, and keeping blood glucose and hypertension under control.”
Advice to Physicians: Avoid a Nihilistic Approach Dr. Lyketsos cautions physicians treating patients with dementia against taking a nihilistic approach to treatment. “Treatment is more than prescribing FDA-approved medications. You need disease management that understands the possible underlying causes, such as hypothyroidism, major depression, and diabetes. If it’s Alzheimer’s, there’s no direct treatment, but management of blood pressure, glucose levels and other co-morbidities is very important to slowing progression. Appreciate that
much can be done to help patients with dementias and their caregivers, and the earlier the better. There is a lot we can do.”
Supportive Care is Critical Dr. Lyketsos believes that supportive care for patients with dementia is critical – proper sleep, consistent routines, adequate hydration and nutrition. “Caregivers also need support. The family should be educated to be good problem solvers – to get respite care as needed and to be detectives who can pick up problems,” he advises. NOVEMBER/DECEMBER 2013
| 13
Your Business Extender providing... STRATEGIC PLANNING Savvy will perform an internal assessment and provide a marketing plan that you and your staff can implement or contract Savvy services. REFERRAL BUILDING Our liaison services will strengthen existing relationships and build new referral sources to grow the practice. GRAPHIC DESIGN & MATERIAL DEVELOPMENT Our designers, along with copywriters can develop any type of promotional materials needed for the right impact. WEBSITE DESIGN & DEVELOPMENT Custom designed & expertly developed. ONLINE REPUTATION MANAGEMENT A public relations program to monitor your online presence and assist in maintaining a positive image.
Experts in
DIGITAL MARKETING Engaging consumers with online education and advertising to promote your services.
Physician Marketing & Referral Building Specializing in health care marketing, Savvy Consulting Services has the expertise to help your practice grow. Think of us as an extension of your practice.
1 CALL US
for a free consultation: 941-518-6170
CHECK our website 2 for more information: www.asavvymarketingsolution.com
Serving Maryland and Metro Washington, DC www.aSavvyMarketingSolution.com
14 | WWW.MDPHYSICIANMAG.COM
Jerold Fleishman, MD, LAc, section chief, department of neurology at MedStar Franklin Square Medical Center
“Common issues are constipation, dehydration, pain, dental problems, and bladder infections. In the winter, respiratory infections are common and much more detrimental to the brain with dementia. The flu can throw a dementia patient for a loop, and patients should get flu shots and pneumococcal vaccines to prevent respiratory problems. “The evidence is very solid that acute medical problems lead to a faster decline,” he adds. “If the patient does contract an illness, be aggressive in trying to return them to functioning. If they stay in bed two to three days, one or two weeks of physical therapy might be needed to reverse deconditioning.” Physicians should also monitor patients to manage neuropsychiatric symptoms, such as apathy, sleep problems, depression and agitation – over 95% of patients with dementia develop one or more of these symptoms over the course of illness. “You want to catch and treat them early,” states Dr. Lyketsos. “If agitation emerges suddenly in a person with dementia, it’s often related to a bladder infection or other medical problem.” The person’s environment also plays a key role in their function. “A new caregiver or change in routine can cause problems,” Dr. Lyketsos adds. “You should encourage activity, such as a day care program, to help patients keep mentally, physically and socially engaged – and to give caregivers who need it some respite. If there are more serious behavioral issues, involve a specialist before prescribing anti-psychotic or other psychiatric medications, which carry significant risk for patients with dementia.” Dr. Lyketsos recommends that
physicians guide family members to address safety issues. “In early dementia, we see issues with driving and medication oversight. Later, nutrition, hydration and safety become more of an issue, especially when patients live alone. Don’t assume that, as the dementia progresses, a nursing home is the next step. When the patient needs more help, we can teach families to do much of what the patient would get at a nursing home to delay admission.”
Enroll Patients in Protocols “Primary care physicians are used to sending cancer patients for protocols,” concludes Dr. Lyketsos. “They need to do that early on for patients with dementia, too. We have 15 dementiarelated protocols going on currently, including Venlafaxine for Depression in Alzheimer’s Disease, a preliminary study on Carvedilol for treating AD and Deep Brain Stimulation for AD. Research participation is key to finding cures and improving care.” Katherine A. Coerver, M.D., Ph.D., neurologist at The Neurology Center in Chevy Chase, MD Jerold H. Fleishman, M.D., LAc, section chief, department of neurology and director of clinical neurophysiology, MedStar Franklin Square Medical Center; clinical instructor of neurology, Johns Hopkins Hospital Constantine G. Lyketsos, M.D., MHS, FAPM, DFAPA, director, Johns Hopkins Memory and Alzheimer's Treatment Center and chair of Psychiatry, Johns Hopkins Bayview campus
STOPPING
Infectious Diseases TESTING BABY BOOMERS, DECREASING ANTIBIOTIC USE ARE KEY BY LINDA HA RDE R • P H OTOGRA P H Y BY T RACE Y BROWN
Despite our ability to nearly eradicate measles and even to effectively treat HIV, a number of potentially deadly infectious conditions are on the rise. Our medical experts suggest the best approaches to stop or treat them.
16 | WWW.MDPHYSICIANMAG.COM
HEPATITIS C: TEST ALL BABY BOOMERS What is the most common infectious disease in the U.S. today? Perhaps surprisingly, it’s not HIV. Instead, it’s Hepatitis C, a disease that is estimated to affect about five million people in the U.S., many of whom are baby boomers born between 1945 and 1965. Compare that to about one million Americans suffering with HIV and 1.5 million with Hepatitis B. “The first thing the average physician needs to know is that our diagnosis rates for Hepatitis C are miserable – about 39%,” observes Anurag Maheshwari, M.D., clinical assistant professor of medicine, University of Maryland School of Medicine, Institute for Digestive Health and Liver Disease at Mercy Medical Center. “That’s in stark contrast to HIV, where the rate is about 90%.” The overall prevalence rates for Hepatitis C are 1.6%, but in baby boomers, the prevalence climbs to 4 or 5%; among inner city baby boomer African American males it may be as high as 8%. “The highest transmission rate peaked in the 1960s,” Dr. Maheshwari notes. “That’s
largely attributable to needle sharing among recreational injection drug users and unsafe medical practices, including blood transfusions and tattooing. Unprotected sex may also contribute, although the rate of sexual transmission of Hepatitis C is much lower than that for HIV. Unfortunately, some 20 to 35% of those infected don’t have identifiable risk factors.” Hepatitis C Testing
That’s why, in 2012, the Centers for Disease Control and Prevention (CDC) recommended that all baby boomers get tested for Hepatitis C at least once in their lifetime, even when they have no identifiable risk factors. Physicians can order a simple blood test, the enzyme-linked immunosorbent assay (ELISA), with 94 to 98% accuracy. Dr. Maheshwari urges primary care physicians to make this assay a routine part of an annual physical for baby boomers who have not yet had the test. “Testing for Hepatitis C should be like getting a colonoscopy for those over age 50,” he advises.
If Hepatitis C is detected by the ELISA test, the next step is determining the quantity and type of the virus. Unfortunately, abnormal liver function tests are not a reliable way to test for this virus. “Patients can have significant liver disease even when their liver function test is normal, so that test doesn’t necessarily indicate that all is well,” Dr. Maheshwari cautions. Changing Treatment Implications
A liver biopsy will reveal the presence of cirrhosis and/or the stage of liver disease. In the past, those with Stage 0 or Stage 1 liver disease were recommended deferring treatment, because interferon treatment has significant side effects that can include fatigue, anemia, rashes, nausea, mood swings and even severe depression. Instead, interferon treatment was reserved for those with Stage 2 or higher. However, with newer treatments that don’t involve interferon, the conventional wisdom for patients at Stage 0 or 1 is changing. “Patients worry about being able to keep working when they take interferon, which is injected subcutaneously,” Dr. Maheshwari says “But thanks to new options, that’s changing. Interferon treatment used to be 48 weeks in length.
Anurag Maheshwari, M.D., clinical assistant professor of medicine, University of Maryland School of Medicine
In the next six months, we will reduce that to three months of therapy. And in the next 24 months, we should be able to completely eliminate interferon and use pills only. Then we can argue that every patient with this virus should be treated.” A recent Phase II trial conducted by the National Institute of Allergy and Infectious Diseases and the NIH Clinical Center, published August 28, 2013 in the Journal of the American Medical Association, found that patients – including those in difficult-to-treat populations – can achieve viral control through all-oral treatment regimens. Patients who were given a 24-week regimen of sofosbuvir along with weightbased ribavirin had a sustained virologic response to treatment of 68%. Another preliminary publication funded by Abbot Pharmaceuticals of a combination of three oral anti-viral medications demonstrated cure rates of between 93-95% of patients in a small study published in the New England Journal (N Engl J Med 2013; 368:45-53). “Some doctors and many patients mistakenly think there’s nothing that can be done to treat Hepatitis C,” warns Dr. Maheshwari. “That myth needs to be dispelled. It’s a curable, treatable condition, and failing to treat it can lead to cirrhosis or liver cancer, with possible liver failure and the need for a liver transplant as a consequence.” No insurance company will provide life insurance if you have Hepatitis C, so why should we physicians leave it untreated? I personally believe that all patients with Hepatitis C should receive treatment, but we need options that are palatable. Thankfully, they’re around the corner.” He concludes, “My dream is to eradicate this virus in the next 10 years. Physicians need to ensure that their baby boomer patients get tested, even those lacking evident risk factors. It takes five to seven years to progress from one stage to the next, but treatment depends on the patient’s personal preference and co-morbid conditions. A young, healthy 50-year-old, for example, should take care of their infection now.”
FECAL TRANSPLANTS FOR C. DIFF BECOME ACCEPTED As the number of U.S. cases of clostridium difficile (C. diff) climbs from roughly 150,000 /year in 2,000 to about 500,000/year today, and as 15,000 Americans now die from the infection each year, finding effective treatments for
refractive cases has become more urgent. The overuse of antibiotics has clearly helped fuel the rise of this disease. Those over 65 and in long-term-care facilities are at highest risk, while a growing number of pregnant women and children suffer from C. diff. In children, those most at risk have inflammatory bowel disease (IBD), are immuno-suppressed due to transplantation or oncological diseases, or are in chronic-care facilities. The CDC recently reported that 75% of patients with C. diff actually were already colonized with the disease when they were admitted to a hospital or nursing home. That flew in the face of accepted wisdom that most patients contracted the disease as a result of their stay in such facilities, and suggested that efforts should focus on avoiding contamination from newly admitted patients. Preventing C. Diff Infection
Maria Oliva-Hemker, M.D., professor of pediatrics and director of pediatric gastroenterology and nutrition at the Johns Hopkins Children’s Center, comments, “The problem with antibiotics is that they kill the good bacteria as well as the bad. In an uncompromised host, there’s some evidence that using probiotics helps. Probiotics can be useful, but they only restore several species of the thousands that populate our gut. And most yogurt in the U.S. has a low concentration of probiotics – if any. As physicians, we need to make sure patients are getting only the antibiotics they need and getting the right ones, though it’s challenging in an era where patients are conditioned to ask for them.” New Treatments
Vancomycin and metronidazole have been the go-to treatments for years. In 2011, the FDA approved fidaxomicin (Dificid, Dificlir) as an alternative treatment to vancomycin or metronidazole for treating this condition. Vancomycin is effective in preventing relapse in about 75% of cases. A recent study demonstrated that fidaxomicin’s relapse rate is only 15%, but it is expensive and far from a panacea. Diverting loop ileostomy with colonic vancomycin lavage is being tested to replace colectomies in some patients. Gaining acceptance as another treatment approach is stool (fecal) transNOVEMBER/DECEMBER 2013
| 17
Maria Oliva-Hemker, M.D., professor of pediatrics and director of pediatric gastroenterology and nutrition at the Johns Hopkins Children’s Center
plantation. The concept dates back to ancient Chinese in the early first century, and to Western usage in the 1950s. However, only recently has it gained real traction, as studies demonstrate its value. While only about 500 published cases of the procedure exist worldwide today, the success rates with stool transplants have been sufficiently impressive to launch its reconsideration. A randomly-controlled trial published in the New England Journal of Medicine (NEJM) on Jan. 17, 2013, found that the infusion of donor feces was significantly more effective for the treatment of recurrent C. diff infection than the use of vancomycin, at least in an adult population. The trial was stopped early as a result of the far greater efficacy of fecal transplantation (81% resolved after one infusion vs. 31% receiving vancomycin alone). Fecal transplants are now being tried as a treatment approach in children. “Some 20% of children with C. diff will have recurrence of their diarrhea following vancomycin treatment, and 40 to 60% of these will have a second episode. Fecal transplant should be considered for children who don’t respond to two standard courses of antibiotics,” Dr. Oliva-Hemker states. Fecal Transplants Extend to Children
While several area hospitals have performed the procedure in adults, the Johns Hopkins Children Center is one of a handful of pediatric hospitals in the country to offer this therapy. Early results are promising, though Dr. 18 |
WWW.MDPHYSICIANMAG.COM
Oliva-Hemker expects a relatively small number of cases in the pediatric C. diff population. Dr. Oliva-Hemker notes, “The procedure has no published short-term side effects, but we don’t know about the long-term. Could the transplant of donor stool lead to obesity, for example? So
GET SMART ABOUT ANTIBIOTICS WEEK Since 2008, the CDC has worked with other government and private partners to promote public and provider education about the appropriate use of antibiotics. Their efforts include an annual Get Smart About Antibiotics Week, occurring this year on Nov. 18-24, 2013. Providers can get free educational materials at www.cdc.gov/getsmart.
caution is still the rule. However, the truly exciting aspect of this treatment is that, in the future, it may be useful for treating ulcerative colitis, Crohn’s disease and other digestive diseases.” “The more we know about the microbiome, the more we respect it,” she concludes. “It’s integral to our immune system.” The Procedure
The procedure involves identifying a suitable donor, often the parent. After extensive screening (similar to that
undertaken for a blood donor) and stool analysis determines that the donor is a low infection risk, the child is scheduled for the procedure. Within 12 hours of the procedure, the donor provides a stool sample. It can be introduced in the patient’s digestive tract through a nasalgastric tube, a colonoscopy, or an enema. According to Dr. Suchi Hourigan, a pediatric gastroenterology fellow involved in the Hopkins protocol, “We use a colonoscopic approach exclusively, which has the advantage of allowing us to view the colon at the same time.” A number of companies are seeking to replace donor stool with cultured organisms. RePOOPulate is one such product. “The science is not there yet, but when we know what part of the microbiome works, this could be a viable approach. It would allow the procedure to be more standardized,” concludes Dr. Hourigan, who is investigating the microbiome changes that occur in fecal transplantation.
MRSA: A BALTIMORE EPIDEMIC? When examining MRSA (Methicillinresistant Staphylococcus aureus) trends, you have to be careful how you look at the numbers. While the organism – caused by a strain of staph bacteria that's become resistant to the betalactam antibiotics such as methicillin, oxacillin, penicillin and amoxicillin – is becoming more prevalent, the rate of MRSA infections is on the decline. The CDC reports that the number of healthcare-associated (HA) MRSA cases climbed from 22% of staph infections in 1974 to 64% in 2004. A national survey in 2010 also documented that MRSA prevalence was higher in 2010 than in 2006. However, compared with 2006, the rate of MRSA infection has decreased at the same time that the rate of MRSA colonization has increased. The most recent CDC data showed that over 62,000 severe MRSA infections occurred in 2011, and more than 11,000 people died. However, life-threatening HAMRSA infections have been declining since 2005, especially for those with bloodstream infections. Further, the proportion of HA-MRSA has decreased as CA-MRSA has increased. Perhaps nowhere is that more true than in Baltimore. Bruce Gilliam, M.D., medical director of the Institute of Human Virology clinic at the Midtown campus of the University of Maryland Medical Center, believes that Baltimore
has one of the highest rates of CAMRSA in the country. “About 60% of the University’s emergency department patients with a culture that grows Staph aureus have MRSA,” he says. “Not everyone gets skin abscesses from MRSA. Those who do likely have the more virulent strains,” explains Dr. Gilliam. “We know there are different strains with different virulence factors. At the 2013 Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) this September, they found that having MRSA when admitted to the hospital was less of a problem than acquiring it in the hospital, because a sick person with multiple co-morbidities will do worse with a bad bug.” “If a hospital can identify that the patient has MRSA when they are admitted, they can better control it,” Dr Gilliam concludes. Rapid Testing Is Key
In place of the standard test for MRSA that involved sending a tissue sample or nasal swab to a lab and waiting 48 hours for results, a number of new rapid diagnostic tests are now available on the market, such as GeneXpert. “However, these tests are expensive and not yet widely used,” Dr. Gilliam observes. “We have to figure out how to use them in a way that improves care. Getting people on a narrow-spectrum antibiotic as soon as possible, such as one that treats gram-positive bacteria only and not also gram negative. Current research has focused on how to identify people with resistant infections versus those whose infections are not resistant.”
Newer Weapons, Similar Outcomes
Hospitals have been pursuing new ways to prevent MRSA. A study of 75,000 ICU patients published in the NEJM in May 2013 found that using daily chlorhexidine wipes and antimicrobial nasal ointment on all ICU patients reduced the presence of MRSA by 37%. This approach was more effective than isolating MRSA patients and treating them differently. Since treating MRSA is expensive – estimated to cost $10,000 or more per case – preventing it is a key component of controlling healthcare costs as well as health. “In today’s hospitals, one factor in our favor is also likely the increase in private rooms,” Dr. Gilliam remarks. “However, most providers don’t identify or address MRSA in the clinic situation or the physician exam room. No one is looking at this – instead, the focus is on hospitals and long-term care facilities.” He adds, “Several new drugs have become available in the past seven to 10 years, including linezolid, daptomycin and ceftaroline fosamil. They can replace vancomycin when there’s toxicity but they may not be better at treating Staph aureus.” Dr. Gilliam concludes, “Unfortunately, we don’t have the silver bullets for MRSA that it appears we’ll soon have for hepatitis C. We have lots of newer weapons, but not necessarily better outcomes. We need a medical system that recognizes that not getting the right care costs more. The Dutch were able to decrease antimicrobial resistance when they decreased usage of antibiotics. We need similar measures here in the U.S.”
Continued Need for Education
“Pediatricians and other physicians are slowly doing a better job of using the appropriate antibiotic only when needed, rather than giving patients who demand an antibiotic one even when it’s not appropriate,” continues Dr. Gilliam. But even physicians don’t always draw a link between giving a patient an antibiotic in the office today and the rise of superbugs – they’re more focused about having an individual patient do well.” Infectious disease experts estimate that as much as half of the antibiotics currently prescribed are unnecessary. “The overuse and misuse of antibiotics is a large part of the problem,” Dr. Gilliam agrees. “Dutch studies involving children with otitis media found that they could reduce drug resistance if they used antibiotics only when needed.”
Anurag Maheshwari, M.D., clinical assistant professor of medicine, University of Maryland School of Medicine, Institute for Digestive Health and Liver Disease at Mercy Medical Center. Maria Oliva-Hemker, M.D., Stermer Family Professor of pediatric inflammatory bowel disease and professor of pediatrics, Johns Hopkins University School of Medicine; director of pediatric gastroenterology and nutrition at the Johns Hopkins Children’s Center. Bruce Gilliam, M.D., associate professor of medicine and medical director of the Institute of Human Virology clinic at the Midtown campus of the University of Maryland Medical Center.
NOVEMBER/DECEMBER 2013
| 19
Healthcare IT
AC C O U N TA B L E C A R E E X PA N D S W I T H OR WITHOUT AN
BY LINDA H A RDE R • PHOTOGRAPHY BY T RACE Y BROWN
Whether or not they have an Accountable Care Organization (ACO), many providers, hospitals and health systems are actively working toward accountable care. Maryland Physician looks at where ACOs stand today, and why some providers choose to participate while others pass.
20 |
WWW.MDPHYSICIANMAG.COM
CMS’s Pioneer ACO Pilot Results In the summer of 2013, the first results from the 32 participants in the Centers for Medicare and Medicaid Services (CMS) Pioneer Accountable Care Organization pilot project became available. All participants met their quality improvement-reporting goals, but only about a third reduced costs. Medicare spending for patients in these ACOs as a whole grew by only 0.3%, compared to 0.8% for a comparable group of non-ACO patients. Seven of these participants shifted to a less risky shared-savings program, while two opted out completely. One of the more successful pilot participants was Beth Israel Deaconness Care Organization, based in Boston. It was able to provide care to about 30,000 Medicare patients at 4.2% below budget, to garner $15 million in shared savings. It achieved these savings by targeting high-risk patients for additional services, such as home visits from nurse practitioners, and by emphasizing care management with its physicians. Private-Sector ACOs While, more than 250 Medicare ACOs are currently in operation, commercial ACOs are also booming, with more than
300 estimated to be running as of mid2013. Aetna reports that it has signed accountable care deals with 27 hospitals or health systems, including five systems in Maine, and that it plans 200 more such deals. Similarly, United HealthCare reports that it has accountable care agreements with over 575 hospitals, including a recent agreement with Mount Carmel Health Partners in Ohio, and that it plans to more than double its accountable care contract payments by 2017. It claims that its accountable care programs have reduced emergency visits by 16% and inpatient days by 17%. One potential advantage of private– sector ACOs is that they can design their benefits plans to provide financial incentives for plan members to use providers within the network. Medicarebased ACOs cannot take this same approach. Maryland’s ACOs In January 2013, five new Maryland ACOs were approved by CMS, bringing the state total to 10. Of the new ACOs, three are overseen by a subsidiary of Universal American, a healthcare organization in New York, while Anne Arundel Medical Center (AAMC) and the
Thomas Pianta, administrator of AAMC Collaborative Care Network
Maryland State Medical Society (MedChi) were approved for one ACO each. Of the 10 ACOs, three are partnered with MedChi. MedChi CEO Gene Ransom comments, “Maryland has been a leader in ACO development. We have 10 ACOs now, out of about 185 in the country, and three Advance Payment ACOs, out of about 30 in the nation. All four of the early ACOs were approved and able to report their data to Medicare. They will get their results back from CMS by the end of 2013.” “I’ve attended some recent board meetings of the existing ACOs and have really been impressed. It’s too early to tell if they will be successful long-term,” Ransom adds, “but they appear to be working. One of their benefits is that they are helping to make other changes in care. It’s a way to keep private practice viable.” He continues, “In Western Maryland, hospitals and physicians are aligned through the Total Patient Revenue payment model, so it’s easier. There have, of course, been challenges. We’ve seen some tension between primary care physicians and specialists, and between physicians and hospitals, but on the whole they’re succeeding in moving to more coordinated care.” Maryland is one of 16 states that are in the running for a Health Care Innovation Award grant,” Ransom notes. “ACOs put us in a good position to be a finalist. Physicians interested in considering an ACO are encouraged to contact MedChi and ask for MedChi Network Services.” AAMC ACO The AAMC Collaborative Care Network (CCN) is one of the CMS Shared Savings ACOs approved in 2013. Its decision to develop an ACO was made in the context of its strategic plan, Vision 2020, which, among other goals, seeks to build relationships with community physicians. A large employed group, Anne Arundel Medical Group, and two other physician groups partnered with the hospital to form the ACO, which was launched in January 2013. It has approximately 10,000 Medicare beneficiaries (5,000 is the minimum) and was established with
NOVEMBER/DECEMBER 2013
| 21
Healthcare IT an upside-risk-only model. The ACO only recently started receiving data on its attributed patients. Thomas Pianta, administrative director of CCN, explains, “In August 2013 we started getting data from Medicare, so we have a better idea where to target our interventions. We are required to submit quality data to Medicare in the first quarter of 2014 on a sample of patients selected by CMS. Additionally we are now receiving data from CRISP (Chesapeake Regional Information System for our Patients).” Combining different data from different sources, as always, has been part of the challenge. “We have different EMRs that don’t all talk to each other,” Pianta comments. Care management of vulnerable patients is a new concept and an important tool in managing ACO populations, although Medicare doesn’t specifically pay for care managers. Luckily, changes in care delivery were already underway at the ACO’s participating physician offices, all of which were already PCMHs. Pianta notes, “Our goal is to target high-care utilizers and those with socioeconomic barriers to good health, such as problems with housing, food or transportation. A priority of ours is to help manage the patient’s ability to access care and get their basic needs met. Healthcare is often the third or fourth thing on the list of what a person needs. We’re trying to make connections with, and more efficient use of, services that already exist.” He believes that “the primary reason to join an ACO is to take advantage of combined resources that make it easier to know about and manage your patients. When you know which patients are managing their diabetes, for example, it makes you a better doctor. We are trying to help our physicians through good data.”
Collaborative Accountable Care Program. There are 100 participating primary care providers, including nurse practitioners (NPs) and physician assistants (PAs), plus some specialists. Some providers are employed and others are aligned with the ACO. The entity currently has four care managers and is hiring two additional ones. It also employs three care coordinators for managing non-clinical issues. Regardless of insurance type, all
GBMC Healthcare ACO Today, after launching in 2012, the Greater Baltimore Health Alliance (GBHA) ACO has slightly more than a year of experience under its belt. It has nearly 14,000 combined beneficiaries in the Shared Savings Program established by Medicare and the Cigna
22 | WWW.MDPHYSICIANMAG.COM
Eric Wagner, MedStar Health executive VP for external affairs and diversified operations
patients cared for by GBHA providers receive the same type of innovative, patient-centric care. For example, participating physician practices have introduced new approaches to caring for urgent issues that include extended office hours and leaving 30% of the daily schedule open for sameday appointments. Data is key. Colin Ward, executive director of GBHA, says, “The ACO is physician driven. We assimilate clinical
information and claims data from the physicians, then give it back to them to foster shared decision-making. The true value of the ACO lies in its ability to get real-time and retrospective information about its patients so doctors can intervene quickly to prevent minor issues from spiraling into major health crises.”
health system. Eric Wagner, its executive VP for external affairs and diversified operations, notes, “CMS ACOs have many restrictions and they have an attributed population, not an enrolled population – so what you can do is more limited. In an ACO, a doctor may not know that a patient is attributed to them
“Many are enthusiastic about ACOs. I have some concerns about whether they will get us where we need to be.” – Eric Wagner
“Our ACO can give participating physicians data such as which of their hypertensive patients are not under good control, or which of their patients have A1C levels that are too high,” Ward continues. “We can provide the clinical data tied to specific patient names to shine a light on places where the physician’s attention is needed.” He adds, “As a pilot program with CRISP, which runs the state’s Health Information Exchange (HIE), the Encounter Notification Service (ENS) has been critical in helping coordinate patient care. We get real-time notification of hospitalizations and emergency visits, so that patients discharged from the hospital have the opportunity to be seen in the physician’s office within 48 hours. “It’s a mindset shift that, if done right, provides clear benefits to both physicians and their patients,” Ward reflects. “An ACO can return joy to the practice of medicine, because physicians can see meaningful changes in the care of their patients.”
Accountable Alternatives to ACOs For over 16 years, MedStar Health has provided some 30,000 Marylanders with managed healthcare through MedStar Family Choice, a provider-sponsored Managed Care Organization participating in the state’s HealthChoice Program and the Maryland Children's Health Program. MedStar Health considered creating an ACO when the CMS regulations were first published, but ultimately decided that the model didn’t make sense for its
until after the fact.” He adds, “However, MedStar Health has long been involved in population health management. We decided we could pursue similar goals in a different way. In our MedStar Family Choice program, we have assumed full risk, not shared risk, for our members. Like an ACO, we have to hit quality metrics and financial targets, and we have care coordination, outreach and other features comparable to a PCMH. In contrast to old-school managed care, we’re managing health, not resources. Financial and quality results follow from a focus on the patient.” The MedStar Family Choice program has roughly 2,500 participating physicians, of which about half are employed by the health system. “It’s not clinic-based care,” Wagner stresses. “We have a full team to handle care management, and outreach staff to connect with patients. We know who is diabetic and whether or not they’ve had care. If a patient is overdue for care, we call them and can even schedule an appointment in a three-way call.” For the Medical Assistance population, asthma and pregnancy have turned out to be some of the key conditions to monitor, along with diabetes. Wagner notes that getting real-time pharmacy data and daily feedback from the state is extremely valuable. “We tie disparate data together with technological tools, to, for example, notify care managers when a patient is admitted to the hospital, do outreach and send a home health care nurse out upon discharge.”
More recently, MedStar has used its experience with Family Choice to pursue other opportunities. In January 2013, they became a participating Medicare Advantage provider in D.C., and they plan to expand to other areas over time. They’re also talking to commercial payers about developing shared risk models within the next six to 12 months. Some 38,000 individuals are covered under their benefit plans. Wagner believes ACOs have yet to prove themselves a viable model, stating, "The jury is out. Many are enthusiastic about ACOs. I have some concerns about whether they will get us where we need to be. My advice to physicians is to think out of the box. Having non-physicians do outreach can free physicians to practice medicine. That can be very rewarding.” Whether physicians decide to participate in an ACO or another model, it appears that most care models are heading toward greater accountability. Hopefully, patients and providers alike will emerge as winners. *************** See the article entitled ACOs: Can They Work for Your Practice? in Maryland Physician Magazine’s November/December 2012 issue for more information. (www.mdphysicianmag.com/2012/11/01/ accountable-care-organizations-can-theywork-for-your-practice/) The Advance Payment ACO Model is designed for physician-based and rural providers who have come together voluntarily to give coordinated, high quality care to the Medicare patients they serve. They receive upfront and monthly payments, which they can use to make investments in their care coordination infrastructure.
Eric Wagner, executive VP for external affairs and diversified operations, MedStar Health Thomas Pianta, administrative director, AAMC Collaborative Care Network Colin Ward, executive director, Greater Baltimore Health Alliance Gene Ransom, CEO, the Maryland State Medical Society (MedChi)
NOVEMBER/DECEMBER 2013
| 23
Policy
Medical Marijuana Commission is Launched Maryland Becomes The 19th State to Legalize Medical Marijuana
W
HEN THE MARYLAND General Assembly passed HB 1101 in its 2013 legislative session, it made history by paving the way for the state’s first hospital-based medical marijuana program. Physicians have been an important impetus to bring this bill to fruition, as it was introduced by Del. Dan Morhaim, M.D., the only physician in the General Assembly, and was based on a proposal from the Secretary of the Department of Health and Mental Hygiene (DHMH) Joshua Sharfstein, M.D. Gov. Martin O’Malley’s administration had previously opposed medical marijuana legislation out of concerns that it could violate federal laws that prosecute state employees involved in distributing medical marijuana. However, the experience of other states with similar programs has eased those concerns, and the administration this year withdrew its opposition. Medical cannabis, or marijuana, has few clinical studies documenting its effectiveness in symptom control for cancer and other diseases, including chronic pain. However, many clinicians believe it can be useful for preventing nausea and vomiting, stimulating appetite, improving sleep and reducing pain. The Commission
The legislation created an independent commission within the Department of Health and Mental Hygiene that is charged with developing a request for proposals from academic medical centers to establish medical marijuana programs for select patient groups, approving applications and monitoring and 24 | WWW.MDPHYSICIANMAG.COM
Paul W. Davies, M.D., chair of Maryland's Medical Marijuana Commission
overseeing the programs that are established. Gov. Martin O’Malley appointed the 11 members of the new commission this September. Its chair is Paul W. Davies, M.D., a pain management specialist who is the founder and CEO of KURE Pain Management. Board certified in interventional pain management and fellowship-trained in pain management, Dr. Davies has over 10 years’ experience treating patients in pain. The other commission members are: > Michael A. Horberg, M.D., MAS, FACP, FIDSA, executive director of Research and Community Benefit for the Mid-Atlantic Permanente Medical Group and director of the Mid-Atlantic Permanente Research Institute > Robert A. Lavin, M.D., attending physician on faculty at the University of Maryland, School of Medicine, and the Kernan Hospital of Baltimore. He is also director of the Chronic Pain Management Program at the Baltimore Veterans > Shawn McNamara, Ed.D., M.S.N., R.N., assistant dean of the School of Health Professions and Nursing Program administrator for the Community College of Baltimore County > Kevin W. Chen, Ph.D., MPH, associate professor in the Center for Integrative Medicine and Department of Psychiatry at the University of Maryland, School of Medicine > Dario Broccolino, J.D., state’s attorney for Howard County since 2008
> William C. Charles, Pharm.D., a
>
> >
>
clinical pharmacist specializing in discharge and readmission reduction at MedStar Franklin Square Medical Center Deborah R. Miran, president and founder of Miran Consulting, Inc., who advised both brand and generic drug makers on the FDA approval process Colonel Harry Robshaw, III, chief of police, Cheverly Police Department Nancy Rosen-Cohen, Ph.D., an executive management professional experienced in healthcare reform and corporate development Eric E. Sterling, J.D., a lawyer with over 32 years of experience in medical marijuana issues
Outcomes-Oriented Programs
Dr. Davies comments, “The commission is charged with developing policies, rules and regulations to implement the legislation. We hope to accept applications starting in 2014 for academic medical programs involved in investigating uses of medical marijuana. Such programs must have residency curriculums and be involved in human research.” Each program applicant must describe what medical conditions will be treated, treatment duration, proper dosage, where marijuana will be obtained, sources of funding, measurement methods for data and outcomes.” They will have to provide DHMH with daily data on participating patients and caregivers that will be shared with appropriate law enforcement agencies.
Some of the many issues the new commission must grapple with include where the marijuana seeds will be obtained, who will grow the plants, what the security criteria will be and who is allowed to dispense it. To oversee implementation of the program, the commission seeks to appoint a full-time administrator. Due to the complexities of implementation, medical marijuana is not expected to become available in Maryland until at least 2015. Chronic Pain Patients Will Benefit
“I’m optimistic that this legislation will benefit many patients with chronic pain,” Dr. Davies notes. “We’ll have to establish which disorders will benefit from medical marijuana, but patients are likely to include those with cancer, HIV/AIDS, chronic pain and neurological disorders. The committee will define specific diagnoses, which is very important, because we should make sure that Maryland patients have access to useful interventions. Our state is unique because we are studying outcomes data to make sure that we see symptom improvement and potential benefits, without significant side effects.” Dr. Davies adds, “We’ll be closely watching developments in Washington, D.C., the closest area to approve medical marijuana. Surprisingly, after three months of operation, they have only enrolled 30 patients, where they expected a stampede. Physicians should closely follow the progress of implementing this program and support it because it may be a new tool to help fight pain.” Physicians and Public Invited to Commission Meetings
The commission held its first meeting on Sept. 24, 2013. In 2014, it will generally meet on the third Tuesday of each month. All meetings are open to the public, and physicians are encouraged to attend. Over the course of the meetings, the commission will be taking testimony from the public, physicians and experts. For more information, physicians should visit http://dhmh.maryland.gov/Site Pages/Medical%20Marijuana%20Com mission.aspx.
HRi gives you the freedom and peace of mind to focus on your patients and practice. We can help you save time and money by providing HR services, including: 2127 Espey Court, Suite 306 Crofton, MD 21114
410-451-4202 www.hri-online.com
✓ HR Consulting–Employee Relations, Handbook, Recruitment ✓ Payroll and Tax Administration ✓ Benefits/401(k) Administration ✓ Worker’s Comp Administration ✓ Web Based “Time and Attendance” ✓ Human Resource Information System (HRIS)
NOVEMBER/DECEMBER 2013
| 25
Living
Sites to See and Explore Across Brandywine Valley
N
By Tracy M. Fitzgerald
ESTLED WITHIN THE rolling hills of Chester County, Pennsylvania, Brandywine Valley has made its mark on the map with its unique combination of art, history, heritage and some of the most impressive displays of horticulture to be found in the United States. Located just an hour west of Philadelphia, “the Brandywine” is easy to get to and promises plenty to explore for tourists who are simply passing through for the day as well as those who are looking for a unique place to unwind for a night or two. Highlighted are a few Brandywine Valley area “hot spots” that you won’t want to miss, regardless of when you go. Longwood Gardens
Charge those camera batteries, for there will be plenty of scenery that you will want to remember forever as you take in Longwood Gardens’ 1,077 acres of beauty. With an international reputation for its exquisite garden design and premier botanical gardens, visitors rave about the more than 11,000 varieties of trees, plants and flowers, imported from around the world, gracing Longwood Gardens. While weaving in and out of the 20 outdoor and 20 indoor garden arenas, you will also be stunned by the design and variety of fountains that complement the grounds, some of which shoot water up to 130 feet in the air. Longwood Gardens is open year-round and is home to more than 800 horticultural and performing arts events annually. Brandywine Battlefield State Park
Tour the very fields where the Battle of Brandywine took place; notably the largest battle in terms of combatants during the War of Independence in the late 1700s. With a goal to broaden the public’s understanding of the significance of the Battle of Brandywine and its 26 | WWW.MDPHYSICIANMAG.COM
impact on the American Revolution, the park organizes tours, educational programs and reenactment events on its 50 square miles that stretch across both Chester and Delaware Counties. The area was named a State Park in 1949 and has been recognized as a National Historic Landmark since 1961. Winterthur Museum, Garden and Library
The former 175-room home of Henry Francis du Pont, the Winterthur Museum, Garden and Library houses a collection of more than 90,000 pieces of historical and decorative artifacts, commemorating the development of American art from the late 1600s through the early 1800s. Guided tours are available to ensure that visitors don’t overlook some of the most notable pieces of American furniture known to exist as well as inspirational fine art, ceramic, glass and metal artifacts, and textile and needlework exhibits. You will also want to plan some time into your day to explore the grounds’ 60-acre garden, including the “Enchanted Woods,” a fairy-tale garden that pleases all ages, and in particular, Winterthur’s youngest visitors. Brandywine Valley Wine Trail
In 2003, a group of small wineries spanning Chester County joined forces to create the Brandywine Valley Wine Trail. Eight wineries within a 50-mile radius are part of the tour, with no designated “start” and “stop” points. Each offers something special for wine lovers along the way, from vineyard tours and tasting rooms, to styles that range from light, fresh and fruity to rich, earthy, and everything in between. The common recommendation is that tourists who wish to “see it all” visit no more than two to three vineyards each day, to ensure the
Longwood Gardens
complete experience can be fulfilled at each venue. Participating wineries include: Black Walnut Winery, Borderland Vineyard, Chaddsford Winery, Kreutz Creek Vineyards, Paradocx Vineyard, Patone Cellars, Penns Woods Winery and Twin Brook Winery. Brandywine River Museum
Housed in a 19th-century grist mill, the Brandywine River Museum features an impressive art collection including American illustrations, still-life paintings and landscapes. The artistic talent of Andrew, Jamie and N.C. Wyeth, as well as more than 100 other famous American artists and illustrators, is displayed here, earning the museum an international reputation and attracting art enthusiasts from around the globe. Additionally, the Brandywine Conservancy’s Wildflower and Native Plant Gardens are located on the museum’s grounds, showcasing naturalized plants, wildflowers, trees and shrubs, and seasonal flowers and foliage. Planning your visit to the Brandywine Valley area is easy, with an abundance of resources, tips and local guides available online. Visit www.thebrandywine.com and www.brandywinevalley.com to get started and learn a bit more about the attractions highlighted, as well as a few others that you may want to visit, while in town.
NOVEMBER/DECEMBER 2013
| 27
ONLINE www.mdphysicianmag.com
MPM online: more content, more answers and more often! Increase the power of your marketing to Maryland physicians, healthcare executives and Maryland healthcare stakeholders via advertising on mdphysicianmag.com
Jacquie Cohen Roth Publisher/Executive Editor 443-837-6948 jroth@mdphysicianmag.com
Advertiser Index Advanced Radiology ....................................................2 www.advancedradiology.com Best Doctors......................................................................5 www.BestDoctors.com/MarylandPhysicians Medical Mastermind.....................................................6 www.medicalmastermind.com/EHR PNC Bank ............................................................................7 www.pnc.com/cashflowinsight Coverys................................................................................8 www.coverys.com Savvy Marketing..........................................................14 www.aSavvyMarketingSolution.com The Doctors Company...............................................15 www.thedoctors.com Papercamera...................................................................19 www.papercamera.com
Clinical Features Maryland Physician spotlights the latest innovations in clinical care and treatment deliv-
Hospice of the Chesapeake....................................25 www.hospicechesapeake.org
ered by your Maryland peers and colleagues as well as advances in medical training which facilitate achieving the highest standards of quality care and practice management solutions.
HRI .......................................................................................25 www.hri-online.com
Healthcare IT
Upper Chesapeake Health ......................................27 www.uchcancer.org
In every issue, Maryland Physician explores a different facet of the race to implement EHRs to meet Meaningful Use and other e-health government incentives. Don’t be left behind – read what Maryland physicians and healthcare IT experts have to say that eases the pain of transition to an electronic world.
In Every Issue and Online Cases xSolutions xCompliance xMedical Beat xPolicy Jacquie Cohen Roth x Publisher/Executive Editor 443-837-6948 xjroth@mdphysicianmag.com www.mdphysicianmag.com
28 | WWW.MDPHYSICIANMAG.COM
KURE Pain Management ..........................................28 www.kurepain.com Center for Vein Restoration ...................................31 www.CenterforVein.com Shady Grove Adventist Hospital .........................32 www.YourCancerTeam.com
Solutions
Five Ways the Taxpayer Relief Act Could Affect Your 2013 Taxes
C
By Karl J. Appel, CPA
OMING INTO 2013, THE fiscal cliff and impending doom associated with it was a major news story. The simultaneous increase in tax rates and decrease in government spending through sequestration, were believed to have potentially catastrophic impacts on our economy. Instead, the American Taxpayer Relief Act of 2012 (ATRA) was signed on January 2, 2013. This act largely resolved the revenue side of the fiscal cliff by modifying, making permanent, or extending a number of the tax provisions from the “Bush Tax Cuts� that expired in 2012 and 2011. The passage of this historic legislation created a number of changes for taxpayers, especially those in higher income tax brackets. Following are five key changes you should consider when planning to file your 2013 tax return. Medicare Surtax
In 2013, there are two significant changes to the Medicare tax. As in prior years, in 2013 the employer and employee will each pay a 1.45% Medicare tax on all wages. In 2013, taxpayers will pay an additional 0.9% Medicare tax on wages in excess of $200,000 ($250,000 married filing jointly). Also in 2013, there is a Medicare surtax of 3.8% on investment (unearned) income for taxpayers with modified adjusted gross income (MAGI) over $200,000 ($250,00 married filing jointly). New Top Tax Bracket
In 2012, the highest marginal tax rate was 35%. This rate was reserved for taxpayers with over $388,350 of taxable income. In 2013, single taxpayers with between $398,510 and $400,000 (between $398,510 and $450,000 married filing jointly) of taxable income
continue to have a marginal tax rate of 35%, but taxpayers with more than $400,000 ($450,000 married filing jointly) have a new higher marginal tax rate of 39.6%. Personal Exemption and Itemized Deduction Phase-outs
In arriving at taxable income, taxpayers can typically take a personal exemption and itemized deductions to reduce their income. In 2013, the Personal Exemption and Itemized Deductions are subject to a phase-out. Individual taxpayers with less than $250,000 of adjusted gross income (AGI) ($300,000 married filing jointly) are able to take the full personal exemption of $3,900 (up from $3,800 in 2012). The personal exemption of $3,900 per person will be reduced by 2% for every $2,500 of AGI in excess of $250,000 ($300,000 married filing jointly) and will phase out completely at $372,500 ($422,500 married filing jointly). Itemized deductions will also be phased out for individual taxpayers with AGI greater than $250,000 ($300,000 married filing jointly). Itemized deductions allow taxpayers to reduce their taxable income based on certain expenses that they incur, including mortgage interest, state income and sales tax and home office expense. The itemized deduction phaseout reduces the value of itemized deductions by 3% of the AGI above $250,000 ($300,000 married filing jointly) to a maximum reduction of 80% in value.
can take an itemized deduction for the amount of certain medical expenses in excess of the AGI Limit. In 2013, the AGI Limit rises from 7.5% to 10% unless you or your spouse is 65 or older. If you or your spouse is 65 or older, the new AGI threshold will not take effect until 2017. Long-Term Capital Gains and Dividends
For most taxpayers, the tax rates on long-term capital gains and dividends will remain the same as 2012. For taxpayers in lower tax brackets (10% and 15%), the rate remains at 0%. For taxpayers in the middle tax brackets, the rate remains at 15%. For those taxpayers with AGI of more than $400,000 ($450,000 married filing jointly), the marginal tax rate for both long-term capital gains and dividends increases from 15% in 2012 to 20% in 2013. When you factor in the Medicare surtax of 3.8% on investment income mentioned above, the marginal tax rate for long-term capital gains and dividends will increase by 8.8% for those taxpayers with AGI of more than $400,000 ($450,000 married filing jointly). These are just a small sample of the tax changes you should prepare for when planning your 2013 tax return. You should consult with your tax advisor for additional changes that may affect you. Karl J. Appel, CPA, is vice president of the Gardiner & Appel Group, Inc. Mr. Appel can be reached at karl@gardinerappelgroup.com.
Increased AGI Limit for Deductible Medical Expenses
Another change that could reduce the amount of itemized deductions you can take is the increase to the AGI limit for deductible medical expenses. Taxpayers NOVEMBER/DECEMBER 2013
| 29
Good Deeds
Thinking (and Working) Outside of the Medicine Box By Tracy M. Fitzgerald
ANIEL BECKER, M.D., always knew he wanted to pursue a career in the medical field. What he didn’t realize when he began his journey as a neurologist was that he would eventually find himself treating patients in places and spaces far from the confines of a hospital or clinical exam room. “The first time I found myself working with a patient who was in a beach chair, I really had to step back and take in the moment,” said Dr. Becker, who specializes in treatment of spinal cord injuries, rehabilitating adults and children who suffer from paralysis brought on by multiple sclerosis, transverse myelitis or a traumatic injury. “I see a lot of patients struggle, and so much of my work is about helping people improve their quality of life. When you take them out of the traditional rehabilitation setting, you can help them see that they can do things they didn’t think they could.” So, as much as possible, Dr. Becker does just that. In May 2011, 10 of his patients learned that they were in fact very capable
COURTESY OF KENNEDY KRIEGER INSTITUTE
D
Committed to helping those with paralysis focus on what they can accomplish in life, Dr. Daniel Becker recently took a group of patients to the Adaptive Sports Center in Colorado for an experience on the ski slopes.
can see it in their faces and hear it in their voices as the people who do these activities to feed off of each other’s positivity. It’s really important to focus on what the person can do rather than what they can’t.”
“This is an out of the box way to do research and gives me a chance to be there for some of the great moments in my patient’s lives.” – Daniel Becker, M.D. of exploring the underwater world when they accompanied their doctor on a trip to the Grand Cayman to go scuba diving. More recently, in April 2013, five patients went along with Dr. Becker to the Adaptive Sports Center in Colorado for a therapeutic skiing trip, proving that in some cases, even those who are paralyzed can still enjoy hitting the slopes. “A patient once told me that he would never be able to do the things he was able to do before he got injured, and now he is skiing,” said Dr. Becker. “You 30 | WWW.MDPHYSICIANMAG.COM
With data from two adventure trips now at his fingertips, Dr. Becker is gaining a deeper understanding of how and why unconventional therapies impact patients with spinal cord injuries. He is investigating and documenting what types of activities are ideal or beneficial for patients with different injury types, and how those activities help or support rehabilitation processes and long-term outcomes. Dr. Becker is planning a second trip out to the Adaptive Sports Center; this time to
provide kids with paralysis a chance to have some fun as their doctor’s research continues. “I have spent a lot of time in my career in labs, doing research,” said Dr. Becker, who serves as an assistant professor of Neurology at Johns Hopkins Hospital, and is founder and director of the International Neurorehabilitation Institute, headquartered in Lutherville. “This is an out-of-the-box way to do research and gives me a chance to be there for some of the great moments in my patients’ lives. The line between my professional and personal life starts to blur because I get to know them on a very personal level and watch them experience and enjoy life. It’s rewarding. It motivates me. It’s why I do what I do.” Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at news@mdphysicianmag.com.