M.D. Update Issue #67

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS January 2012

Providers at Louisville-based Integrative Psychiatry reflect on the desire among doctors and patients to get something more than just prescriptions out of mental health care.

Psychiatry and the New Science of the Mind

Special Section

Psychiatry Volume 3, Number 1

Also inside

Former Medicare pro advises providers on new payment models Coordination of Care: Neuropsychologist is your ally in diagnosis

We’re not here for the glory. It’s you, the patient, that’s at the center of everything we do. Based on feedback from you, the inpatient services in all seven of our hospitals have received the J.D. Power and Associates award for “An Outstanding Patient Experience”. Thank you.

Saint Joseph Hospital | Saint Joseph East | Saint Joseph - Berea | Saint Joseph - Mount Sterling Saint Joseph - London | Saint Joseph - Martin | Flaget Memorial Hospital For J.D. Power and Associates 2011 Distinguished Hospital ProgramSM info, visit jdpower.com.

Contents

January 2012 Volume 3, Number 1

3 Headlines

cover story

5 Finance 6 Practice Management>Billing 7 Practice Management Funding

8 Practice insights Physiology

10 cover story 13 Special Section Psychiatry 19 Coordination of Care Neuropsychology

20 news 30 events 31 arts

Providers at Louisville-based Integrative Psychiatry reflect on trends in psychiatry and the desire among doctors and patients to get something more than just prescriptions out of mental health care.

Psychiatry and the New Science of the Mind

On the Cover:

Dr. Robyn S. Stinnett, Dr. Chris Schrodt, and Dr. Randy Schrodt (seated) of Integrated Psychiatry

Story and photography

By Megan C. Smith P.10

Special Section Psychiatry

13 Q&A with Dr. Mary Helen Davis

16 UK Psychiatrist Fills Broad, Statewide Needs

14 The Risks of Untreated Mental Illness

16 Addiction Treatment - The Give and Take

January 2012 1

2012 EDITORIAL CALENDAR featuring COORDINATION OF CARE

February | Cardiac & Thoracic Surgery, Cardiology | Occupational Therapy March | Anesthesiology & Pathology, Pain Medicine | Information Technologist April | Plastic Surgery, Vascular Surgery, OTO-HNS | Psychosocial Therapy May | Gynecology & Obstetrics, Female Pelvic Medicine | Genetics Counseling June | General Surgery, Orthopaedic Surgery, Sports Medicine | Physical Therapy July | Consumer Health Edition – Louisville & Western Kentucky | Community Resources August | Dermatology, Allergy + Immunology | Respiratory Therapy September | Internal Medicine, Pediatric Subspecialties, Sleep Medicine | Nutritional Therapy October | Medical + Radiation Oncology, Medical Genetics | Nurse Navigators November | Psychiatry + Neurology, Physical Medicine + Rehab | Speech Therapy December | Emergency Medicine | Case Management

baptisteast.com/weightloss, (502) 897-8131 Barr, Anderson, Roberts.........................................7 barcpa.com, (859) 268-1040 Cane Manor of Lexington, Ky..............................15 kyvacationrental.com, (859) 309-9939 Cash Flow Concepts.............................................26 AlternativeCashFlowConcepts.com, .1-800-594-4530 Central Baptist Hospital.........................................9 centralbap.com, (859) 260-6100 Central Kentucky Audiology.................................22 heartodayheartomorrow.com, (859) 277-5090....

D. Scott Neal, Inc................................................21 dsneal.com, 1-800-344-9098 Henkel-Denmark..................................................23 henkeldenmark.com, (859) 455-9577 Kentucky Audiology & Tinnitus Services..............26 rhotenwhite@windstream.net, (859) 554-5384

Paul Miller Luxury Motors....................................18 PaulMillerLuxury.com, (859) 244-4232 Physician Billing Group........................................24 ThePhysiciansBilling.com, (502) 855-3491 Physicians Financial Services...............................18 physiciansfinancialservice.com, (502) 893-7001 Republic Bank......................................................28 republicbank.com, (859) 266-3547 Saint Joseph Hospital......................................... C2 sjhlex.org, (859) 313-1000 Soterion Medical Services...................................29 soterionmedical.com, (859) 233-3900 Unified Trust........................................................ C4 unifiedtrust.com, (859) 296-4407 x 202 WUKY.....................................................................4 wuky.org, (859) 257-9026 YMCA of Central Kentucky...................................30 ymcaofcentralky.org, (859) 254-9622

Lexington Art League.......................................... C3 lexingtonartleague.org, (859) 254-7024

Mentelle Media Welcomes New Editor-in-Chief; Announces Healthcare Media Initiative

up our Louisville/Kentuckiana and Western Kentucky news bureau.

Past editor and Mentelle Media creative director Megan C. Smith has been named a Tow-Knight Foundation Mentelle Media welcomes Jennifer S. Fellow in Entrepreneurial Journalism at Newton as the new editor-in-chief of the City University of New York (CUNY) M.D. UPDATE School of Journalism, and she will spend magazine. Jennifer 2012 developing an innovative healthcare is an experienced media initiative that will link patients with healthcare media local healthcare providers, news, and and marketing information. One of just 12 fellows selected professional, and, from a global pool of applicants, Megan based in Louisville, was selected to develop a new media Ky, she will head platform that addresses the challenges unique to local healthcare media and Jennifer S. Newton > jnewton@md-update.com the medical providers it serves.

2 M.D. Update

Publishers

Gil Dunn gdunn@md-update.com Megan Campbell Smith mcsmith@md-update.com Editor in Chief

Jennifer S. Newton jnewton@md-update.com Sales Manager

advertisers index Baptist Hospital East............................................25

Volume 3, Number 1 January 2012

Bias Tilford bias.tilford@md-update.com General Manager

Wesley Shears wshears@md-update.com Photographers

Kirk Schlea Liz Haeberlin

Graphic Designer

James Shambhu art@md-update.com

Contributors:

Andrea Coates Dr. Robert P. Granacher, Jr Dr. John Kitchens Brenda Kocher Jennifer Montgomery Scott Neal Trish Starns Krissie Woodward

Contact us: Advertising:

Bias Tilford bias.tilford@md-update.com

Integrated Physician Marketing:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax Standard class mail paid in Denver Co. Postmaster: Please send notices on Form 3579 to 921 Beasley Street, Suite 210 Lexington, KY 40509 M.D. Update is peer reviewed for accuracy.

However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials.

Copyright 2011 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher.

Please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter.

Thank you.

Individual copies of M.D. Update are available for $9.95.

Headlines

Former Medicare Pro Brings Insider Perspective to KMA One year into her new role as the medical business advocacy manager for the Kentucky Medical Association, Lindy Lady, CPC, CPCO, sits down with M.D. UPDATE copublisher Megan C. Smith to discuss the most pressing issues in healthcare today.

Before joining the KMA staff, Lady spent over 35 years helping physicians master Medicare through her work as provider outreach and education consultant with National Government Services. She is also a certified professional coder and certified professional compliance officer.

M.D. UPDATE: Lindy Lady, you have enjoyed a full career with National Government Services, and you are a certified professional coder and certified professional compliance officer. How did your past work help you prepare to be an advocate for KMA members?

Lindy Lady: The work I did for Medicare was similar to what I do now.

I worked with physicians to help them through system transitions. During coding transitions, for example, I would make sure everything worked effectively. I helped physicians when they found themselves at a stalemate and couldn’t get assistance. One of our biggest priorities in outreach had to do with payments because by the time payments issues came to our department, it was often in the crisis mode.

Today, my work at the KMA takes a more proactive role.

At the KMA, we help inform physicians of major changes that can impact their practices. We use webinars and seminars to discuss new procedure codes, for example, or new preventive services that Medicare now covers.

Transitioning to the new CGS Medicare payment models made 2011 a difficult year for physicians. When they made that transition, physicians had to create an electronic funds transfer form. If that wasn’t

completed, they weren’t getting paid. So we helped them with that process to make sure people got paid.

is payments based on healthy outcomes.

The healthier your patient is, the more money you can receive. We are working now to educate physicians on electronic What do you think is the most important health records, and we did a seminar a issues facing physicians today? couple months ago on quality and bundled Recovery Audit Contractor (RAC) payments. audits should be at the top of all physiThe bundled model would mean you cians list because Medicaid is going to start get paid on a global perspective. When a performing those audits as of this month, patient has a surgical procedure done, the January 2012. Medicare has been perform- surgery and all of its pre- and postoperaing RAC audits for a number of years. tive care is bundled up into one payment. I The scope of audits being performed think for Medicare, at least, physicians are today is five times greater than it was three going to see the movement towards qualyears ago. It is no longer a ity where the potential to make more question whether a phymoney is in providing better quality sician may get audited. It services to a patient. is a question when they We also help physicians with will get audited.

Physicians Quality Reporting System The problem with (PQRS), Medicare’s effort to capture audits is that Medicaid and report data. The hope is that you and Medicare are auditget an incentive for physicians to deliver ing money that the pracbetter care. With diabetes, for example, tice has already received. there are five measures a doctor should Lindy Lady, CPC, CPCO is They are auditing these take. Most of those measures physicians the medical post-payments, so the do all the time, but there are some spebusiness advocacy practices have already cific ones like checking the feet that we manager for the spent the money. If remind them to do. The hope is that it Kentucky Medical there are discrepancies will get everybody into doing all of the Association. in those audits, practices things required for a diabetic patient. have to give the money In my own physician’s office, she has a back. This creates a huge financial burden, note in the patient room that reminds her and this is why all practices need to put to check feet. That note wasn’t there until a compliance and audits at the very top of couple of years ago. their list.

The new MCOs have different types And commercial payers have jumped of incentives that are very hard to underon audits as well. Anthem does coding and stand. What I think will happen is that compliance audits, as does Humana. Some MCO incentives will grow, leading to betdo pre-pay audits, but they all do some sort ter measures and physicians getting paid for of post-pay audit. The biggest hazard, of healthier outcomes. That is the payment model we talk about a lot here at the KMA. course, is in post-pay.

An additional danger of Medicaid RAC Medicare’s movement is already underway. is that they go beyond the identification of overpayments and underpayments. The What is the biggest complaint that state of Kentucky is also looking for fraud, physicians come to you for help with?

The biggest complaint I am hearing waste, and abuse, and expects referrals to law enforcement agencies. Physicians need right now are pre-authorizations, which to be aware that Medicaid RACs can have a are very cumbersome because so many procedures require pre-authorization and long term impact on their practice. the administrative time required to get it What other changes in payment models is great. are you helping physicians with?

To assist with the administrative burThe trend with Medicare and Medicaid den, we compile Q&As for KMA members.

January 2012 3

Headlines

Sometimes, the administrative problems are simple, like pre-auths. We can help with those kinds of issues simply by giving people the correct information.

In our monthly Communicator, we give physicians the ability to contact us with their issues. I work as a liaison with the MCOs, and the MCOs have been pretty responsive to physician concerns. They will get right back with me, which is great.

Access to care is also problematic in some places in Kentucky, like Eastern Kentucky where the regional hospital has only signed with one MCO. Since patients in those counties signed up with other MCOs, they had to travel to another hospital in another county. If you are on Medicaid and your funds are limited, you may not literally have the gas money to go outside your county. So access to care has been my second biggest complaint after pre-authorizations.

Providers want to know what to expect from managed care organizations. What do you think is the worst case scenario?

In my opinion, the RAC Audit for Medicaid is far more concerning than the move to managed care. Most physicians probably wouldn’t agree with me, but the reason I say that is because the RAC is going to take back the money that you have already received and spent. In order to defend that audit, it is going to cost you administrative time and

potentially legal counsel. If it is a very negative audit, you could end up having to go outside your practice.

The administrative hassle for the movement to managed care has been an annoyance for physicians, and a lot of them don’t like it, but I think the RAC audits have a much more long-term impact. Eventually it will get better with the administration.

that will be ethical and legal. I tell them to develop their compliance plan and base it off the plan by the Office of the Attorney General (OAG).

If they are audited, I always say, there is no red button you can push to make it go away. So don’t panic. Usually if you have been audited by any federal or state, they find something, even if it is a small something.

Physicians need to be aware that Medicaid RACs can have a long term impact on their practice.

RAC audits aren’t going to go away. Because our state has its financial woes and has to have a balanced budget, the Medicaid RAC audits may be more aggressive than the Medicare RAC audits.

Right now, maybe physicians are only seeing the administrative hassle. They are so focused on it that it is hard to think about the long term. But I have seen the long term effects of the RAC audits, which are serious.

What, then, is your best advice?

I tell providers, first of all, they need to have a compliance plan. That compliance plan insures you have current standard operating procedures, chart audits, and that you have a way to run your business

So don’t panic. Take a look at what they are saying, take a look at your records, and then start your legal strategy. Both Medicare and Medicaid have a very detailed appeals process. Not nearly enough physicians use them, but I think we will see an increase in it.

We help those who have an interest in appealing do so. We sit down with them and talk them through the process. If they have a compliance plan and they do audits, they can catch the problems before someone else does. It is always about being proactive.

Lindy Lady can be reached for comments or questions by calling (502) 426-6200 or emailing lady@kyma.org. ◆

WUKY’s Winemaker Dinner

Date: January 27, 2012 Location: Downtown Lexington Hilton Time: Tasting 7-9 p.m Details: Special VIP entertainment provided by The Swells & The Big Maracas Get your tickets at www.wuky.org!

4 M.D. Update

Date: January 26, 2012 Location: Hillary J. Boone Center, University of Kentucky Details: This exclusive event includes a selection of wines from the Trinchero Estates paired with a multi- course meal. Only 130 seats available. Reserve by calling today: 859.257.9026

Finance

No regrets.

Last month’s column addressed year end planning ideas. However, some readers have told me they didn’t get around to reading the article; and some read it but did not take any action. There should be no regrets at this point. But now the focus should be on what you can do for 2012 to improve your family’s living standard now and in the future.

If you are already independently wealthy and have enough money to fund your family’s living standard at an acceptable level for the rest of your lives, stop reading now!

If you are looking for ways to improve, or at least maintain, that living standard, read on.

Every person is unique and the thing that constrains your financial well-being is likely different than the next person’s. A good place to start the year would be to determine the locus of your core constraint and focus at least some of your time and energy on breaking that constraint. That’s physics and common sense 101. For most people, it is cash flow—making the most effective use of one’s cash flow.

First, a review of what we mean by living standard. Did you know that your

standard as the amount available to be Spent after all other allocations are made, including debt service. Act now to determine reasonable 2012 estimates for each factor in (1) above

BY Scott Neal and to track your progress month-by-month.

If you are so inclined, a very robust tool, such as Economic Security Planner (see www.esplanner.com) can be used to determine your smooth, maximum sustainable living standard given your present resources and those you expect in the future. We use this tool routinely and have found that it helps point out the answers to life’s most perplexing financial questions. Our firm has also developed a relatively simple lowtech way to track total spending through the year. We will provide an explanation of it simply for the asking—see my email address or phone number below.

Many people are presently collecting

If you are already independently wealthy and have enough money to fund your family’s living standard at an acceptable level for the rest of your lives, stop reading now! living standard is not determined by your income, but rather is the amount that you have available to spend this year and in the future adjusted for inflation? Spending is a function of resources which may include, but not be limited to, simply income. That seems easy enough: whatever comes in goes out.

RI=T+D+G+SI+S

For most, the total resources coming in (RI) goes out in one of 5 places: taxes (T), debt payments (D), gifts to others (G), saving/ investing (SI), or spending (S).

I know that, for many people, the debt service on their residence would be considered a major contributor to living standard, but for our purposes we define living

data for the preparation of their 2011 tax return. Nevertheless, one should be spending as much time (or more) determining an accurate projection of 2012 taxes. Now is the time to revise your withholding or estimated tax payments to avoid refunds in 2013. Those are simply interest-free loans to the government. Remember, have no regrets for failure to plan in 2011. Now is the time to work toward reducing 2012’s tax burden while eliminating a refund in 2013!

As you probably know by now, Congress remains quite conflicted about whether to allow your taxes to automatically increase for 2012. The 2% Social Security tax reduction that was put in place for 2011 was extended for only 2 months of 2012. The Social Security wage base increased from

$106,800 in 2011 to $110,100 for 2012 resulting in an automatic increase, with our without the 2% discount. Stay tuned, we haven’t heard the last of this story.

Let’s suppose that you have solved the spending issue and your total annual spending is at or below your maximum sustainable level. Let’s further suppose that you and your tax preparer have reduced taxes as much as legally possible. What other constraints keep you from financial well-being?

While interest rates are low, the temptation to borrow more money or to extend current loans is great. If you are investing the borrowed money at a rate of return that exceeds the interest rate on the loan, then economically it would be rational to borrow as much as possible and invest it. There comes a limit to borrowing, however. Know the reasonable limit for you and your family, and work in 2012 to get below it and stay there. A good night’s sleep often trumps economic rationality.

Inertia is often the chief constraint to sound investing. I mentioned last month in passing that one should reassess risk capacity and risk tolerance, and also make sure the portfolio is aligned with that outcome. The web has a preponderance of very poor tools for determining risk tolerance and a distinct lack of tools for determining risk capacity. Our risk tolerance tool is known to be psychometrically valid.

During the remainder of January and all of February, we will provide access to our risk tolerance tool free of charge to any reader that mentions this article. We will also give you our formula for determining risk capacity. Together these two factors combine to form your risk profile. That should inform your investment decisions in what looks to be a very volatile year for financial assets.

Remember, no regrets. Make 2012 your best year yet!

Scott Neal is President of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm with a presence in Lexington, Louisville, Cincinnati, and anywhere via WebEx. Contact him via email at scott@ dsneal.com or 1-800-344-9098. ◆ January 2012 5

Practice Management  Billing

Where’s the Money?

Throughout the entire US healthcare continuum, it is obvious to both practitioners and patients that they are becoming indentured to the business of healthcare. Patients know it because of the real dollars flowing out of their checking accounts and into their insurance plans (instead of their mortgage premiums). Providers know it because their reimbursement amounts seem to be going down while their expenses are increasing. Both parties are wondering, “Where’s the Money?”

While there is little doubt that Big Health Insurance is getting theirs, many providers are trying to grasp their money before it drains away. Because typical private medical practice compensation structure equals reimbursement minus expenses, there are really only two choices: increase reimbursement amounts or decrease expenses. Neither perspective looks attractive, much less attainable.

What we are experiencing is a systematic failure of proper medical billing, and if I’m not mistaken it’s happening in your practice sort of like this: First you try to increase reimbursement.

You call your largest insurance providers and tell them you want to negotiate an increase in your fee schedule. They don’t call you back. You see more patients. You may feel that your personal pastimes haven’t

the problem, but it is definitely AR related. You get a bill for $250 and think, “Clearly I should have been an accountant.”

You’d ask your practice manager, but you don’t have one due to

BY Krissie Woodward aforementioned expense concerns. So you ask your assistant/scheduler/biller/appeals/compliance/ drug rep gatekeeper/phone answerer person.

She said she filed it all to insurance, and you think on the way out to your kid’s 5th grade soccer game, “What does that mean? I guess the insurance will pay it at some point.”

You begin to feel anxious. You know how to save lives, you know how to make people feel better, but you are not entirely sure where your money is. Its dark outside, its dark in the office. A lone lamp is on, how ironic. You’re certain you are late for at least one thing, you’re starving, you notice the fast food sign down below, you haven’t worked out in six months….you begin to think…This is not how it was supposed to be…

Just then you get a series of emails,

You know how to save lives, you know how to make people feel better, but you are not entirely sure where your money is. mattered much in the last 10 years anyway, so what’s a few more hours at work each day? To top it off, you feel like you’re losing referrals to new health system alignments.

Next you try to lower expenses. You cut whatever bills you can - rent, utilities, personnel, IT, supplies, biohazard. “Yellow pages is $230 a month? Look at this Lab bill!” Then you call your accountant and over coffee on a Sunday morning he tells you that basically the problem is your accounts receivables are way out of line.

You ask him how to straighten out your AR. He says he isn’t sure how to fix 6 M.D. Update

from people that you know, more from people you don’t. They all want you to pay for something else because the sky apparently fell while you were sitting there alone. Healthcare Reform, Medicare payment cuts, EHR, ICD-10, Meaningful use, incentive offers, tablet or notebook, RAC Audits, and on.

At this point you feel like you’re collapsing like stack of unsupervised claims in a RAC audit. Don’t freak out. You didn’t create this reimbursement problem, but there is something you can do about it.

Hire someone with skills, someone who

was actually trained to manage and extract money from payers. If, in retrospect, it seems you put your assistant/receptionist in charge the most important effort of your entire practice - making sure you get paid - then read the practice management ads on Craigslist for the group therapy effect, and move straight away to hire a traditional medical billing company that specializes in billing, follow-up, appeals and payment tracking.

In the era of cloud computing, it probably sounds old fashioned, but a medical billing company has a compelling reason to improve your reimbursements. These reasons are: They can actually lower your overall cost of collections by identifying incorrect information and fixing it prior to claim submission.

They can actually increase your revenue by tracking unpaid claims and making certain they are paid.

They offer practical advice on workflow, coding, compliance and information technology.

They devote 100% of their effort to getting physicians paid, without office politics, patient flow issues or other distractions.

They stay alert on industry knowledge, payer changes, technology advancements and connectivity requirements. They know what things like ICD-10 means for you, even if you don’t.

They don’t get paid until you get paid, and they are far less expensive than hiring your own employee.

You don’t need an online portal. You don’t need a pie-in-the sky. You just need to get paid for the services you have rendered.

You need someone that cares about getting old claims paid, someone whose job it is to make sure that every patient (read: dollar) is tracked every time to every payer and then tracked to your bank account, in a timely fashion, and presented to you in language you understand.

Krissie Woodward is vice president of operations for The Physicians Billing Group in Louisville. You may reach her by email at kwoodward@thephysiciansbilling.com or by calling (502) 855-3491. ◆

Practice Management  funding

Easing Cash Flow Woes You are a dedicated physician, committed to providing the best possible care to your patient population. You are always striving to provide better, more comprehensive care to improve the quality of life for your patients.

Do you have some great ideas on how to deliver outstanding health care on a larger scale?

Maybe you would purchase more advanced technology or instrumentation.

Maybe you would move to a larger facility to provide more integrated services to your patients and their families. Maybe you would open another location or merge with another practice, increasing the number of patients you can treat.

Now… quit daydreaming. Wake up and smell the money. Where would you get the funding for these fine plans? How quickly would you be able to get substantial funds? And how much time do you or your practice administrator have to devote to this project?

Many physicians have no idea that there are funding companies that will purchase their future credit card receivables. These are called merchant cash advances. It is a common cash flow alternative to a traditional bank loan, frequently used in retail businesses. But it can also be a valuable funding option for medical offices (excluding mental health practices).

Here’s how it works. The funding company looks at the last six months of credit card statements and bank statements, along with a simple application. Based on your

previous volume of credit card sales, the funding company will buy your future credit card receivables.

In other words, you receive an advance on future credit card payments. This is an

BY Trish Starns advance, not a loan, so there is no interest rate and no fixed monthly payments to make. Each time a credit card is swiped, a larger portion goes to you, and a smaller portion goes to the funding company. The process is continued automatically through

tion process is quick and simple, as opposed to trying to qualify for a bank loan, requiring massive documentation, business plans, collateral and personal guarantees. Approval rates are very high, unlike the lower approval rates for bank loans. You can pay your balance off quicker with no early penalty.

And you can request more funds after three or four months with no additional applications. And there are no restrictions on how you use the funding.

After receiving your credit card statements, bank statements and application, the funding company can give you a quote on how much funding you can receive within a matter of days. If you accept that proposal and submit any necessary documents required to prove information on the

Merchant cash advances are a common cash flow alternative to a traditional bank loan, frequently used in retail businesses but also a valuable funding option for medical offices. the credit card processor until the advance is paid off. For medical offices, some funding companies can also take into account their electronic receivables (health insurance payments), allowing the offices to be qualified for even more funding.

There are other great benefits to merchant cash advances. There is no application fee and no out of pocket costs. The applica-

application, you could receive your funding in as little as seven-ten business days.

Quick and painless… unlike some medical procedures!

Trish Starns is the Owner of Cash Flow Concepts in Lexington. She can be reached at 1-800-594-4530 or by email at trish@ alternativecashflowconcepts.com. ◆

2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com

January 2012 7

Practical Insights  physiology

Making Health Work

Central Baptist HealthwoRx Fitness & Wellness Center is not your average gym.

By Brenda Kocher For many patients, especially those who are morbidly obese or elderly, when told to diet and exercise, it is simply too vast a statement. Most patients will try to lose weight and exercise on their own, but become discouraged because they lack the support and knowledge it takes to make changes safely and effectively.

LEXINGTON

Located at Lexington Green Mall, HealthwoRx is part of Central Baptist Hospital’s outreach programs, but it is not necessary to have an established connection to the hospital in order to join.

HealthwoRx is staffed by credentialed health professionals including exercise physiologists, registered dietitians, nurse health educators and certified fitness practitioners, also called personal trainers. When

Central Baptist HealthwoRx Fitness & Wellness Center provides a supportive environment that incorporates all the necessary components to lead people toward a healthier lifestyle.

Central Baptist HealthwoRx Fitness & Wellness Center provides a supportive environment that incorporates all the necessary components to lead people toward a healthier lifestyle. HealthwoRx is the place for patients who are at risk for developing illnesses associated with a sedentary lifestyle and obesity such as heart disease, diabetes, high blood pressure and some forms of cancer. The center also specializes in exercise help for those who already have existing health problems.

“Our focus is on health-risk reduction,” says Teresa Smith, MS, RD, LD, HealthwoRx director. “If we get people eating right and exercising more, that’s the foundation of reducing health risk.”

8 M.D. Update

new members join, they complete a health assessment, set reachable goals and get a personalized fitness plan based on their level of

fitness and what they want to accomplish. A free nutrition consult is also available.

The skilled staff can consult with members’ doctors in developing exercise programs and are available to answer questions and give assistance during workouts. For example, after heart patients have completed cardiac rehab and therapies, HealthwoRx can help these patients stay in shape.

“We are available to provide continued support to help them maintain their health and encourage continued fitness,” Smith says.

Smith calls the center’s program a guided exercise experience. Personal trainers walk members through exercise programs and are always on the floor available to help members, to challenge them and to coach them.

In addition, staff help members adjust their workout every six to eight weeks so that the workout keeps them moving toward their goals and doesn’t become stale. Staff also encourage members to come often.

“We look for you,” Smith says. “If you haven’t been in a while, we ask you where you’ve been.”

In addition to state-of-the-art strength and cardio equipment, HealthwoRx offers a variety group fitness classes such as Cardio Fit, Zumba, Spinning, Tai Chi, Yoga, and Pilates to name a few. HealthwoRx is proud to offer the Healthways SilverSneakers Fitness Program for senior citizens. Many health or Medicare plans pay for membership at facilities that offer SilverSneakers classes. At HealthwoRx, SilverSneakers classes are taught Monday – Friday at 11:15 a.m. ◆

The skilled staff can consult with members’ doctors in developing exercise programs and are available to answer questions and give assistance during workouts. For example, after heart patients have completed cardiac rehab and therapies, HealthwoRx can help these patients stay in shape.

3099 405 1

U.S. HOSPITALS

TOP PERFORMERS

IN KENTUCKY

The Joint Commission, the nation’s oldest and largest health care standards-setting and accrediting body, has recognized us as Kentucky’s only Top Performer on all four Key Quality Measures. Which only confirms what we’ve always known: Our doctors and staff are top performers.

Of course, we know it’s not about numbers.

But if you’re ever our patient, you’ll have some on your side. centralbap.com | jointcommission.org

January 2012 9

All data submitted 2010

cover story

Integrated Psychiatry partners Dr. Robyn S. Stinnett, Dr. Chris Schrodt, and Dr. Randy Schrodt (seated) combine medication, mindfulness meditation, and transcranial magnetic stimulation to help people with mood disorders repair the neural circuitry that causes depression and anxiety.

Psychiatry and the New Science of the Mind story and photography By Megan C. Smith

Breakthrough depression therapy complements mindfulness philosophy at Kentucky’s only private psychiatry practice to offer TMS. LOUISVILLE The last frontier of science. That’s how Nobel Laureate Eric Kandel describes the work of psychiatry today.

Speaking on PBS’s Charlie Rose this past November, Kandel explained that our understanding of the inner workings of the human 10 M.D. Update

psyche have evolved remarkably in the past forty years. Whereas psychiatrists and neurologists had previously divided their work into mental and physical illnesses respectively, “a new synthesis occurred within psychiatry,” said Kandel, “driven in good part by basic science. First of all, there was a kind of philosophical synthesis when cognitive psychology, the science of the mind, merged with neuroscience, the science of the brain, to formulate a new science of the mind.”

This new science of the mind, spurred famously by Kandel’s insistence that psychiatric medicine become more empirical, is founded on the assumption that every mental process is mediated by the brain. “And of course psychiatrists began to realize that all mental disorders,” he concluded, “must be

brain mediated.“ Over the past few decades, this emphasis on empirical psychiatry has netted a few essential findings that shape the psychiatry practice of today. As Kandel points out, scientific evidence has greatly changed the understanding of the basis of mental illness by demonstrating that mental disorders are genetically predisposed but, significantly, expressed by one’s development and environment. It follows from this that mental disorders afflict the young, and by the time adults seek psychiatric care, they are likely to have advanced disease that is difficult to treat.

One of the primary derivatives of the study of the biological basis of mental illness is the prescribing of psychopharmaceuticals

around which, it often seems, the modern psychiatry office runs. While the biological basis has helped to defeat of the stigma of mental illness as a weakness of moral character, it has in other ways resulted in both patients and doctors seeking more out of psychiatric care.

Another finding of the new science of the mind comes from advanced imaging techniques that demonstrate the brain recovers function following mental illness or injury by creating novel neural pathways, or workarounds, in a process called neuroplasticity, Measurable by functional MRI yet idiosyncratic, neuroplasticity enables recovery through therapies as diverse as mindfulness meditation and electroconvulsive therapy, thereby suggesting that the route to wellness is unique to each individual.

Today, the frontier of mental health lies in the technological advancements that assist the creation of workarounds for persons recovering from mental illness, broadly defined as the field of neuromodulation.

The most exciting among them - the newly approved transcranial magnetic stimulation for the treatment of depression.

tine of psychiatric practice entailed seeing patients for fifteen minutes every few months for medication management, and therapy, if there was any, was outsourced to providers who had limited contact with the psychiatrist. Schrodt, through his twenty-plus years’ experience in hospital-based academic psychiatry, found it just left doctors and patients feeling unsatisfied.

“People came to our practice because they realized psychiatric care is more complicated than that,” says Schrodt. Combining medical and psychological therapies with mindfulness meditation, Integrative Psychiatry set out to restore cognitive function and promote stress reduction for persons with mood disorders, particularly depression and anxiety.

Joined soon by his brother Christopher “Chris” Schrodt, MD, a specialist in cognitive and mindfulness therapies working at the time in a hospital-based complementary medicine stress and pain management center in Indianapolis, Integrative Psychiatry began attracting patients in search of effective treatments for medication resistant depression.

Depression, we know now, is difficult to treat. On the positive, cognitive-behav-

ioral therapy has been shown to be equally effective as antidepressants in achieving remission of depressive symptoms. On the negative, depression can be recurring, and with each successive episode the chances of remission are greatly diminished.

Antidepressants can stop working, so for some patients depression becomes a lifelong chronic disease.

Medications, Meditations, and Machines

Talking with Robyn S. Stinnett, MD, partner with Integrated Psychiatry since 2001, one understands how deeply the philosophy behind integrated psychiatric care runs through this practice. It’s practically legendary. Years earlier, when Randy Schrodt mentored Stinnett during her residency at UofL, he was already a local thought leader in the mindfulness approach to healing brains.

Today, Stinnett makes sure that people know she is “not just a robot writing a prescription.”

Therapy, she says, is an essential complement to psychopharmacologic medicine.

Local Innovators of Psychiatric Care

One might not guess by appearances that in a quiet Louisville suburb, in a converted Victorian filled to the brim with unassuming offices whose names reveal a common interest in complementary therapies, that behind the door marked Integrative Psychiatry there is a small group practice delivering the ultimate advancements in psychiatric therapies.

When lifelong Louisvillian G. Randolph “Randy” Schrodt, Jr, MD founded Integrative Psychiatry in 2001 along with former partner Mary Helen Davis, MD (see our interview with Davis on page 13 of this issue), the rouTMS is the latest FDA approved neuromodulation therapy for depression. It uses rapid, repetitive magnetic stimulation to excite neural pathways that are slowed by depressive episodes. About 40% of patients at Integrative Psychiatry have full remission of depression symptoms following TMS therapy.

January 2012 11

cover story

Medication resistant depression can bring a person to despair. But, there is cause for hope as the transcranial magnetic stimulation (TMS) allows for the first time a safe, non-systemic, convenient and effective way to relieve the symptoms of chronic, long term depression.

“Today’s neuromodulation aims for subtlety and sophistication,” says Dr. Randy Schrodt.

“And with its ability to improve mood and cognitive function so great, its use is going to continue to expand.”

Focusing on the practice of psychopharmacotherapy, Stinnett unites the practice of psychiatric medicine with cognitive and Interpersonal therapies and her concern for the total person. “People really appreciate someone who is willing to listen and learn about them. Developing a personal relationship,” she says, “means my patients and I spend a lot of time talking. We work through decisions, especially concerning their total health and wellness.”

Medication resistant depression can bring a person to despair. But, she says, there is cause for hope as the newest therapy for major depression allows for the first time a safe, non-systemic, convenient and effective way to relieve the symptoms of chronic, long term depression.

Transcranial magnetic stimulation, or TMS, is the latest FDA approved neuromodulation technique for the treatment of depression. TMS is a non-invasive form of focused brain stimulation using rapid, repetitive, high energy magnetic pulses comparable in strength to MRI. TMS works by stimulating neurons of the left prefrontal cortex that are under12 M.D. Update

Dr. Chris Schrodt is an expert in several types of meditation and mindfulness therapies that complement the psychopharmacological and interpersonal therapies employed at Integrated Psychiatry.

active during depressive episodes. A comfortable procedure, TMS therapy occurs in a reclined position in a calm environment and is sensed only as a slight tapping in sound and touch.

TMS sessions last approximately 40 minutes, and Chris Schrodt emphasizes that this is the ideal arrangement for practicing mindfulness meditation. Mindfulness, he says, is probably the biggest trend in cognitive-behavioral therapy because it brings awareness to the form of one’s thoughts (mindfulness) which can help a person determine how they should consider the content of one’s thoughts

(cognitive therapy).

“From a meditation perspective, life is just a movie,” he says. “We are always becoming absorbed and fused into the experience that is being projected onto the screen of consciousness. If we can get ourselves grounded into the idea that life is just a movie we can better observe our thoughts and do a better job in cognitive therapy. Cognitive therapy would ask, ‘Did he really ignore me or is there another explanation for why he might have done that?’ Mindfulness therapy would then say, ‘Well that’s just a thought. Why do I need to give it much weight anyway?’ In this way, the two therapies complement each other.”

In September 2011, the Schrodts with Randy’s son Zachary A. Schrodt, BA, published a scientific paper in the Journal of the Kentucky Medical Association demonstrating the effectiveness of TMS in the private practice population. Generally, patients here are sicker than the population in the academic research center investigational studies that made up the FDA approval trials; many here have multiple comorbidities and have failed multiple therapies in the past. Still, 40% of patients at Integrative Psychiatry have full remission of depression following TMS therapy.

While TMS is used primarily for the treatment of mood disorders, it is also showing promise in the treatment of posttraumatic stress disorder (PTSD), various pain syndromes including fibromyalgia, auditory hallucinations, and various addictive and compulsive disorders. “Today’s neuromodulation aims for subtlety and sophistication,” says Randy Schrodt. “And with its ability to improve mood and cognitive function so great, its use is going to continue to expand.” ◆

Special Section  Psychiatry

Q&A with Dr. Mary Helen Davis Mary Helen Davis, MD, director of behavioral oncology at the Norton Cancer Institute, talks with M.D. UPDATE past editor-in-chief Megan Campbell Smith about the integration of psychiatry into cancer care, her appointment to the Governor’s KASPER Advisory Council, and her run for president elect of the American Psychiatric Association.

This commitment is demonstrated by embedding our behavioral oncology staff in with the oncology programs. We are partners with the medical and surgical partners of the cancer institute. Other programs may have psychiatrist come in and do a consult, but we are fully integrated. We attend tumor boards, we are present in the hospital and in the clinic, and we also have our own offices at Norton Suburban campus for outpatient services. Our staff employs two psychiatrists, and both of us are certified in

M.D. UPDATE: How does behavioral oncology fit with the care delivery trends emerging from the Healthcare Reform Act?

DR. DAVIS: Our program at Norton Cancer Institute typifies the trend of integrated healthcare where providers are looking at patient- and family-centered care for the whole patient. There are models across the country that are doing this with primary care – the diamond model – where psychiatrists are placed in primary care clinics. The philosophy behind that is, in looking at any type of chronic disease state, outcomes are better when you screen and control depression and anxiety.

We know how screening and controlling depression helps with diabetes compliance and heart disease, so you can imagine the great benefits in oncology, where people are living longer with a cancer diagnosis.

With current treatments, the types of cancer that people might succumb to in the past now have more long-term survival.

There can be issues of living with cancer as a chronic illness, or being in remission, where you are concerned about the time frame before you have disease progression.

This can lead to increased anxiety and depression in many cancer patients.

What are you doing at Norton Cancer Institute to meet these challenges?

The Norton Cancer Institute has made a huge commitment to managing psychosocial concerns. We do individual, couples, family, and group psychotherapy along with medication management across the spectrum of the cancer diagnosis. We also pay attention to palliative care as well as end of life needs when it comes to that.

Dr. Mary Helen Davis

psychosomatic medicine, or the psychiatric care of the medically-complex patient. We have two nurse practitioners and a social worker who cover the clinical aspects of behavioral oncology.

What is your role in caring for the medically-complex patient? Why is this subspecialty necessary?

Chronic disease requires significant adjustment on the part of the individual patient and their family. We also know that a lot of these chronic diseases will be impacted by depression, and a significant part of this population has a coanxiety disorder. If those depression and anxiety

disorders are undertreated or unrecognized, patients can become demoralized in addition to being depressed. They are not as motivated to be compliant with their diabetic regimen or other things they need to be adherent to such as exercise.

Give us a few examples of your expertise in action.

We know that for patients going through chemotherapy, that treatment effects the GI tract, leading to nausea and vomiting. If patients get depressed on top of that, the antidepressants that are normally used for the general patient population may not be well tolerated and can create additional nausea in cancer patients. We can help be selective with what medication is used to make sure it will work best given their complex medical problems.

We often help find solutions for many symptoms of cancer treatment.

For example, some people get anticipatory anxiety and nausea that gets paired with being in the hospital, and we may develop interventions that help them cope with that.

At the completion of treatment, some patients become anxious, and we may help them manage the transition from being a patient to being a survivor.

You were recently appointed by Governor Beshear to chair the KASPER Advisory Council. Considering your practice responsibilities and your run for president of the American Psychiatric Association, how were you able to make this additional commitment of your time?

The support I receive from Norton Cancer Institute administration has allowed me to participate in community and advocacy activities. This support is what has allowed me to accept the nominations to the KASPER Advisory Council and the president elect of the American Psychiatric Association.

I think it is part of a broader mission for general healthcare- this whole prescription drug abuse problem. Prescribed substance abuse has reached epidemic levels in Kentucky, and I have been very active in medical regulation and professionalism. ◆ January 2012 13

Special Section  Psychiatry

The Risks of Untreated Mental Illness

by Dr. Robert P. Granacher For primary care physicians, and physicians in general, the risks of untreated mental illness are generally poorly understood. The epidemiology of mental disorders has given us a considerable body of information within the last 30 years. There are three major outcomes from untreated mental illness: (1) Significant functional impairment such as days lost from work and chronic disability, (2) morphological brain changes, and (3) increased risk of physical diseases such as coronary artery disease, cerebral stroke, and Alzheimer’s disease.

With regard to the impairment affecting functional capacity, recent research supported by the National Institute of Mental Health at the University of Michigan and Harvard University, chaired by Ronald Kessler, Ph.D., enlightened medical practitioners to the negative impacts of mental illness upon our youngsters.

This study found that half of all lifetime cases of mental illness began by age 14, and that despite the presence of effective treatments, there are long delays, often for decades between the first onset of symptoms and when people seek and receive treatment. This study also reveals that an untreated mental disorder can lead to a more severe and refractory mental illness and it may lead to the development of other comorbid mental illnesses. The critical mental disorders with onset in youth include mood, anxiety and substance abuse disorders.

Unlike most disabling physical diseases, most mental illness begins very early in life.

Half of all lifetime cases begin by age 14 and three-quarters of all lifetime cases have begun by age 24. For example, anxiety disorders often begin in late childhood, mood disorders in late adolescence and substance abuse in the early 20s. Unlike heart disease or most cancers, young people with mental disorders suffer disability when they are in the prime of life, when they would normally be the most productive. In fact, the risk of mental disorders is substantially lower among people who have matured out of the high risk age range. Prevalence of these diseases increases from the youngest group (age 18-29) to the next oldest age 14 M.D. Update

According to Dr. Robert P. Granacher, “One of the newer concepts in psychiatry and neuropsychiatry is the impact of untreated depression upon physical comorbidities and the likelihood that depression aggravates or plays a causative role in some of these.”

group (age 30-44) and then declines, often substantially, in the oldest group (age 60+).

Unfortunately, individuals with one mental disorder, particularly if untreated, are at a higher risk for also having a second mental disorder (comorbidity). Forty-five percent of those with one mental disorder in the Kessler study met criteria for two or more disorders, with severity strongly related to comorbidity. In particular, substance abuse disorders are highly comorbid with the strongest relationship seen between those who also suffer bipolar illness. It is generally recognized that females have higher rates of mood and anxiety disorders while males have higher rates of substance use disorders and impulse disorders.

Pervasive delays in getting treatment tend to occur for nearly all mental disorders, though they vary according to specific diagnostic categories. The median delay across disorders is nearly a decade; the longest delays are 20-23 years, for social phobia and separation anxiety disorders. This is possibly due to the relatively early age of

onset and fears that therapy will involve social interactions. Untreated psychiatric disorders can lead to more frequent and more severe episodes, and are more likely to become resistant to treatment. Early onset mental disorders that are left untreated are associated with school failure, teenage childbearing, unstable employment, early marriage, and marital instability and violence.

Recent brain morphometry, using voxel-based MRI measurements, indicates that chronic depression, particularly if poorly treated or untreated, leads to atrophy of the hippocampi. The hippocampi are important not only for memory, but play significant roles in other aspects of cognition and behavior.

Studies upon victims of posttraumatic stress disorder, particularly if extremely chronic and untreated or refractory to treatment, show similar alterations of brain morphology.

Morphological changes in the frontal lobes of first onset psychosis and schizophrenia have been documented and as the chronicity of schizophrenia progresses, the temporal lobes become involved and ventricular size increases due to ex vacuo dilatation. Brain mass is lost.

Thus, it behooves all of us physicians to recognize depression, posttraumatic stress disorder, schizophrenia and other mental morbidities early on and do as much as possible to ensure that patients are adequately assessed and treated and that compliance with treatment can be maintained as treatment may be brain sparing.

One of the newer concepts in psychiatry and neuropsychiatry is the impact of untreated depression upon physical comorbidities and the likelihood that depression aggravates or plays a causative role in some of these is beginning to emerge. The scientific bodies of cardiology and psychiatry have noted in epidemiological studies a significant association between major depression and coronary artery disease. Moreover, there is recent evidence that untreated major depression, or depression that is poorly responsive to treatment and not in remission, increases the risk of myocardial infarction. This increased risk is about twice as high as the risk in an ordinary population without depression. Kenneth Kendler, M.D. published in the Archives of General Psychiatry (2009) results of a study indicating that after

the first diagnosis of major depression, there is a 2.5 fold increased risk for coronary artery disease in the next 12 months. The risk thereafter was more modest.

Two new studies firmly establish anxiety as an independent predictor for subsequent coronary heart disease down the line. Dr. Roest, and her colleagues, published a landmark study in the Journal of the American College of Cardiology in 2010 indicating

a metaanalsysis by Pan et al. Twentyeight respective cohort studies comprising 317,000 patients reported on approximately 8500 stroke cases. There was found to be an increased risk of cerebral stroke associated with depression which was consistent across most subgroups. The study authors concluded: “Depression is associated with a significantly increased risk of stroke morbidity and mortality.”

Pervasive delays in getting treatment tend to occur for nearly all mental disorders that anxious people have a 25% greater risk of coronary heart disease and almost 50% higher risk of cardiac death. In her study, the mean followup was more than 11 years.

The second study, also published in the same JACC journal studied 50,000 Swedish men who were examined for military service and followed for an average of 37 years.

Those with an anxiety disorder, diagnosed by psychiatrists, were twice as likely to suffer coronary heart disease or acute myocardial infarction, even after adjustment for baseline confounders. Dr. Roest has been quoted as saying about her study, “Our most important finding was that anxiety was associated with the development of incident coronary heart disease in initially healthy persons.”

Earlier this year, in the Journal of the American Medical Association, there was

Lastly, two papers appeared in Neurology last year. The first study followed 1239 United States citizens and looked at the number of times a person experienced depression and then related this to the risk of dementia. The investigators found that having two or more episodes of depression nearly doubled the risk of subsequent dementia. Meanwhile, the other study looked at data on almost 1000 people with an average age of 79, who had been enrolled into a large heart study. At the beginning, all were examined and found to be free of dementia.

By the study end, 17 years later, among those who were diagnosed with dementia, 22% had been depressed at the study start compared to 17% who were not depressed. A 60-point depression screening test was utilized and the researchers found that for each 10-point increase in score, there was a 50% increased risk of dementia. The authors concluded:

“Depressed people were more than 1-1/2 times more likely to develop dementia than people who were not depressed.”

Those of us who have practiced medicine for more than 25 years recall that in our psychiatric training in medical school, little if anything was known about the biology of mental illness. Much has transpired in the last 2-1/2 decades to improve our current understanding. The emerging body of evidence is becoming quite indicative that there is a strong relationship between untreated and poorly treated major mental disorders and the development of significant physical and brain diseases. The brain is the most wonderful, complex, and profound organ in our body. However, emerging scientific evidence indicates that it fails with poor control of many diseases, including psychiatric illness, diabetes, hypertension, elevated lipids, inflammatory diseases, and others. It is recommended that physicians develop an increased awareness that major psychiatric illness, undiagnosed or poorly treated, contributes to increasing brain and physical morbidity.

Robert P. Granacher, Jr, MD, MBA is a distinguished life fellow of the American Psychiatry Association and works in private practice at Lexington Forensic Neuropsychiatry. Dr. Granacher can be reached for comment by telephone at (859) 277-7423 or by email at dnswashburn@aol.com. ◆

January 2012 15

Special Section  Psychiatry

UK Psychiatrist Fills Broad, Statewide Needs

By Gil Dunn LEXINGTON When Cletus Carvalho, MD came to UK in 2005, he already had a varied experience practicing clinical outpatient and inpatient psychiatry in Hazard, KY. Feeling compelled to bring his skills and ideas to an academic setting, Carvalho accepted a position with the UK Department of Psychiatry that allows him to continue his broad involvement in psychiatric care.

Today, he acts as medical director of the Adult Psychiatry Unit and director of UK’s Psychiatry Residency program. From his new vantage point, Carvalho sees how UK helps fulfill broad psychiatric needs statewide.

According to Carvalho, UK’s Psychiatry Residency focuses on the traditional psychiatric specialties. Each year, six new residents train in childhood, adolescent, geriatric, addiction and forensic psychiatry, and there is even an option to participate in additional training in a child and adolescent psychiatry fellowship.

Outpatient Addiction Clinic

Treating opiate and alcohol dependence, the UK Outpatient Addiction Clinic provides a way for residents to gain experience in the biopsychosocial addiction treatment model.

“Medication therapy in opiate and alcohol dependence has increased as more medications have been approved by the FDA for treatment of these conditions. Combining medications with twelve step meetings and other psychotherapies significantly increases treatment success rates,” says Carvalho.

“Family involvement is also key.”

Many factors cause addiction, and family history and stress play huge roles, often putting people at risk of relapse. Alcoholism in a first-degree relative like a parent or sibling can increase the risk about fourfold.

Inpatient Psychiatry

Meeting the needs of the chronically mentally ill, the 19 bed Inpatient Psychiatry unit at UK Good Samaritan Hospital (UKGSH) provides treatment for adults who suffer from psychosis, mania, dementia, and severe depression and anxiety.

The majority of patients at UK Inpatient 16 M.D. Update

Cletus Carvalho, MD

Psychiatry (UKIP) come from underserved populations in central, eastern and southeastern Kentucky where the geography and social scenes are very different, but similar problems and diagnoses exist. According to Carvalho, “There seems to be more addiction in underserved areas.”

UKIP is one of few centers in Kentucky providing detoxification and methadone maintenance initiation for pregnant women addicted to opiates. A small number of patients are referred through the courts and through emergency rooms, and Carvalho says working with the UK OBGYN department bring in referrals from across the state.

Still, “the vast majority of primary care doctors and OBGYNs are still learning about this program,” he says.

Adult Outpatient Psychiatry

Carvalho is excited about recent technological improvements that allow him to provide to electroconvulsive therapy (ECT) with fewer cognitive side effects. Through UK’s Outpatient Adult Psychiatry unit at Good Samaritan Hospital, Carvalho says that the new ECT technology defies the old “electroshock” stereotype.

In the past, sine-wave machines discharged electrical current, de-amplified to reduce burns, and induced seizure in the patient suffering from medically-resistant depression, among others. Carvalho points out that the old sine wave technology could excite a neuron multiple times per period, inducing cognitive problems that made “electroshock” infamous.

Today, however, ECT machines remove all portions of the sine wave except for the apex of the wave, which delivers a brief stimulus pulse at a discreet point in time.

Patients have a single seizure with fewer cognitive side effects. Advances in anesthesia technique have also significantly reduced other problems associated with ECT. ECT makes remission of symptoms possible for people suffering from schizophrenia, depression, and sometime catatonia who have not responded to medication therapy.

Performed under general anesthesia, ECT treatment takes only 5 minutes to administer. Common side effects are headache or nausea from the anesthesia along with mild muscle ache, memory loss, and decrease in cognitive function.

“Patients may feel that these are unwanted side effects,” says Carvalho, “but untreated depression has many negative cognitive side effects as well.” While it is understudied, Carvalho says that most reports demonstrate that the patient’s cognitive functions are better than before treatment at the two and six month marks following ECT. There are many variables in depression, but Carvalho estimates that ECT is effective in 50-90% of patients who have medicallyresistant depression. With schizophrenia, the range is 40-50%. The acute treatment phase Continues on page 18

Special Section  Psychiatry

Addiction Treatment - The Give and Take

By Gil Dunn Picture this. A long time patient with drug dependency issues calls your office and says “I’m in trouble. I’m stressed out. What do I take?” What is your answer?

This is a real life scenario that Piotr A. Zieba, MD encounters at his Central Kentucky Psychiatry practice in Danville.

“Please come in for an evaluation,” responds Dr. Zieba. Then he proceeds to describe what he wants his patient to do.

This is one example of addiction treatment in Kentucky.

Central Kentucky Psychiatry, founded

by Zieba in 2008, is an adult general psychiatry practice offering treatment in geriatric psychiatry with special interest in addiction, dementia, and depression. He admits psychiatric patients at Ephraim McDowell Regional Medical Center in Danville.

Addiction treatment is a large part of Zieba’s practice. Patients come from a hundred mile radius and more because he is passionate about helping his addiction patients.

Zieba views addiction treatment broadly, in part due to many theories on the causes

Danville

Dr. Piotr A. Zieba, Central Kentucky Psychiatry

many ways, a valuable currency in the street drug marketplace as some addicts trade it for opiates, other drugs, or money in the daily negotiation to get high or stay straight. Zieba states that some patients presenting for initial treatment tell him that illegally obtained Suboxone was the “best thing that ever hap-

Suboxone is only one of the tools opiate addicted people can use in order to stay straight. The 12 step oriented program is the best way to recovery. of addiction. Is addiction a disease of the brain or the consequence of lifestyle choices and environment? Zieba’s experience with hundreds of addicts tells him that although addicts should follow the same rules, he prefers an individualized approach.

A Practitioner’s View of Opioid Addiction

Suboxone (Bprenorphne and Naloxone) is an opiate receptor blocker approved in 2002 by the FDA for detoxification replacement therapy as an outpatient medication. Its success relies on self administration within a home environment. Current regulations limit the number of patients per physician who can receive Suboxone.

Unfortunately, Suboxone has become, in

pened to them, because it worked and helped them to control their habit.”

Zieba maintains a nearly full complement of Suboxone patients, but he always leaves room to take on a new case. He has found that a short term regimen of 90-120 days is often ineffective. Many of his patients have voiced they “need to be on Suboxone for life because without it, they know they’re not going to make it.” Recovering addicts, he says, know their environment, their social structure; and it isn’t easy.

This is where Zieba introduces psychosocial therapy to his addict patients. He points out that addicts have completely different coping skills than people without addiction issues. These are people, says Zieba, who spend all their time “hustling,

dealing, talking to different friends, negotiating to obtain their drug.” When they are stabilized on a Suboxone maintenance program, they need help coping with an entirely new lifestyle that includes the normal stressors of work and maintaining healthy relationships.

Most addictive patients have crossaddiction issues, says Zieba, ranging from opioids and sedatives to alcohol and marijuana. Their whole lifestyle is about addiction choices and sources. He also observes that many of his patients have mood disorders such as depression, bipolar disorder, and ADHD. He believes many addicts develop drug use because of undiagnosed psychiatric problems, and these people abuse drugs at a much higher rate than the general population.

Questions on Prevention and Recovery

Many questions surround the issue of addiction prevention and recovery. For starters, should public health policy play a role?

According to Zieba, public health policies alone make it hard to eliminate drug abuse because human behavior is too complex for broad base regulations. Two individuals with all the same physical characteristics will respond differently to the same drug or situation. One will become an addict, for example, while another will take medication as prescribed.

Is addiction a genetic issue or an environmental problem? It depends on the individual, he emphasizes. Everyone is different.

Even identical twins can respond differently to the same medications or stress inducing situations. Zieba points to psychodynamic theories suggesting that the coping skills we use in life develop before the age of three, so the value of individual therapy always plays a key role.

Can Suboxone cure addiction? Not hardly, he says. “It is a tool that offers a replacement medication for someone who wants to get off street drugs. The only cure for addiction is to completely stop using the addictive medication, and that is so hard to do. The 12 step program is ultimately the best path to recovery.”

The treatment of addiction not only January 2012 17

Special Section  Psychiatry

T h e F i n e s t P re - O w n e d S e l e c t i o n

974 Beasley Street • Lexington • PaulMillerLuxury.com • 859-244-4232 • 1-800-300-3673

Paul Miller Luxury Motors has a great selection of the finest luxury vehicles - all in one location. We offer exclusive prices for vehicles that usually have only had one owner. Our customers enjoy tremendous savings - as much as 35% below book value. For high-end, luxury pre-owned vehicles at a great price, visit PaulMillerLuxury.com today to view a full list of our inventory or to utilize the Car Finder service.

If you would like to sell your luxury vehicle or have a vehicle ready to come off lease, please contact us and set up an appointment to receive top dollar!

2008 Chrysler 300

2009 Jaguar XF

New Delivery • Low Miles Sharp Car • W11049

Heated and Cooled Seats P11177

$13,590

$33,990

2006 Hummer H3

2008 Cadillac Escalade

Nice SUV • C0336036A

Navigation • DVD • P11130

$16,990

$37,990

2006 BMW 325i

2008 Range Rover

Local Trade • P11093A

43,830 miles • Sport Black • One Owner • P11137

$17,990 2010 Chevy Camaro LT New Delivery • Local Trade CGA51574A

$20,990

$39,590 2010 Ford Mustang GT Calipari Edition “Like-New” • A5181470

$39,890

Price excludes tax, title and license. Images for illustration purposes only. See dealer for complete details.

PMFM-7301 4.8542x4.875 4C LuxMot.indd 1

involves the chemicals and brain areas affected, says Zieba, but also the social aspects. It is not some disease one develops de novo. Rather, the choices that addicts make influence the path of their addiction.

Statistically, Zieba does not see much improvement in addiction today versus twenty years ago; it’s not getting any better. The reason, he says, is that humans continue to experience life’s challenges and continue to view drugs as a coping mechanism. “We are going to face these problems for a long time before anything can be changed,” he says. “I’m truly hoping there will be some kind of cure for every sort of addiction. Naltrexone, for example, is an opiate blocker which can be taken as a tablet or an injection that blocks the euphoric effect of opiates. There is more hope on the horizon.” ◆

UK Psychiatrist Fills Broad, Statewide Needs Continued from page 15

12/14/11 11:19 AM

entails two or three sessions of ECT per week, and after 10-12 sessions, many patients start to show a response. At that point, Carvalho says he would gradually reduce the sessions down to just once or twice a month – the maintenance phase. After successful ECT, many patients return to using psychiatric medications and psychotherapy.

Geriatric Psychiatry

The Geriatric Psychiatry clinic at UK addresses the unique psychosocial challenges and psychiatric disorders in individuals over the age of 65.

“Coping with aging, losing family members to illness and economic difficulties are major sources of stress for many of these individuals” says Carvalho. “Finding new and effective ways to manage stress is important.

There are also generational differences in how psychotherapy is accepted by older patients, many of whom may not be initially comfortable with this type of treatment.”

Carvalho’s goal for the clinic is to be a place where people receive specialty geriatric psychiatric care and return to their family physician. “We see our role as caring for issues that comes with aging, such as dementia, depression or substance abuse but are otherwise being treated.” ◆ 18 M.D. Update

Coordination of Care  Neuropsychology

Lean on Neuropsychologists to Solve Cognitive Function Mysteries

By Megan C. Smith Lexington Asking Lacey Price, PhD, PsyD about the role of the neuropsychologist in healthcare today, one quickly discovers her work is a lot more complex than the term implies. For starters, Price doesn’t provide psychological therapy. “Obviously, every physician does some psychology,” she acknowledges, “but in neuropsych, I look at the brain and how it effects behavior. I help physicians understand their patients’ cognitive problems.”

Price, who works with Saint Joseph Neurological Associates in Lexington, is often called to help physicians diagnose neurological and psychiatric conditions including complaints of memory loss, attentional disorders, dementia, epilepsy, stroke, multiple sclerosis, traumatic brain injury, as well as comorbid psychiatric diagnoses. She provides differential diagnosis among the many types of dementia, and she performs pre-surgical evaluations, especially for bariatric surgery neurostimulators. Says Price, “Physicians find objective symptom validity testing particularly helpful for conditions such as ADHD and others that can include an element of secondary gain.”

Assessing brain function, she says, is critical. “We have regular physical examinations of the body, but somehow a crucial element to our functioning, the brain, gets left out,” says Price. “There is not always a relationship between the size of a lesion in

ed in all evaluations to ensure results are valid and reliable.

Validation, she says, is a big part of her role in healthcare.

“You can’t have a treatment plan until you have an accurate diagnosis. That is where I come in,” says Price.

Validation of a patient’s symptoms paves the way to do something about it, or, conversely, shows that a patient is normal. Either way, neuropsychology plays a pivotal role in the patient’s search for answers to their cognitive problems.

“Everyone thinks they have attention or memory problems, but there’s more to it than that,” says Price.

While many patients Dr. Lacey Price is a worry about the onset come from internal medicine, neuneuropsychologist with of dementia, Price caurology, family practice, and psySaint Joseph Neurological tions that symptoms of chiatry. Price, who spends about Associates in Lexington. memory loss are multifive hours with a new patient, performs objective tests of brain function tests faceted and can be attributed to numerous that are normed for a person’s age, gender, medical conditions. Endocrine dysfunction, and education. “I assess all aspects of cogni- sleep apnea, COPD, and side effects of medications and chemotherapy are common but overlooked causes.

In a culture where brain games abound, Price observes one sure way for people to improve their memory function. She says, “What people don’t realize is that exercise will do more for them than puzzles. Staying tive functioning including attention and healthy is the best thing you can do for your concentration, processing speed, memory brain.” abilities, visuo-spatial skills, sensory-motor functioning, and frontal/executive func- Reader Advisement: This is the first in our tioning that involve reasoning and problem year-long look into key healthcare providers solving,” she says. “I get all of that together, in the coordination of care. Upcoming and it gives me a pattern that tells me topics include occupational therapy, case what might be going on with the patient.” management, and information technologists Objective symptom validity tests are includ- (among many others). ◆

A neuropsychological assessment provides objective analysis of brain function that is normed to the general population. the brain and the functional skills of the person. Understanding how a neurological condition affects the person’s functional skills is vital to improving quality of life.” To this end, her evaluations culminate in medical and therapeutic recommendations since “it is useless to provide a diagnosis without saying what we are going to do about it.”

Neuropsychological referrals typically

January 2012 19

????????

news  events  Arts

news KentuckyOne Health is the newest, biggest healthcare system in KY

Send your NEWS items to M.D UPDATE > news@md-update.com

and Catholic Health Initiatives. As part of KentuckyOne Health, historically Jewish facilities will remain Jewish. Historically Catholic facilities will remain Catholic.

“We have had a mutually beneficial relationship with Catholic Health Initiatives for the last six years. We’re confident this is the right direction for the Jewish Hospital organization,” said Gerald Temes, MD, chair, Jewish Hospital HealthCare Services. “We are looking forward to growing together.”

Catholic Health Initiatives will invest $320 million to launch KentuckyOne Health. The new system plans to invest in an integrated electronic health record system and other IT improvements plus make additional facility, equipment and telehealth investments in communities across the state.

According to the Centers for Disease Control and Prevention and the American Heart Association, Kentucky ranks among the 10 states with the worst health indicators for cancer, obesity and death due to heart disease and stroke. More than half of the state is designated as medically underserved and there is a growing scarcity of physicians across Kentucky.

KentuckyOne Health includes hospitals, clinics, specialty institutes, home health agencies, satellite primary care centers, and physician groups with more than 80 locations, 2,500 staff physicians and more than 13,000 employees across the state of Kentucky and southern Indiana.

Jewish Hospital & St. Mary’s HealthCare and Saint Joseph Health System announced at a joint press conference on Jan 6 the completion of the merger of the Ruth W. Brinkley, FACHE two organizations. The new parent corporation, KentuckyOne Health, is now the well as academic medical centers and comlargest health system in the commonwealth. munity hospitals. Ruth’s background shows a The merger is effective retroactively to proven track record in improving the healthJanuary 1, 2012. care delivery system to better serve people and The partners originally envisioned a communities.” three-way merger that included University The system will collaborate with all Hospital | James Graham Brown Cancer healthcare providers, enhancing existing Center in Louisville. relationships and developDespite receiving feding new partnerships.

Brinkley introduced the name and corporate logo of the merged eral and church approv“This is an exciting corporation, KentuckyOne and important era for Health. The Jewish and Catholic healthcare in Kentucky,” healthcare systems will maintain said Brinkley. “The orgatheir local brands and cultures. nizations have come together as KentuckyOne Health because they recognize that continuing to function as we have is not going to solve the issues. We must change to more effectively meet the als, University Hospital did not receive the health needs of those we serve.” necessary state approvals to participate.

KentuckyOne Health is a nonprofit “This is an historic day for the charitable organization that honors the rich Commonwealth of Kentucky,” said Bob Jewish and Catholic heritages of its two sponHewett, chair of the board for KentuckyOne sors, Jewish Hospital HealthCare Services Health. “The people of Kentucky face sig“We are working with the nificant health threats, not just from dis- University Hospital Governor’s office to try to out as member of the ease, but also from issues related to access to mitigate the concerns that new corporation “at preventive and advanced medical care and caused him to withhold his this time”. a severe shortage of physicians. We believe approval.

We are hopeful that LOUISVILLE In a statement given that this new health system will make for a the partners of KentuckyOne to M.D. UPDATE on Jan 6, 2012, healthier Kentucky.”

Health will keep the door open Hewett introduced Ruth W. Brinkley, UofL Health Care community for University Hospital | James and media relations manager FACHE, 59, as the president and chief Graham Brown Cancer Center David McArthur stated, “We executive officer of the new organization. should the Governor offer his are obviously disappointed that She is a nationally recognized healthcare approval early next week.

University Hospital | James leader and former executive at Ascension “Yesterday we met with the Graham Brown Cancer Center, Health and Catholic Health Initiatives.

Governor to emphasize that despite having received federal “Ruth Brinkley has the experience and University Hospital’s ability to regulatory and church approvals, the vision to lead this new organization into continue to provide excellent was not authorized by the Governor the future,” Hewett said. “She brings valuable patient care – including care for executive experience in a national system as to participate in this merger.

LOUISVILLE

20 M.D. Update

the most vulnerable – and first rate medical education to the next generation of physicians is at risk.

“Without the ability to participate in this merger or an infusion of significant and ongoing funding from the state, we will be unable to continue to provide the same level of service or training.

“We look forward to the Governor’s response early next week to the potential solutions we discussed yesterday in Frankfort.”

news

Kentuckiana Cancer Institute to Join Norton Healthcare

In an announcement made Dec 23, 2011, Kentuckiana Cancer Institute (KCI) officials agree to join Norton Cancer Institute, part of the Norton Healthcare system. The agreement, which includes nine oncologists, will expand the depth and reach of Norton Healthcare’s regional cancer care options while bringing access to additional services to current KCI patients. KCI provides medical oncology, hematology and infusion services to some 5,000 patients in the Louisville area and Southern Indiana.

“As the dialogue between both institutes evolved, we were excited about both the possibilities of working together to fight cancer and the remarkable synergies that result both in the patient care as well as the clinical research arenas,” said Robert N. Shaw, president, Norton Cancer Institute.

“We have long recognized the need for greater collaboration and increased access to comprehensive treatment throughout our community. This agreement better enables Norton Healthcare, Norton Cancer Institute and the physicians of KCI to help meet the needs of our community.”

With KCI operations in downtown and northeastern Louisville, LaGrange, Bardstown, Corydon, Clarksville and New Albany, KCI officials saw clear benefits in aligning with Norton Healthcare. “Norton Cancer Institute is a leading provider of cancer care in the region, with an expansive and comprehensive array of innovative treatment options,” said Renato LaRocca, MD, director of KCI. “This agreement will provide our patients with access to services and support programs, as well as expanded clinical trial options, that are ahead of the curve and will yield a measurable impact on oncology outcomes.”

“Partnering with Norton Healthcare and Norton Cancer Institute represents a tremendous opportunity for KCI,” said Shawn Glisson, MD, physician of KCI, “and will lead to excellent outcomes and access to care for our patients and their families. We are very excited to work with the great physicians of Norton Cancer Institute LOUISVILLE

and the excellent medical staff and nurses at Norton Healthcare.”

Current KCI patients will soon receive letters advising them of today’s agreement with Norton Healthcare, along with details of any changes regarding where they should go for treatment or regularly scheduled medical consultations. If patients have questions, they should call the transition line at (502) 588-9411, Monday through Friday, 8 a.m. to 6 p.m.

Trover Health System and Baptist Healthcare System Begin Merger Negotiations

MADISONVILLE On Nov 16, 2011, Trover Health System, located in Madisonville, and Baptist Healthcare System, headquartered in Louisville, announced that they have entered into exclusive negotiations to

form a strategic partnership whereby Trover Health System will become a member of the Baptist system.

The Trover board of directors reviewed letters of intent submitted by three finalists — Baptist Healthcare System, LifePoint Hospitals and Owensboro Medical Health System. Each finalist was selected based on its ability to assist Trover with objectives for the affiliation process that included assistance with the design and implementation of new models of care and payment reform, providing access to capital, experience with recruiting and sustaining physician relations, and developing service line partnerships.

Trover Health System is an integrated healthcare provider serving western Kentucky residents for more than 55 years. With seven locations in six counties, Trover offers 55 services and specialties and

Direct Access: Plug Into D. Scott Neal’s Expertise With D. Scott Neal’s financial planning and guidance, you have direct access to the power of his knowledge and the energy of his wealth management philosophy.

No middle man to take a cut, water down the plan, or slow the process.

With D. Scott Neal, the connection is direct, the possibilities are electrifying.

Call Scott. Plug in.

F E E - O N LY F I N A N C I A L P L A N N I N G

Lexington | Louisville | Cincinnati 800.344.9098 |

D S N E A L . C O M

January 2012 21

news

UK First in Kentucky to Use Tomosynthesis for Breast Cancer Detection

LEXINGTON The Comprehensive Breast Care Center at the UK Markey Cancer Center announced on Dec 15, 2011 that it will begin offering state-of-the-art digital tomosynthesis for breast cancer screening. UK will be the only medical center in the state with this new technology.

Tomosynthesis is 3-D technology that allows radiologists to see individual breast structures without the confusion of overlapping tissues. In addition to providing the traditional top and side images of the breasts taken during a regular mammogram, tomosynthesis also allows the technician to take multiple X-ray pictures of each breast from many angles. A computer then combines all this information into one 3-D image.

Because a scan with tomosynthesis is more comprehensive than a regular mammogram, it is able to find much smaller

22 M.D. Update

Margaret Szabunio, MD

and earlier-stage cancers. A tomosynthesis exam will feel no different from a usual mammogram, except that it takes just four seconds longer.

In addition, the technology will be especially useful for women with dense or fatty breast tissue. On a traditional mammogram, dense tissue can sometimes be mistaken for cancer. More than 50 percent of women under the age of 50 and more than 30 percent of women over 50 have dense breast tissue.

Margaret Szabunio, MD, associate medical director of the Comprehensive Breast Care Center (CBCC) and division chief of

women’s radiology at UK HealthCare, specializes in using tomosynthesis for the early detection of breast cancer. “ To mo s yn th e si s produces images in tiny slices that can be reconstructed into a 3-D image of the tissue, similar to way a CT scanner works,” Szabunio said. “It allows us to look at breast tissue in a way we’ve never been able to before.”

The CBCC plans to begin using tomosynthesis on patients beginning in February.

Szabunio says her team will initially implement the technology for diagnostic mammograms, meaning that women who have had an abnormality on a regular mammogram will come in for tomosynthesis as their follow-up. The team will then begin using tomosynthesis as a regular screening tool for women who are at a high risk for breast cancer or who have dense breast tissue.

news

Baptist Medical Associates Welcomes New Members Baptist Medical Associates Family and Sports Medicine

Gregory J. Potts, MD, family and sports medicine, is a 1991 graduate of the University of Louisville School of Medicine. He completed his family medicine residency at University of Louisville Hospital in 1994, serving as chief resident 1993-94. He is board certified in family medicine and board eligible in sports medicine. He serves as team physician for the University of Louisville football and men’s basketball teams, as well as Spalding University and Male High School. He also serves as medical director for the Kentucky Derby Festival miniMarathon and Marathon.

Christopher V. Pitcock, MD, family and sports medicine, is a 1991 graduate of the University of Louisville School of Medicine. He completed his family and community medicine residency at University of Louisville Hospital in 1994. He is board certified in family and sports medicine and was named a Louisville Magazine Top Doc in 2003, 2005, 2007, 2009 and 2011. He serves as team physician for the University of Louisville football and men’s basketball teams.

Kali Edwards, APRN, is a 2008 graduate of the Spalding University nurse practitioner program and holds a bachelor’s degree in nursing from McKendree University.

Baptist Medical Associates Dixie Highway

Elizabeth Cull, APRN, is a 2009 graduate of the Spalding University nurse practitioner program. She holds a bachelor’s degree in nursing from St. Louis University in St. Louis, Mo.

Healing Growth January 2012 23

news

employs more than 90 staff physicians and residents.

Baptist Healthcare System owns five acute-care hospitals with more than 1,650 licensed beds in Louisville, Lexington, Paducah, Corbin and La Grange, and manages Hardin Memorial, a 300-bed acute-care hospital in Elizabethtown, and Pattie A. Clay, a 105-bed acute-care hospital in Richmond. To help navigate the rapid changes affecting healthcare organizations nationwide, Baptist Healthcare System brings in-depth experience in hospital/clinic ownership and management, employed and independent physician relationships, home health services, health insurance through its Bluegrass Family Health plans, occupational health services and wellness programs for businesses. Each of these components plays a critical role in the future success of healthcare, and offers a strong foundation for the development and growth of local services.

Trover president and CEO E. Berton Whitaker said, “All three of the finalists are highly respected healthcare organizations. We are confident that Baptist’s sterling reputation and commitment to quality care will assist us in serving our region of Western Kentucky. By joining the Baptist system, Trover joins the Baptist state-wide network of hospitals and will gain access to a broad range of operational and financial resources, as well as Baptist’s clinical quality initiatives and experienced leadership.”

Prather Named Baptist Healthcare System Chief Medical Officer

LOUISVILLE Jody Prather, MD has been named chief medical officer for Baptist Healthcare System, effective Feb. 27, 2012. He currently serves as vice president and chief medical officer at Hardin Memorial Hospital, a position he has held since July 2010. Prather will continue in his role at Hardin Memorial through Jan. 27. Hardin Memorial has been managed by Baptist Healthcare since 1997.

“This newly created position fills a crucial role as we further prepare for the demands of healthcare reform,” said Tommy Smith, CEO for Baptist Healthcare System.

In his new role, Prather will work closely with clinical leadership across Baptist Healthcare System to develop clinical performance improvements. In collaboration with hospital and physician leadership, Prather also will identify best practices that can be implemented across the system to ensure quality and cost-effective care is delivered consistently.

“Building on my experience as a family practitioner, I have a personal commitment to the health of our Kentucky residents, and hope to be involved in statewide initiatives and public policy that can help improve their well-being,” explained Prather. “I also see some wonderful opportunities to reach out not only to our Baptist-affiliated physicians, but also to those who are independent

Jody Prather, MD

or who practice outside our system. These partnerships will be critical in accomplishing the goals of keeping Kentucky healthy.”

Prather is a 2000 graduate of the University of Louisville School of Medicine and completed a family medicine residency at Trover Clinic/Regional Medical Center in Madisonville. He also is past president of the Hardin/Larue Medical Society, in addition to holding leadership roles with Hardin Memorial Hospital’s medical staff. Prather is board-certified in family medicine and was in private practice in Elizabethtown for seven years before joining Hardin Memorial.

Jewish Hospital Cardiologist named Governor of American College of Cardiology Louisville

Medical Physician American Governor

Jesse Adams, III, MD of Jewish Center Cardiologists, Jewish Group, has been elected by the College of Cardiology as their of Kentucky. Adams is board-

You spent over a decade training to be a doctor.

But you didn't expect this...

Decreasing reimbursements, increasing expenses, staff problems, inconsistent cash flow.

It wasn’t supposed to be like this.

Now it doesn't have to be.

PBG THE PHYSICIANS BILLING GROUP Local. Dependable. Billing.

24 M.D. Update

502.855.3491 www.ThePhysiciansBilling.com

news

certified by the National Board of Medical Examiners, the American Board of Internal Medicine, and the American Board of Internal Medicine Division of Cardiology.

His three-year term as Governor will begin in March of 2013.

Involved in many organizations and societies, some of which include the American Heart Association, the American Society of Echocardiography, the Greater Louisville Medical Society and the Kentucky Medical

munity have relied on Hospice for end of life expertise for more than 30 years.

Hospice of the Bluegrass is committed to compassionate quality patient care. This commitment to patients requires Hospice to continually evaluate how care is provided

to ensure that services the terminally ill patients receive remains at an exceptional level.

“Through feedback from staff and families, we have determined that patient needs require increased nursing interventions.

Feel better.

know someone facing a weighty decision?

A free info session on bariatric surgery answers patients’ questions and could change their lives.

Association, Adams also serves on the Jewish Hospital Heart and Lung Institute Advisory Board. He has been a member of the Jewish Hospital medical staff since 1995.

More Nurses, and Layoffs, Coming to Hospice of the Bluegrass

Hospice of the Bluegrass announced last month that it is changing staff caseloads to increase the availability of nurses to patients and families. This move will create 10-12 additional nursing positions by early next year. Unfortunately, the move will mean the elimination of up to 20 social work positions across the state in Hospice’s 32 county service area.

Patients, families and the medical com-

LEXINGTON

© 2012 Baptist Healthcare System, Inc. / Member, Baptist Healthcare System

Jesse Adams, III, MD

If you have a patient whose health is dramatically affected by excess weight, here’s a way to make the bariatric surgery decision a little lighter. The Baptist East Bariatric Center is offering a series of free patient seminars discussing laparoscopic surgical weight loss procedures which include adjustable gastric banding, gastric bypass, sleeve gastrectomy, as well as revisional incision-less procedures.

To refer a patient, visit baptisteast.com/weightloss or phone (502) 897-8131 for more info.

• Thursday, Jan. 5 (6:30 p.m.)

• Saturday, Jan. 21 (10 a.m.)

• Thursday, Feb. 2 (6:30 p.m.)

• Saturday, Feb. 18 (10 a.m.)

facebook.com/baptisteastweightloss

baptisteast.com/weightloss

January 2012 25

Your Cure for the Cash Flow Blues

ALTERNATIVE COMMERCIAL CASH FLOW SOLUTIONS BROKERED LOCALLY BY

Cash Flow Concepts

news

This caseload modification will increase the time nurses can spend with patients,” said Gretchen Brown, president and CEO. Hospice of the Bluegrass has offices in Lexington, Nicholasville, Frankfort, Cynthiana, Florence, Hazard, Corbin, Harlan and Pikeville. The Corbin, Harlan and Pikeville offices will not lose any social work positions.

Employees affected by the change will be offered a severance package and given at least 60 days notice in order to make appropriate arrangements.

“This was not an easy decision, nor will it be an easy process in the coming months. We would prefer attrition as a way to achieve the targeted caseload assignments, but social workers have the lowest turnover rate of all disciplines and it could take several years to reach the appropriate staffing level,” added Brown. “Ultimately, Hospice makes decisions based on what will improve the quality of the care received by patients and families. At the same time, we care about the employees who are losing their positions and will do what we can to make a difficult situation more bearable.”

Brown added that this move is not financially motivated because the personnel costs for the new nurses will be about the same or greater than the costs of the displaced social workers.

Norton Names New Women’s and Children’s Hospital

LOUISVILLE On Jan 4, Norton Healthcare announced the intended name for its women’s and children’s hospital. The work to convert Norton Healthcare’s Suburban Hospital into the new women’s and children’s hospital is ongoing. Once complete, the women’s component of services will be named Norton Women’s Hospital. The pediatric component will be named Kosair Children’s Hospital - St. Matthews.

The campus surrounding the hospital will also receive a new name at the time of transition: Norton Healthcare - St. Matthews Campus. Lynnie Meyer, MSN, RN, CFRE, system vice president and chief development officer, Norton Healthcare, 26 M.D. Update

Lon R. Hays, MD, MBA

said, “While the hospital proper will be dedicated to an advanced model of health care solutions for women and children, the campus surrounding the hospital will meet the needs of the entire family through a range of specialty services for men, women and children.”

The transformation into Norton Women’s Hospital and Kosair Children’s Hospital - St. Matthews will continue over the next 36 months.

UK’s Psychiatrist Elected Secretary of ABAM

LEXINGTON In a Jan 2 press release, UK announced that Lon R. Hays, MD, MBA Chair of the University of Kentucky Department of Psychiatry, was elected secretary of the American Board of Addiction Medicine (ABAM). In addition to being elected secretary of the organization, Hays serves on the Finance Committee, Maintenance of Certification Committee, the External Relations Committee and the Credentialing Committee. Said Hays, “The work of the ABAM is increasing in its relevance particularly as the epidemic of prescription drug abuse continues to grow.

I’m glad to be a part of the great work this organization is doing.”

ABAM is an independent medical specialty board established in 2007 to certify addiction medicine physicians from several specialties, including emergency medicine, family medicine, internal medicine, obstetrics and gynecology, pediatrics, preventive

news

medicine, psychiatry and other specialties. Prior to ABAM’s formation, only one medical specialty (psychiatry) offered subspecialized training and certification in addictions.

To ensure that ABAM-certified physicians maintain life-long competence, ABAM offers a rigorous certifying examination developed by an expert addiction medicine committee and the National Board of Medical Examiners, as well as a maintenance of certification program. Nearly 2,600 physicians have been certified. Physicians from any specialty who are certified by a member board of the American Board of Medical Specialties (ABMS), or who have completed an ACGME-accredited residency in their primary field, may qualify to sit for the ABAM examination and become board certified in addiction medicine.

Cardiologist Joins Ephraim McDowell

Adrian Messerli, MD, formerly of St. Joseph Cardiology in Lexington, has joined Ephraim McDowell Cardiology in Danville with Dr. Gary Grigsby. Messerli earned his medical degree in 1997 from Louisiana State University and completed an internal medicine residency in 2000 at the University of Arizona. He completed a

DANVILLE

A Very Special Thank You to our Newset Subscribers!

Thanks to the participation of our local healthcare professionals, M.D. UPDATE continues to gain recognition for its unique quality and value.

Rizwan Akhtar, MD John R. Barton, MD Paul E. Brown, MD Arnold N. Brownstein, MD Robert J. Bunge, MD Michael T. Cecil, MD, FACS Mark E. E Einbecker, MD Martha M. Foster, MD Frank R Goad Lewis P. Hicks, MD William A. Hymes, MD Kenney Orthopedics Navin R. Kilambi, MD Stephen S. S Kiteck, MD Robert L. McQuady Jr., MD

Jewraj G Maheshwari, MD Mario Maya, MD Daksha P. Mehta, MD Robert N. Pope, MD Dattatraya S. Prajapati, MD Barton L. Ramsey III, MD K. Sheth, MD Rajesh K Alben B. Shockley, MD Laura P. Stadler, MD Patricia Lynn Starns Patricia Reed Tate, MD Frank P. Vannier, MD Frederick A. Walker, DO Richard G. G Voigt, MD

M.D. UPDATE is your trusted source for local healthcare media. We strive to create positive, compelling, and meaningful media for and about Kentucky’s healthcare professionals. All of our paid subscribers receive a complimentary listing in our consumer healthcare media and a special invitation to participate in the development of groundbreaking health media platform!

Individual subscriptions are $39.95 for 12 months.

You can also sign up for our free EMAIL

EDITION

when you text

DOCTOR to 22828

Adrian Messerli, MD

and reply to the automated message with your email address.

Name__________________________________________ Comany ________________________________________ Address_________________________________________ City ST Zip ______________________________________ Email __________________________________________ Phone _________________________________________

January 2012 27

news

cardiovascular medicine fellowship in 2003 at the Cleveland Clinic Foundation in Cleveland, OH and an interventional cardiology fellowship in 2004 at Barnes-Jewish Hospital in St. Louis, MO. Messerli is board certified in interventional cardiology and cardiovascular disease. Messerli’s practice focuses on treating patients with high blood pressure, heart disease, peripheral vascular disease and those who are recovering from heart failure or heart attack.

New Corporate Offices in Eastpoint for Baptist Healthcar

With the help of three benefactors, Baptist Healthcare System has purchased a larger building in the Eastpoint Business Center near Anchorage. The threestory, 99,653 square foot building, located on 5.6 acres at 2701 Eastpoint Parkway, will ST. MATTHEWS

be used for office space.

The $6.6 million purchase price was augmented by generous donations from the Nolen Allen family, the Clyde F. Ensor family and the Michael Ehrler family. Allen has served on the Baptist Healthcare System board, the Baptist Hospital East board, and the board of the Baptist Hospital Foundation of Greater Louisville, Inc. The late Mr. Ensor served on Baptist boards for more than 30 years. Michael Ehrler is the retired Ehrler’s Dairy co-founder and a Louisville-based investor.

Sts. Mary & Elizabeth Hospital Gets Advanced Microscope for Cataract Surgery

LOUISVILLE Sts. Mary and Elizabeth Hospital (SMEH) has acquired a new surgical microscope - the Carl Zeiss Meditech

Looking for a Bank That Understands

Your Special Needs?

OPMI LUMERA 700 – which is used in cataract surgery and provides significantly greater clarity and depth perception during cataract surgery.

The new technology provides the latest illumination system called Stereo Coaxial Illumination (SCI), which provides a crisp, stable image and reveals objects and nuances in the eye that previously could not be viewed in real time during surgery. Providing enhanced contrast and improved depth perception, the system enables surgeons to more easily identify and distinguish subtle anatomical structures of the eye.

“The investment in new technologies helps us to provide the best possible outcomes for our patients,” said Rishi Kumar, MD, Kentucky Eye Surgery Associates.

“This equipment sets the new standard in microscope technology allowing us to see

We’ve Been Serving the Medical Community for Over 25 Years.

Cha

Please contact any of our medical finance specialists for your banking needs: irma

n an

d CE

O-

Repu b

lic B ank

Jenifer Duncan • 266-3547 Emily Miller • 266-3724 We were here for you yesterday.

We are here for you today.

We will be here for you tomorrow.®

28 M.D. Update

news

New Treatment Option for Age-Related Macular Degeneration

by Dr. John Kitchens LEXINGTON For the first time in over five years, patients have a new treatment option for exudative age-related macular degeneration. Eylea (aflibercept) was approved in November 2011 by the FDA to treat the wet form of macular degeneration, a leading cause of vision loss in elderly

patients. It is the first new drug approved for this condition since Lucentis (ranibizumab) was approved in 2006. Avastin has been used off-label for this condition since 2005.

“This marks yet another advance in the care of patients with wet macular degeneration,” said William Wood, MD director of the Macular Degeneration Institute at Retina Associates of Kentucky (RAK). “We are happy to have another option for our patients.”

FDA approval was based on the results of two phase-3 clinical trials comparing Eylea to Lucentis. The drugs were similar in efficacy with Eylea

the eye in greater detail, which in return provides even greater accuracy.”

Cataracts are the leading cause of visual loss in adults over the age of 55 and the leading cause of blindness worldwide. Most cataracts are highly treatable. More than three million Americans undergo cataract surgery each year, which involves removing the cloudy lens from the eye and replacing it with an intraocular lens transplant.

In addition to cataract surgery, the equipment can also be used in retina and glaucoma surgical procedures.

To better serve both healthcare professionals and patients, the OPMI LUMERA 700 provides wireless foot controls that allow for hands-free operation of the system, a second independently controlled microscope through which an assistant or trainee can view the surgery; and a touch screen for a paperless operating room, and a high-definition video monitor that shows the surgery in real time in incredible detail, providing the entire surgical team with a reliable source of information throughout the procedure. ◆

John Kitchens, MD

given every two months (after three monthly injections) compared to Lucentis monthly. According to RAK partner Rick Isernhagen, MD decreased dosing frequency is a major advantage of the new treatment.

“This can mean fewer visits to the doctor for injections for

our patients,” said Isernhagen.

“Each new breakthrough in treatment is important, we still have very good treatment options,” noted Thomas Stone, MD, director of the CATT study at RAK. Options are always an essential aspect of quality patient care which allows us as many alternatives for patients as possible. This includes not only newer, cutting-edge treatments but also traditional therapies for many patients. Low Vision Services are provided for patients whose disease does not respond to any treatments.

In the end, providing the most comprehensive patient care is always our foremost objective.

CERTIFY YOUR CODING STAFF The only AAPC certified Professional Medical Coding Curriculum in Central & Eastern Kentucky taught by AAPC certified PMCC instructor

PATRICIA CORDY HENRICKSEN MS, CHCA, CPC-I, CPC, CCP-P, PCS

WWW.SOTERIONMEDICAL.COM SOTERION@WINDSTREAM.NET

859-233-3900

AAPC CERTIFIED MEDICAL CODING CLASSES

NEXT CLASS FEBRUARY 22, 2012 January 2012 29

events Go Red for Women

LEXINGTON At Lexington’s annual Go Red for Women symposium and luncheon, Nov 18, 2011 at the Lexington Center, women (and men) donned their red-hued finery to support the American Heart Association (AHA) Go Red for Women campaign. The 2011 symposium and luncheon was chaired

by Sara Haynes and Dr. Michele Morton.

National sponsors were Macy’s and Merck, and the local sponsor was Saint Joseph Health System.

Featuring the harrowing, yet hysterical, encounter with heart disease faced by comedienne Tracey Conway, the Go Red for Women luncheon continued its legacy of raising awareness of the unique presentation of heart disease among women while supporting the research effort of

the AHA. Presentations included a video postcard from Denton A. Cooley, MD, who performed the first implantation of a total artificial heart, a Go Red fashion show donning heart disease survivors in red hot fashions from Macy’s, and a grand finale presentation of red pashmina shawls by dozens of Lexington firefighters.

Sara Haynes, event co-chair, and Jennifer Ebert, special events coordinator with the Central Ky AHA, lead the on-stage dance party inspired by comedienne Tracey Conway’s hysterical CPR advice - drop the mouth to mouth, and pump to the beat of “Stayin’ Alive”.

The 2011 Central Kentucky Go Red for Women Luncheon & Symposium took place Nov 18, 2011, at the Lexington Center.

Dr. Sylvia Cerel-Suhl, Circle of Red chair, Madeline Abramson, AHA supporter, and Lindy Carnes, 2012 Go Red for Women event chair.

Go Red for Women supporters are eager to receive pashmina shawls from Lexington firefighters.

30 M.D. Update

Domestic Matter #4

by Hui Chi Lee Pencil & colored pencil on paper 22” x 30”

Arts

Body and Figure Join Nude

Lexington Art League’s signature event moves from object to metaphor

By Andrea Coates Lexington For the past 25 years, The Lexington Aat League’s Nude has grown to be the most anticipated exhibition presented at the Loudoun House. This coming season, however, LAL has shifted the focus from the nude as object to including more metaphorical representations.

Body | Figure | Nude, on display at the Loudoun House gallery January 14 through March 11, 2012, is a group show of 40 national artists, juried by Anna Brzyski (Chellgren Endowed Associate Professor of Art History and Visual Studies at University of Kentucky) and Becky Alley (LAL Exhibitions & Programs Director).

Back in 2010, Professor Brzyski answered a few questions for LAL’s blog, artbeatlexington.com. When asked what time periods throughout art history were significant or transformative in regards to the nude, she stated, “In terms of the most dynamic and controversial periods, I would have to choose either the turn of the century or the present.

In both instances, the nude was/is used by artists to tackle socially sensitive areas, in particular those pertaining to sexuality.”

From Egon Schiele to Robert Mapplethorpe, the body has been used not

only for artistic study, but also to convey concepts ranging from eroticism to what it means to be human.

The works in Body | Figure | Nude concentrate on the latter. The artists move beyond an art practice and into allegorical territory.

Themes and media vary from femininity (like that found in the mixed-media installation Cosmic Egg by Sondra Schwetman) to privacy and identity, (evidenced in the digital life-sized Body Scans by Nick Reszetar), and to burden and psychology (taken from Evolution I, the graphite drawing by Kirsti Anderssen).

All works, no matter the media used, employ the body, figure or nude as a vehicle for expressing today’s culture and the “socially sensitive areas”, as Professor Brzyski stated.

SCHEDULE OF EVENTS

Guests have the opportunity to view the exhibition a day before it officially opens at the QX.net Opening Preview Party on January 13 from 6p to 10p, supported by M.D. UPDATE. The evening is a cocktail attire event including live jazz with Detour Ahead, heavy hors d’oeuvres by Executive Chef Sam Sears, CEC AAC of South-Van Events, a cash bar with fine spirits and beverages and flowers by Greg Jordan of Fine

Flowers and Events. Tickets are $30 for LAL Members and $40 for potential members.

Other scheduled social events are Fifth Third Bank 4th Fridays from 6p – 9p on January 27 and February 24, with appetizers and cash bar by DaRae & Friends Catering and live music with DJ Warren Peace (January) and Tommy & the Oh’s (February). Admission is free for LAL Members and $7 for potential members.

As part of the exhibition, LAL will offer opportunities to learn and engage with the works. A Gallery Tour with The Jurors on January 24 at 7p, and a Discussion with Exhibition Artists on February 11 at 1p (including Don Ament, Kevin Gardner, Jack Girard, Sharon Lee Hart, Hui Chi Lee, and Mary Rezny) are both are free and open to the public. Lastly, Workshops in Life Painting and Life Drawing (led

by Dongfeng Li and by Hui Chi Lee, respectively) are open for registration until January 10, 2012 and are $70 for LAL Members and $85 for potential members.

More information and tickets for the events and lectures as well as workshop registration and instructor biographies can be found on LAL’s website www.lexingtonartleague.org. ◆ January 2012 31

art

Redefining Normal

By Jennifer Montgomery Louisville Eighty-five children were diagnosed with cancer at Kosair Children’s Hospital in 2010. Although these children may have different types of cancer and received different treatments, they share a common bond – being kids and having cancer. An insightful photo exhibit documenting some of these kids’ experience with cancer was recently displayed at the Kentucky Museum of Art and Craft. Titled Redefining Normal: A Photo Documentary of Children Fighting Cancer, the collection of photographs taken

by Paige Greene, a survivor of acute myeloid leukemia and former patient of Kosair Children’s Hospital, gave viewers insight into the highs and lows of children battling cancer.

“The purpose of the Redefining Normal photography project was to provide honest photographs of what it’s like to have cancer as a child,” said Greene. “Through these photos, I aimed to show these children as they are - simply kids who just happen to be sick. I wanted people to see how normal these kids are, instead of being afraid to look at them or talk about it. Kids are more resilient than we think, and I hope viewers can see the good in that.”

Greene chose to document experiences through a portrait series because she wanted to include as many kids as possible in the project, providing strength in numbers. She wanted each portrait to represent a different aspect of the emotions and medical care involved.

“As a former cancer patient, I look back at all the memories I have of Kosair Children’s Hospital,” said Greene. “For every painful procedure, for every strand of hair that fell to the floor, for every moment that made me 32 M.D. Update

Patrick “Pat-pat” Zeitz, 3 years old by Paige Greene

(ABOVE)

Left to right: Salvatore Bertolone, M.D., Kosair Children’s Hospital Pediatric Oncology Specialist and director of Pediatric Hematology and Oncology at the University of Louisville School of Medicine.

Paige Greene, photographer.

Emily R. Johnson, Art Therapist with the Norton Cancer Institute at Kosair Children’s Hospital

(LEFT)

cry, there was an opposing force of love and compassion and laughter. Having cancer at 14 had such a profound impact on my life. It made me believe I could do anything I wanted to, so long as I wanted it badly enough. I decided a long time ago that I would go back and do something to help. It was a combination of that idea and falling in love with photography three years prior to starting this that formed the foundation for this project. I felt as if I didn’t have much to offer in a lot of ways.

I can’t save lives; I’m just a poor college kid. However, I do have a camera, a good sense of humor and compassion. Those things help beyond our wildest imaginations.”

Salvatore Bertolone, M.D., Kosair Children’s Hospital pediatric oncology specialist and professor of Pediatric Hematology and Oncology at the University of Louisville School of Medicine states, “Cure rates of childhood cancer have increased dramatically.

Along with that comes with what we call and define the ‘new normal.’ New normal for

pediatric oncology is treating patients to the point of severe toxicity and neutropenia, and we ask things of children and their families that we never asked before. The chemotherapy protocols of the children’s oncology group are so diverse and so intense, but the result is you have better cure rates. Now, we fully expect 90% of children diagnosed with the common childhood leukemia, Acute Lymphocytic Leukemia, to take their rightful place in society. This is the ‘new normal.’ You have devastating cancer disease and you live to take your rightful place in society. The amount of attention that a society pays to children says something about the future of that society.”

Redefining Normal: A Photo Documentary of Children Fighting Cancer was made possible by the Expressive Art Therapy programs at Kosair Children’s Hospital, Norton Cancer Institute and the Children’s Hospital Foundation.

For more information about supporting the Expressive Art Therapy Program, please call (502) 629-8060 or visit HelpKosairChildrensHospital.com. ◆

Who undeRstands the financial needs of a Medical pRactice MoRe than a doctoR?

Dr. Gregory Kasten, Founder/CEO Unified Trust

In the early 1980’s Dr. Gregory Kasten was a successful, practicing anesthesiologist. He began exploring ways to achieve successful financial outcomes for both himself and his fellow physicians and his innovative ideas lead to the creation of Unfied Trust.

Today, Unified Trust is a national trust company. We’re located in Lexington, Kentucky and are one of a handful of companies in the country that offer true fiduciary responsibility.

We also have more experience and expertise in dealing with the unique issues facing physicians, medical practices and groups than anyone in the area.

To learn more about our innovative and systematic approach to helping doctors and medical practices reach their financial goals, call Gregory Kasten at 859-296-4407 x 202 or visit unifiedtrust.com.

W e a lt h M a n ag e M e n t

R e t i R e M e n t p l a n c o n s u lt i n g a d v i s o R s e R v i c e s

Not FDIC Insured | No Bank Guarantee | May Lose Value