M.D. Update Issue #70 by Mentelle Media

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS may 2012

Special SectioN

Women’s Health

Tabula Rasa

a blaNk Slate proVideS the caNVaS for premier GyNecoloGy aNd obStetricS to reiNVeNt womeN’S care alSo iNSide

Physician Viewpoints on Pelvic Organ Prolapse and Cosmetic Surgery  Practical Insights into Vascular Care  Coordination of Care: Psychosocial Therapy  Audiology Treatments

Volume 3, Number 4



The Leader in Heart Care. Saint Joseph Heart Institute is at the forefront of cardiovascular services in Kentucky, providing the most comprehensive care in the region. But being the region’s leader in pioneering heart care isn’t new to us. Saint Joseph is the site of the state’s first heart cath in 1954 and central Kentucky’s first open-heart surgery in 1959. Our groundbreaking legacy also includes Lexington’s first heart catheterization lab, first balloon angioplasty, first Chest Pain Emergency Center and first da Vinci® heart surgery in Kentucky. Using the most sophisticated equipment and techniques to diagnose and treat heart disease, our unmatched team of cardiologists, heart surgeons, nurses, and other healthcare professionals provides the latest treatments - from common problems to life-threatening conditions. Yes, we’re proud of our many accomplishments. We want you to know why you can trust your heart to the veteran team and staff at the Saint Joseph Heart Institute who performed 951 open-heart procedures last year alone, as well as more than 18,700 procedures in our Cath and EP labs.

SaintJosephHeartInstitute.org

First Row: The physicians pictured here represent both Saint Joseph employees and independent practitioners who provide services at Saint Joseph Heart Institute.

Second Row: Third Row:

Simply, your heart matters to us.

Richard DiNardo, DO; John Thomas, MD; Donald Wakefield, MD; Naresh Anjur-Kapali, MD; Michael Schaeffer, MD; Steve Lin, MD; Jonathan Waltman, MD; Theodore Wright, MD. Michael Sekela, MD; S. Michelle Morton, MD; Lon Keith, MD; William Jeffrey Schoen, MD; Sameh Lamiy, MD; Thomas Goff, MD; Nezar Falluji, MD. David O’Reilly, MD; David Cassidy, MD; Hamid Mohammad-Zadeh, MD; Mark Tussey, MD; Robert Salley, MD; Dermot Halpin, MD; Kiran Saraff, MD; Mubashir Qazi, MD.

Contents

May 2012 VoluMe 3, NuMber 4

2 letters

Cover story

4 HeadliNes 6 FiNaNce 7 practice MaNageMeNt 9 legal 11 pHysiciaN ViewpoiNt 14 practical iNsigHts 16 coordiNatioN oF care 18 coVer story 22 special sectioN  woMeN’s HealtH 27 audiology 29 News

Tabula Rasa

a blank slate ProviDes tHe Canvas For Premier GyneColoGy anD obstetriCs to reinvent Women’s Care by JenniFer s. neWton PHotoGraPHy by liz Haeberlin page 18

On ThE COVEr:

Premier Gynecology and obstetrics physicians (l to r) Dr. kimberly alumbaugh, vice president and executive director of Women’s services for Jewish Hospital & st. mary’s HealthCare, Dr. Jeremy scobee, Dr. thomas benninger, Dr. Catherine Case, Dr. robert zoller, president and medical director of PGo, and Dr. shannon thomas.

sPeCial seCtion Women’s HealtH

22 The Powerful Benefits of Estrogen

24 Focusing on Female Pelvic Disorders

26 Kleinert Kutz Increases awareness and Volume of Plastic Surgery Services

May 2012 1

eDitor’s Desk 2012 editorial caleNdar FeaturiNg coordiNatioN oF care

Volume 3, number 4 May 2012 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

The Kentucky Derby may be over, but at M.D. UPDATE we are off to the races. Our content is overflowing this month as we have a more comprehensive magazine than usual for you, combining our April and May issues into one mega-issue. While our topics range from OB/GYN and female pelvic medicine to plastic surgery to ENT to vascular care, there are a couple of common denominators that we consistently heard from the physicians we spoke to these past months. Health topics such as cancer, stroke, and heart disease often absorb much of the spotlight, as the severity of those diseases warrants, but many physicians are successfully treating conditions that get less attention but are making a dramatic impact in the quality of patients’ lives and their risk factors for comorbidities. Two examples are female pelvic disorders and venous disease, which are uncomfortable, debilitating, even painful, conditions where new minimally invasive procedures can fix problems that patients previously shied away from because of the implications of major surgery. Both Drs. Susan Tate and Hamid Mohammad-Zadeh, who you will hear from in this issue, express surprise at the constant feedback they receive from patients who are incredibly grateful for the difference those treatments have made in their lives. At Women First, Drs. Rebecca Terry and Rebecca Booth are espousing the superpowers of estrogen in the prevention and treatment of osteoporosis and in hormone therapy to greatly impact women’s total

health and wellbeing. In these instances, simple lifestyle changes coupled with individualized therapy that minimizes adverse consequences can make tremendous differences in decreasing health risks. Our cover story on Premier Gynecology & Obstetrics likens to the mythological legend of the rising of the phoenix, capitalizing on the opportunity to recreate women’s care from a blank slate and revolutionize the system through a network of interconnected services centered on the patient’s best interests. Still other articles on plastic and cosmetic surgery and audiology round out the range of non-life-saving procedures that contribute to overall patient wellbeing. I am constantly inspired by your passion as physicians and the daily efforts you make to provide care that is thoughtful, personalized, and innovative. I also love to hear the enthusiasm you have for our magazine and the forum we have created to help you communicate better with your peers. Our editorial calendar for the rest of the year is included on this page. If you have a story you think would be a good fit for one of our upcoming topics or if you just have a story you think is worth telling, we want to hear from you! You can submit your ideas to me directly at jnewton@md-update.com or by calling (502) 541-2666. All the best, Jennifer s. newton Editor-in-Chief

submit your letter to tHe eDitor to JenniFer s. neWton at JneWton@mD-uPDate.Com 2 M.D. UPDaTE

Bias Tilford bias.tilford@md-update.com geNeral MaNager

Wesley Shears wshears@md-update.com pHotograpHers

Liz Haeberlin

grapHic desigNer

James Shambhu art@md-update.com

coNtributors: Gerald G. Edds, MD Michael Heit, MD, PhD Patricia Cordy Hendrickson Lisa English Hinkle Molly Nichol Lewis Scott Neal Ann Rhoten Kathy Sandusky Ginny Sprang, PhD

Bias Tilford bias.tilford@md-update.com

iNtegrated pHysiciaN MarketiNg:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

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HeaDlines

Director of trauma surgery at uk sees the Gift of organ Donation First Hand April was Donate for Life Month by Gil Dunn lexiNgtoN As a Level 1 trauma center serving a population of over one million potential patients, the new UK Hospital has seen over 3,000 trauma victims in its first year of operation. The new trauma center opened in May 2011. Organ donation from trauma victims is the “ultimate silver lining in a very dark cloud” says Andrew Bernard, MD, director of Trauma Surgery at UK HealthCare, who joined the staff in 2003 after attending medical school and residency at UK College of Medicine. He became Director of Trauma and Acute Care Surgery in July 2011. According to information provided by Kentucky Organ Donor Affiliates, (KODA) more than 800 Kentucky residents are waiting to receive hearts, livers, lungs, kidneys, and other organs. In 2011, 79 organs were transplanted from 24 organ donors at UK HealthCare alone. In Kentucky, there were 100 organ donors and 284 organs transplanted in 2011. On average, 18 people die every day in the US waiting for organ transplants, and there are more than 113,000 men, women, and children on the national waiting list. The Kentucky Organ Donor Registry “gives hope to those in need of organ and tissue transplants, while leaving a legacy of generosity for the donor and his or her family,” says Bernard, who is often in the position of initiating the conversation between potential donor families and KODA representatives. “My first priority in a trauma situation is preserving the life of the victim,” says Bernard. Fortunately, the life sustaining measures that are undertaken in trauma and critical care also maintain internal organs for possible transplant, he says. At some point, however, Bernard addresses the life-ending situation with the victim’s family and contacts KODA. “It is the hardest, yet the most rewarding part of my job,” 4 M.D. UPDaTE

KODA FSL’s take on multiple roles in the end of life crisis, says Threlkeld, such as tending to the physical and emotional needs of the victim’s family and facilitating communication between the healthcare team and the victim’s family through a series of “huddles” that ensure mutual understanding of the situation. Bernard says he has seen KODA counselors stay with the victim’s family non-stop, even for days, during the decision above: Dr. andrew making process. Bernard, Director of In some cases, Trauma Surgery at FSL’s work with family University of Kentucky members to understand Left: KODa volunteers, the concept of “brain staff, and organ donors death” for patients on gathered at UK for ventilators in ICU’s Donate Life month during a sequence of celebrations meetings while information is assimilated and processed. “In crisis situations, some family members only understand 20% of what they are told. Communications over a period of time are critical,” says Threlkeld. KODA has seven Family Support Bernard says. KODA representatives meet first with the healthcare team and then with Liaison professionals: three are based in the victim’s family. “The KODA Family Louisville, three in Central Kentucky, and Support Liasions are grief counselors, are one in Huntington, West Virginia. The majority of donors are trauma victims excellent at what they do, and when organ donations are arranged, many lives are posi- from car or motorcycle accidents and some are stroke victims, says Bernard. In addition to tively affected,” adds Bernard. heart, lung, kidney, liver, and pancreas, other KODa advocacy tissue such as vein, cartilage, corneas, and KODA Family Support Liaisons (FSL) are skin can be used for transplantation. For the engaged in a “dual advocacy role,” says recipients, often “the only option for survival Tom Threlkeld, KODA’s director of Client is a transplant,” states Bernard. More organs Services, as they represent both the wishes are needed. He says, “the demand exceeds the of the donor, the donor’s family, and the supply by as much as 10 to one.” thousands of potential organ recipients on Threlkeld recalls what the mother of a the waiting lists. Threlkeld has been with young donor told him, “The opportunity KODA since its inception in 1987 and for organ donation was a lifeline out of the oversees the FSL’s, who receive extensive abyss of my sorrow and grief.” training at KODA and at The Gift of Life Institute in Philadelphia in the difficult end For more information on KODa, visit www. donatelifeky.org ◆ of life conversations and organ donation.

HeaDlines

microsurgery Gives Plastic surgeons an edge for Head and neck repair New algorithms for flap selection are the key by JenniFer s. neWton lexiNgtoN New and advanced microsurgical equipment, techniques, and optics have opened up realms of possibilities for plastic surgeons in the last decade. Nowhere are the advancements more potent than in head and neck reconstructive surgery for cancer patients. Now, microvascular flaps, large areas of tissue with an intact blood supply, can be transferred from virtually anywhere in the body, if necessary, says Brian Rinker, MD, associate professor of plastic surgery at the University of Kentucky (UK). “The number of flaps used is limited only by the imagination,” says Rinker. Rinker and Joseph L. Hill, MD, chief resident at the UK Division of Plastic Surgery, recently published a paper on the reconstructive challenges presented by advanced cutaneous malignancies of the head and neck1, which often invade peripheral tissue, leaving deeper structures, such as the skull, dura, orbit, and sinus, exposed after resection. Adding to the challenge of restoring large volumes of lost tissue is the fact that patients with these defects frequently have already undergone previous surgery in the same area plus radiation therapy. The advent of microsurgical techniques over the past decade provides the platform for plastic surgeons to address these issues. “It allows us to import healthy tissue and reconstruct devastating defects to the head and neck using composite parts of the body, such as soft tissue, bone, and cartilage, … in the relative size and shape that we need,” says Rinker. Algorithms developed and refined by numerous researchers provide a blueprint for identifying suitable tissue to create unique flaps for each situation. “I found the plethora of flaps now available to be one of the more interesting facets of plastic surgery,” says Dr. Hill. “It’s like a puzzle. There are algorithms that help solve the puzzle.” The availability of free tissue transfer

Chief resident Dr. Joseph hill and Dr. Brian rinker, associate Professor of Plastic Surgery at UK

allows surgeons the ability to completely excise tumors with clear margins without regard for saving surrounding tissue for reconstruction. Microsurgery gives plastic surgeons the creativity they need to fabricate and restore form and function. “As

the same purposes in the head and neck. Fibula flaps including bone are often used to reconstruct and maintain the appearance of the mandible, which presents a significant challenge because of the multiple functions of chewing, speaking, and swallowing. Other areas of the body where skin cancer defects occur and reconstruction is needed are the breast, hand, and perineum. Although large area head and neck cancer is statistically rare, Rinker believes that his colleagues at UK see more than the average number of cases of cutaneous malignancies due to lifestyle choices, including tobacco and alcohol use and patient delay in seeking treatment. “Denial is a power-

one of our goals is to help educate other plastic surgeons who don’t see as many head and neck cancer defects as we do. plastic surgeons, we are trained in aesthetics as well as reconstruction,” says Rinker. In deciding which flap to use, UK plastic surgery residents are taught to ask two questions, “What’s missing?” and “What’s needed to repair the defect?” In addition to the type of tissue and the visual effect, surgeons must consider three-dimensional form and function of the head and neck. The most commonly used flaps for head and neck reconstruction are distal radial forearm and anterolateral thigh (ALT) because the thin, pliable skin is used for

ful force,” says Rinker. “People convince themselves it’s not something to worry about. The lesions are not painful so there’s no motivating reason.” Hill adds, “Lack of access to quality healthcare is also a factor.” endnotes 1 rinker b and Hill J l. microsurgical reconstruction of large, locally advanced Cutaneous malignancy of the Head and neck. international Journal of surgical oncology, vol. 2011, article iD 415219, 5 pages, 2011. doi:10.1155/2011/415219 ◆ May 2012 5

FinanCial

your House: asset or liability? For years Dave Ramsey has claimed that the house you live in is not an asset, but a liability. Of course, on your financial statement showing assets, liabilities, and net worth, your residence goes on the asset side of the ledger. I think Dave thinks of it as a liability because it is expensive to maintain, costly to insure, and you have to pay substantial property taxes to keep it. It is also a thing to which we become enormously emotionally attached. It is, after all, our castle. In proffering advice, many financial advisors simply ignore the value of the client’s house altogether, either because it does not represent a value that can be invested by them or they simply deem it to be irrelevant to one’s future financial well-being because it is a useasset rather than an investment asset. This has never seemed right to me since, for many, it represents a very substantial asset. You might have heard many rule-ofthumb recommendations from your financial advisor. Pay off the mortgage before you retire. Consider refinancing only after x% drop in interest rates. Use home equity as a last resort source of funds. Some however suggest using it first. It is standard advice that a mortgage or home equity loan is always the last debt to be paid off because the interest is tax deductible. Prior to 2008, the most egregious rule-of-thumb assumption by nearly everybody, advisor and client alike, was that house values would always go up at approximately the inflation rate providing a handy hedge against inflation. Dr. Larry Kotlikoff refers to rules-of-thumb as “rules of dumb” because they typically do not consider all the variables. It is easy to think too simplistically as we think about housing. This is especially true of our particular castle. The questions that we hear from clients while discussing housing seem to have a familiar ring to them. The most common is “should I pay off the mortgage or pay extra on the mortgage?” You may already know that there is an economic answer to the question that involves whether the after tax interest rate on the mortgage is more or less than the after tax rate of return on your portfolio. If the

portfolio produces the higher rate, then don’t prepay. This of course assumes that the money that would be used to pay on the mortgage would alternatively be invested in a portfolio producBY Scott neal ing some assumed rate of return. This ignores the risk component. Prepaying the mortgage produces a risk free rate of return equal to the interest rate on the mortgage. Investment portfolios carry some uncertainty to the return. It also ignores the elation that most people feel when they know that their house is debt-free. There is a flip side to this that good analysis may help to address. That is knowing just how much that elation is going to

stocks on margin, but prudent to buy them ‘on mortgage?’” Kitces wonders if the advisory community is contradicting its own advice. I wonder who’s best interest is being served by not prepaying the mortgage. One dimension of housing that we like to explore with clients is whether they plan to keep their house for the rest of their lives. If so, we then ask, what will become of it then? We find that children are rarely as interested in owning the family residence as their parents might think that they are. Once this question is confronted, access to the equity in the house if needed during retirement becomes more of a reality. If you plan to live in your house for the remainder of life, it might make some sense to develop a strategy to tap into the equity of the house at some point. Reverse mortgages are costly but not out of the question. They can often be accessed less expensively via a family member than through a typical mortgage or insurance company. Private annuities with children who can afford them should also be considered, using the house as the asset transferred in exchange for the annuity. If clients do not expect to keep their house for their lifetime, we then explore what will be the triggering event that would cause them to move? Too often we hear something like “when I am no longer able to take care of it.” Or, “when I can no longer get up and down the stairs.” The problem with this line of thinking is that both of these usually occur over time with much ebb and flow. The result is that the house deteriorates as one becomes increasingly unable to provide the ongoing maintenance while becoming more reluctant to pay somebody to do it. Another result is often that a sale becomes absolutely necessary at a particular time rather than when it is more optimal. We like to help people think through these things as part of their financial plan.

in proffering advice, many financial advisors simply ignore the value of the client’s house altogether … this has never seemed right to me since, for many, it represents a very substantial asset.

6 M.D. UPDaTE

cost you in living standard for the rest of your life. Maybe that good feeling would be worth $X, but not worth $Y. Notice here that this statement assumes that there is a cost, rather than a benefit, from prepayment. The time value of money, as well as the assumed inflation rate and tax rates are all important variables to consider in performing these analyses. Sorry, things financial are rarely as simple as they seem. While conducting interviews for an article in The Journal of Financial Planning, Ed McCarthy determined that most advisors are not currently in favor of prepaying the mortgage. However, in that same article, he quotes Michael Kitces, another advisor, who recently asked a very relevant question in his blog, “Why is it considered risky to buy

Scott neal is President of D. Scott neal, Inc., a fee-only financial planning and investment advisory firm. you may write with questions or comments to scott@dsneal.com or visit www.dsneal.com. ◆

PraCtiCe manaGement

Compliance Dates For 5010 & icd-10 extensions Hitech Final Rule Expected Soon The Department of Health & Human Services (HHS) has announced changes for two important compliance mandates. A short-term extension of an additional 90-days delays the enforcement of HIPAA 5010 standards until June 30, 2012. A more far-reaching compliance change involves a proposed rule to delay until October 1, 2014, implementation of ICD-10-CM/ PCS, which was originally scheduled for October 1, 2013. The Centers for Medicare and Medicaid Services (CMS) announced that the extension for enforcement of 5010 was based upon industry feedback, which revealed that testing between some covered entities and their trading partners had not yet reached a threshold that would allow them to meet an earlier compliance date. The CMS Office of E-Health Standards and Services (OESS) also stated that it had received reports that many covered entities are still awaiting software upgrades. Under pressure from the AMA, MGMA, and several other groups, HHS Secretary Kathleen G. Sebelius introduced on April 9, 2012, a proposed rule that the ICD-10 implementation requirements be extended until October 1, 2014. “ICD-10 codes are important to many positive improvements in our healthcare system,” Secretary Sebelius said. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead, and we are committed to working with providers to reexamine the pace at which HHS and the nation implement these important improvements to our healthcare system.” ICD-10 codes provide more specificity for diagnoses and procedures, requiring precise medical record documentation, and are designed to help improve patient care and accuracy in reimbursement, as well as fraud detection and patient noncompliance. HHS stated that all covered entities must be compliant with ICD-10 at the same time in order to ensure a smooth tran-

sition to the new code sets and that failure of one industry segment to achieve compliance would negatively impact all other industry segments, which would result in rejected claims BY Patricia Cordy henricksen and provider payment delays. HHS considered three main issues in the deadline extension, including realization that the transition to 5010 has not been as smooth as expected, many surveys still show a lack of readiness by providers and payers for the transition, and providers are concerned about a lack of resources due to investment in competing statutory initiatives. In addition to extending ICD-10 implementation, the proposed rule includes directives for adoption of new standards for a Unique Health Plan Identifier, as well as a National Provider Identifier. Healthcare providers are also awaiting the final Health Information Technology for Economic and Clinical Health Act (HITECH) regulations amending the

been released. Despite the ongoing delay in HITECH, covered entities and business associates should continue to review, update, and implement their HIPAA privacy and security policies and procedures with diligence. Some key HIPAA privacy and security components include: Disclosure of PHI (Protected Health Information) is permitted only when used for treatment, payment, and operations (TPO), except when records are subpoenaed, required by law, or requested by public agencies such as the FDA or law enforcement. Under HIPAA, patients have the right to review their records and to request a copy. According to Kentucky statutes the first copy is free, with a modest charge allowed for additional copies. When releasing records, only the minimum information necessary to respond to the inquiry should be released and a log documenting to whom the records were released is required. No consent is required when PHI is released for public health activities, such as to the FDA for drug efficacy, public health concerns, or cases involving abuse, neglect, and domestic violence, although release documentation must be logged. Third party entities, including attorneys, accountants, and billing companies, who have access to PHI are required to have Business Associate Agreements with Covered Entities (CE) in order to protect inappropriate disclosure of PHI, and they must return or destroy any records containing PHI upon conclusion of their contracts with the Covered Entities. Privacy Notices must be posted in patient waiting areas and patient acknowledgement of receipt of Privacy Practices must be retained in the patient’s medical record. HIPAA disclosure logs must be maintained for at least six years. A Covered Entity must also maintain privacy policies and procedures, privacy notices, and records

We are committed to working with providers to reexamine the pace at which HHs and the nation implement these important improvements to our healthcare system HIPAA privacy and security regulations. Although the Final Rule was expected at the end of 2011, the HHS Office of Civil Rights (OCR) is still addressing numerous policy reviews and responding to more than 300 comments it has received, so the Final Rule for HITECH has not yet

May 2012 7

PraCtiCe manaGement

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for disposition of any complaints for six years after the last effective date. The HITECH Final Rule will definitely address increased enforcement for protection of patient health information, especially with respect to breach notification regulations, which require Covered Entities and Business Associates to report a breach of unsecured PHI, including loss or theft of unsecured PHI. Stronger enforcement of breach reporting is mandated under the HITECH Act final regulations, along with provisions for civil and criminal penalties. Prior to release of the Final Rule, self audit of HIPAA policies and practices is strongly encouraged. Formerly, government audits were only conducted when breaches were reported, however, investigations are now being conducted randomly. The audit services firm KPMG began random audits in January of 2012, under a $9 million contract with the HHS Office for Civil Rights. Initially the audits will focus on Covered Entities of various sizes, with only 10 business days allowed for provision of the requested documentation. According to attorney and HITECH expert, William O’Toole, “mandatory penalties will be imposed for willful neglect on the part of the health care provider. It is not possible to explain today what ‘willful neglect’ could be interpreted to mean in the future, but sound advice to providers includes once again a careful review of your existing policies and procedures with regard to the protection of patient information.” Helpful websites for further information regarding HIPAA can be found at: www.hhs.gov/ocr/privacy/hipaa/understanding.html www.cms.gov/hipaaageninfo/ www.ama-assn.org www.hipaasurvivalguide.com/hitech-acttext.php Patricia Cordy henricksen, MS, ChCa, CPC-I, CPC, CCP-P, PCS, aCS-PM, is the Executive Vice President of Medical Services, www. soterionmedical.com ◆

leGal

Hospital Payment For Performance: Driven by Physician’s Quality aDDitional text by molly niCol leWis As the fate of the Affordable Care Act is being determined by a divisive Supreme Court, the health care industry is being led or possibly dragged by the Department of Health and Human Services (HHS) and the Center for Medicare and Medicaid Services (CMS) into new payment systems that focus on quality of care, outcomes, and individual provider performance rather than the traditional fee for service payment model. Even if the Supreme Court finds the Affordable Care Act to be unconstitutional, the change from a payment system focused upon individual services to payment focused upon the quality of the care and patient outcomes are being woven into the fabric of the Medicare reimbursement system. While change in the system is assured, whether the new models will actually bring about better and more efficient care or just reduce available reimbursement is unknown. Despite the unknown effect of paying for performance based upon quality, CMS is marching on with new programs and payment penalties. Physicians, whether employed by a hospital or in a private practice, should be aware of how quality is beginning to drive hospital reimbursement as well as the importance of the physician’s role in determining the quality of care provided by hospitals. By 2017, 6% of all DRG payments will be subject to quality measures through new CMS payment programs for hospital readmissions, value based purchasing, and hospital acquired conditions. With these new programs determining a significant amount of payment, physicians must understand the programs and direct their services accordingly. Likewise, hospitals must develop ways to compensate physicians for providing high quality care in a manner that allows hospitals to earn performance payments.

hospital readmissions

Effective October 1, 2012, Medicare payments to hospitals with readmission rates exceeding established levels will be reduced

based upon a formula that compares each hospital’s payments for actual riskadjusted readmissions to payments based on an estimate of that hospital’s expected risk-adjusted BY Lisa English hinkle hikle readmissions. For FY 2013 and 2014, the payment reduction cannot exceed 1% and 2% respectively, but is increased to 3% for 2015. Readmission occurs if a patient is admitted with one of the specified conditions within 30 days of the initial hospitalization. The readmission can be to the original hospital or to another hospital and is counted as a readmission regardless of the cause of the readmission (unless the admission is for a scheduled PTCA or CABG) and irrespective of the payor. For FY 2013, the specified conditions include heart attack, heart failure, and pneumonia and will most likely be expanded to COPD, CABG, PTCA, and other vascular conditions by 2015. While CMS acknowledges that hospitals have little to no way of knowing whether a patient has been readmitted when the readmission is to another hospital or for an unrelated problem, CMS wants hospitals to reduce admissions for all causes. As the gatekeeper for hospital admissions, physicians play an important role by being involved in determining when and whether a patient is readmitted. Hospitals must work with physicians to improve communication about admissions. By becoming more involved in a patient’s transition from the inpatient unit to home, physicians can assure more successful transition by ordering the necessary services and communicating with patients and their families on a regular basis after discharge to assure that medications are being taken and orders followed. Likewise, hospitals must find ways to reward physicians for taking more responsibility for pre-

vention of readmissions through payments for high quality care.

Value Based Purchasing Program for hospitals

The goal of the CMS Value Based Purchasing program (VBP) for hospitals is to reward hospitals financially for providing a higher quality of care. To accomplish this, CMS is reducing DRG payments to hospitals that meet the criteria for the program by withholding 1% (which will grow to 2% over five years) to fund a pool that will be used to make payments to hospitals that demonstrate high or improving quality of care. To determine a hospital’s quality of care, CMS has developed a scoring system based upon three aspects of care that are called “Domains” to measure hospital performance with selected specific measures. CMS has established a performance standard and benchmark for each measure. To determine a hospital’s score on each individual measurement, both the hospital’s achievement and its improvement will be calculated and the highest score will be used. This reflects CMS’ intention to reward not just high quality but also improvement. For FY 2013, CMS has adopted 12 process of clinical care measures that focus on acute myocardial infarction, heart failure, pneumonia, healthcare associated infections, and surgical care. An experience of care measure has also been developed that includes patient satisfaction. In FY 2014, an outcome or mortality measure will be included. Based upon these measures, scores are calculated that determine whether a hospital will receive a payment and the amount of the payment. The domains and measures will change from year to year so that hospitals will continually have to improve quality to maximize their VBP payment. Because the statute requires that the program be budget neutral and for the best performing hospitals to be paid more than other hospitals, it follows that the worst perMay 2012 9

leGal

forming hospitals will be paid less, which of the patient’s entire hospital admission. means that even though a hospital may This, in turn, has the potential to affect meet the benchmarks, its score may be the patient’s satisfaction scoring for his or low by comparison and the hospital may her hospital stay. While gamesmanship not be paid. will be involved in a hospital’s scoring for Physicians play crucial roles that influ- the VBO, physicians and their treatment ence a hospital’s performance as mea- of patients will significantly impact a hossured under both the readmission pay- pital’s score. ment reduction and the VBP program. To a significant extent, the ability of a hospital-acquired Conditions hospital to avoid adverse payment con- Effective in FY 2015, hospitals in the top sequences depends upon garnering the quartile with respect to national rates of support, understanding, and cooperation hospital-acquired conditions (HAC) will of its medical staff. With the readmis- have their Medicare payments for all dission reduction, even a simple scheduling charges reduced by 1%. A HAC is defined mistake for a patient’s surgical procedure as a condition that an individual acquires has the potenduring a hospiPhysicians play crucial roles that tial to influtal stay which ence a reducthe Secretary influence a hospital’s performance designates as tion by being counted in the subject to the as measured under both the pool. Likewise, restriction. a physician’s nformation readmission payment reduction and Iabout early discharge HAC’s of patient into will also be the vbP program. a setting where published on compliance the Hospital with discharge plans is unlikely may Compare website. While physicians are precipitate a readmission. With the VBP not able to control whether a patient program, direct measures of performance experiences a HAC, physicians can be often turn upon physician compliance instrumental in influencing such things with protocols for treatment and good as a hospital’s infection control policies communication with patients. A physi- as well as personally using best practices. cian’s poor communication with his or her Hospitals should compensate physicians patient stands to influence the perception with good track records.

10 M.D. UPDaTE

Conclusion

Because physicians will significantly affect a hospital’s payments based upon quality of care, hospitals must find new ways to reward physicians for maintaining high quality of care. While payments to physicians raise issues under both the Stark and Anti-Kickback statutes, these statutes have important exceptions that should be used to reward physicians who provide high quality care that positively impacts a hospital’s performance. These arrangements can include personal services contracts, full and parttime employment, consulting agreements, gain-sharing, agreements, among others. Without the understanding and cooperation of physicians, hospitals will experience significant decreases in their Medicare reimbursement for inpatient services. Lisa English hinkle is a Partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. hinkle concentrates her practice area in healthcare law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780. Molly nicol Lewis is an associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. This article is intended as a summary of newly enacted federal law and does not constitute legal advice. ◆

PHysiCian vieWPoint

if you could see what i see … would it bother you? by miCHael Heit, mD, PHD There has been a firestorm of controversy surrounding the FDA’s decision to warn patients about the safety, risks, and complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Class action suits are being joined by patients encouraged by TV commercials paid for by legal experts suggesting causal link between adverse events and these “prolapse mesh kits.” It is important to understand the diagnostic and therapeutic history of pelvic organ prolapse to reconcile this controversial topic. Traditionally, a considerable number women with pelvic organ prolapse were offered vaginal hysterectomy, anterior and posterior colporrhaphy with McCall’s culdoplasty for uterine prolapse, cystocele, rectocele, or enterocele, respectively. However

Dr. Michael heit

Healing Growth

the anatomic failure rate of these “native tissue repairs” was unacceptably high, ranging from 40 to 60% in some case series. In the early 1970s, abdominal sacrocolpopexy using surgical mesh analogous to that used for abdominal wall hernias was introduced to improve the anatomic outcomes of “native tissue repairs.” Long term anatomic success rates of 85 to 95% were achievable with this durable “gold standard” operation at the risk of complications associated with laparotomy, including wound infection, internal organ injury, post-operative pain, deep vein thrombophlebitis, hemorrhage, and prolonged recovery times. In the late 1990s, tension free vaginal taping (TVT) revolutionized the surgical treatment of patients with stress urinary incontinence through transvaginal placement of a synthetic mesh sling, thereby eliminating the need for laparotomy during

winnerÊ ofÊ theÊ 2012 landscaperÊ ofÊ theÊ year award May 2012 11

PHysiCian vieWPoint

retropubic colposuspension (Burch, MMK) while maintaining equivalent success rates of 85 to 90%. Medical device manufacturers encouraged by the success of tension free vaginal taping developed “prolapse mesh kits” through the FDA’s 510K approval process, which requires proof of equivalence to an already established product rather than new human clinical trials. These “prolapse mesh kits” met the need for a minimally invasive surgical procedure to treat pelvic organ prolapse with success rates that exceeded “native tissue repairs” because of the addition of a larger volume of synthetic mesh through a transvaginal route. Transvaginal placement of surgical mesh for treatment of pelvic organ prolapse quickly became the preferred method of repair in 75% of cases because of an aggressive marketing campaign by the medical device manufacturers who create demand for their products by training physicians with limited knowledge, experience, and surgical skills necessary to care for these patients. The anatomic cure rates of transvaginal placement of surgical mesh for treatment of pelvic organ prolapse approaches 90% in many cases series at an increased risk to the patient. Mesh erosion/exposure rates of 10 to 20% were being reported in the medical literature compared to the two to three percent rates associated with abdominal sacrocolpopexy. Pelvic pain and painful intercourse due to mesh shrinkage or inappropriately tensioned mesh was seen in 10% of cases compared to two to three percent rates associated with abdominal sacrocolpopexy. A fourfold reduction in reoperation for recurrent pelvic organ prolapse after “native tissue repair” was now being replaced by a fourfold increase in return to the operating room for synthetic mesh revision and removal, prompting the FDA, in July 2011, to develop a warning advisory that complications after transvaginal placement of surgical mesh for pelvic organ prolapse are not rare and may require multiple reoperations

and in some cases permanent injury. Paradoxically, only two to four percent of the 40 to 60% of patients with anatomic failure after “native tissue repair” requires reoperation, provoking researchers to redefine pelvic organ prolapse from the patient’s perspective. Approximately 50 to 60% of asymptomatic women attending a gynecologic clinic have anatomic evidence for pelvic organ prolapse by physical examination. However, only nine percent of US community-dwelling women are bothered by feeling or seeing a bulge corresponding to when the leading edge descends past the vaginal opening. Researchers have, in my opinion, erroneously reclassified any asymptomatic pelvic organ whose leading edge is above the vaginal opening as “normal” because most women are not bothered by what they cannot feel or see. Yet, we do not know whether women would be bothered if

examined had the leading edge of their vaginal walls descend as low as one centimeter short of the vaginal opening while participating in a study to determine the distribution of pelvic organ prolapse in a US community-dwelling population. Vaginal delivery results in a traumatic evulsion of the levator ani muscles from their bony attachments in the pelvis leading to pelvic support defects seen on physical examination of multiparous asymptomatic women. Clearly, asymptomatic women with pelvic support defects on physical examination should not be offered a surgical intervention. Surgical intervention should be reserved for symptomatic women reporting seeing or feeling a vaginal bulge that descends beyond the vaginal opening. Conventional laparoscopic sacrocolpopexy has minimized the risk of complications associated with laparotomy while maintaining the high rates of anatomic success for this “gold standard” operation for the select number of physicians capable of conquering its steep learning curve. Robotic sacrocolpopexy offers a shorter learning curve but typically costs more ($2,500 per procedure) and takes longer (60 minutes) than a conventional approach. The FDA’s decision to warn patients of the risks of transvaginal placement of surgical mesh for pelvic organ prolapse, while warranted, has increased confusion. The problem is not the surgical mesh but the route of introduction of a large volume of synthetic material into the clean contaminated vaginal field. Therefore the FDA’s warning does not apply to use of synthetic mesh placed via an abdominal or endoscopic route during sacrocolpopexy or transvaginal placement of a smaller volume of mesh for treatment of stress urinary incontinence. Surgical results, good and bad, depend on the provider’s knowledge, experience, and surgical skills, which is why patients with pelvic organ prolapse should be offered referral to a board-certified Female Pelvic Medicine and Reconstructive Surgery (Urogynecology) subspecialist. ◆

Just because women cannot see or feel their vaginal bulge until it descends past the vaginal opening does not mean it is “normal.”

12 M.D. UPDaTE

they were shown what we see on physical examination. We also do not know the progression rates of asymptomatic women with “normal” pelvic organ support either prior to or after surgical repair. “Native tissue repairs” traditionally associated with 40 to 60% anatomic failure rates are now being recommended by the FDA as the treatment of choice for pelvic organ prolapse because they eliminate the risks associated with transvaginal placement of surgical mesh and have similar success rates when the new definition of “normal” is applied. Just because a women cannot see or feel their vaginal bulge until it descends past the vaginal opening does not mean it is “normal.” None of the 125 nulliparous women

PHysiCian vieWPoint

the american academy of Cosmetic surgery Promoting quality and safety in cosmetic surgery by GeralD G. eDDs, mD Having been a member of the American Academy of Cosmetic Surgery (AACS) for over 25 years, I was honored to be named the 2012 President of the Academy this past January. The AACS is an international, multi-specialty community of more than 2,500 healthcare professionals from diverse backgrounds. With education as its primary function, the Academy draws from the unique experiences and expertise of multiple specialties, including plastic surgery, facial plastic surgery, dermatologic surgery, general surgery, oculoplastic surgery, oral and maxillo-facial surgery, and gynecologic cosmetic surgery. The media often use the terms “cosmetic surgery” and “plastic surgery” interchangeably, contributing to the confusion of patients and the general public. By definition, cosmetic surgery is an AMA recognized discipline of medicine focused on enhancing appearance through medical and surgical procedures. Because these procedures generally treat non-diseased areas, cosmetic surgery is elective. Plastic surgery is a specialty that includes aesthetic procedures and deals significantly with reconstruction of facial and body defects due to birth disorder, trauma, burns, and disease. Physicians who are board-certified in one of the previously mentioned specialties and who complete an approved fellowship and/ or demonstrate extensive experience in cos-

Owensboro cosmetic surgeon Dr. Gerald G. Edds is the 2012 President of the american academy of Cosmetic Surgery

metic surgery may sit for the written and oral examinations to become certified by the American Board of Cosmetic Surgery (ABCS). The experience route to certification by the ABCS is scheduled to be phased out over the next two years, after which completion of a fellowship in cosmetic surgery will be required for all candidates. Education and patient safety are at the very core of the AACS’ mission to advance the specialty of cosmetic surgery and quality patient care. In providing high-quality continuing medical education to cosmetic sur-

geons, the AACS believes it improves the quality of patient care and, as a direct result, patient safety. Such education is provided through yearlong approved fellowships, a variety of live patient and cadaver dissection workshops, videos, and other supplemental educational materials. Challenges facing all cosmetic surgeons are numerous and are the same for me practicing in Owensboro as for those in other areas. As elective surgery, the economy has affected all but the most mature practices. Competition, both within and among various specialties will always be a challenge. The AACS recognizes that its most important challenge is improving the quality and safety of cosmetic surgery. The requirement that our members perform cosmetic surgery only in a surgery center accredited by a nationally recognized accrediting organization and a continual update of practice guidelines are just two of numerous ongoing initiatives to improve patient safety. Gerald G. Edds, MD, is a board-certified cosmetic surgeon practicing in Owensboro, Kentucky, and the 2012 president of the american academy of Cosmetic Surgery. For more information, contact him at (270) 9269033, toll-free (800) 820-4833, or at www. eddscosmeticsurgery.com. ◆

May 2012 13

PraCtiCal insiGHts vasCular Care

lexington vein & aesthetics Center

Board certified phlebologists provide minimally invasive, highly effective treatment in a center dedicated to vein treatment by JenniFer s. neWton As a cardiovascular surgeon, Hamid Mohammad-Zadeh, MD, FACS, noticed many of his bypass patients had significant painful varicosities in their legs. Upon discussing it with them, he found that many had tried to address the problems with their doctors without resolution. “After that I realized a lot of the patient population was suffering from varicose veins, significant chronic venous insufficiency, and the symptoms associated with them, so we decided to do something about it,” says Zadeh. Zadeh enlisted the help of Lexington internist Fadi Bacha, MD, who had begun offering cosmetic procedures such as Botox, fillers, hair reduction, and spa treatments in his practice. “I thought it was a brilliant idea,” says Bacha. “A lot of places do vein. A lot of places do aesthetics. But combining the two is like bread and butter.” As founder of the Urgent Treatment Clinics in Lexington, Bacha provided the business expertise and infrastructure for the venture. Another deciding factor in opening the center was that, at the time they opened four years ago, there were no other facilities in Lexington dedicated solely to venous issues. To differentiate themselves in the field, Zadeh and Bacha sought additional training and certification from the American Board of Phlebology. While physicians with a variety of backgrounds provide vein treatment, the partners believe their certification illustrates they have taken the extra step in providing quality care.

Vein Treatment

The legs are comprised of two venous return systems: the superficial system and the deep system. Treatment is limited to the superficial system where valves inside the veins become insufficient and patients develop varicosities and symptoms. “The main service that 14 M.D. UPDaTE

Dr. Mohammad-Zadeh performs outpatient EVLT procedures on a wide variety of male and female patients.

we provide to our patients is the procedure of endovenous laser therapy (EVLT), which is basically the treatment of choice these days for symptomatic chronic venous insufficiency,” says Zadeh. Other treatments include ultrasound-guided sclerotherapy and ambulatory phlebectomy. Lexington Vein & Aesthetics Center’s diagnostic process begins with a detailed patient history, including current symptoms, which can include edema, swelling, itching, and dry skin. More extreme symptoms include bleeding and venous ulcers. Physical examination focuses on the location of varicosities, their origin, and the condition of the skin itself, whether there is dryness, hyperpigmentation, change in

color, or ulcerations. “Following that we do an ultrasound exam of the venous system, which I think is the best tool that we have,” says Zadeh. “It’s the golden tool that we have and use for confirming of our diagnosis.” Key components of the practice are on-site ultrasound examinations and ultrasound technicians, who are trained specifically in venous insufficiency studies. Unlike traditional vein stripping procedures, which require hospitalization, general anesthesia, and multiple cuts, EVLT is done in a 45-minute outpatient procedure through a needle stick under ultrasound guidance. Placing a laser fiber through an introducer into the vein, physicians precisely position the laser. According to Zadeh, excellent positioning is critical to avoid damaging the deep system and significant complications. Tumescent is used to locally anesthetize the vein and also serves the purposes of compressing the vein for even distribution of the laser and “acts like a cooling agent to prevent thermal injury to the surrounding tissues and skin,” says Zadeh. When the laser fiber is removed, the vein closes, and patients are able to walk out of the office following the procedure. Possible complications include deep vein thrombosis (DVT) and damage of the deep venous system, a complication Lexington Vein & Aesthetics has not seen but one Zadeh cautions could occur with an inexperienced clinician. They monitor for DVT by having the patient return for office visits at weeks one and three post-treatment. More cosmetic and temporary complications can include ecchymosis or bruising in the leg for a prolonged time, burning of the skin, and numbness.

aesthetic Services

Bacha is responsible for the cosmetic aspects of the practice, including removal of spider or varicose veins for cosmetic pur-

Dr. Fadi Bacha concentrates on the business and cosmetic aspects of the practice.

poses, and shares the duties of evaluating all vein patients with Zadeh. “As far as the aesthetic part, we do everything that has to do with the non-surgical correction of facial blemishes,” explains Bacha. Services include Botox, dermal fillers, chemical peels, fractional laser skin resurfacing, photo facial rejuvenation with pulsed light treatment, hair removal and reduction, and topical skin care products. Bacha emphasizes a healthier look rather than promising to make patients look younger.

Patient crossover is common in the practice, where patients who have had vein treatment often return for cosmetic services. Both physicians agree word-of-mouth is their best source of referrals. Bacha describes the cosmetic population as mostly baby-boomers, but says the center’s vein patients range “from 14 years to 93 years, depending on where we catch them in the disease process.” Both Bacha and Zadeh split time between the vein center and their original

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the important thing to realize is chronic venous insufficiency is a disease, and there are outpatient treatments available. although they are elective, our services are usually covered by insurance companies.

practices and have wait times of up to two months for new patient appointments. They pride themselves on being accessible, including providing their cell phone numbers to any patient who has a vein procedure and scheduling extra time between patients “to make sure we are available for patients when they arrive,” says Zadeh. ◆

For patients with health issues dramatically affected by excess weight, the Baptist East Bariatric Center is offering 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, June 7 (6:30 p.m.) • Saturday, June 16 (10 a.m.) • Thursday, July 5 (6:30 p.m.) • Saturday, July 21 (10 a.m.)

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May 2012 15

CoorDination oF Care  PsyCHosoCial tHeraPy

integrated Healthcare for traumatized Children by Ginny sPranG, PHD There are decades of empirical work that establish the link between mood, cognitions, sensory perception, and the experience of physiological suffering (Tang, Salkovskis, Hodges, Wright, Hanna & Hester, 2008; Stroud, Thorn, Jensen, & Boothby, 2002). Furthermore, perceived threats to the physical or psychological integrity of self or others can produce physiological dysregulation and alterations in neurophysiology and neurofunctioning (Schore, 2001; DeBellis, Keshavan, Clark, Casey, Giedd, Boring, et al. 1999; Perry, 2001). However, 21st century healthcare is still largely characterized by a siloed approach to service delivery, where physiological and psychological treatments are provided by disparate groups of professionals, in separate settings, with little coordination of care (Hogan, 2003). In contrast, integrated models provide behavioral health

16 M.D. UPDaTE

services within primary care settings and emphasize collaboration between primary care professionals and mental health providers. In 2003, the President’s New Freedom Commission on Mental Health recognized this gap and issued a challenge, “Understanding that mental health is essential to overall health is fundamental for establishing a health system that treats

mental illnesses with the same urgency as it treats physical illnesses.” (p. 15). A meta-review of behavioral outcome studies for several disease categories (i.e., cardiovascular disease, diabetes, chronic back pain, depression, asthma) noted positive changes in physiological and service utilization outcomes as a result of psychosocial intervention delivered in healthcare settings (Center for the Advancement of Health, 2000). However, to some, the most persuasive argument for an integrated healthcare model is embedded in the medical offset research that documents significant healthcare savings in venues where psychosocial treatments are used in conjunction with physical care. In fact, Cummings, O’Donohue, & Ferguson (2003) report a 20% to 30% reduction in medical cost above and beyond expenditures associated with psychosocial or behavioral care provision in an integrated model, findings that have been replicated across settings and sectors (Levant, House, May, & Smith 2006; Chiles, Lambert, & Hatch, 1999). The promise and utility of integrated healthcare is particularly salient in the pediatric arena. Childhood can be a vulnerable period for the onset of emotional and behavioral problems, often brought about by child maltreatment, violence exposure and other adverse childhood experiences (Shonkoff & Phillips, 2000). If untreated, these problems may persist into adolescence and adulthood and are associated with a compromised health trajectory, and increased healthcare cost (See Adverse Childhood Experiences Study by Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, et al. 1998). The University of Kentucky Center on Trauma and Children provides a pathway to integrated care for trauma-exposed children by providing training on traumatic stress detection for pediatric healthcare providers, conducting biopsychosocial assessments of at-risk children, and through the provision of integrated behavioral healthcare. The center uses a framework that supports integration of psychosocial and physical care through: Coordinated design and implementation of services: Building a cooperative culture by involving all partners in the development and implementation of the care model.

Structured coordination: Operationalizing roles and responsibilities so that boundaries and points of interface are clearly defined, communication pathways are established, and accountability is appropriately sited. Maintenance of reciprocal feedback loops that keep the partners informed of client outcomes, feedback, areas for quality improvement, and the effectiveness of small tests of change. This integrated framework allows for the expeditious delivery of psychosocial and healthcare interventions to families in all areas of the state, where access to services may be limited. The center also strives to create community capacity to provide integrated trauma-informed care to children throughout the state, through its training and education programs. For more information about the UK Center on Trauma and Children and integrated trauma-informed care for children, please visit our website at ctac.uky.edu.

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Ginny Sprang, PhD, is the Buckhorn endowed professor of Child Welfare and Children’s Mental health at the University of Kentucky and executive director of the Center on Trauma and Children. She can be reached at (859) 543-0078. ◆ reFerenCes Chiles Ja, lambert mJ, Hatch al. (1999). the impact of psychological interventions on medical cost offset: a metaanalytic review. Clinical Psychological science and Practice. 6:204-20. Cummings, n. a., o’Donohue, W. t., & Ferguson, k. e. (eds.). (2003). behavioral health in primary care: beyond efficacy to effectiveness. Cummings Foundation for behavioral Health: Health utilization and cost series (vol. 6). reno, nv: Context Press. Debellis, m., keshavan, m., Clark, D., Casey, b., Giedd, J.,boring, a. et al. (1999). Developmental traumatology part ii: brain Development. biologic Psychiatry, 45, 10, 1271- 1284. Felitti vJ, anda rF, nordenberg D, Williamson DF, spitz am, edwards v, koss mP, marks Js. (1998). relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (aCe) study. american Journal of Preventive medicine,14: 245–258. Hogan, m. (2003). new Freedom Commission report: the President’s new Freedom Commission recommendations to transform mental health care in america, Psychiatric services, 54,11,1467- 1474. levant, r., House, a., may, s., & smith, r. (2006). Cost offset: Past, Present, and Future, Psychological services, 3, 3 195207). Perry, b.D. (2001). the neurodevelopmental impact of violence in childhood.. in textbook of Child and adolescent Forensic Psychiatry, (eds., D. schetky and e.P.benedek) american Psychiatric Press, inc., Washington, D.C. pp. 221-238. schore, a., (2001). the effects of early relational trauma on right brain development, affect regulation, and infant mental health, infant mental Health Journal, 22, 201-269. shonkoff, J. P. & Phillips, D. a. (2000). From neurons to neighborhoods: the science of early Childhood Development. Washington, DC: national academies Press stroud, m., thorn, b., Jensen, m., & boothby, J. (2000). the relation between pain, beliefs, negative thoughts, and psychosocial functioning in chronic pain patients, Pain, 84, 347-352. tang n. salkovskis, P., Hodges, a, Wright, k., Hanna, m., Hester, J. (2008). effects of mood on pain responses and pain tolerance: an experimental study in chronic back pain patients, Pain, 138, 392-401.

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D S N E A L . C O M

May 2012 17

cover story

Tabula Rasa

A blAnk slAte provides the cAnvAs for premier GynecoloGy And obstetrics to reinvent womenâ&#x20AC;&#x2122;s cAre By Jennifer s. newton

LouisviLLe Healthcare reform is one of the most hotly debated political issues of the 21st century. Physicians across all specialties agree the system needs repair. How to fix it is another matter entirely, one that physicians, hospitals, insurance companies, and patients all view differently. Imagine then, if instead of trying to make incremental adaptations to an enormous system with innumerable failures, you could simply start over from the beginning. Tabula rasa. A blank slate. In essence, that is the opportunity seized upon by Premier Gynecology and Obstetrics (PGO), a physician partnership formed in July 2011 encompassing five Louisville OB/GYN

18 M.D. UpDate

practices and 25 board-certified physicians, who have aligned themselves with the legacy Jewish Hospital & St. Maryâ&#x20AC;&#x2122;s HealthCare organization (JHSMH), which is part of KentuckyOne Health. Unlike the hospital-employed physician models, PGO is an affiliated model. Leaders describe the relationship between the five original groups as an on-going blending of practices. In relationship to KentuckyOne, PGO is aligned with, but not owned by the healthcare system. PGO represents some of the longest-standing, most experienced practices and practitioners in Louisville. The five independent practices that make

premier Gynecology and Obstetrics encompasses five OB/GYN practices and 25 board-certified physicians in Louisville.

up PGO are: Louisville OB/GYN, Louisville Physicians for Women, Partners in Women’s Health, Susan Bornstein, MD, and Total Woman. The group is led by PGO President and Medical Director Robert Zoller, MD, an OB/GYN with Partners in Women’s Health who oversees the executive council and clinical operations among physicians. Vice President and Executive Director of Women’s Services for JHSMH, Kimberly Alumbaugh, MD, a founding member of Total Woman, represents the women’s service line interests within the larger system and plays a strategic and creative role in shaping the women’s care agenda of KentuckyOne. The concept for PGO began to take root nearly three years ago in off-the-radar conversations between physicians. Knowing they were disparate in the way they transacted patient care, the partners were surprised at how similar their philosophies and goals were. Originally, including a hospital or healthcare system was not part of the plan, but the financial backing and infrastructure a healthcare system could provide was an attractive addition. The legacy JHSMH’s lack of a gynecologic and obstetric presence in Louisville made them the perfect blankslate partner. “I don’t know that you could find a better group of physician leaders. This was a courageous move. They moved from doing what they had done forever to recognizing an opportunity and just striking out anew,” says Alumbaugh.

Better Business and a Collective advantage

Kentucky’s poorly ranked overall health, looming changes to healthcare regulations, increasing costs of overhead, and a general unhappiness with previous hospital relationships were galvanizing points for the physicians. Previous interaction with hospitals had been one-sided relationships. “OB/ GYN is very much an outpatient world. We spend 10 months of care with our obstetric patients and there’s a very brief, isolated window that’s done in a hospital,” says Alumbaugh. Comprehensive patient care

(Left) pGO

president and Medical Director Robert Zoller, MD, and Vice president and executive Director of Women’s Services for JHSMH, Kimberly alumbaugh, MD (BeLOW) Catherine Case, MD consults with a patient at Jewish Hospital Medical Center east. (faR BeLOW) Shannon thomas, MD

should not be solely based on that one occurrence, but transformed because of it, she asserts. “It just seemed like a model that was a hybrid,” says Thomas Benninger, MD, an OB/GYN with Louisville Physicians for Women. “It was different than anything that we had envisioned with most practices becoming employees of hospitals. This seemed like it could potentially be flexible with independence for the physicians but extremely beneficial because of the management expertise of Jewish.” KentuckyOne serves as an outsource for operational and practice management services, such as coding, billing, human resources, and electronic medical records (EMR). Two of the practices already use EMR but will transition to Allscripts beginning this fall as the other practices are brought online with the system. Zoller contends that the concept of providing the best care at the right time in the most efficient way was the unifying link between the groups. “Focusing on the patient’s overall health and providing professional and technical excellence is how we hope to make a difference. It matches our mission statement perfectly,” he says. Incorporating the best practices of each group and the system at large is a tremendous benefit. “We are learning from each other … We’re bringing each other up in different ways,” says Zoller. Constant dialogue and a fluid operating plan that adapts as needs arise are also some of the secrets of their early success.

patient-Centered total Care for Women

Not only has PGO found a partner in KentuckyOne whose leadership and innovation match their own mission, they also have found a system with a reputation for excellence and a network of comprehensive services. OB/GYNs are often the only physician a woman sees on an annual basis and those relationships span a lifetime of care, making it the perfect access hub to integrate and synthesize the many disciplines that encompass women’s care. For KentuckyOne, the relationship is also about extending the things OB/GYN already does well, like prevention, to other services. Of her role, Alumbaugh says, “What I do is envision how the care the doctors give in the office and the hospital can be enhanced, and then I try to build that model outward. The patient is our center, and helping our doctors deliver optimal patient care is critical.” MaY 2012 19

cover story

Minimally Invasive Surgery

Stephen Lebder, MD, OB/GYN with Louisville OB/GYN, says the top three most common diagnoses in minimally invasive gynecologic surgery are fibroids, adenomyosis (a condition where the endometrium invades the muscular tissue of the uterus), and dysfunctional uterine bleeding. Lebder estimates only five to 10% of patients need surgery from the outset, as many patients can be controlled with medical therapy, such as oral contraceptives, hormonal injections, anti-inflammatories, or intrauterine devices (IUDs). One minimally invasive treatment for fibroids and bleeding abnormalities is endometrial ablation. “Ten to 15 years ago patients who had fibroids or adenomyosis or even dysfunctional uterine bleeding were more likely when they failed medical therapy to undergo hysterectomy. A large number of those now can actually have an endometrial ablation,” says Lebder. He asserts that 75 to 80 percent of ablations are effective long-term at improving symptoms and quality of life. Minimally invasive fibroid surgery mainly consists of two options: myomectomy and hysterectomy. Over the last 20 years, laparoscopic techniques have evolved from laparoscopic-assisted vaginal hysterectomy to laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy. The newest iterations are single-site surgeries and robotic surgeries. “The old traditional laparoscopic hysterectomies require patients to have usually two or three, if not a fourth port. Now we’re trying to accomplish many of those types of surgeries with a single port,” says Maria Schweichler, MD, OB/GYN with Total Woman. She cites the ability to see around corners using a flexible camera with single-site as a big advantage, as well as its potential for economic sustainability. “You have to look at technology as a cost and contain it so that the smartest technologies succeed … single-site has been a real homerun with that,” says Schweichler. Robotic surgery, as Lebder sees it, is 20 M.D. UpDate

Stephen Lebder, MD Maria Schweichler, MD (faR BeLOW) thomas Benninger, MD (tOp RIGHt) (BeLOW)

another extension of laparoscopy that allows for better visualization and more precise movements in more complicated cases.

Breast and Incontinence Care

“We see lots of women concerned with their breast health, breast lumps, breast pain, and just a lot of women aren’t really comfortable with their breasts because they’re worried about them,” says Catherine Case, MD, OB/GYN with Total Woman, which is one reason why PGO and KentuckyOne are developing a multidisciplinary breast care center of excellence. While most of the PGO offices have mammogram on-site, the infrastructure of Jewish Hospital Medical Center East provides a comprehensive range of diagnostic tools, the digital technology to rapidly communicate results, and easy access to followup care. “It’s a very streamlined system that really helps with getting patients in early, biopsies done earlier, everything done as smoothly as possible,” says Shannon Thomas, MD, an OB/GYN with Partners in Women’s Health. Another common clinical issue is incon-

tinence. “The fundamental question is what causes the incontinence and then you can tailor your treatment to fixing it,” says Case. Specialized bladder testing helps differentiate the problem. Simple solutions include dietary changes, kegel exercises, bladder training, and antibiotic treatment. In some cases, surgery is warranted to support the neck of the bladder. Tension-free vaginal tape (TVT) or transobturator tape (TOT) procedures are done as an outpatient and can be bundled with hysterectomies.

pregnancy and Delivery

PGO physicians deliver at Baptist Hospital East and Norton Suburban Hospital, as the legacy JHSMH does not offer labor and delivery services. Two of the physician groups have begun sharing call at Suburban, one of the many integrations that will grow as the groups become more familiar with each other. Beyond typical pregnancy care, the OB/GYNs of PGO manage advanced age pregnancy and many high risk patients. According to Thomas, women over 35 have a harder time conceiving, an increased risk of chromosomal abnormalities, and a greater chance of medical issues, but for the most part patients over 35 do really well and have a good experience. Screening tests are offered to all patients, but invasive tests such as chorionic villus sampling (CVS) and amniocentesis are given more consideration by women over 35. PGO will celebrate its one-year anniversary on July 1. “As far as working together, the potential for improving patient care and total care, we’ve only scratched the surface,” says Zoller. ◆

Freedom regained. Dr. Michael Heit, Louisville’s Premier Pelvic Floor Specialist, is accepting referrals for take‑charge women seeking expert care at the new Norton Women’s Hospital and Kosair Children’s Hospital – St. Matthews.

Offering minimally invasive treatments including:

Louisville Urogynecology offers comprehensive, state‑of‑the‑art diagnostics and minimally invasive treatments for pelvic floor disorders including pelvic organ prolapse, surgical mesh complications, stress urinary incontinence, overactive bladder, anal incontinence, difficult defecation, and painful bladder syndrome. Your patients are our number one priority – we schedule appointments and surgeries within one month of a self‑referral or physician referral and accept all common insurance plans, including Medicare, Medicaid, and Passport.

• Laparoscopic Sacrocolpopexy • Pessaries • Midurethral Slings • Interstim Therapy (Sacral Neuromodulation) • Botox Bladder Injections • Periurethral Injections

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speciAl section women’s heAlth

the powerful benefits of estrogen by Jennifer s. newton – Rebecca Booth, MD, OB/ GYN with Women First of Louisville, estimates only 15 to 20% of her patients in the menopausal range accept traditional hormone therapy because of the negative stigmas and somewhat misleading information published regarding the risks. While she acknowledges that all medical therapy has risks, she believes estrogen has powerful benefits. The average age for natural menopause is 52, although symptoms can begin as early as the mid-30s. “Women are cyclic by nature, so blood levels after puberty of the sex hormones vary widely across a normal menstrual cycle. Therefore blood levels become somewhat irrelevant with regard to an approach toward menopausal systems … Symptom relief becomes more

LouisviLLe

Dr. Rebecca Booth

relevant,” says Booth. As a species with ovaries programmed to retire, hormonal aging is a natural process, not a disease state. Consequently, treatment approaches are extremely individualized and should utilize the lowest dose possible to relieve symp-

toms with maximum benefit. Booth makes a distinction between two issues: estrogen withdrawal and estrogen deficiency. The classic symptoms associated with menopause are the result of estrogen withdrawal in the brain. These may include: hot flashes, insomnia, irritability, palpitations and depression. “On parallel with that are symptoms that could result in disease processes that are from estrogen deficiency,” says Booth. A decline in estrogen with menopause is part of a woman’s biological design, but low estrogen levels can lead to a decrease in total body col-

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22 M.D. UpDate

lagen, which can affect skin, vascular elasticity, and bone density. Low estrogen also results in increased insulin resistance and may lead to weight gain, as well as negative effects on lipid metabolism. Osteoporosis is currently one of the easiest of these disease processes to be objectively measured, however clinicians are giving more consideration to monitoring metabolic changes thanks to data linking menopause and an increase in type 2 diabetes. In perimenopausal women, hormonal contraception, in the form of a low-dose birth control pill, vaginal ring, or hormonal IUD, is often effective at stabilizing the cycle and controlling symptoms of estrogen withdrawal and abnormal bleeding. SSRIs such as fluoxetine can be used as needed for PMS symptoms. Hormonal treatment for menopausal women usually involves the use of transdermal estrogen, whether through a patch, gel, spray, or vaginal insert, which data shows carries a significantly diminished risk of a venous thromboembolic events relative to oral therapy. “Estrogen is the key to obtaining positive results with hormonal therapy,” says Booth, who only uses progestins to protect the lining of the uterus. Non-hormonal recommendations include nutrition, exercise, supplements, non-hormone medications, and over-the-counter products.

Osteoporosis

Osteoporosis is a skeletal disorder defined by compromised bone strength, which increases the risk of fracture. According to Rebecca Terry, MD, OB/GYN and comanaging partner of Women First and a certified clinical densitometrist, one in four women suffer from osteoporosis, and 50% of women over age 50 will have a bone fracture. “Loss of estrogen in the menopausal years is associated with an increased risk of osteoporosis because the first two years after we lose estrogen, we lose up to a third of our bone mass,” says Terry. “The gold standard for detecting osteoporosis is a bone density scan,” says Terry. Dexagrams measure bone density in the hip, spine, or wrist. The International Society of Clinical Densitometry recommends the following populations be screened: women over 65 and men over 70, women over 50 with a history of fracture, women in menopause with history or risk of fracture, post-menopausal women under 65 with risk of fracture, and women who are stopping estrogen therapy.

Dr. Rebecca terry

To supplement bone density screening, Women’s First utilizes a computer-based algorithm developed by the World Health Organization called FRAX®, which calculates a person’s 10-year risk probability for hip and major osteoporotic fractures. FRAX is especially useful for general practitioners because it can detect osteopenia, low bone mass that is not yet severe enough to be called osteoporosis, and determine who warrants treatment. When discussing treatment, Terry says it all starts with prevention, including getting adequate amounts of calcium and vitamin D, using estrogen as a part of hormone therapy, and considering lifestyle

factors such as smoking, alcohol intake, and exercise. Once osteoporosis is diagnosed, treatments to increase bone mass, but more importantly lower fracture risk, include estrogen, bisphosphonate drugs, calcitonin, a RANK ligand inhibitor called Prolia®, and Forteo®, a parathyroid hormone. Not only is estrogen effective in the prevention and treatment of osteoporosis by protecting bone mass, Terry also exalts the benefits of estrogen for other women’s health issues, such as preventing atrophy in the brain, protecting collage, and positively affecting sleep. Data shows that transdermal estrogen in women within the first five years of menopause decreases the risk of cardiovascular disease. The healthcare costs of osteoporosis treatment are staggering in comparison to the inexpensive, simple measures that can be used to prevent it. In 2005, costs associated with osteoporosis were estimated at $17 billion. The estimate for 2025 is $25.3 billion a year. “Osteoporosis is a silent disease, but it takes so little to make a major impact,” says Terry. ◆

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speciAl section women’s heAlth

focusing on female pelvic floor disorders

Dr. Susan Tate joins Hardin Memorial to create a multidisciplinary pelvic floor center by Jennifer s. newton “Female pelvic floor disorders are ubiquitous,” says Susan Tate, MD, urogynecologist and reconstructive pelvic surgeon with Hardin Memorial Health’s Urogynecology Specialists. However, women with these disorders are a largely untreated population. Too often the mentality is that these problems are just a normal part of aging, and many women are uncomfortable even discussing their sensitive and somewhat embarrassing nature. Newly employed by Hardin Memorial Health, Tate’s dream of establishing a multidisciplinary pelvic floor center is coming to fruition. Trained as a general OB/GYN in gynecologic surgery at a time when urology was dominated by men and urogynecology did not exist as a specialty, Tate pursued a fellowship in London, England, under renowned urogynecologist Stuart Stanton. “My practice now is absolutely focused on all aspects of female pelvic floor disorders, encompassing the entire range from the simple to the highly complex,” says Tate. No longer practicing general gynecology, she has been careful to establish herself as a resource for managing recurrent or complex problems, not replacing the care of gynecologists or urologists who often refer to her.

eLizaBethtown

a Shared Vision

To execute her vision, Tate needed the assistance of partners with similar expertise. Linda Blackwell, RN, is a nurse clinician with extensive experience as a patient educator and clinical researcher. In 2010, Tate teamed up with Rick Rayome, RN, who was one of the first to provide video-urodynamics in Kentucky to assess patients with complex incontinence and voiding difficulties. Additionally, she partnered with Dennis Shoff, MD, an Elizabethtown gynecologist whose surgical experience made him a good collaborator on complex cases. Hardin Memorial Hospital, with state-of-the art laparoscopic and robotic operating room equipment for minimally invasive surgery, also serves as an essential partner for Tate’s practice. She believes Hardin Memorial is a perfect fit because of their 24 M.D. UpDate

smaller size, approachable atmosphere, reputation for innovative thinking, and enthusiasm for the program. “Hardin recognized this was something no one else was doing. No one else is doing this in Kentucky on this scale. Hardly anyone else is doing this in the United States,” she says. Beyond her immediate partners, Tate

Dr. Susan tate

also works closely with urologists, colorectal surgeons, general surgeons, gastroenterologists, and other specialists because so many of the diagnoses overlap.

pelvic floor Disorders and treatment

The expanse of pelvic floor disorders covers anything pertaining to urinary complaints, prolapse, and bowel complaints. Bladder symptoms can include overactive bladder,

In addition, prolapse can alter the anatomy in a way that results in bladder and bowel dysfunction. Many patients suffer from a combination of urinary issues and prolapse. The diagnostic process is critical in tailoring treatment to each individual. “We fit the operation to the woman, to her specific problems, to her specific complaints, and to her specific physical health otherwise,” Tate says. Diagnostic testing for urinary complaints may include urodynamics testing, cystourethroscopy, radiologic imaging studies, anorectal manometry, and defecography. Treatment options vary from conservative behavioral interventions to medication therapy to complex surgical procedures. “Treatments we have now in terms of urinary urge incontinence and urinary frequency are infinitely better than we had before,” says Tate. In properly selected patients, two treatments that significantly impacts patients’ quality of life without the need for medication or major surgery are sacral neural modulation and posterior tibial nerve stimulation. Sacral neural modulation, a simple outpatient procedure, functions essentially as a bladder pacemaker implanted into the sacral nerve area to offer stimulation controlled by the patient. Posterior tibial nerve stimulation is another alternative procedure that provides stimulation to the bladder via the tibial nerve in the

i have always wanted to establish a specialized, multidisciplinary pelvic floor center focused on addressing these issues for women in a comprehensive manner, and our vision is to grow this service statewide. urgency, frequency, and stress incontinence. Pelvic organ prolapse can affect the vagina, uterus, bladder, and rectum. Symptoms of prolapse include the feeling of a bulge, pressure, or something falling in the vagina.

leg using a very small needle attached to an external stimulation device. This painless treatment is done in 30-minute sessions once a week for a 12-week period, after which many do not need further treatment or may

need only an occasional booster. Vaginal slings have revolutionized treatment for stress incontinence. What used to require major surgery with a large abdominal incision and hospital stay can now be done as an outpatient in 20 minutes under local anesthesia with sedation. Additional techniques utilized by Tate for stress incontinence include transobturator slings and intra-urethral bulking agents. The most common procedures for Tate are combinations: prolapse and urinary incontinence or prolapse and bowel dysfunction, in which individualizing surgery and treatment are paramount. “The gold standard for marked prolapse is sacral colpopexy,” says Tate, but it is a major surgery that may not be appropriate for every patient. Advancements in abdominal sacral colpopexy include laparoscopic and robotic surgery options. Tate acknowledges the recent controversy with vaginal mesh, but says abdominal sacral colpopexy falls outside those criticisms because this approach is not vaginal and not all grafts are synthetic. In many cases the etiology of the prolapse is that the cervix or vagina has detached from the uterosacral ligaments. For a first or second repair, prolapse can be treated vaginally, laparoscopically, or robotically without graft material, synthetic or otherwise, by suturing the vaginal walls back in place. There are cases when a patient is not a candidate for surgery or desires more conservative options such as a vaginal pessary or pelvic floor biofeedback and rehab. Pelvic floor rehab, which is administered by a specially trained physical therapist at Hardin Memorial’s Therapy & Sports Medicine Center, can be very effective in improving patient symptoms.

New Board Certification

Access to urogynecologists nationwide is a challenge, as there are a limited number of these specialized practitioners. However, there is growth on the horizon. Tate is part of a group of urogynecologists and urologists who have supported board certification for the subspecialty of Female Pelvic Medicine and Reconstructive Surgery through the American Board of Medical

Subspecialists. Its first exam will be administered in 2013. ◆ for referraLs:

Dr. Susan tate, Urogynecology Specialists, 1310 Woodland Drive, elizabethtown, KY 42701, (270) 765-6141.

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

MaY 2012 25

speciAl section women’s heAlth

kleinert kutz increases Awareness and volume of plastic surgery services Famed Hand Practice Uses Internet to Innovate by Gil dunn

big jump in office-type procedures for the last five years.” she says. “We have expanded our plastics services from New Albany, Indiana, to our new Louisville east end office on Chamberlain Lane and hope to add another plastic surgeon to the group in the near future.”

LouisviLLe The world renowned practice of Kleinert Kutz is synonymous with hand surgery. Less well known is that they also offer comprehensive plastic surgery services, such as breast reconstruction and aesthetic surgery, as well as nonsurgical cosmetic treatments like makeovers, skin care, and plastic Reconstructive injectables. Kleinert Kutz has an excellent Surgery reputation for hand surgery, which seems Palazzo’s path to plastic surgery was an to cloud the community’s understanding of organic, albeit unusual, route. Pursuing what a center like theirs can offer. “Plastics fits into the overall hand concept as part of a three-specialty team – plastic surgery, general surgery, and orthopedic surgery,” says Michelle Palazzo, MD, one of Kleinert Kutz’s plastic surgeons. “As a plastic surgeon, my training is quite broad, so I am able to perform just about any cosmetic or reconstructive procedure.” Recently Kleinert Kutz used internet marketing, in the form of Groupon, to expand the marketing message of the practice. The on-line marketing effort resulted in over 200 new aesthetic patients, one of the best responses of the year Dr. Michelle palazzo is for the Louisville area. Positive worda board-certified plastic of-mouth advertising continues as surgeon and breast cancer patients experience what Kleinert Kutz survivor who is utilizing has to offer and spread the word of a career in engiher unique perspective to their experience. neering via a masexpand the comprehensive plastic surgery services of Palazzo states that referrals come ter’s degree from Kleinert Kutz. from physicians or patients who the University understand the broad plastics capabiliof Illinois, she ties that Palazzo and her colleague Luis A. embarked on a master’s thesis testing breast Scheker, MD, offer. Patients are referred implants. While observing breast reconto Palazzo for plastic surgery services by struction and implant surgeries, Palazzo dermatologists, internists, general surgeons, saw the potential for utilizing her artisOB/GYNs, oncologists, and pediatrics for tic interests and engineering skills. So she problems such as skin and breast cancers entered medical school at Southern Illinois or excess breast or abdominal tissue. Often, University, followed by a residency in plaspatients who were previously referred to tic surgery at St. Louis University. She the center for hand issues are subsequently was chief resident when she was diagself-referred for their cosmetic concerns. nosed with breast cancer and went through Palazzo’s toxin and filler patients are pri- breast reconstruction. This experience, she marily women in their 30s to 50s, but the relates, fueled her desire to do a breast number of men is increasing. “We've seen a fellowship at Georgetown University in 26 M.D. UpDate

Washington, DC, and is her passion as a surgeon. She completed her training with a hand and microsurgery fellowship at the Christine M. Kleinert Institute for Hand and Microsurgery. Joining Kleinert Kutz in 2006, Palazzo wanted to build up the group’s plastic surgery services, along with colleague Scheker. “About 75% of my time is spent with hand surgery patients and about 25% is plastics patients. I would like to see that grow to about 50% each,” says Palazzo. She currently performs surgeries at Kleinert Kutz’s surgery center and Floyd Memorial Hospital in New Albany, Indiana, as well as Jewish Hospital, Baptist Hospital East, and Baptist Eastpoint Surgery Center in Louisville. As a fully trained board-certified plastic surgeon, Palazzo performs non-cosmetic procedures such as removal of skin cancers, breast reductions, and breast reconstruction. Breast reductions are a common part of her practice and are often a medical necessity because of the neck, back, and shoulder pain caused by the weight of large breasts. With breast reconstruction, “Patients who are left with a defect from breast cancer treatment may be candidates for reconstruction, which often involves surgery of the other breast for symmetry,” says Palazzo. She may perform immediate reconstruction after a patient undergoes lumpectomy or mastectomy and is still under anesthesia, or she may see a woman post-surgery who wants to improve the appearance of her breasts after treatment. Either way, most cancer-related surgeries, as well as breast reductions if significant enough, are covered by insurance. In addition to toxins such as Botox and non-cosmetic procedures, Palazzo offers the full spectrum of cosmetic procedures such as tummy tucks, liposuction, facelift, eyelid lifts, brow lifts, fillers, and laser treatments. ◆

AudioloGy

It’s Not Just About Hearing by kAthy sAndusky One of the primary reasons a patient visits an audiologist is because they have begun to notice a decrease in their ability to hear, understand, and generally communicate. As audiologists, one step in the process of counseling patients to use new hearing instruments is to tell them they must now re-learn how to listen as sounds are reintroduced to their auditory system. We, as audiologists, should follow our own advice when it comes learning how to listen. We often sit with the patient, ask a battery of questions, note their answers, and follow a protocol of evaluation and treatment, seldom deviating from a “one size fits all” model. We may trick ourselves into thinking that we are individualizing treatment because our industry software chooses different hearing aid settings based on each

patient’s audiogram. If we want to be successful in providing the absolute best result for every patient we see, we must ourselves be dedicated listeners. The ability to become a skilled listener can be a challenge. Often practitioners are much too eager to close a sale than to take the time and put forth the effort to truly LISTEN to what our

patients are saying/asking us. What one patient says is “too loud” may not require the same fix as the next patient with the same complaint. We must not only ask general questions about our patients’ complaints, we must ask probing questions, to get to the real meaning of what they are saying before we can really expect to serve their best interests. As professionals, we should never “jump ahead” of the patient and anticipate what we assume they might say just because we’ve heard the same complaints over and over. In order to provide our patients with the care they deserve, we must provide not only a technical knowledge of their condition and appropriate treatment solutions, we must also provide dedicated, undistracted, listening. We must always remember that effective communication is a two way street, and we need to hold up our end. ◆

Of the more than 600,000 hysterectomies performed annually in the U.S. (1 in 3 women by age 60), 70% are open surgeries,* requiring 6-12 inch incisions, 3-5 day hospital stays and initial recovery times of 6-8 weeks. At Women First, our statistics are much different. Our physicians are pioneers in laparoscopic and daVinci® robotic hysterectomies so that open surgeries are fewer than 6%** of all surgeries we perform, radically reducing your health risks and recovery time. We protect your health and wellbeing through minimally-invasive gyn surgeries with minor incisions, fewer complications, less pain and significantly shorter recovery times… so you can get back to your life quickly! Find out more about Women First’s all-female OB/GYN practice and our comprehensive, innovative health care services for women on our web site. www.wfoflou.com

Women…and leading-edge health care…First, in all we do.

Get back to life sooner after surgery

* The National Women’s Health Information Center and HealthNewsDigest.com ** Based on total number of patient surgeries from 2007-2010 at Women First of Louisville, PLLC

Visit us on Facebook or find out more online: www.wfoflou.com Or call to set up a new patient appointment: (502) 891-8700 Baptist East Medical Pavilion, 3900 Kresge Way, Suite 30, Louisville

Pictured from left to right: Dr. Lori Warren, Dr. Mollie Cartwright, Dr. Rebecca Terry, Dr. Rebecca Booth, Dr. Holly Brown, Dr. Leigh Price, Dr. Kelli Miller, Dr. Stephanie Dutton, Dr. Ann Grider, Dr. Michele Johnson, and Dr. Margarita Terrassa

MaY 2012 27

AudioloGy

tinnitus: is there really something that can be done? by Ann rhoten Epidemiological studies suggest about 50 million people in the United States have tinnitus. The majority of those people experience tinnitus, but their lives are not significantly impacted by it. However, about a quarter suffer or are debilitated by the tinnitus, experiencing depression, loss of concentration, sleep problems, and loss of enjoyment of life. People who suffer with tinnitus have been told they have to “learn to live with it.” Not only is this untrue, but it enhances the feelings of hopelessness and fear by enhancing the belief that tinnitus is an incurable disease. In many cases this negative counseling from healthcare professionals is responsible for transforming the person from someone who experiences tinnitus to someone who suffers from tinnitus. Historically, treatment options have been lacking. We have all heard and seen claims on the internet, in the newspaper, and on the radio advertising “vitamins,” which claim to relieve the sufferer of the tinnitus. Most only have anecdotal evidence with no scientific studies to prove their worth. However, there are things that can be done to help. We now have options, which have been scientifically researched, to offer the tinnitus sufferer. Tinnitus Retraining Therapy (TRT)

28 M.D. UpDate

has repeatedly been demonstrated to be more than 80% effective in relieving the debilitating effects of tinnitus. The majority of people who experience tinnitus habituate to its perception without any intervention. There is no need for treatment. However for the person who suffers from tinnitus, the tinnitus signal cannot be ignored, making it impossible to habituate. TRT is a treatment for tinnitus that helps those people suffering from tinnitus to recategorize it to a neutral signal. When tinnitus becomes neutral, it can be habituated. TRT consists of two components: counseling/education and sound therapy. During counseling sessions, patients are taught about the auditory system and other systems in the brain that are relevant to the source of tinnitus and to the origin of the suffering that sometimes accompanies it. The instruction demystifies tinnitus, downgrading it to a neutral signal with about as much importance as the refrigerator running. This facilitates habituation of the reaction to tinnitus. The second component, sound therapy, utilizes sounds to decrease the contrast between the tinnitus signal and the background neuronal activity. Because our senses work not on the absolute value of a stimulus but on the difference between the stimulus and back-

ground, enhancement of the level of sound coming to the ears results in a decrease in the tinnitus-related signals reaching the cortex. In addition, continued sound therapy eventually reduces the loudness of the tinnitus, aiding in the habituation of its perception. Our goal is to facilitate habituation of both the tinnitus reaction and tinnitus perception. Often people who suffer from tinnitus experience sound tolerance issues as well. Estimates suggest 40% of tinnitus sufferers also experience hyperacusis. People with hyperacusis find everyday sounds, which are not even noticed by most people, to be debilitating. There are several different forms of sound tolerance issues (hyperacusis, misophonia, phonophobia), and each form must be managed in a different way. People who experience sound tolerance issues often restrict social and employment interactions, sometimes living in total isolation. Similar to tinnitus, many healthcare professionals do not know where to refer people who experience these uncommon sound tolerance issues. Professionals trained in TRT are trained to manage both tinnitus and sound tolerance issues. ann Rhoten, Doctor of audiology, is the owner of Kentucky audiology and tinnitus Services, which specializes in the treatment and management of tinnitus and sound tolerance issues. You may reach her by email at arhoten@kytinnitustreatment.com or by calling (859) 554-5384. ◆

send your news items to m.d updAte > news@md-update.com

Barnett joins Baptist Medical associates

LouisviLLe Darel Barnett, MD, pain management, has joined the Baptist Center for Pain Control at 2400 Eastpoint Parkway in Louisville, part of Baptist Medical Associates. Dr. Barnett is a 2006 graduate of the University of Louisville School of Medicine. He completed Darel Barnett, MD his anesthesia residency at the University of Louisville Hospital in 2010. He completed a fellowship in interventional pain management at Washington University-Barnes Jewish Hospital in St. Louis in 2011. He is boardcertified in anesthesia and board-eligible in interventional pain with certification in pain management.

General surgery group joins Baptist Surgical associates

LouisviLLe Peter Conway, MD, and Anthony George Jr., MD, general surgery, have joined Baptist Medical Associates. Their practice is located at 3900 Kresge Way, Ste. 31. Dr. Conway is a 1976 graduate of the University of Louisville School of Medicine. He completed his general surger y/endoscopy peter Conway, MD residency at the University of Louisville Hospital in 1981. He is board certified in general surgery. Dr. George is a 1995 graduate of the University of Louisville School of Medicine.

He completed his general surgery residency at Wright State University in Dayton, Ohio, in 2000. During his residency, he was elected Most Outstanding Resident and was chosen Outstanding Young Man of anthony George Jr., MD American in 1998. He is board certified in general surgery.

Cardiology of Kentucky joins Baptist Medical associates

Cardiology of Kentucky has joined Baptist Medical Associates. Physicians in the group are: Sudhakara Chennareddy, MD, FACC, board certified in cardiovascular medicine, interventional cardiology, and internal medicine, is a 1989 graduate of Rangaraya Medical College at Andhra University in India. Dr. C h e n n a r e d d y Sudhakara completed his Chennareddy, MD, faCC internal medicine residency at Wayne State University School of Medicine in Detroit, Mich., in 1997. He completed a cardiovascular medicine fellowship there in 2000 and an interventional cardiology fellowship at University of Alabama Medical School Hospitals in Birmingham in 2001. He is a fellow of the American College of Cardiology. George Stacy Jr., MD, FACC, board certified in cardiology and internal medicine, is a 1986 graduate of Duke University School of Medicine. Dr. Stacy completed his internal medicine internship and residency at Southwestern Medical Center

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and Parkland Hospital in Dallas in 1989. He completed a cardiology fellowship at Vanderbilt University in Nashville, Tenn., in 1992. He is a fellow of the American College of Cardiology.

Central Kentucky Surgery Joins Lexington Clinic

Lexington Clinic announced the association of Central Kentucky Surgery as part of a strategic alliance to further enhance healthcare service delivery to patients. Central Kentucky Surgery is a physician group practice that has been providing surgical care for residents of Central and Eastern Kentucky since 1993. This association is expected to take effect on August 1, 2012, at which time Central Kentucky Surgery physicians will become members of Lexington Clinicâ&#x20AC;&#x2122;s Associate Physician Network. LeXinGton

Dr. Ryan a. Stanton named Spokesperson of the Year by aCep

LeXinGton Dr. Ryan A. Stanton, director of emergency medicine at UK HealthCare's Good Samaritan Hospital and assistant professor of emergency medicine in the University of Kentucky College of Medicine, has been named the 2012 Spokesperson of the Year by the American College of Emergency Physicians (ACEP). He is one of four emergency medicine physicians who will be honored by the organization. Stanton, along with the three Communications Lifetime Achievement Award recipients, will be recognized May 21 at the 2012 Leadership and Advocacy Conference in Washington D.C. Stanton, who also is vice president and president-elect of the Kentucky Chapter MaY 2012 29

news

of the American College of Emergency Physicians, is being honored for being a versatile and highly visible member of ACEP’s Spokesperson’s Network, regularly offering comment on complicated policy issues as well as consumer health topics, according to ACEP. He appears on television, and is regularly quoted in radio and print stories in national publications.

Central Baptist Hospital uses da Vinci® technology for Weight-Loss Surgery

LeXinGton Bariatric surgeon Dr. G. Derek Weiss performed the first da Vinci Surgical System-assisted gastric banding, sleeve gastrectomy, and greater curvature plication weight-loss procedures in Lexington at Central Baptist Hospital April 11 and 12. Performance of the procedures marked the first time the new technology has been used in Lexington to perform some of the

most popular types of weight-loss surgery. The da Vinci Surgical System is a sophisticated robotic platform designed to expand a surgeon’s capabilities and, in many cases, offer better surgical outcomes than minimally invasive surgery. The da Vinci system gives surgeons greater precision, increased range of motion, improved dexterity and enhanced access to patient anatomy. Through small incisions, the surgeon is able to introduce miniaturized instruments and a high-definition 3-D camera to view the surgical site. The surgeon’s hand movements are translated by robotic and computer technologies into precise micromovements of the da Vinci instruments. Dr. Weiss, who serves as medical director of bariatric surgery at Central Baptist Hospital, says the robotic surgery is a stateof-the-art advancement in medical technology and hopes it will continue to push the limits of weight-loss surgery. He looks

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forward to utilizing the da Vinci technology in many future weight-loss surgical procedures at Central Baptist Hospital, offering patients the potential of less pain, shorter hospitalization and faster recovery.

National accreditation awarded to Baptist Hospital east for excellence in breast care

LouisviLLe Baptist Hospital East has been awarded a three-year full accreditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. This signals to breast cancer patients that they’re receiving the highest quality of care when they choose Baptist East. Baptist East is one of seven Kentucky hospitals to have earned the designation. Accreditation is given to centers following a rigorous evaluation process and performance review to ensure compliance with NAPBC standards. To earn accreditation, a breast center must meet or exceed quality standards in 27 areas established by the NAPBC. Receiving care at a NAPBC-accredited center ensures that a patient will have access to: Comprehensive care, including a full range of leading-edge services A team of professionals to coordinate the best treatment options Information about ongoing clinical trials and new treatment options

Norton Neuroscience Institute enrolls first patient in national aCCLaIM study

LouisviLLe Area multiple sclerosis patients have a unique opportunity to participate in a prestigious National Institutes of Health study with Norton Healthcare. Norton Neuroscience Institute is enrolling patients in a national trial to test the disease-modifying drug abatacept as a treatment for multiple sclerosis (MS). Norton Neuroscience Institute is the only facility in Kentucky, Indiana, and Ohio to participate in this national study. The National Institutes of Health has created the ACCLAIM study, a clinical trial to test whether the drug abatacept

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can stop or delay the progression of relapsing-remitting multiple sclerosis. Norton Neuroscience Institute enrolled its first patient in the ACCLAIM study in April. A number of disease-modifying drugs have been created to slow the advance of multiple sclerosis. Each drug affects patients differently, some with more positive outcomes than others. Because many patients are uncomfortable with the side effects and additional health risks associated with these drugs, researchers are seeking a safer, more effective treatment for MS. Abatacept has been used in studies on several autoimmune diseases, such as rheumatoid arthritis and psoriasis, but it has not been thoroughly tested for treatment of MS until now. Norton Neuroscience Institute is currently involved in five clinical trials for MS, more than any other group in the region.

ephraim McDowell receives four Gold Seals of approval™ from the Joint Commission Ephraim McDowell Regional Medical Center (EMRMC) has earned four Gold Seals of Approval™ for health care excellence. The nation’s most respected health care accrediting agency, The Joint Commission, has awarded EMRMC and their partners, Danville Orthopedics and Sports Medicine and Central Kentucky Spine Center this esteemed recognition for Total Hip & Total Knee Replacement and Spinal Fusion & Laminectomy care. Of the 131 hospitals in Kentucky, Ephraim McDowell Regional Medical Center is the only one to hold this distinction. This is the second such designation for the Total Knee & Total Hip Replacement. The programs underwent an extensive on-site evaluation by an expert medical sur-

DanviLLe, Ky

veyor from The Joint Commission. Each disease-specific program is evaluated for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management.

Norton Healthcare names Charlotte Ipsan president of St. Matthews hospital

LouisviLLe Norton Healthcare today named Charlotte Ipsan, system vice president, pediatric services, Kosair Children’s Hospital, as president, Norton Women’s Hospital / Kosair Children’s Hospital – St. Matthews. Ipsan’s appointment is effective May 1, 2012. Ipsan’s new role encompasses all current daily operations for Norton Suburban Hospital, which is in the process of being converted into the region’s first women’s and children’s hospital, as well as the duties of president of the new hospital once the

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conversion is complete. Ipsan is a former staff nurse at Norton Suburban Hospital, and has served as nurse manager and the director of women’s services within the Columbia system. She went on to serve as an advanced nurse practitioner and the director of the ARNP program for Neonatal Associates PSC and the University of Louisville. In 2009, Ipsan was named system vice president, pediatric services, Kosair Children’s Hospital, and vice president, administration, Kosair Children’s Medical Center – Brownsboro. In her new role, Ipsan will continue to be supported by more than 80 transition project and program work teams.

Jewish Sports Medicine Gets Musculoskeletal Ultrasound

LouisviLLe Jewish Sports Medicine primary care sports medicine physicians and physical

therapists are learning to use a state-of-theart new diagnostic tool, musculoskeletal ultrasound. This cutting-edge technology is one of the first in the region. The musculoskeletal ultrasound exposes part of the body to high-frequency sound waves to produce pictures of muscles, tendons, ligaments, joints, and soft tissue. The machine is an important tool in sports medicine because many sports-related injuries do not appear in an x-ray and are not visible to the naked eye. The machine is located at Jewish Sports Medicine’s Central Station location near Papa John’s Cardinal Stadium and the Jim Patterson Baseball Stadium, making it easily accessible for athletes from the University of Louisville and local high schools. It was purchased through the Jewish Hospital & St. Mary’s Foundation. ◆

the Kentucky Medical association alliance capped off its Spring Leadership Conference with a luncheon featuring keynote speaker patrick House, winner of the Biggest Loser season 10.

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Dr. Philip Bernard Chief, Heinrich A. Werner Division of Pediatric Critical Care at UK HealthCare

KHIE is vital when time is critical. When Dr. Philip Bernard has a severely injured child

date, if he or she has any known drug allergies, who is

transferred to his care, chances are the parents

the primary care physician, and the last time the child

are still in route. How does he quickly obtain crucial

was on antibiotics,” says Bernard. Knowing this kind of

medical information about this child? The answer is

information can make all the difference when he’s trying

the Kentucky Health Information Exchange. “Often,

to save a child’s life. It could make a huge difference for

we can find out if the child’s immunizations are up to

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For a limited time, there is no charge for your hospital or practice to join KHIE. Visit www.khie.ky.gov or call 502-564-7992 to learn more.