M.D. Update Issue #72

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS August 2012

Special Section

Dermatology and Allergy

Planning for Market Leadership How Dermatology Associates of Kentucky became one of the largest freestanding practices in the US.

also inside Volume 3, Number 6

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Dr. David Dunn addresses UofL’s readiness to take on the PPACA. 

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All Women OB/GYN maintains independence.

Dr. Joseph Fowler takes an inquisitive approach to skin allergies.

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Size: 15.5" x 10"

Client: Saint Joseph Hospital Job No: SJH-37407 Title: Heart Care Faces Ad - Lexington

August 2012 1

Letters

A Call for Clean Air. When was the last time you used the expression “A Breath of Fresh Air?” It’s not really in vogue right now. Maybe because it’s not partisan enough or tech speak friendly. Can you text or twitter, “A Breath of Fresh Air” …. ABOFA!! I can’t think of any code word inferences of “A Breath of Fresh Air” that would always favor the user. Who’s against it, unless you’re the “Un-fresh Air?” “Smoke Free” on the other hand, immediately draws attention and lines of offense and defense are formed. Smoke Free Kentucky, a coalition of non-profit businesses and other interest groups is organizing a campaign for a state-wide smoking ban. Legislation that will ban smoking in all public places will be introduced in the Kentucky House of Representatives in 2013 by Representative Susan Westrom, D-Lexington.

Westrom expects opposition from various groups who say the smoking ban is a government intrusion into personal property rights. Studies from the Kentucky Chamber of Commerce say about 70% of Kentucky businesses support a smoking ban. Healthy employees are good for business and studies show that smoking bans have not adversely affected bars and restaurants when enacted.

Outgoing KMA president Dr. Shawn Jones led the Smoke Free Paducah effort.

Dr. Jeremy Engel a family medicine doctor with St. Elizabeth Physicians in Northern Kentucky is running point for a smoke

free northern Kentucky.

Last November, a group of Louisville physicians and healthcare administrators gathered to discuss the deleterious effects of air pollution at “Sacred Air: Breath BY gil Dunn of Life” at the annual Festival of Faiths. During the discussion conducted by KMA past-president Dr. Gordon Tobin, Dr. Jesse Roman, pulmonologist & chair of Department of Medicine stated that “Lung disease is a global problem, an epidemic.” Roman was addressing lung disease as a result of environmental air pollution from bio-mass fuel production.

The point is, there is awareness by many in the healthcare community that breaths of fresh air are needed, not in the metaphorical sense, but the real, everyday sense. We applaud and encourage those community members who are acting on their belief in the fresh air approach.

If you’re interested in aiding the legislative effort, go to www.susanwestrom.com .

August 2012 Best regards Gil Dunn Publisher, M.D. Update

submit your Letter to the editor to Jennifer s. newton At Jnewton@md-updAte.Com 2 M.D. upDAte

Volume 3, Number 6 August 2012 Publishers

Gil Dunn Print gdunn@md-update.com Megan Campbell Smith Digital mcsmith@md-update.com eDitor in Chief

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

Bias Tilford bias.tilford@md-update.com graPhiC Designer

James Shambhu art@md-update.com

Contributors: Lisa English Hinkle Dr. Kelly C. McCants Scott Neal Calvin Rasey

ContaCt us: aDvertising:

Bias Tilford bias.tilford@md-update.com

integrateD PhysiCian Marketing:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax standard class mail paid in Lebanon Junction, Ky. postmaster: please send notices on Form 3579 to 921 Beasley street, suite 210 Lexington, KY 40509 M.D. update is peer reviewed for accuracy.

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

Copyright 2011 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher. please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter. thank you.

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

Contents Cover story

aug 2012 voluMe 3, nuMber 6

2 letters 4 regional PolitiCs 5 global aDvanCeMents 8 finanCials 9 legal Matters 11 it’s your Money 12 one on one 14 PraCtiCal insight 16 CoorDination of Care 17 Cover story 22 sPeCial seCtion -allergy anD DerMatology 26 news & events

Planning for Market Leadership

how dermatology Associates of Kentucky became one of the largest freestanding practices in the us.

by GiL dunn photoGrAphy by Liz hAeberLin pAGe 17

ON tHe COVer: guiglia, MD; April ramsey, MD; Charlie Becknell, MD; (seated) Ira p. Mersack, MD; Fernando r. de Castro, MD; Laurie r. Massa, MD; sherri Baer, pA-C; Anir Dhir, MD. Not pictured: todd Clark, MD. (L-r) Mary

speCiAL seCtion Dermatology anD allergy

22 Family Allergy & Asthma

24 inquisitive Approach

August 2012 3

reGionAL poLitiCs

westrom presses on for smoke-free Kentucky

by GiL dunn leXington Kentucky legislators are preparing to introduce a bill in 2013 that would codify statewide restrictions on smoking in public places and enclosed work places in Kentucky. The bill would not restrict smoking in cars, public outdoor places or private places. A similar bill was introduced in the House of Representatives in 2012, by Susan Westrom, D-79th Lexington, but did not reach the House floor for a vote.

Westrom says that in an election year, such as 2012, members did not want to vote on a controversial bill when they were up for re-election in November. Westrom says her decision not to push a full house vote on her legislation was “saving political capital” until she needed it.

According to Westrom, a statewide ordinance would help set minimum standards for local smoking restrictions. All local smoking laws would have to comply with the state law, but local regulations could add additional restrictions on smoking if desired. Westrom emphasizes that her legislation is a commonsense approach to a public health issue. “Protecting the public

health is government’s role, just like having children vaccinated. We are not proposing a ’smoking ban,’ she says, but restrictions on where people can smoke.”

Westrom expects opposition from factions in rural, tobacco growing areas and

ellen J. Hahn, phD, rN, FAAN, with smoke Free Kentucky with Mrs. sally stevens, Dr. David stevens, representative susan Westrom, Mike scanlon, president, thomas & King at smoke Free Kentucky awareness event in Lexington on August 1, 2012. stevens and scanlon were members of Lexington City Council when the first smoke-free workplace ordinance in Kentucky was passed in 2004.

from organized lobbying from the tobacco industry. Westrom says there that there is public support for statewide smoking restric-

Kentucky representative susan westrom, d-79 Lexington, is working toward a statewide ordinance that would set minimum standards for local smoking restrictions. All local smoking laws would have to comply with the state law, but local regulations could add additional restrictions on smoking if desired.

4 M.D. upDAte

tions, citing a poll taken by “Smoke Free Kentucky” that says 59% of Kentuckians support a statewide law restricting smoking.

A study from the UK College of Nursing and co- authored by KMA president Shawn C. Jones, MD, on the before and after

effects of a smoke free ordinance in Paducah measured indoor air quality from 20052007 and again 2007-2009. There was an 89% decline in measured indoor air pollution after the smoking ban went into effect in Paducah in 2007. (Kentucky Department of Public Health, Special Series), November 2011/Vol 109) Jones says that when his term as KMA president is over in September 2012, he will vigorously work for the statewide Smoke Free Kentucky Coalition. “We have the science that proves second hand smoke is harmful,” says Jones. Additionally, Jones says the positive effects that Smoke Free Paducah has had on businesses and anecdotal evidence he has personally received tell him, “It’s the right thing to do and the time is now.”

Westrom concurs. “This is a golden opportunity for Kentucky physicians to step up and be the guardians of the public’s health that people expect them to be.” ◆

GLobAL AdvAnCements think you know thymus?

According to Dr. Stefanie Seltmann, head of Press and Public Relations for the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), German researchers have disproven “a dogma of immunology” that the thymus depends upon progenitor cells from the bone marrow to develop T lymphocytes.

In a July 2012 press release, Seltmann states that DKFZ researches have shown that “the thymus is obviously capable of producing mature T cells for several months without any supply from the bone marrow.” The animal experiments, conducted by Hans-Reimer Rodewald, head of the Division of Cellular Immunology, Vera Martins, and DKFZ colleagues, led to the startling observation that, when bone marrow is compromised, the thymus gland acts like a reservoir to ensure a steady production of immune cells. Read more about this in the Journal of Experimental Medicine.

heiDelberg, gerMany

Vera C. Martins, eliana ruggiero, susan M. schlenner, Vikas Madan, Manfred schmidt, pamela J. Fink, Christof von Kalle, and Hans-reimer rodewald: thymus-autonomous t cell development in the absence of progenitor import, Journal of experimental Medicine, doi: 10.1084/jem.20120846

us-german Bio/meD-tech innovators meet in Dual conferences

The international innovation network NYCMedTech.com, and its counterpart in Frankfurt, Germany, announce dual programs for both chapters Sept 11 and 13, 2012 that will bring together many of the world’s preeminent leaders in bio/med-tech within an interdisciplinary setting conducive to the acceleration of emerging health solutions. frankfurtmeDtech, septemBer 11, 2012, frankfurt, germany

Keynote speaker Robert Weiss, chairman and president of the X PRIZE Foundation, will discuss how the X PRIZE brings about radical breakthroughs for the benefit of humanity, thereby inspiring the formation of new industries and the revitalization of markets that are currently stuck due to existing failures or a commonly held belief that a solution is not possible. Also presenting will be Heat Biologics (Heat) from North Carolina. Heat is a clinical-stage company focused on developing its novel “ImPACT” (Immune PanAntigen Cytotoxic Therapy) off-the-shelf therapeutic vaccines to combat a wide range of cancers and other diseases. More info at FrankfurtMedTech.de nycmeDtech, septemBer 13, 2012, new york, ny

The NYCMedTech conference will begin with a presentation by David Roth, cochairman of Board of Directors at the Tick-Borne Disease Alliance (TBDA) and a managing director at Blackstone Real Estate Advisors of New York. Roth will discuss his decision to fund an X PRIZE challenge. Keynote speaker Dr. Eric Schadt, Mount Sinai Medical School, chairman and professor, Department of Genetics and Genomic Sciences and director, Institute of Genomics and Multiscale Biology, will discuss his efforts to generate and integrate large-scale, high-dimension molecular, cellular, and clinical data to build more predictive models to better diagnose and treat disease. More info at NYCMedTech.com. ◆

August 2012 5

the future of heALth mediA

social media for a healthy practice leXington A few months back, I sat in Facebook’s New York office discussing business use cases for the ubiquitous social platform. That’s where I learned this gem-dandy: One billion people use Facebook.

I emphasize: One-seventh of the world’s population uses Facebook.

That’s on the web, on their mobiles, and almost all of them are regular users.

I’m a regular Facebook user. Go ahead and look me up (0megancampbellsmith0).

I post photos of my adorable children, my caring husband, and I discover a ton of new music through the Spotify app, my new favorite improvement to the Facebook experience.

But importantly to you, I reach about 56,000 Facebook users everyday with my links to the articles we publish here in M.D.

Megan Campbell smith, Mentelle Media’s creative director, recently completed a fellowship in digital media at the City university of New York.

UPDATE. Because of it, our online readership is more than double our print readership, and our site analytics show that almost all of our digital readers are patients.

What all this personal disclosure serves to illustrate is that social media is more than a place where folks go to be liked. They do that, but clever folks like you can use social media

to glean invaluable insights into your customer, vendor, and peer communities. Used well, social media can impact all areas of your business.

I propose, here at the one billion benchmark, that it is time to stop thinking of social media as a place where people go to be sociable and start thinking of it as a resource to make your business more impactful, efficient, and profitable.

everyone Is Doing It, except Doctors

To greater or lesser effect, social media is now the primary access point to digital information for people the world over. With about six times the influence of Google, social media connects more people to the things that matter to them than any other known source.

And what matters most to people?

Sturgill Turner’s health care legal team is committed to providing comprehensive legal services to health care professionals, institutions and managed care organizations.

Serving health care providers with integrity.

LEXINGTON ◆ STURGILLTURNER.COM 6 M.D. upDAte

THIS IS AN ADVERTISEMENT

pHOtO BY VOLKer LANNert

by meGAn C. smith

Second only to sex, the most popular reason people go to the web is to get health and medical information.

So what’s the problem? Very few healthcare providers actively contribute to making the web of medical information interesting, factual or useful. An October 2011 poll by the Journal of General Internal Medicine says 94% of physicians shy from social media because they do not trust it to communicate effectively without compromising patient health information.

The solution, of course, is to stop thinking of social media as idle chatter. Some of it may be, but a good bit more really matters. Think of social media with your scientific mind, and you will realize its core technological competency is built to deliver benefit to your business practices. Communication, surely, but also transactional processes like scheduling and billing, strategy processes like assess-

revenue by selling ads and licensing content.

Yet, you don’t have to be big and notable to start taking advantage of social media’s strengths right away.

If you want to increase customer satisfaction, increase compliance, reduce the time you spend counseling patients individually while increasing the overall quality of patient information, consider developing a social media channel for patients with conditions that benefit from information sharing. Diabetes, cancer, and lupus

to learn more about social media strategies for your practice, contact Megan Campbell smith at mcsmith@md-update.com. ◆

KNOW SOMEONE FACING A

start thinking of it as a resource to make your business more impactful, efficient, and profitable.

WEIGHTY DECISION? FREE BARIATRIC SURGERY INFO SESSIONS. QUESTIONS ANSWERED. LIVES CHANGED.

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

ing community need, and quality processes like improved compliance, all can be accomplished with minimal capital investment when you utilize social media channels to complement your traditional business practices.

Incidentally, if you are one of the thousands of doctors who worry that social media is trying to encroach on your domain, take heart in this fact: The Pew Internet & American Life Project (2011) found that 90% of Americans still believe that medical advice comes from doctors, not “the web.” Here is where physicians and other healthcare providers who maintain social media connections with their patients really flourish.

One reason for social media’s exponential growth is its defiance of the zero-sum mentality. In social media, there’s always more to go around. Social media eliminates barriers, and your marketplace is ever-increasing.

Across the US, several notable health systems are already applying social media’s strengths to their core business strategies.

The Mayo Clinic, for example, operates its own social publishing platform which serves to reinforce the brand, reduce customer acquisition costs, and improve patient compliance and outcomes. They also earn extra

groups are well known, but maybe your practice should have an asthma group, an ADHD circle, or a breaks and falls club. Hopefully you won’t have many permanent members, but your customers will remember the guidance and bonding and recommend it to friends when they read on Facebook, “OMG My son just fell of the jungle gym. Heading to ER now.”

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, Sept. 13 (6:30 p.m.)

• Saturday, Sept. 15 (10 a.m.)

• Thursday, Oct. 4 (6:30 p.m.)

• Saturday, Oct. 20 (10 a.m.)

facebook.com/baptisteastweightloss

baptisteast.com/weightloss

August 2012 7

finAnCe

financial planning and Cars Cars are ubiquitous and expensive and they are many things to different people. For some they are merely transportation. For others they are a hobby, work of art, or cultural icon.

Admittedly, I am a “car guy.” My first car was a red ’63 Chevy Impala SS with a bellowing four barrel carb, four on the floor, and a 4:11 ratio rear end that would get us to the car’s top speed in about 1/8 mile from a standing start. Since living in Germany 35 years ago, I have driven mostly BMWs for their outstanding handling. Once clients know this about me, it is easy for them to talk with me about a planned automobile purchase. I am happy to oblige. And since cars usually represent a major purchase and because our firm is all about helping people make better financial decisions, we are glad to help our clients where we can. I have even visited dealerships with or for some clients.

It is entirely helpful to know the rules of the sales game before sitting down at the desk to discuss “the deal” with the salesperson. Recently, a sales manager at a new car dealership explained how he must have an average profit of $x on all the cars they sell. He drew a bell curve and said that customers fall into three camps: there are some few (the upper tail on the bell curve) that will simply pay, without negotiation, whatever the dealer asks. Another few (the lower tail) will negotiate hard to get the car for as little as possible— often for approximately “dealer cost.” The remainder (the vast middle of the bell curve) will negotiate some, but not extensively, allowing the dealership to make an average profit. Part of the salesperson’s job is to determine where you, the buyer, fall on that

curve and then to exploit that maximize profit.

I assured him that our client wanted to be on the lower tail of his bell curve. It might take a few hours, but it could save thousands in the BY scott Neal process.

I recently received a Saturday morning text message from one of our clients asking if I knew the fair price for “paperwork” when buying a new car. He had negotiated the price of the car on a previous visit to the dealership. We had quantified the effect that his purchase would have on the family’s living standard. As he was taking delivery, the salesperson presented him with a larger than expected cost including $599 for “paperwork prep.” Thus, his question.

My response was that it was simply an add-on to try to re-negotiate the price of the car. He referred the salesperson back to the agreed-upon price, resolved that he wouldn’t pay more, and the paperwork fee was eliminated.

New car buying services can do much of the work for you. USAA claims that they save members $4,606 off the manufacturer’s suggested retail price.

AAA has “partnered” with dealers who are willing to offer its members a great price up front. Autofinder. com purports to be the largest new car buying service with pre-negotiated discount dealer pricing for all new vehicles. Even if you want to buy locally from your favorite dealership

houses and cars are both personal assets that are too often ignored in financial plans. the cost of cars purchased during one’s lifetime is usually only second to houses.

8 M.D. upDAte

or salesperson, these services may simply level the playing field for you to know that you have a fair price.

The danger of buying a used car is not what it used to be. We all know that the new car depreciates quickly after you drive it off the lot and that buying a “nearly new” car can be a terrific way to save some money.

I have bought 5 cars from distant sellers on either eBay or via the classified ads in a car club magazine. It became an adventure to pick up a BMW on Long Island and another in New Hampshire and drive them home. That process is obviously not without its pitfalls, but if you know what you want to own it’s a great place to find out where it can be found and what the price is likely to be. Shipping a car is always an option when you buy from afar, but where’s the fun in that?

Leasing a car often makes sense for many people, but it is highly situational.

There are many factors to consider when choosing leasing vs. purchasing and that will be the subject of a future article. Did you know that you can lease a used car by stepping into somebody else’s lease? Check out www.swapalease.com for how to do it.

This is somewhat like an eBay purchase and some of the same caveats apply. You take certain avoidable risks if you follow the company’s process and sign the paperwork before you take delivery. Sometimes people will actually pay you to take over their lease.

It’s worth considering.

Houses and cars are both personal assets that are too often ignored in financial plans. The cost of cars purchased during one’s lifetime is usually only second to houses. However, there is a significant difference: depreciation on one and appreciation on the other. Before plunking down tens of thousands of dollars on a depreciating asset, make sure that you have done your homework. scott Neal, is the president of D. scott Neal, Inc. a fee-only financial advisory firm. Contact him via email at scott@dsneal.com or 800344-9098. Visit the firm’s website at www. dsneal.com ◆

LeGAL mAtters

the perils of prescribing Controlled substances As the Kentucky Board of Medical Licensure’s (KBML) implementing regulations for House Bill 1 are now effective on an emergency basis for the next six months, physicians, nurse practitioners, and other licensed prescribers have specific statutory and regulatory requirements establishing when and how they may prescribe controlled substances. These rules must be followed or physicians and others may face serious consequences that include criminal misdemeanor offenses, loss of prescribing privileges, and disciplinary actions against professional licenses. All practitioners must pay careful attention to these rules because even minor violations may create problems. Because the KBML’s regulations are more comprehensive than the requirements of House Bill 1, a great deal of confusion exists concerning what physicians and practitioners are required to do and when.

Recognizing that compliance with its emergency regulations may mean major changes in the way physicians practice medicine, the KBML has announced that it expects full compliance by October 1, which creates a welcome grace period. While the ambiguities and details will be worked out over the course of the next six months, physicians should take heed and incorporate these things into their practices.

Assess your practice to assure that it is not an unintentional pain management facility that must register with the Cabinet or the KBML

The definition of a pain management facility is so broad that it may cover private physician practices in unexpected ways. House Bill 1 defines a pain management facility to be a facility where the majority of the patients receiving treatment from the practitioners at the facility are provided treatment for pain that includes the use of controlled substances, and (i) the facility’s practice primary component is the treatment of pain; or (ii) the facility advertises in any medium for any type of pain management services.

This means that even though a physician’s specialty practice may be something other

than pain management, if more than 50% of the patients are treated for pain and prescribed controlled substances for pain, then the practice may constitute a pain treatment facilBY Lisa english Hinkle ity regardless of whether the practice is an urgent treatment center, an internal medicine practice, or other medical practice. Neither the statute nor the KBML’s regulation is clear about whether a subspecialty practice like orthopedic surgery would constitute a pain treatment facility in the event that a majority of its patients present seeking treatment for pain or painful conditions. If the practice advertises that it treats pain, then it qualifies as a pain treatment facility.

Pain treatment facilities must register with the Cabinet for Health and Family Services and obtain a license if the ownership of the entity includes only non-physicians or with the KBML if the ownership of the entity consists of physicians. The KBML has noted on its website that the deadline for registration is September 1, 2012.

Major exceptions to the classification as a pain treatment facility exist for hospitals, which include hospital clinics and the offices of their employed physicians; educational institutions; hospice programs; ASCs; and long term care facilities. Physicians should know that failure to register when required may constitute a misdemeanor and result in disciplinary action.

register for KAsper

House Bill 1 contains strong requirements that every physician who holds a DEA permit must register to use KASPER. In addition, the KBML requires physicians to register within three days of receipt of DEA permit. In fact, the KBML regulations state that to lawfully prescribe controlled substances, a physician must have the DEA permit and register with KASPER.

Make a KAsper inquiry every time a controlled substance is prescribed

House Bill 1 and the KBML establish different standards for prescribing controlled substances and requirements for KASPER inquiries. House Bill 1 applies to Schedule II controlled substances and Schedule III controlled substances containing hydrocodone. The KBML’s regulations, on the other hand, apply to all Schedule II and Schedule III controlled substances and selected Schedule IV and V controlled substances that have been determined to be highly addictive. These Schedule IV and V medications include Ambien, Anorexics, Ativan, Klonopin, Librium, Nubain, Oxazepam, Phentermine, Soma, Stadol, Stadol NS, Tramadol, Valium, Versed, and Xanax.

While House Bill 1 only requires KASPER inquiries when Schedule II drugs and Schedule III drugs containing hydrocodone are prescribed, the KBML requires that a physician request and review a KASPER report before prescribing any of the controlled substances listed above.

Exceptions to the requirement for KASPER inquiries exist for hospice or end of life patients, cancer patients, residents of a long term care facility, and for patients experiencing an emergency. Interestingly, the requirements for physicians to obtain KASPER reports for hospital patients differ between House Bill 1 and the KBML regulations. House Bill 1 states that an admitting physician should query KASPER and then make the report part of the patient’s medical record. An inpatient’s subsequent physicians satisfy the KASPER inquiry requirement when they review the report in the medical record prior to prescribing controlled substances and prior to discharging the patient with a prescription for no more than a 72-hour supply of controlled substances.

Both House Bill 1 and the KBML regulations have mandatory requirements for KASPER inquiries. Because of the penalties associated with a failure to adhere to the requirements, physicians should establish a KASPER inquiry process as part of the rouAugust 2012 9

LeGAL mAtters tine practice of medicine, even if this means making inquiries that may be unnecessary.

Regulators have promised that the KASPER inquiry system will be quick and convenient for users.

Implement the prescribing standards for controlled substances into the routine practice of medicine Both House Bill 1 and the KBML regulations establish prescribing standards for controlled substances that must be followed and have the potential to subject a physician to serious disciplinary action for violations.

In fact, the KBML has also revised its disciplinary regulations to create new standards to make it easier to issue emergency orders restricting physicians from prescribing or practicing. The standards for prescribing are complicated and vary based upon the timing of the prescribing.

Initial prescribing

For initial prescribing of controlled substances, a physician must verify the patient’s ID, perform a history and focused physical that is documented; obtain and review a KASPER report; make a deliberate decision to prescribe controlled substances that is medically appropriate after weighing the risks and benefits; prescribe only the amount of medication necessary to treat a specific medical complaint for a definite, pre-determined time period; not prescribe long-acting or controlled release opioids for acute pain; and explain to the patient the need to discontinue the medication when the patient’s condition is resolved.

patient’s complaint if necessary to justify the long-term prescribing of controlled substances; establish and document a working diagnosis; formulate a treatment plan with specific and measureable goals; screen the patient for abuse, dependence and psychiatric or psychological conditions that may create a diversion risk and make appropriate referrals; obtain a baseline urine drug screen and not prescribe controlled substances if the test indicates improper use; obtain the patient’s’ informed consent to the long term use of controlled substances; and try noncontrolled substances treatments prior to prescribing.

Long term prescribing

When a physician decides to prescribe controlled substances beyond the initial 3 month period, the KBML emergency regulations require: seeing the patient once a month until medication is titrated and not causing side effects and that sufficient monitoring is in place; evaluating the patient and reviewing the working diagnosis; reviewing functional goals and obtaining consent to speak with others; managing breakthrough pain by identifying the triggers and attempting noncontrolled medications; performing or assuring that the patient’s primary care physician has performed an annual preventive health screening or exam; reviewing KASPER reports at least every three months and taking action immediately if the report indicates that the patient is not taking the medication or diverting medications and reporting it to law enforcement; stopping or tapering prescribing; performing random urine drug screens; performing random unannounced pill counts; and discontinuation of treatment and to refer an addiction specialist when there is no improvement, significant adverse effects of drug-seeking behavior, or diversion.

Additional standards have been promulgated for physicians who prescribe within the emergency department.

regulators have promised that the KAsper inquiry system will be quick and convenient for users.

prescribing for more than 3 months

If a physician intends to prescribe any controlled substance for a period more than three months, the physician shall perform and document a thorough history that includes patient and family history of abuse, dependence and psychosocial history; perform and document a comprehensive physical exam; obtain medical records from other physicians who have previously treated the 10 M.D. upDAte

Documentation requirements

Physicians must document all relevant

information in the patient’s medical record in sufficient detail to provide for (1) a meaningful diagnosis and treatment; (2) the safe and medically appropriate assumption of care by another physician at any given time; and (3) the KBML to determine whether the physician is conforming to professional standards for prescribing.

patient education requirements

In addition to the professional standards for prescribing controlled substances, the KBML has declared that it is the acceptable and prevailing medical practice to educate patients on the following matters about controlled substances through verbal or written counseling including proper use; impact on driving and work safety; effect of use during pregnancy; potential for overdose and appropriate response to overdose; and safe storage and proper disposal of controlled substances. This, of course, means that a physician must provide educational consultation or materials to patients or risk finding that

Conclusion

House Bill 1 and the KBML’s emergency regulations change how physicians must operate on a daily basis and interact with their patients. The Governor’s Office has announced that public hearings on the KBML regulations will be held on September 26 and 27, 2012 in Frankfort.

These meetings will provide an opportunity for comments on the KBML regulations. House Bill 1, on the other hand, has become law, is incorporated into Kentucky’s statutes, and is not subject to anything but legislative change. Regardless, concern about the ability of physicians to perform all the tasks are required by the emergency regulations, the KBML’s regulations are now effective even though a grace period for enforcement exists. Good luck!

Lisa english Hinkle is a partner of McBrayer, Mcginnis, Leslie & Kirkland, pLLC. Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. she can be reached at lhinkle@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. ◆

it’s your money

what is your estate and how do you Create A plan?

There is a tongue-in cheek expression that says your Estate is what’s above the ground when you are put under the ground. Being that estate planning can be traced as far back as the fourth Egyptian Dynasty it is obviously not a new trend; it is something that has always been on our minds.

Estate planning is the preparation for the distribution and management of a person’s estate after death; through the use of wills, trusts, insurance policies, tax liabilities and other arrangements. Your estate is made up of everything you own, including: cash, stock, bonds, retirement’s accounts, personal effects, life insurance, business and real estate.

As you can see, one does not have to be a Rockefeller to have a substantial estate and estate tax. Although the federal estate tax has been repealed for 2010, add restructuring in 2011 with a $5,000,000 extension rate and a 35% tax rate, for 2011 and 2012. Currently, this is only a two year Hiatus until the much feared return of the prior law in 2013 with a $1,000,000 exclusion and maximum 55% tax rate. Also, we can’t forget that Kentucky is one of the seven states that have an inheritance tax; which is a tax upon the privilege of an heir to receive assets from an estate and trust. In

Inter Vivos Trust is a contract that holds to and controls your assets.

One difference between a Will and Living Trust is when they take effect. A Will only takes effect when you die, a

BY Calvin r. rasey Living Trust takes effect when you execute it and transfer assets into it. A Living Trust will allow you to avoid the probate process which can be expensive, time consuming and very public.  Durable Power of Attorney—A Durable Power of Attorney allows you to designate someone to work on your behalf in regards to your financial affairs; whether it be immediately or upon an incapacitation or unavailability. This can include, but not be limited to, paying bills, collecting AR’s, filing taxes, dealing with lawsuits and litigations or investments.  Health Care Proxy—Also called a Durable Power of Attorney for Health Care,

estate planning is the preparation for the distribution and management of a person’s estate after death. other words, an inheritance tax is based upon who receives the deceased person’s property and how much they receive.

An estate plan is much more than who gets what when you are finished with it, but is also the incorporation of asset protection and tax reduction strategies as well.

There are a few estate planning tools we should all take advantage of:  Wills—A Will is a written document in which you identify what you would like done with your assets upon your death. It is also the best place to name guardians for children under the age of 18.  Living Trust—A Living Trust or an

a Health Care Proxy is a document that identifies the person you would like to make medical decisions on your behalf, if you become unable to make them yourself. This should include a HIPAA release form that will allow medical professionals to discuss your medical condition with your personal representative.  Life Insurance—Life Insurance planning is an essential component of the estate planning process. The goal of Life Insurance in the Estate Plan depends on many factors specific to the estate owner. Generally, Life Insurance goals can be divided into two categories: Estate

Enhancement and Estate Liquidity.  Living Will—A Living Will is an instrument, signed with the formalities necessary for a will, by which a person states the intention to refuse medical treatment and releases healthcare providers from all liability if the person becomes terminally ill and unable to communicate such refusal.  Business Succession Plan—Succession planning is the process of identifying and developing people with potential to fill key leadership or ownership positions at the instance of retirement or death. Business Succession planning seeks to manage all issues that can arise, in order to allow for a smooth transition between current and future owners.

As the legal complexities surrounding the transfer of property at death becomes further complicated by federal and state taxes, more people are becoming concerned about protecting their property from tax erosion. In essences Estate Planning today is the art of accumulating, conserving and possibly transferring portions of one’s property during their lifetime and disposing of property at death in a manner that minimizes taxes, probate costs and other related expenses, while remaining consistent with one’s lifetime goals.

The content in this article gives a very brief description of general Estate Planning.

To meet an individual’s needs, a plan must be carefully tailored by an experienced team of advisors. If you know where to turn, I encourage you to get your current plan reviewed or create a new plan. Remember the words of Winston Churchill: “Failure to plan is planning to fail.” ◆ securities offered through securities America Company.*member finrA/sipC·Calvin r. rasey·registered representative Advisory services offered through securities America Advisor’s, inC.·A registered investment Advisor·Calvin r. rasey·investment Advisor representative securities American & its representatives do not provide tax or legal advice∙tax-law is subject to frequent change; therefore it is important to coordinate with your tax advisor for the latest irs rulings and specific tax advice, prior to undertaking and investment plan. physicians financial services ii, LLC and securities America Companies are not under Common ownership

August 2012 11

one on one

uofL Leadership ready to move on ppACA

M.D. UPDATE editor-in-chief Jennifer S. Newton sits down with David L. Dunn, MD, PhD, UofL’s executive vice president for health affairs. David L. Dunn, MD, PhD, is executive vice president for health affairs at UofL. Dunn has 35 years’ experience in healthcare as a general and transplant surgeon and as an administrator and healthcare policy expert. He joined UofL in July 2011. rently probably won’t even think of going to a physician because it would be a choice between out-ofpocket expenses for a preventive medicine visit or buying groceries or gasoline for their car will have more accessible and affordable healthcare. We’re the third sickest state in the union, and so that’s a really good thing to have these people be able to access healthcare.

Jennifer s. newton: what was your reaction to the supreme Court’s ruling to uphold the Affordable Care Act? David L. Dunn: I was very pleased with it. It extends the scope of healthcare to millions more Americans, which as a physician I believe to be a really great thing. what’s the biggest challenge presented by the Affordable Care Act? I think the biggest problem we face with the Affordable Care Act being enacted is the looming shortage of physicians and other healthcare practitioners, but in particular, primary care physicians and mid-level providers, such as nurse practitioners, so called physician-extenders. The prediction for the Commonwealth out to about 2020, but it could occur before then, is that we could face a shortage of as many as 3,000 to 4,000 physician providers. With the bill extending Medicaid, if the state decides to opt in to 133% of the poverty level, we could have as many as 300,000 to 350,000, maybe as many as 400,000, new Medicaid patients just within the Commonwealth alone.

The bottom line is the bill does not provide for health science centers, such as this one at UofL, to be supported in ways so that we can recruit more faculty, train the next generation of physicians and nurses, and doesn’t provide us the residency slots to do that. Those are capped at 1997 levels and have never been changed. It also 12 M.D. upDAte

doesn’t change the dynamic that it is hospitals rather than medical schools that own the residency slots. So if I were to create a much more perfect world for this, the medical school would actually get the residency GME dollars, both IME and DME. what does it mean for the healthcare public in Kentucky?

My opinion is it means good things because the 350,000 more people who cur-

do you think this will have financial implications for physicians in their practices?

I think it depends on how the practice is run. If you look at University Medical Center, this likely will be a boon to the tune of about $6 to 10 million because we serve a population that is 25% indigent, completely unable to pay, and this would allow some of these people to reimburse the hospital through Medicaid. UMC provides $80 million in indigent care, and that’s not even counting what University physicians and our clinical faculty provide. We receive funding from metro, state, and other sources, but there’s still a gap of about $20 million.

There are also concerns about what will occur after 2016 when the federal government is no longer supporting 90% of the financial implementation of the expanded program with the state being on the hook for the remainder. In the current program rather than this expanded program, federal covers 70%, state covers 30% of the cost. With many more covered lives, there are concerns about

the financial burden that creates. do you have any recommendations for Kentucky physicians on how they can prepare for the changes and capitalize on the good things that are happening?

The other process that’s running alongside this is the formation and approval of Accountable Care Organizations. Over 80 new ACOs were just approved nationally, three in the Commonwealth, so I think that’s something the physician groups should think about. There are a series of moving parts to federal healthcare reform and the other is high-tech, which is the implementation of electronic health records, e-prescribing, and related initiatives. So, forming or joining an ACO, changing how the practice works using mid-level providers as physician extenders, and moving toward a patient centered medical home model are just a few things to consider.

personally i think the benefits far outweigh those liabilities because if this is done right, more people will have healthcare, more people will have access to preventive medicine, and that should decrease the overall disease burden, as the costs of medicine are huge for emergency care and for dealing with chronic disease.

There are a number of physician practices across the nation that are becoming very innovative with new models.

with primary care physicians being such as huge emphasis and not necessarily being the specialty with the highest income, how do you get more people into that specialty and how do you make that work?

We should be paying them more money, and we should be providing incentives for them to go into these fields and also to practice in underserved areas. We don’t have the right formulas right now for that. There is a different mechanism, which is forming large multi-disciplinary group practices such as we are doing here through University of Louisville physicians or health system physician employment, when you have everyone under the same financial umbrella you can create those financial incentives internally, if you choose to do so. ◆

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August 2012 13

prACtiCAL insiGht  ob/Gyn

All women ob/Gyn maintains independence in a Changing healthcare Landscape

by Jennifer s. newton

(JHSMH) in this case, elicited concern from the physicians of All Women. While the final arrangement with JHSMH allows the physicians of PGO to remain independent, all other elements of the practices are owned by the system, including employees and all assets.

While Salerno asserts her practice was never out to make more money for the physicians, financial implications were certainly at the forefront of their decision to remain independent. As a practice without any loans or debt, one that pays its physicians based on production rather than a monthly guarantee, and one that invested

louisville To be or not to be… independent, affiliated, or employed. That is the question plaguing many practices across the Commonwealth and the nation. The changing landscape of healthcare is prompting physicians to take stock of their practices and position themselves for longevity.

For All Women OB/GYN in Louisville, who recently faced a hospital-affiliation opportunity, the answer was independence.

One of the original groups in talks for the Premier Gynecology & Obstetrics alliance (PGO), featured on the cover of M.D. UPDATE in May 2012, All Women opted out of the scenario and remained one of a handful of Louisville OB/GYN practices that are still independent.

All Women was originally drawn to the idea of PGO because it presented the opportunity to be part of a bigger entity that would have more leverage with insurance companies and would promote fair and equi“We felt that somehow the physician table reimburseis always the one that pays the price ments among the of healthcare costs and also the one to group’s membe blamed for escalation in healthcare bers. “We felt expenses, but in reality our fees have that somehow not been going up for years,” says the physician is elena salerno, MD, board-certified OB/ gYN with All Women since 1999. always the one over $1 million to implethat pays the ment EMR in 2004, they price of healthwere somewhat immune to care costs and also the one to be blamed the immediate financial implications of hosfor escalation in healthcare expenses, but in pital-affiliated benefits. However, she says reality our fees have not been going up for the main reason was, “I think it was more years,” says Elena Salerno, MD, board-certi- the uncertainty of losing the freedom and fied OB/GYN with All Women since 1999. selling our assets that was the major part.”

The overwhelming estimated cost Without assets the practice would be left of the group merger and the subsequent with nothing to go back to if they became involvement of a health system partner, dissatisfied with the arrangement. Salerno Jewish Hospital & St. Mary’s Healthcare was also mindful of the jobs that can be lost 14 M.D. upDAte

as a result of centralizing billing and managerial tasks under hospital employment and the impact on their staff.

Impact on patients

Hospital affiliations can provide economic stability, cost savings on overhead, and access to new technology, but for the time being, the perceived detriments to affiliation outweighed the positives for All Women.

Being able to refer to the physician she deems most qualified rather than whoever is in a hospital network is a liberty Salerno values.

“We always use a wide variety of resources to refer patients because we don’t have an alliance with anybody,” she says. Capitalizing on referral patterns can be a boon for hospitals. “What you produce as an axillary – your mammograms, all your referrals, your CT scans, your surgeries, your deliveries – it’s everything you do outside the office that really doesn’t bring money to you as a practice, but it’s a huge amount of money for the hospital.”

Differences in hospital or outpatient coding versus inoffice coding can also increase healthcare costs for the patient and for the system as a whole.

Salerno cautions that mammograms, ultrasounds, and lab work funneled to a hospital or outpatient center to centralize services can end up costing almost double that of those performed in-office.

A practice of five board-certified female OB/GYNs – Lisa Crawford, MD, Sarah Cawthon, MD, Amy Deeley, MD, Aimee Paul, MD, and Salerno – All Women OB/ GYN is located in the Women’s Pavilion at Norton Suburban Hospital, but the physicians deliver at both Suburban and Baptist East. All Women offers in-office mammograms and labs, but the mammography is owned by radiologist Dr. Arthur McLaughlin,

II, and operates as a satellite office.

Despite the challenges presented by remaining independent, Salerno believes it is easier for an OB/GYN practice to survive independently than for other specialties because their business is not driven solely by physician referrals. Instead, word-ofmouth referrals and direct advertising drive their business. In addition, they form lifetime relationships with their patients, often serving as the only physician a woman sees each year. “We treat the whole person, not just the female parts … It’s not just, ‘Here we go. Your uterus looks great. Your ovaries look great. See you next year,’” she says.

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we are not looking to make more money for ourselves. what we look for as a group is to maintain our identity and remain independent so long as we can afford to do that.

A native of Italy, Salerno has a point of reference to compare today’s healthcare market in the US with the socialized medicine of other countries. She acknowledges that despite the Supreme Court’s ruling on the Affordable Care Act, no one knows exactly how things will play out in the months and years to come. In the meantime, while the PGO merger was not the right fit for All Women, they are not completely closed to the idea of a merger in the future.

Maintaining their own identity and remaining independent are their goals for the present. “So what we look for as a group is to remain independent and what remaining independent means is the economic stability to be able to afford that … We are happy where we are. We are in a good place,” says Salerno. ◆

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August 2012 4/2/12 3:15 PM15

CoordinAtion of CAre

Kentuckyone health facilities unique program to reduce heart failure readmission rates

by KeLLy C. mCCAnts, md The Affordable Care Act is pushing hospital’s to come up with an effective, coordinated effort to reduce heart failure readmissions or else face a costly penalty starting in October 2012.

Hospitals across the country are faced with the challenge of creating programs that employ coordinated, multidisciplinary care, patient education, and effective utilization of healthcare resources to address heart failure readmissions.

The process began when Medicare reviewed 235 diagnoses and found that heart failure was number one in hospital readmissions. The review found that 20% of heart failure patients are readmitted to the hospital within 30 days. And, in fact, 50% of the Medicare deficit is spent on heart failure care.

To begin addressing this issue, Jewish Hospital and Sts. Mary & Elizabeth Hospital, both a part of KentuckyOne Health, began a pilot program called HeartCheck in partnership with VNA Nazareth Home Care in June 2011.

HeartCheck is a complete, interdisciplinary approach to heart failure management that employs skilled nurses, dietitians, physical, occupational, and speech therapists, pharmacists, and social workers under the direction of physicians with advanced training in heart failure.

Through the program, VNA providers and physicians collaborate to teach patients the appropriate tools for the self-management of heart failure. It also provides support for patients in the environment where they face their daily challenges – at home and in the work place.

There are approximately six million people living in the United States with heart failure. About 60% of those patients can be safely managed in the outpatient setting through programs like HeartCheck, which provides frequent follow up and reinforcement of the tools being used to manage the disease in the acute care setting.

In 2010 and 2011, Jewish Hospital and Sts. Mary & Elizabeth Hospital had 2,700 discharges with heart failure diagnoses and 16 M.D. upDAte

a readmission rate of 25%, which is similar the outpatient care clinic. During their to many acute care hospitals in the nation. care, there is ample time for patient eduPatients in the HeartCheck pilot had a cation, which includes everything from 3.5% readmission rate — a 21.5% reduc- a dietitian providing a lesson about salt tion. intake to other critical tips for managing HeartCheck‘s uniqueness is not only the disease. Following care at an outpatient centered around its affiliation with a heart care clinic, patients receive a follow up visit failure and transplant center that per- from their VNA care provider within two forms 15 to 18 transplants per year and or three days. upwards of 70 LVADs, With HeartCheck, a but it is also the first patient’s primary care procoordinated effort to vider remains an active treat patients with heart part in the management failure that is guidelineand care of the patient. driven and employs They review and sign off “best practices” from the on order sets and receive Heart Failure Society of regular updates and notiAmerica and American fications of any intervenHeart Association, while tion from the VNA liaison. emphasizing the patient’s The program also provides role in managing the disprimary care providers ease process. with the opportunity for VNA providers are their patient to arrange folexperienced with evalulow up care in their office ating and treating heart or at a heart failure outpafailure patients. More tient care center.

Dr. Kelly C. McCants is the than 200 VNA nursVNA hopes medical director of VNA Heart Failure/HeartCheck es have been trained HeartCheck will become program, director of Cardiac through HeartCheck to a model for hospitals transplantation and assistant assess fluid volumes and across the country workdirector of the Center for administer IV diuretics ing to reduce heart failure Advanced Heart Failure and in the home. They are readmissions. Currently Cardiothoracic transplantation also trained in recogniz70 patients are enrolled at Jewish Hospital, part of ing heart failure medical in the program. The KentuckyOne Health. emergencies. patients are educated and Instead of heading to the emergency empowered to manage their disease process. room, HeartCheck patients are instructed The early success of HeartCheck is very to contact their VNA liaison who can triage promising and the program has the capacity the necessary next steps, often eliminating to handle more than 200 patients at once. the need for an emergency room visit. The Individuals at high risk for readmission liaison communicates with the primary who may be candidates for HeartCheck care provider and heart failure physician to are New York Heart Association Class III determine a course of treatment. Often the heart failure patients who are admitted to VNA liaison can administer IV diuretics the hospital on average twice a year, have a in the home, and the patient can be seen prolonged hospital stay, or are identified by for follow up at the outpatient care clinic discharge planner or primary care provider. at either Jewish Hospital or Sts. Mary & primary care and other physicians can refer a Elizabeth Hospital.

Crisis intervention can also occur in the patient to the HeartCheck program by calling outpatient setting. HeartCheck patients (502) 585-7699 or simply writing an order for can receive IV diuretics for eight hours at the VNA HeartCheck program. ◆

Cover Story

Planning for Market Leadership

(L-R) Mary guiglia, MD; April Ramsey, MD; Charlie Becknell, MD; (seated) Ira P. Mersack, MD; Fernando R. de Castro, MD; Laurie R. Massa, MD; sherri Baer, PA-C; Anir Dhir, MD. Not pictured: todd Clark, MD.

how Dermatology associates of Kentucky became one of the largest freestanding practices in the uS.

By Gil Dunn

PhotoGraPhy By liz haeBerlin

Lexington Imagine UofL’s Papa John’s Cardinal Stadium filled to capacity or UK’s Commonwealth Stadium with all but the corners filled and you can picture the annual volume of Lexington-based Dermatology Associates of Kentucky (DAK), which boasts 55,000 patient visits a year.

DAK’s eight physicians, three PAs, and 89 employees work in one of the largest free-standing dermatol-

August 2012 17

Cover Story

Built 2002, DAKs flagship facility comprises over 45,000 square feet on three floors and includes its own AAAHC and Medicare-accredited ambulatory surgery center.

We treat much more than warts and acne. often we can diagnose systemic illnesses by complete physical exams of the skin.

– Dr. laurie r. Massa

18 M.D. uPDAte

ogy centers in the United States, built in 2002 with over 45,000 square feet on three levels, including its own AAAHC and Medicare accredited ambulatory surgery center. In October 2011, DAK opened a facility in the Beaumont area to accommodate patients on the west side of Lexington, and they also have a Frankfort location.

Current managing partner Laurie R. Massa, MD, attributes the growth of DAK to a simple practice philosophy of an emphasis on patient care throughout the entire staff. “We treat each patient as we would want our family member to be treated,” states Massa.

DAK has embraced the evolution of dermatology practices and now incorporates general dermatology with outpatient surgery, including Mohs micrographic surgical techniques, clinical dermapathology, immunodermatopathology, and cosmetic dermatology. “We treat much more than warts and acne,” says Massa. “Often we can diagnose systemic illnesses by complete physical exams of the skin.”

Off-label use of medications is a common occurrence in dermatology because some of the skin’s more unusual diseases will not generate sufficient pharmaceutical research and development to create the necessary drugs. Massa has seen such off-label

use in her own practice, using Enbrel, the psoriasis and rheumatoid arthritis tumor necrosis factor inhibitor, to treat a patient with multicentric reticulohistocytosis.

Skin cancer prevention by routine fullbody examinations is a growing part of general dermatology that Massa has seen in recent years. “We are now seeing patients in their 30s and 40s who are looking to prevent skin cancer, not waiting for melanomas to develop,” states Massa. Cancer prevention exams plus cosmetic dermatology have fueled the practice’s growth and are a trend Massa expects to continue.

Massa and April Ramsey, MD, share the cosmetic dermatology duties at DAK’s Bellege Medispa. Other physician members of the practice are Mary Guiglia, MD, a double-boarded internist and general dermatologist; Charlie Becknell, MD, a double-boarded internist and general dermatologist who performs cutaneous and laser surgery; and Todd Clark, MD a general dermatologist and cutaneous surgeon.

The certified physician assistants at DAK are Sherri Baer, Braeye Rueff, and Victoria Falconer.

Mohs Micrographic surgery

The current gold standard of micrographic surgical techniques for the removal of

malignant cancer cells while the patient is in surgery was created by Dr. Frederic Mohs. It allows the surgeon to microscopically examine the tissue specimens in three dimensions and obtain complete circumferential peripheral margin control. The cited cure rates with Mohs surgery are 98 to 99% for basal cell carcinoma. Mohs surgical technique is the preferred method for removal of skin cancers in anatomical and cosmetically important areas such as eyelid, nose, and lips.

Anir Dhir, MD, is the Mohs surgery specialist at DAK, performing over 2200 Mohs surgeries each year since he joined DAK in 1999. Dhir admits that his high volume of surgeries “may sound dramatic,” but it’s achievable because surgery is all he does. “I can do surgeries five or six days a week only because my partners conduct the clinics. Our extenders hold the screenings and do the follow-up care.”

Dhir received his medical degree from Baylor College of Medicine and took residency in dermatology at Emory University, followed by a fellowship in Mohs micrographic surgery, facial reconstruction, and cosmetic surgery at Dermatology Associates

with Dr. Gary Monheit in Birmingham, Alabama.

Mohs surgery is more expensive and can be more time-consuming, but Dhir is passionate that the advantages outweigh the negatives. Using the Mohs technique, Dhir says he can chase a tumor in the three dimensional field, not in a “bread loaf slice,” in real time before the patient is stitched and leaves the operating room. The advantage being that Dhir is both surgeon and pathologist. “The buck stops with one person,” says Dhir, “the surgeon.” Dhir’s cure

Laurie R. Massa, MD, managing partner, attributes the growth of DAK to a simple practice philosophy of an emphasis on patient care throughout the entire staff.

(ABove)

(LeFt) Fernando

R. de Castro, MD, is double board-certified in medical and surgical dermatology and clinical and laboratory dermatological immunology.

August 2012 19

Cover Story

Anir Dhir, MD, performs over 2200 Mohs surgeries each year.

among its many positive attributes, Mohs surgery is a tissue saving procedure and is ideal for patients who are at risk for general anesthesia surgery.

20 M.D. uPDAte

rate is “over 99.5%,” based on 13 years of follow-up care with thousands of patients.

Mohs surgery is also a tissue saving procedure and is ideal for patients who are at risk for general anesthesia surgery. All anesthesia is local, says Dhir. Patients are sedated but awake. “It’s like a trip to the dentist,” says Dhir.

Dhir is equally passionate about uncovering the underlying dangers of skin cancer.

“What you see on the surface has very little bearing on what’s below the surface,” the surgeon says. He has treated many tumors that look like a surface pimple but the cancer cells run deeply through the muscle fibers and even to the nerves. “Like pulling out a weed,” Dhir says, “you have to get out the root.”

Dermapathology & Immunodermatopathology

It’s not unusual for a dermatology practice to have a dermatopathologist and immunodermatopathologist in the practice, but it is not that common either. Fernando R. de Castro, MD, is double board-certified in medical and surgical dermatology and clinical and laboratory dermatological

immunology. He is fellowship trained at the Mayo Clinic in Rochester, Minnesota, in Dermatology, Dermatopathology & Immunodermatopathology, where he studied under the renowned Dr. Richard Winklemann, a founding member of the American Society of Dermatopathologists, before joining DAK in 1995.

His fellowship training is an asset to DAK, says de Castro because it allows him to bring more focus to the work up and therapies of the skin diseases presented by patients. While skin cancer, sun damaged skin, and common skin disorders are the majority of the DAK patient population, occasionally a patient will present an uncommon condition such as bullous pemphigoid, in which the patient’s body has become sensitized to a protein in the skin. In such a case de Castro will prescribe systemic corticosteroids and steroid sparing immunosuppressive drugs including rituximab. De Castro is also encouraged by new psoriasis treatments such as TNF alpha inhibitors and IL 12/23.

The success of DAK is the result of a combination of factors, says de Castro.

“We, the physicians, all get along in a very

communal and professional way,” he says.

“We have a shared vision, the goal to be the best practice of medicine for our patients and the best at practicing the business of medicine.”

DAK Legacy

The roots of DAK go back 61 years to 1951 and the founding partner, Ullin W. Leavell, Jr., MD. Current senior partner, Ira P. Mersack, MD, joined Leavell in 1972. W. Patrick Davey, MD, joined

(ABove) (LeFt) Ira

Anir Dhir, MD.

P. Mersack, MD, DAK’s longest-standing founding partners. Mersack recently celebrated his 40-year anniversary with DAK.

Leavell and Mersack in 1987. In 1988 Mersack was managing partner and saw the growth potential beyond Lexington and changed the practice name to Dermatology Associates of Kentucky. “We were already seeing many patients from southern and eastern Kentucky,” says Mersack, “so we knew the potential was there for expansion.

And I didn’t want our practice to sound like a law firm,” says Mersack.

Mersack recently celebrated his 40 year anniversary with the practice. At the celebration, he humorously recalled the early years of visiting doctor’s offices in eastern and southeastern Kentucky to introduce himself.

He drove the Kentucky back roads with a plentiful supply of chocolate pinwheels that rarely lasted the entire trip. “It was effective,” Mersack recalls, “I think we got a lot of referrals from those pinwheels, but boy did my waistline suffer.”

Mersack arrived in Lexington in 1972 with wife Anita after completing military

service in the US Army, serving as “a battlefield surgeon” in Vietnam during the most intensive combat arena, the Tet Offensive in January 1968. It is hard to imagine the soft spoken and gentle Mersack today as a captain in an Army infantry unit performing battlefield triage, but he recalls vividly his time in Southeast Asia.

In 1988 Mersack began his involvement with thoroughbreds. His first equine acquisition was Persian Gold, which he bought as a yearling at Keeneland. Persian Gold went on to become a three times stakes winner and earner of $270,803, and Mersack was hooked. Fueled by his own admitted “delusions of grandeur,” Mersack, with his farm manager and partner Steve Johnson, purchased the J.T. Lundy Farm near Midway, Kentucky. The farm was renamed Margaux Farm and continues to operate as a successful breeding and training facility for stakes winners.

Louisville dermatologist Dr. Joe Fowler [Editor’s note: See story on Fowler on pg 24], who created the International Physicians Thoroughbred Owners Society (IPTOS) and wife Lynn Fowler, RN, BSN, joined Mersack as coowners of Margaux Farm. Together they have introduced many physicians to the highs and lows of the horse industry.

Throughout his long and varied career as doctor, businessman, and entrepreneur, Mersack views himself as a physician first. “I receive great pleasure in making another person’s life better. That’s what keeps me going,” he says. He notes that the success of DAK is derived from many factors, including the vast majority of patients that are referred by the friends and family members of other patients.

Mersack recalls what his mentor Leavell told him many years ago, “Take care of your patients and they will take care of you.” ◆

August 2012 21

SPeCial SeCtion  DerMatoloGy anD allerGy

Family allergy & asthma

An effective business model provides quality care and regional outreach By Jennifer S. newton Imagine needing to buy milk, but when you get to the grocery store they tell you the product has been so successful it will not be available for three months.

That is how James L. Sublett, MD, founder and managing partner of Family Allergy & Asthma, describes the irony of medical practices that measure success in how far out they are booked. Focusing on the guiding principal of “patient satisfaction first,” Sublett prides the practice on “certain initiatives like getting people in when they’re sick, not making them wait days or weeks.”

Established in 1979 by Sublett, and Stephen J. Pollard, MD, Family Allergy & Asthma began with one office in Louisville’s east end. “One of the early things we realized was there was a need for outreach to smaller communities for specialty services,” says Sublett, who says they were the first allergy practice to do so in the Commonwealth.

They now have 22 office sites and 22 providers in Kentucky and southern Indiana.

Their expansion strategy is a hub and spoke model, with hub offices in Louisville, Lexington, Paducah, and Florence. Offices in Somerset, Campbellsville, and Bullitt County are considered sub-hubs with essentially full-time coverage by a physician or nurse practitioner. From there, satellite offices branch out throughout the region.

Seven of Family Allergy & Asthma’s 22 providers are nurse practitioners, and one is a physician’s assistant. Sublett explains they use a “tag team” approach, where every new patient sees a team consisting of one physician, on APRN, and two nurses. On subsequent visits the patients will alternate seeing the physician and APRN, which expands the use of providers but helps to maintain the high level of quality patients and referring physicians expect.

LoUiSViLLe, Lexington

Allergy and Asthma

An equal mix of children and adults, the most common diagnoses they see are chron22 M.D. uPDAte

common myths, asthma can occur in the over 65 population and never really goes away, although the severity can change over time.

According to Rajiv Arora, MD, who heads Family Allergy & Asthma’s Lexington office, close follow up is the key to “better control of symptoms, maintaining control (ABove) James L. with less medicine, sublett, MD, founder and maintaining more and managing long-term control.” partner of Family Pulmonary function Allergy & Asthma. testing and exhaled (BeLoW) Rajiv Arora, nitrous oxide, a new MD heads up the Lexington office. technique to measure airway inflammation, are used to diagnose and monitor asthma.

While many primary care physicians treat asthmatics, Arora offers that an allergist can be helpful in testing for potential allergic triggers, evaluating for immuic sinusitis, allergic rhinitis, and asthma. notherapy, and educating patients on Allergies occur in about one-in-four avoidance measures and the proper use of people, half of which will self-identify as medications. moderate to severe, with symptoms interfering with their daily life. “Those are Immune Deficiency the patients allergists can help with,” says A less common condition, whose preSublett. “Oftentimes what people call sentation is more ambiguous and more sinus problems are chronic allergies. Two- difficult to identify, immune deficiency thirds of people have year-round aller- occurs when a defect does not allow gies. There’s this misconception that it’s the immune system to fight infection seasonal,” he adds. Evaluating indoor and effectively. Often undiagnosed, patients outdoor inhalant allergies and food allergies with immune deficiency may present with through prick skin testing and intradermal frequent infections, infections unrespontesting and a three-legged approach to treat- sive to typical antibiotics and requiring ment – avoidance measures, medications, multiple courses or IV antibiotics, and and immunotherapy – are services Family atypical infections.

Allergy & Asthma provides.

“In our fellowship, a lot of it is developed Sublett estimates 25% of people with on immune deficiency and the immune allergies have asthma, putting their asth- system, so we are uniquely trained to idenmatic patient population over 10,000. tify, evaluate, and treat immune deficiency Dual diagnoses are common because aller- patients,” says Arora. In order to diagnose gies can trigger inflammation of the air- and identify immune deficiency, “It’s a ways, a hallmark of asthma. Contrary to matter of looking at the different types of

Advanced

DERMATOLOGY antibodies and immune cells, the numbers of them, and how they’re working,” he says.

The presentation of the infection and the age of the patient help allergists determine what part of the immune system is affected.

Treatment can include antibody replacement therapy such as IV or subcutaneous immunoglobulins, prophylactic antibiotics, and blood cell transplants in children with severe cases.

Arora’s advice to practitioners with potential immune deficiency patients is “to have a high index of suspicion.” A primary care manager is crucial to help identify patients with frequent or unresponsive infections who may require further evaluation.

Research Initiatives

Leigh Ann Scalf, M.D. “Board Certified in Dermatology and Dermatopathology”

1618 Harrodsburg Road Lexington, KY 40504

(859) 288-5004

www.advanceddermatologypsc.com

     

Skin Cancer Screening & Surgery “Interesting” Rashes Dermatopathology Lab Comprehensive Patch Testing Psoriasis Center with nbUVB Laser for Psoriasis

Another early initiative of Family Allergy & Asthma’s founding partners was research.

The practice has a full-time research department housed at their Sts. Mary & Elizabeth Hospital campus office, which employs three full-time certified research nurse coordinators. “Any allergy or asthma medication that’s been developed in the last 25 years we’ve been involved in,” says Sublett.

Although not a significant profit center, studying medications, biologicals, and allergy responses gives their physicians early firsthand knowledge of new treatments.

In a recent paper, they reported 17% of pediatric patients were positive for mouse allergen, which Family Allergy & Asthma now includes in their battery of indoor inhalant testing.

One upcoming pilot project Sublett is particularly excited about is Asthmapolis, a study in conjunction with Metro Louisville utilizing an inhaler sensor on reliever medications and mobile phone technology to track inhaler use and measure asthma control. Louisville received a grant from IBM to provide evaluation of the city’s environmental triggers and computer analysis of the data. The project will enroll 500 participants in Metro Louisville through November 2012, including 100 who will also receive a sensor for controller medications. ◆ August 2012 23

SPeCial SeCtion  DerMatoloGy anD allerGy

inquisitive approach

Even Common Cutaneous Allergies Require Active Management By MeGan C. SMith LoUiSViLLe With only a handful of dermatologists in the Commonwealth specializing in patch testing, chances are you already know Joseph F. Fowler, Jr, MD, of Louisvillebased Dermatology Specialists, as the doctor who manages those very difficult skin rashes. Allergic contact dermatitis, atopic dermatitis (eczema), and psoriasis top your list of referrals, but it’s really an expertise in contact dermatitis that makes up Fowler’s claim to fame.

For the past 28 years, Fowler has honed an expertise in the diagnosis and treatment of contact dermatitis that has garnered international attention. Pharmaceutical corporations contract with him for clinical research and consulting, and, active in teaching and lecturing, Fowler is often seen leading trends in the clinical care for chronic dermatitis.

For patients and practitioners alike, treating chronic dermatitis can be a frustrating experience. There’s a sense of mystery to its causality that keeps us guessing as to the best path toward relief of symptoms.

But, with specialized diagnostic techniques and access to hundreds of allergens, Fowler is able to steer patients toward a successful reduction in cutaneous allergy complaints.

Without an accurate diagnosis, many patients experience long term, persistent allergic contact dermatitis. To combat this, Fowler employs a systematic, inquisitive approach to first identify the offending compounds and then eliminate those allergens and their symptoms from the patient’s daily routine. With patch testing, he identifies the cause in most of his cases.

He says, “About 70 compounds have been identified as contributing to over 90% of the allergies we see in the US. These make up our routine test kit. There are some exceptions, for example, for people of certain occupations or people with specific hobbies - like hairdressers or woodworkers - who may be exposed to specific occupational or recreational allergens.

“We find that if we test for those 70 or so compounds, then we will find most causes of allergy. We also draw upon our 24 M.D. uPDAte

Joseph F. Fowler, Jr, MD, is a founding partner of Dermatology specialists of Louisville. His expertise in contact dermatitis is world-renown.

large supply of prepared chemicals to customize testing for individuals according to their job or recreational exposure.”

Patch testing and the Divergent Paths of Dermatology and Immunology

For most patients, the real treatment for allergic contact dermatitis is to avoid the cause. Medical management through corticosteroids, topically or internally, may help while patients are working toward this goal or if they are unable to avoid contact with the allergen. “The problem is, those are only for short term use,” cautions Fowler.

“Any time a patient has chronic dermatitis that either doesn’t respond well to treatment or that requires systemic corticosteroids beyond a reasonably safe level, that patient ought to get patch tested.” Indeed, when creams can’t do the trick, doctors from across the region refer their patients to Fowler for his patch testing expertise.

Patch testing, of course, involves the systematic exposure to known allergic compounds in order to test by observation the emergence of a cutaneous allergy within a few days of application. Most common

allergens here in the Commonwealth are discovered through the application of the 30-sample TRUE Test, and still more specialized compounds can be applied. The test is rather straightforward; it’s the specialist performing the test that’s unique.

With an expertise built up over decades of research, Fowler has access to hundreds of chemical samples that make his test kit far more effective for the elusive allergic contact dermatitis diagnosis.

Fowler recalls when he and his colleagues at Dermatology Specialists began doing pharmaceutical research about 15 years ago in the area of contact dermatitis, their work included research on the TRUE Test, observing how it works, and comparing it to other systems for patch testing. “As time went on,” he says, “pharmaceutical companies saw that we did a good job on their projects, and over time we have taken on clinical research studies in practically all phases of dermatology - acne, psoriasis, eczema, warts, toenail fungus, and so on.

We may have between 12-20 clinical studies going on at any given time, and we have four RNs dedicated to our research arm.”

As part of a well-rounded medical dermatology practice, Fowler sees an inter-

esting overlap in the dermatological and immunological allergy of eczema, or atopic dermatitis. This condition is not primarily an allergic contact process but rather a genetic defect causing a poor cutaneous barrier function. Skin affected by eczema can be dry and susceptible to irritation.

“In eczema, the skin just isn’t as tough as ought to be,” explains Fowler. “Add to this some overreaction of the immunologic activities, and those patients tend to have a lot of the respiratory allergies that the allergist deal with. Sometimes patients with atopic dermatitis or eczema end up more at the allergist’s ballpark. Otherwise, they end up in mine if they develop contact dermatitis as a secondary phenomenon beyond their eczema.”

Fowler emphasizes that there is a significant difference between medical dermatological treatment of cutaneous allergies and the work of allergists who treat respiratory or food allergies. “With contact dermatitis, there is no hyposensitization. There is no shot to prevent it. It is strictly a matter of identification and avoidance. Like with poison ivy, you have to know what to look for

With contact dermatitis, there is no hyposensitization. there is no shot to prevent it. it is strictly a matter of identification and avoidance. like with poison ivy, you have to know what to look for in the forest. in the forest.” If Fowler finds that a person is allergic to a chemicals found in skin care products, for example, he coaches them to read labels on their soaps and shampoos to avoid the offensive substance, be it fragrance, quaternium-15, and another, perhaps less common allergen.

Finally, in an important aside, Fowler explains that many doctors refer patients to him with presumed drug allergies.

“Unfortunately, there are almost no good tests for drug allergies,” he says. “There are a few exceptions, but with 95% of the drugs out there, we are not going to be able to test to find a presumed drug allergy.” ◆

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neWS  eventS  artS

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Anthony Named Chief of Medical oncology

Lexington Dr. Lowell Anthony has been named chief of medical oncology at UK HealthCare. His appointment to this leadership role will be effective Aug. 1.

Anthony received his graduate medical education and advanced specialty training at Vanderbilt University.

After being on faculty at Vanderbilt for several years, Anthony moved Dr. Lowell Anthony to Louisiana State University where he ascended the academic ranks and served for a period as the Acting Director of their Division of Hematology and Oncology. Anthony joined the UK College of Medicine as professor of medicine and member of the Markey Cancer Center in October 2011. He is a nationally recognized authority in neuroendocrine tumor medicine and is a widely published author in the field

been appointed

by Dr. Patrick Gallagher, Director of the Commerce D e p a r t m e n t ’s National Institute of Standards and Technology (NIST), to the 2012 Board of Examiners for the Malcolm Baldrige val slayton, MD National Quality Award. The Award, created by public law in 1987, is the highest level of national recognition for performance excellence that a U.S. organization can receive. This is Dr. Slayton’s third year of service on the Board of Examiners.

As an Examiner, Dr. Slayton is responsible for reviewing and evaluating applications submitted for the Award. The board is composed of approximately 500 leading experts selected from industry, professional and trade organizations, education and health care organizations, and nonprofits (including government).

val slayton, MD, Appointed examiner for 2012 Malcolm Baldrige National Quality Award

uK HealthCare, Norton Healthcare earn top rankings in u.s. News & World Report Best Hospitals

LoUiSViLLe Val Slayton, MD, MPP, MBA, CPE, of the legacy Jewish Hospital & St. Mary’s HealthCare, part of KentuckyOne Health located in Louisville, Ky., has

AND LEXINGTON UK HealthCare and Norton Healthcare announced that their combined efforts to provide the best in specialized care to

LoUiSViLLe

Kentucky residents have been validated by earning the top rankings in U.S. News and World Report’s Best Hospital analysis.

University of Kentucky Albert B. Chandler Hospital has been ranked No. 1 in Kentucky and Norton Healthcare ranked No. 1 in Louisville and No. 2 in Kentucky in U.S. News & World Report’s Best Hospitals 2012-13 released on July 17.

This is the first time state rankings have been included in the listing giving consumers a way to compare hospitals to other neighboring institutions across the state.

The rankings are available at http://health. usnews.com/best-hospitals.

U.S. News & World Report released its 23rd annual listing of Best Hospitals.

This year’s rankings showcase more than 720 of the nation’s roughly 5,000 hospitals.

Fewer than 150 are nationally ranked in at least one of 16 medical specialties. Norton Healthcare was rated as “high performing” in cancer, cardiology and heart surgery, diabetes and endocrinology, gastroenterology, geriatrics, gynecology, nephrology, neurology and neurosurgery, orthopedics, pulmonary, and urology.

In addition to the top hospital ranking in the state, UK Chandler Hospital was nationally ranked in orthopedics and listed as “High Performing” in 10 specialty areas.

These clinical areas include Cancer, Diabetes & Endocrinology, Ear, Nose & Throat, Gastroenterology, Geriatrics, Gynecology, Nephrology, Neurology & Neurosurgery,

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

26 M.D. uPDAte

“People always ask me, ‘What can I do to help?’”, said Lexington Mayor Jim gray (BeLoW) “the six saint Joseph facilities along with the six Louisville facilities will give us a truly statewide reach,” said Dr. Dan varga, Chief Physician executive, Kentuckyone Health.

(LeFt)

StateWiDe PartnerShiPS ForMeD to tarGet CanCer Prevention Pulmonology, and Urology. Overall, UK was among 140 of the 4,825 U.S. hospitals ranked in one or more 16 specialties.

In 2011 UK HealthCare and Norton Healthcare announced plans to work together across the state of Kentucky and beyond to target the region’s most pressing health problems: stroke, cancer, and heart disease. This focus is in response to the commonwealth’s incidences of these health conditions that far exceed most other states.

Norton Healthcare becomes first health care provider in Kentucky to launch da vinci surgery program with genesis™

Norton Healthcare recently acquired its fourth da Vinci surgical system, making the institution the only health care provider in Louisville to offer this level of increased procedure capability and visualization for surgeons. The da Vinci systems

LoUiSViLLe

Dr. Mary gordinier and the da vinci si HD system.

American Cancer Society Announces Cancer Prevention Study in partnership with KentuckyOne Health and YMCAs of Greater Louisville and Central Kentucky

a new nationwide long-term study aimed at cancer prevention has been launched by the american Cancer Society’s (aCS) Department of epidemiology & Surveillance research with the goal of recruiting over 300,000 adults across the uS and Puerto rico to document the lifestyle, environmental and genetic factors that cause or prevent cancer.

Kentucky will have recruitment sites for the Cancer Prevention Study-3 (CP-3) in lexington and louisville at the yMCa of Central Kentucky and the yMCa of Greater louisville. individuals who enroll in the CPS-3 complete a comprehensive personal information history with blood sample and waist measurement and agree to leXinGton

periodic follow-up surveys over a 20 year time span. researchers will use the data from CP-3 to build on evidence from aCS studies that began in the 1950’s that have involved millions of volunteer participants. the current study CPS11 which began in 1982 is ongoing but changes in lifestyle and cancer research necessitate the initiation of a new study that will stretch nearly into mid century. ‘’like the early Sisters of Charity of nazareth who lived on the frontier in constant fear of starvation, attack from the natives and death, Kentuckians live with the fear of cancer,” said Dan varga, MD, chief medical officer of Kentuckyone health. lexington Mayor Jim Gray said that volunteering for the cancer prevention study was “one way for people who want to help in

the fight against cancer.”

Six Saint Joseph facilities in Central Kentucky will participate: Saint Joseph hospital, Saint Joseph east, Saint Joseph Jessamine, Saint Joseph Berea, Saint Joseph london and Saint Joseph Mount Sterling. the louisville hospitals that are part of the study are Jewish hospital Downtown, Jewish hospital Medical Center northeast, Jewish hospital Shelbyville, Sts. Mary and elizabeth hospital, Jewish hospital Medical Center South, and Flaget Memorial hospital. ◆

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August 2012 27

neWS account for tremendous improvements in patient experience due to enhanced technology and minimally invasive techniques. In addition, Norton Healthcare will be implementing the Genesis™ program for operating da Vinci surgeries. This will allow patients at Norton facilities to experience reduced trauma and recovery times associated with several types of cancer and other diseases.

The addition of another da Vinci and the Genesis program advance the facility vision to become a pelvic floor health center of excellence. This will involve a multi-disciplinary team of providers with a nurse navigator to offer specialized care by in the treatment of pelvic floor dysfunction. This care involves Urology, Gynecology, Colorectal Surgery and more. Using the da Vinci system will allow physicians to treat pelvic floor issues without leaving the expected large scars and long recovery times.

As Norton Suburban Hospital transforms into the region’s premier women and children’s hospital, it is important that the

facility achieves early productivity using the latest and greatest version of da Vinci systems. The Genesis program has been put in place to ensure the full potential for the robotic devices is met, especially as relates to pelvic floor health. Completion of all three Genesis phases will allow Norton Suburban Hospital to improve quality of care, differentiating the niche hospital as proficient in minimally invasive surgeries that treat various gynecological cancers in addition to many other diseases.

valinda Rutledge Named Kentuckyone Health Market Leader Louisville and President of Jewish Hospital

LoUiSViLLe KentuckyOne Health has named Valinda Rutledge as Market Leader Louisville and President of Jewish Hospital effective July 23, 2012. She will have responsibility for the oversight of the Jewish Hospital downtown medical campus, Sts. Mary & Elizabeth Hospital, Our Lady of Peace and Frazier Rehab Institute,

in association with

Baptist physicians Lexington, inc.

Offering Career Opportunities in: Gynecological Oncology Neurology Family Practice Internal Medicine & Pediatrics Internal Medicine Pulmonary Critical Care Intensivist

For more information, contact:

Derrick Hord, Physician Recruitment (859) 260-6286 • (859) 260-6965 (fax) • derrick.hord@bhsi.com

centralbap.com 28 M.D. uPDAte

all in Louisville, in addition to Flaget Memorial Hospital in Bardstown and Jewish Hospital Shelbyville in Shelbyville.

Rutledge comes to KentuckyOne from the Centers for Medicare and Medicaid Services (CMS) where she served in a senior leadership role in the Center for Medicare and Medicaid valinda Rutledge Innovation as director of the Patient Care Models Group since June 2011. There she led the development and implementation of the National Bundled Payment Initiative.

In both 2010 and 2011 of Becker’s Hospital Review, Business & Legal Issues for Health System Leadership, Rutledge was listed as one of 56 top Women Hospital & Healthcare Leaders.

CoNtINues oN PAge 30 

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Healthcare Economy Conference Unites Physicians, Hospital Leadership and Local Government

By Gil Dunn leXinGton the first Mayor’s healthcare economy Conference, presented by lexington health, economy and life Science institute (healS) was held June 26 at the hyatt regency hotel in lexington, Ky. over 150 physicians, medical administrators and healthcare professionals gathered to hear a presentation

by Gregg nunziata, Senior Director, the advisory Board Company, in Washington, DC. “healthcare at a Crossroads, Surveying the landscape at a time of Fundamental Change” was nunziata’s theme. the conference was held two days before the Supreme Court’s ruling on the affordable Care act, but nunziata stated that whatever the Court’s decision, “health [care] reform changes in the rules of the game.” a major outcome of healthcare reform, said nunziata, was that “physicians were getting paid less, to do less.” With an emphasis on fewer hospital re-admissions and

sergio Melgar, sr. vP for Health Affairs and HealthCare CFo, uK HealthCare, gregg Nunziata, sr. Director, the Advisory Board Company, emery Wilson, MD Chair, Lexington HeALs Institute at the Mayor’s Healthcare economy Conference in Lexington, KY.

pay-for performance, “Washington is keeping score. hospitals are being judged and it’s based on patient satisfaction,” said nunziata. a presentation followed on the economic impact generated by the four lexington hospitals. the panel included Gary Payne, Ceo, Cardinal hill rehabilitation hospital; Preston P. nunnelley, MD, vice- president of Medical affairs, Central Baptist hospital; eric Gilliam, administrator Saint

David J. Bensema, MD, Baptist Physician services and HeALs Institute Board with Ardis Dee Hoven, MD, president–elect AMA.

Joseph east; and Michael Karpf, executive vice president for health affairs, university of Kentucky and was moderated

by Bob Quick, president/ Ceo, Commerce lexington. a standing ovation greeted ardis Dee hoven, MD, newly announced president-elect of the american Medical association, as she was warmly introduced by David J. Bensema, MD, lexington healS institute Board. Dr. hoven

gave a brief summary of her path from physician to aMa presidentelect, citing her work for the lexington Medical Society and the Kentucky Medical association. addressing the affordable Care act, (aCa) hoven stated that although the aCa gives physicians the opportunity to be paid for providing care to all their patients, “the SGr must be repealed.” the aMa will “continue to be a voice for physicians with an emphasis on physician satisfaction. We need to take the politics out of healthcare,” hoven stated. hoven received the henry Clay ambassador award from lexington Mayor Jim Gray for her lifelong commitment to the healthcare industry in Kentucky.

Bensema concluded the conference with a strong call to action to fellow physicians. “it is the vision of healS to make lexington the healthiest midsize city in america. We are the leaders of the health care team.

Gone are the days of working solo. We must collaborate to reach that vision.” ◆

15th Annual shoulder symposium Draws Record Crowd lexington the largest group of attendees ever, 234, attended the 15th annual Shoulder Symposium presented by the Shoulder Center of Kentucky where an international panel of orthopedic experts discussed the Clinical implications for Scapular Dyskinesis in Shoulder injury in lexington Ky, July 27-28. orthopedic surgeons and sports medicine physicians plus numerous physical therapists and athletic trainers from across the country formed the audience in the nearly sold out venue, according to aaron Sciascia, of the Shoulder Center and Symposium coordinator. sciascia attributed the success to the clinical and research contributions from the faculty. this year’s course summarized traditional methods of

(l-r) David ebaugh, PhD, Pt-Drexel university; tim uhl, PhD, AtC, Pt, FNAtA- uK; John Borstad, PhD, Pt-ohio state university; Amee seitz, PhD, Pt-Northwestern; Aaron sciascia Ms, AtC, Pesshoulder Center of Kentucky; John e. Kuhn, MD- vanderbilt; W. Ben Kibler, MD-shoulder Center of Kentucky; Klaus Bak, MD-Parkens Privathospital- Denmark; Paula Ludewig, PhD, Pt-university of Minnesota; Phil McClure, PhD, Pt-Arcadia university; Lori Michener, PhD, Pt, AtC- virginia Commonwealth university; Lane Bailey, Pt-Proaxis Physical therapy

evaluation and rehabilitation of scapular dysfunction in shoulder injury and presented new evidence either confirming or refuting the application of the methods. each presentation complimented the subsequent presentations allowing for increased continuity within the established

course curriculum. “As we continue to move forward with our research efforts, we will strive to make the information readily available to practicing clinicians in open meetings such as this symposium in an attempt to enhance clinical practices,” said sciascia. ◆ August 2012 29

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John smithhisler Named Kentuckyone Health Market Leader Lexington and President of saint Joseph Hospital

LoUiSViLLe KentuckyOne Health has named John Smithhisler as Market Leader, Lexington and President of Saint Joseph Hospital, effective July 23, 2012. He will have responsibility for the oversight of the Saint Joseph Hospital and Saint Joseph East.

Smithhisler comes to KYOne from Health Care Consulting in Shrewsbury, MA, and has served in a senior leadership role at several hospitals. Over the last year, he has been working with small and medium size businesses to reduce health care costs and premiums by negotiating with insurance companies and health care providers.

From 2005 to 2011, Smithhisler John smithhisler was president/CEO of a 348-bed Catholic hospital based in Worcester, MA. Saint Vincent Hospital, a teaching facility, saw continued growth of all major volume indicators, net revenues and earnings under his leadership.

Smithhisler’s earlier experiences include six years with Health Care Consulting, where he provided leadership as a president or CEO for health care facilities going through leadership transitions and also assisting in the development of short and long term business and strategic planning.

Norton Healthcare certified as orthopedic Center of excellence by the Joint Commission

LoUiSViLLe The need for quality orthopedic care continues to grow as our population ages. That need is compounded by individuals who desire to maintain an active lifestyle later in life and by those who struggle with excessive joint pressure caused by obesity. In the next decade, the number of hip replacements is expected to rise by 22 percent and the number of knee replace30 M.D. uPDAte

ments by 34 percent.

Norton Healthcare has recently been certified by The Joint Commission as a Center of Excellence for knee and hip replacements. This makes Norton Healthcare a leader in orthopedic care as the first and only certified Orthopaedic Center of Excellence in the region and the first multisite hospital system in Kentucky to achieve this designation.

The credentialing process included a series of on-site reviews by members of The Joint Commission. Several categories were reviewed for compliance with The Joint Commission standards that ensure exceptional patient care. The Joint Commission also conducted individual tracer activity, where patients were followed throughout the entire program associated with a hip or knee replacement. The competence assessment and credentialing process were based on a detailed review of all aspects of care, from when a patient is determined to be a candidate for joint replacement through shortly after discharge.

The multidisciplinary team of professionals at Norton Healthcare has collaborated for more than 18 months to obtain The Joint Commission certification at all four adult-service hospitals. A patient-centered focus has enhanced the overall patient experiences and outcomes of total joint replacement surgery. The protocols used to implement clinical practice guidelines meet The Joint Commission’s standards of excellence, and Norton Healthcare will continue to improve on program care and services.

Norton Healthcare approved by the National Accreditation Program for Breast Centers

LoUiSViLLe Norton Healthcare has been granted a three-year full accreditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. Norton Healthcare is the only healthcare network in Kentucky to achieve this accreditation for all its adultservice facilities. Accreditation is given only to those centers that demonstrate the highest level of quality breast care during a rigorous evaluation process.

During an extensive performance review by the NAPBC, Norton Healthcare demonstrated proficiency with all standards for

treating women diagnosed with the full spectrum of breast disease. The standards reviewed include center leadership, clinical management, research, community outreach, professional education, and quality improvement. Compliance with these standards allows Norton Healthcare to provide patients with every significant advantage during a trying time in their lives.

The NAPBC designation process took about two years to complete. The performance reviews and strict evaluation of standards involved physicians from multiple specialties and all adult-service facilities, as well as ancillary staff from each facility. The comprehensive process addressed each point of care from diagnosis through survivorship.

Norton Cancer Institute selected to continue participation in National Cancer Institute program

LoUiSViLLe The National Cancer Institute (NCI), part of the National Institutes of Health, recently selected Norton Cancer Institute to continue participation in its national network of community cancer centers. A member of the NCI Community Cancer Centers Program (NCCCP) since 2010, Norton Cancer Institute was awarded $901,882 to fund participation in the NCCCP network for the next two years.

Norton Cancer Institute is one of only 21 facilities in the nation to be selected for this program, which will directly benefit cancer patients and survivors in the local community and beyond.

The NCCCP is a network of community hospitals that work together to expand cancer research and improve quality of patient care with an emphasis on underserved populations. The goal of the program is to provide cutting-edge treatment in communities so more patients can remain close to home during treatment rather than traveling to major academic medical centers. The NCCCP network serves approximately 53,000 people newly diagnosed with cancer each year.

Launched in 2007 as a pilot program comprising 16 community hospitals, the NCCCP added 14 additional sites to the network in 2010. Funding available from the American Recovery and Reinvestment Act allowed the 30 NCCCP hospitals to compete for a program extension, and 21 have been awarded funds to continue participation.

Norton Cancer Institute’s selection ensures that the NCCCP network’s ongoing efforts

neWS to offer state-of-the-art, coordinated care and create research opportunities will continue to be addressed in Greater Louisville. Norton Cancer Institute’s continued participation in the program helps support NCI’s overall mission of accelerating cancer research and improving outcomes for cancer patients across the United States.

uK Chandler Hospital selected for National Initiative to Increase Breastfeeding Rates

The University of Kentucky Albert B. Chandler Hospital has been selected to participate in Best Fed Beginnings, a first-of-its-kind national effort to significantly improve breastfeeding rates in states where rates are currently the lowest.

Although breastfeeding is one of the most effective preventive health measures for infants and mothers, half of US-born babies are given formula within the first week, and by nine months, only 31 percent of babies are breastfeeding at all. Best Fed Beginnings seeks to reverse these trends by

Lexington

dramatically increasing the number of U.S. hospitals implementing a proven model for maternity services that better supports a new mother’s choice to breastfeed. The National Initiative for Children’s Healthcare Quality (NICHQ) is leading the effort through a cooperative funding agreement with the Centers for Disease Control and Prevention (CDC), and will be working closely with Baby-Friendly USA, Inc. In addition to UK Chandler Hospital, 89 other hospitals are participating in this initiative and were selected from 235 applicants. The groups will work together in a 22-month learning collaborative, using proven quality improvement methods to transform their maternity care services in pursuit of “BabyFriendly” designation. This designation verifies that a hospital has comprehensively implemented the American Academy of Pediatrics-endorsed Ten Steps to Successful Breastfeeding, as established in the WHO/UNICEF Baby-Friendly Hospital Initiative. Breastfeeding rates are higher and disparities in these rates

Patients turn to social media for answers.

are virtually eliminated in hospitals that achieve this status.

Daugherty Named editor-in-Chief of Premier Academic Journal

Lexington Alan Daugherty, director of the University of Kentucky Saha Cardiovascular Research Center, senior associate dean for research in the UK College of Medicine and Gill Foundation Chair in Preventive Cardiology, has been named the new editor-in-chief of the premier academic journal Arteriosclerosis, Thrombosis, and Vascular Biology: Journal of the American Heart Association (ATVB), a monthly journal devoted to the biology, prevention and impact of vascular diseases.

The July 2012 issue of Arteriosclerosis, Thrombosis, and Vascular Biology is the first issue produced by the new editorial team.

AMA Honors Carolyn Kurz with Medical executive Lifetime Achievement Award

Lexington The American Medical Association (AMA) announced today that

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August 2012 31

neWS Carolyn H. Kurz, executive vice president and chief executive officer at the Lexington Medical Society in Kentucky, has been presented with the Medical Executive Lifetime Achievement Award.

The award is given by the AMA to honor a medical association executive who has contributed substantially to the goals and ideals of the medical profession.

“The AMA gratefully recognizes Carolyn Kurz for her legacy of notable accomplishments and her 40 years of dedication to the medical profession in Kentucky,” said Robert M. Wah, MD, past chair of the AMA Board of Trustees.

“She has proven to be an outstanding leader and a highly respected advocate for physicians and their patients.”

Kurz began her career at Lexington Medical Society with a minimal budget and a membership of 350. Under her leadership the Society has become a full-service organization that has attracted more than 1,500 members and funds numerous programs that benefit physicians and patients.

Kurz has been active with The Rotary Club of Lexington, serving as its first female president from 2004-2005. As a member of Commerce Lexington, an organization dedicated to business and economic development, Kurz worked with area hospitals and facilitated the formation of the Lexington Health Economy and Life Sciences Institute, an innovative economic development program.

study suggests touch therapy Helps Reduce Pain, Nausea in Cancer Patients Lexington

A new study by the University of

Kentucky Markey Cancer Center shows that patients reported significant improvement in side effects of cancer treatment following just one Jin Shin Jyutsu session. Jin Shin Jyutsu is an ancient form of touch therapy similar to acupuncture in philosophy.

Presented at the 2012 Markey Cancer Center Research Day by Jennifer Bradley who is the Jin Shin Jyutsu integrative practitioner at Markey, the study included 159 current cancer patients. Before and after each Jin Shin Jyutsu session, Bradley asked patients to assess their symptoms of pain, stress, and nausea on a scale of 0-10, with 0 representing no symptoms.

The study found that in each session patients experienced signifiJennifer Bradley cant improvement in the areas of pain, stress, and nausea with the first visit and in subsequent visits as well. The mean decreases experienced were three points for stress and two points for both pain and nausea.

Funded by a grant from the Lexington Cancer Foundation, Jin Shin Jyutsu is considered part of an integrative treatment plan available at the UK Markey Cancer Center. Bradley offers Jin Shin Jyutsu to all cancer patients at no charge. Patients may self-refer, though half are referred by their physician or Markey staff.

The study did not include controls for several parameters including the time between sessions or location and duration of service. Bradley’s next study will control

more of these variables, and her team will access patients’ medical records over the time period of their participation to evaluate changes in patients’ medication usage for cancer and symptom management of pain, stress and nausea.

Kentucky eye surgeon Presents at Retina Conference in Milan, Italy

Lexington Dr. John W. Kitchens, partner with Retina Associates of Kentucky, will be presenting at the Euretina Annual Congress in Milan, Italy in September. His talk to be given to the European Society of Retina Specialists is entitled: Ranibizumab for diabetic macular edema: Impact of concomitant therapy with glitazomes or fenofibrates.

Dr. Kitchens joins retina specialists from around the world to discuss the most current treatments and therapies for diseases of the retina and vitreous.

“Diabetes and diabetic retinopathy is a major problem in Kentucky”, says Dr. John W. Kitchens Dr. Kitchens, “it is rewarding to work on research that applies so directly to our patients.”

Retina Associates of Kentucky is a member of the DRCR Network, a network of elite retina practices across the US researching different treatments for diabetic retinopathy. Kitchens is the President of Kentucky Academy of Eye Physicians and Surgeons ◆

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