MD-UPDATE Issue #101

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #101 WWW.MD-UPDATE.COM

SPECIAL SECTION ORTHOPEDICS & SPORTS MEDICINE

Patient-Driven.

Precision-Made.

KentuckyOne Health Orthopedics redesigns patient access and pursues perfect surgical precision ALSO IN THIS ISSUE  ROBOTIC JOINT SURGERY IS THE FUTURE VOLUME 7•#5•JULY 2016

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QUESTIONS: 859.313.1705 KentuckyOneHealth.org SaintJosephFoundation.org ISSUE#101 | 1 SaintJosephHospitalFoundations

CONTENTS

ISSUE #101

4 HEADLINES 5 FINANCE 6 ACCOUNTING 8 LEGAL 10 COVER STORY 15 SPECIAL SECTION: ORTHOPEDICS & SPORTS MEDICINE 28 COMPLEMENTARY CARE 31 EVENTS

Patient-Driven. Precision-Made.

KentuckyOne Health Orthopedics redesigns patient access and pursues perfect surgical precision

BY JENNIFER S. NEWTON Photos by Rob Densmore and KentuckyOne Health

SPECIAL SECTIONS ORTHOPEDICS & SPORTS MEDICINE

15 VIDEO GAME VISION, ONE MILLIMETER ACCURACY: BLUEGRASS ORTHOPEDICS

2 MD-UPDATE

18 STATE-OF-THEART TECHNOLOGY IN PEDIATRIC CARE: LEXINGTON SHRINERS HOSPITAL

20 ONE STEP AT A TIME: KENTUCKY ORTHOPEDIC ASSOCIATES

22 YOU DON’T KNOW WHAT YOU’VE GOT TILL IT’S GONE: LEXINGTON CLINIC

24 PROPELLING SPORTS PERFORMANCE TO THE NEXT LEVEL: BAPTIST HEALTH

LETTER FROM THE PUBLISHER

MD-UPDATE MD-Update.com Volume 7, Number 5 ISSUE #101 PUBLISHER

Gil Dunn gdunn@md-update.com EDITOR IN CHIEF

Jennifer S. Newton jnewton@md-update.com GRAPHIC DESIGNER

James Shambhu art@md-update.com

CONTRIBUTORS:

Jan Anderson, PsyD, LPCC Scott Neal L. Porter Roberts Chris Shaughnessy Adam Shewmaker

CONTACT US:

ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:

Gil Dunn gdunn@md-update.com

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How Things Change and Get Better Welcome to MD-UPDATE, the Orthopedics and Sports Medicine issue, where you’ll meet Kentucky orthopedic surgeons and providers who are practicing innovative therapies and life-altering procedures with positive outcomes for patients of all ages.

Here are a few examples of new technologies that are improving orthopedic care in Kentucky that we highlight in this issue. Ultra low-dose, stand-up or sit down, 3D X-ray for children; spine-straightening for pediatric patients with scoliosis via lengthening rods that are controlled by magnets and don’t require invasive procedures; robotic-smart hand tools that stop cutting when the blade goes beyond the prescribed perimeter; and new joint replacement materials with longer life spans that can be implanted sooner to relieve pain and restore function for a wider, younger patient population.

We also discuss new approaches to orthopedic care and sports medicine such as biologics, aggressive physical therapy, and arthroscopy for the elite athlete and the weekend warrior. As always, we talk to the Kentucky physicians and providers who bring their expertise to the workplace daily so others can get back to work and living.

Summer is Baseball Season

All this talk about joint repair and sports medicine brings me to my favorite topic, baseball. I grew up in Maryland rooting for the Baltimore Orioles, and I check the standings almost every day during the summer months. That’s a pleasant experience this summer because at this writing, my team is in first place in the AL East. I know we have a wide variety of readers who follow other teams of their childhood: the Reds, Pirates, Cubs, Cardinals, Braves, and so on.

I believe there are two records in baseball that will never be broken: Joe DiMaggio’s 56-game hitting streak and Cal Ripken Jr. playing in 2,632 consecutive games. They both exemplify consistency and grace under pressure. Qualities we all need to embrace.

My son Chandler met Cal Ripken Jr. in 2011 while playing in the Cal Ripken World Series. Chandler is still playing baseball. Some things haven’t changed but have gotten better.

Cal Ripken Jr. and Chandler Dunn, 2011 BELOW Chandler Dunn, Henry Clay Blue Devils, 2016 LEFT

All the Best,

Gil Dunn Publisher, MD-UPDATE Send your letters to the editor to: jnewton@md-update.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax ISSUE#101 | 3

HEADLINES

A Single Breath Breath ‘signature’ presents promise for earlier diagnosis of lung cancer

A single breath may be all it takes to identify the return of lung cancer after surgery, according to a study authored by University of Louisville Researchers and posted online by The Annals of Thoracic Surgery.

Exhaled breath contains thousands of volatile organic compounds (VOCs) that vary in composition and pattern depending on a person’s health status. A subset of four VOCs — called carbonyl compounds because of their carbon base — have been discovered in the exhaled breath of lung cancer patients. Being able to identify this lung cancer “signature” through a simple breath test has emerged as one of the most promising ways to diagnose the disease.

Now the test is being used to monitor for disease recurrence.

Erin M. Schumer, MD, Victor van Berkel, MD, PhD, and colleagues from the University of Louisville analyzed breath samples collected before and after surgery from 31 lung cancer patients and compared their carbonyl VOCs levels with samples from 187 healthy patients.

The researchers found a significant decrease in overall carbonyl VOC levels following surgery; in fact, three of the four carbonyl VOCs normalized after surgery, matching levels in the control group.

“The rapid normalization of almost all of the four compounds after surgery provides strong evidence that they are directly produced by the tumor environment,” Schumer says. “This study confirms that the technology is accurate.”

Lung cancer is the leading cause of cancer death. The American Cancer Society estimates that more than 224,000 Americans will be diagnosed with lung cancer this year, and more than 158,000 lung cancer patients will die — that translates to 433 lung cancer deaths per day in the United States.

Schumer said those grim statistics underscore the need for early detection.

LOUISVILLE

4 MD-UPDATE

PHOTOS PROVIDED BY U OF L

ABOVE LEFT:

Breath analysis is simple. The patient blows into a specialized balloon that is connected to a pump and pulls the breath over a small microchip. The microchip is then sent to a lab for analysis of the chemicals.

ABOVE RIGHT: The microchip is smaller than the size of a quarter.

The bag, microchip, and lab tests together cost about $20.

RIGHT Erin M. Schumer, MD, U of L researcher, says, "We hope that breath analysis will allow us to diagnose patients with primary or recurrent lung cancer long before they suffer from symptoms."

FAR RIGHT Victor van Berkel, MD, PhD, U of L researcher, says their hope is that breath analysis will serve as the primary screening tool for lung cancer recurrence and that their next step is getting FDA approval.

“We hope that breath analysis will allow us to diagnose patients with primary or recurrent lung cancer long before they suffer from symptoms, when we have more options for treating them, giving them the best chance for cure,” she explains.

Currently, lung cancer patients are followed after surgery with chest computed tomography (CT) scans, which can be inconvenient, expensive, and expose the patient to radiation. “We hope that the breath analysis can serve as the primary screening tool for cancer recurrence and a CT scan will be ordered only if the breath test suggests that there has been a change,” van Berkel says.

How the breath test works The process of breath analysis is relatively

simple. The patient blows a single breath into a specialized balloon. The balloon is then connected to a pump that pulls the breath over a small microchip that is smaller in size than a quarter, trapping the chemicals.

The microchip is sent to the lab, where the chemicals are analyzed within hours. Breath collection can be performed in the doctor’s office.

The pump is reusable; the balloon, microchip, and lab test together cost around $20, all supporting the increasing acceptance of breath tests as a cost-effective, easy-to-perform, non-invasive and rapid option for the diagnosis of lung cancer.

“The great potential with breath analysis is detecting lung cancer at any point, both as a primary screening tool and to follow patients after disease has been treated,” van Berkel says. “The technology is pretty robust. Our next step is getting approval from the FDA.” ◆

FINANCE

Time for a Talk Long-term care, often interpreted as a euphemism for nursing home residency, is hard to think about. And even harder to discuss. “It won’t happen to me,” is the mantra that plays in our minds – until a loved one has the need for it. Not-so-fun fact: The U.S. Department of Health and Human Services projects that 70 percent of Americans over age 65 will need some form of long-term care during their remaining lifetime. Time for a talk.

For planning purposes, a broader vision of long-term care must be embraced.

Establishing the actual care plan is the primary task. If I become incapacitated for longer than X amount of time, how would I want to be cared for? Who would provide the care? Where would it be provided?

These are critical questions that must be discussed by each of us, with our families, before we can fully address how it will be paid for.

We are not talking about end of life planning (though I highly recommend Dr. Ken Murray’s excellent 2011 article, “How Doctors Die”). What we are talking about is the time between now and whatever you would define as the trigger that time is short. During that time, should a health event or an accident cause incapacitation, the answers to the questions above can prove to be invaluable – especially if they have been thoroughly considered, discussed with family, and written down long before they are actually needed.

Of course, as financial planners we do ultimately place focused attention on the cost of such care, and our job is made easier and much less expensive with the answers to the questions above. This year, I have attended continuing education sponsored by the Institute for Healthcare Improvement with the focus on facilitating these conversations with clients and their family members. We

have developed a more extensive long-term care questionnaire and will be happy to send it to any reader upon request. We have one for singles and a separate one for couples.

BY Scott Neal Genworth just published its 2016 study on the cost of care by state and region. The study breaks down levels of care into the following categories and related median annual cost of each for Kentucky: home health aides ($42,900), homemaker services ($41,184), adult day services ($17,940), assisted living ($39,600), nursing home private ($83,722), and nursing home semi-private ($75,192).

The good news is that the annual cost of care for each category except adult day services has actually declined in Kentucky from 2015 levels.

There are essentially three ways to pay for needed care. They are: private pay, insurance, and the government via Medicaid.

Most of our clients simply dismiss the idea of Medicaid planning, assuming that they could never qualify for the benefit, or

BREXIT

Some will ask why we haven’t addressed the news of Great Britain’s exit from the EU. At this writing, the Brexit is very much an evolving story that could have long-ranging implications. Everything from “much ado about nothing” all the way to global recession is still on the table for discussion.

Watch for a future article for our diagnosis about Brexit and our prognosis of its impact on our planning and investments.

assuming that care paid for by Medicaid would somehow be sub-standard. Some are ethically opposed to having the government pay if they are able to pay themselves.

We respect these views but believe that the decision needs to be more fully informed.

There are also other very family-specific considerations.

Private pay should be considered an option only if assets are reasonably expected to be available when needed. However, it should not be thought of in a vacuum without also thinking about the risk of sacrificing other family goals. When a need arises, the stress on the family increases exponentially. Generally, when addressing the potential cost of care, it is important to note that these are not always added expenses. Some living expenses will likely go down should the need for care arise.

Identifying these ahead of time and informing family of expectations is an important communication to have with all the family members who might be impacted.

The long-term care insurance industry has changed dramatically over the last several years. Lifetime benefits are a thing of the past. Additionally, some policies can be partnered with governmental assistance to allow the policy holder to retain assets through a feature known as “asset disregard” under Kentucky’s Medicaid Policy.

If you have insurance, it is important to review your coverage from time to time. If you don’t, we suggest that you evaluate the risk and if insurance is indicated or desired, develop a request for proposal before talking with an insurance agent. We can help you with that.

Scott Neal is the president of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. He can be reached at scott@dsneal.com or by calling 1-800344-9098. ◆

ISSUE#101 | 5

ACCOUNTING

MACRA: Are you prepared to protect your Medicare reimbursement?

Is your practice prepared for MACRA (The Medicare Access and CHIP Reauthorization Act) and the potential reductions in Medicare reimbursement associated with the recently proposed rules? Perhaps lost in the shuffle last year due to the implementation of ICD-10, was the creation of MACRA, which was signed into legislation

by President Obama on April 16, 2015. Fast forward one year later to current day and the recently proposed MACRA rules, which have been described as the most significant Medicare policy change in recent history.

Unless you are a new Medicare provider, bill a very low volume of Medicare claims, or are associated with a Rural Health Clinic or Federally Qualified Health Center, your Medicare reimbursement is at risk – there is no opting out of this program.

MACRA replaces the sustainable growth rate (SGR) formula with a framework that rewards (or penalizes) providers for providing higher quality care through the creation of two reimbursement pathways: Meritbased Incentive Payment System (MIPS), and Alternative Payment Models (APMs).

Additionally, the proposed rules collapse three existing quality reporting programs (PQRS, Value-based Payment Modifier, and Meaningful Use) into the newly created MIPS pathway. By all indications, the majority of providers will follow the MIPS pathway with only providers taking on a risk-based payment model following the APMs track. Because most providers will follow the MIPS pathway, it is important to understand the four components contributing to a MIPS score:

BY

AdamShewmaker

BY

Porter Roberts

Based on these four categories, providers can earn a score ranging from one to 100, and then will be compared to a national statistic. On November 1 of this year, CMS is scheduled to release its listing of quality reporting criteria, which will include measures from existing programs as well as new and updated measures. Each provider must then select the six criteria on which they choose to be evaluated. The initial reporting and evaluation period is scheduled to start on January 1, 2017 with provider quality data impacting 2019 Medicare reimbursement – either positively or negatively. Since MACRA was designed to maintain overall budget neutrality, there will only be winners and losers. The following outlines the proposed Medicare Part B reimbursement impact relative to the MIPS pathway:

To be eligible for the APM track, the provider’s participation in a qualifying APM will be reviewed by CMS. To qualify for the APM track, providers must get at least 25 percednt of their Medicare Part B business (defined as patients or charges) through an 6 MD-UPDATE

advanced APM. The percentage threshold for this pathway climbs from 25 percent in 2019 to 50 percent in 2021 and 75 percent in 2023. In short, if providers are not already participating in an APM track, it may be difficult to keep pace with the thresholds and qualify for this track. As CMS outlined in the proposed rules, roughly 30,000 to 90,000 providers will qualify for the APM track, as compared to approximately 700,000 participating in the MIPS track. Based on the proposed rules, the APM that satisfy MACRA criteria are:  Comprehensive ESRD Care (LDO Arrangement)  Comprehensive Primary Care Plus (CPC+)  Medicare Shared Savings Program: Track 2  Medicare Shared Savings Program: Track 3  Next Generation ACO Model  Oncology Care Model Two-Sided Risk Adjustment Also of note, providers cannot participate in both reimbursement pathways – that means that providers eligible for an APM pathway will not be MIPS eligible and vice versa.

MACRA will change Medicare Part B reimbursement as we know it. To help protect your Medicare Part B reimburse-

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ment from future penalties, now is the time to assess your readiness and implement operational changes that might be needed to potentially share in the positive reimbursement adjustments scheduled in 2019.

Remember, there will only be winners and losers – you must act now to increase your chances at improving your Medicare Part B reimbursement.

Thinking clearly. Caring deeply.

Adam Shewmaker, FHFMA, is director of Healthcare Consulting Services at Dean Dorton. He can be reached at 502.566.1054 or ashewmaker@ddafhealthcare.com.

L. Porter Roberts, Jr. CPA, is director of Tax and Healthcare Consulting at Dean Dorton.

He can be reached at 859. 268.1040 or at proberts@deandorton.com ◆

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ISSUE#101 | 7

LEGAL

A Checkup on Medicaid and Behavioral Health Services It has been a long time coming, but on March 30, 2016, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule (“the Rule”) that should strengthen access to mental health and substance use services for those with Medicaid or Children’s Health Insurance Program (“CHIP”) coverage.1 This new rule is the latest step in a series of laws and regulations that extend back twenty years in an attempt to provide more treatment options for mental and behavioral health.

The slow build towards behavioral health coverage signals a profound shift in how policymakers consider substance abuse, but the state of behavioral health is still somewhat of a mixed bag for those who need treatment. There are signs that the patient is improving, however.

Access to Behavioral Health Care

Two days before the publication of the Rule, the U.S. Department of Health and Human Services published a report that evaluated access to behavioral health services in light of state acceptance of the Medicaid expansion under the Affordable Care Act.2 The report found, for instance, that a substantial share – 28% - of the low income uninsured individuals in states that have not accepted the 1 42 C.F.R. 438, 440, 456, and 457 (2016).

2 U.S. Dept. of Health and Human Services, Office of the Asst.

Sec. for Planning and Evaluation, Benefits of Medicaid Expansion for Behavioral Health (2016).

Medicaid expansion required mental health or substance use disorder treatment recently.3 Research on the effects of Medicaid coverage also suggests

BY Christopher J. Shaughnessythat acceptance by the remaining holdout states would decrease the number of individuals experiencing symptoms of depression, for example, by 371,000, according to the report.4 The implication of the report is that coverage under Medicaid is equivalent to access to behavioral health services, but this is only one piece of the puzzle.

The New Rule

The Rule helps to shore up another front – just because a state accepted the Medicaid expansion did not (until the Rule) mean that behavioral health received parity in coverage. The Rule now applies the provisions of the Mental Health Parity and Addiction Equity Act of 2008 to any state managed-care plans that contract with Medicaid and CHIP. Currently, states could provide services through delivery mechanisms other than Medicaid managed 3 Ibid. at 4.

4 Ibid. at 7.

care organizations. These systems could place limits on the type and frequency of services available in behavioral health, and medical necessity rules often stymied coverage as well.

Under the Rule, all beneficiaries who receive behavioral health services through managed care organizations, alternative benefit plans or CHIP must receive mental health and substance use disorder benefits on parity with other medical benefits, regardless of the mechanism for delivery of services. Additionally, these plans must disclose information on any mental health or substance use disorder benefits when requested, as well any criteria for determinations of medical necessity. States must also disclose the reason for a denial of payment for behavioral health services.

The Rule effectively brings these programs in line with parity requirements on private insurers, but it notably does not apply to traditional Medicaid programs.

State Level Action

Now that the expansion of Medicaid has taken root and new rules require parity for coverage of mental health and substance use disorders, the next part of the equation is state administration. To understand the state of behavioral health in Kentucky, it is probably best to address one of the more enduring, challenging and proliferating problems confronting behavioral health

Focus on what matters most.

We’ll handle the rest.

• Revenue cycle assessment and • Reimbursement optimization management • Accounting and financial • Physician coding and documentation outsourcing improvement • Compliance and risk • Managed care contract negotiations management services 8 MD-UPDATE

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MOBILE INTRAOPERATIVE TO BALANCE USE AIRO® TECHNOLOGY, AMONG OTHER CLINIC NEUROSURGEONS TREATMENT LEXINGTON JOSEPH HOSPITAL, FOR OPTIMAL CT AT SAINT AND EXPECTATIONS PATIENT NEEDS

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Issue #102, August/September

 SKIN DEEP Dermatology, Plastic Surgery, Vascular Medicine Issue #103, October

 CANCER CARE Oncology, Hematology, Radiology Issue #104, November

 IT’S ALL IN YOUR HEAD Neurology, Ophthalmology, ENT Pain Medicine, Mental Health Issue #105 – Dec/Jan 2016

PRIMARY CARE AND PEDIATRICS Primary Care, Internal Medicine, Family Medicine, Pediatrics *EDITORIAL TOPICS ARE SUBJECT TO CHANGE.

Christopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, PLLC. Mr. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office. He can be reached at cshaughnessy@mmlk.com or at (859) 2318780.

This article is intended as a summary of state law enforcement activities and does not constitute legal advice. ◆

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2016 VOLUME 7•#2•MARCH

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5 KRS 205.6311 ISSUE#101 | 9

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Efforts to expand access to behavioral health services have been substantive in recent years, but there is still a gulf that divides those who need mental health and substance use disorder treatment and provision of the services themselves.

Policymakers have been steadily working on easing the demand for these crucial services, but they are still short on incentives to increase the supply.

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To recap, the Medicaid expansion brought expanded coverage, the new CMS Final Rule will ostensibly bring parity of benefits, and Kentucky laws and regulations place a

Conclusion

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Where are the Providers?

premium on access to behavioral health services. The final piece in the puzzle remains the shortage of providers.

Kentucky, for instance, is listed by the HHS Health Resources and Services Administration as having 100 health professional shortage areas in the field of mental health, and a map depicting these areas covers almost the entire state, save for counties directly adjacent to relatively large municipal areas. If low-income Kentuckians who need behavioral health services now have coverage, their next challenge is finding a provider of that care.

Medicaid’s low reimbursement rates may be a factor in the shortage, with behavioral health providers loath to accept these rates in such highly regulated areas of care such as medication-assisted therapies for substance use disorder treatment. With the increased law enforcement component, providers may not see the reimbursement rates as justification for the regulatory burdens and potential consequences of noncompliance.

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– epidemic substance use disorder.

As a response to the opioid addiction epidemic in the state, Kentucky accepted the Medicaid expansion early and moved to implement expanded behavioral health services, creating a multitude of new behavioral health provider types that are eligible for reimbursement under the state������������������������������������ ’s Medicaid plans.������������������ The most significant are the Behavioral Health Services Organization (“BHSO”) and the Behavioral Health Multi-Specialty Group (“MSG”).

Licensed under 902 KAR 20:430, BHSOs may provide a comprehensive variety of services from mental health and substance disorder providers.

While the acceptance of the Medicaid expansion has ostensibly led to expanded access to behavioral health treatment among the uninsured population, it is unclear how the current administration’s attempts to transform the Medicaid system in Kentucky will affect the provision of these services. Still, there has been no indication that behavioral health benefits will be curtailed.

In 2015, in response to the rising heroin epidemic in Kentucky, the General Assembly passed Senate Bill 192, the “heroin bill,” which provides an array of tools at the state level to increase access to care for those with substance use disorders. Among those tools is statutory language providing that “The Department for Medicaid Services shall provide a substance use disorder benefit consistent with federal laws and regulations which shall include a broad array of treatment options for those with heroin and other substance use disorders.”5 The law also exempts several behavioral health providers from Certificate of Need requirements, easing a key regulatory burden.

ARE PROFESS

AND HEALTHC Y PHYSICIANS

COVER STORY Dr. Arthur Malkani performs joint replacement surgery using the Mako robotic system. “It’s the first time in my career that I’m getting intraoperative numbers on the patient’s leg length, position, and size of the implant …

It’s not doing the surgery for you, but it’s making you a better surgeon and more accurate,” he says.

PatientDriven.

PrecisionMade.

KentuckyOne Health Orthopedics redesigns patient access and pursues perfect surgical precision

BY JENNIFER S. NEWTON No surgeon is perfect. Even the most precise, experienced surgeons have a margin of human error. But, what if a robot could change that? What if surgeons could achieve perfect surgical precision? And, then, what if a healthcare system redesigned its service lines and access points to better reflect how patients experience episodes of care and how they want their needs to be met?

All these hypotheticals are converging in reality in orthopedic care at KentuckyOne LOUISVILLE

10 MD-UPDATE

Health in Louisville. Through a combination of new robotic technology, redesigned care plans, and new access points, KentuckyOne Health Orthopedic Associates is designing the ultimate patient experience.

With 12 employed orthopedic surgeons and two fellowship trained double board certified primary care sports medicine specialists, KentuckyOne Health Orthopedic Care covers the full spectrum of care from joint replacements to sports medicine and from spine surgery to trauma.

Greg Rennirt, MD, orthopedic surgeon and physician market leader of the West

PHOTOS BY ROBERT DENSMORE AND KENTUCKYONE HEALTH

Market (Louisville area) for KentuckyOne Health, says, “What we’re trying to do from a service line perspective is redesign our care to better mirror the way the patient sees our healthcare system. We’re trying to set up teams around episodes of care so there is more of a seamless transition.” These pathways are horizontal across multiple specialties, rather than the vertical silos of the past in medicine.

KentuckyOne recently completely redesigned its total joint replacement care plans to follow this new philosophy, including opting into the Centers for Medicare and

LEFT Dr.

Greg Rennirt is an orthopedic surgeon with KentuckyOne Health Orthopedic Associates specializing in sports medicine and shoulder repairs and is the physician market leader of the West Market (Louisville area) for KentuckyOne Health.

RIGHT Dr. Arthur L. Malkani, orthopedic surgeon with Shea Orthopedic Group, part of KentuckyOne Health, started Jewish Hospital’s total joint program in 1997 and now performs total hip and partial knee replacement using the Mako robotic system.

Medicaid bundled payment program. (For more information, see the sidebar Bundling Payments, Improving Outcomes on page 12.)

“Probably the biggest difference in what KentuckyOne can offer versus all the other orthopedic surgeons in Kentucky is our total joint program. What we have in our total joint program through our bundled payment program with CMS is really unique,” says Rennirt. “We’ve significantly improved outcomes. We’ve dramatically cut length of stay. We’ve cut the cost of surgery.

Patient satisfaction is through the roof. That really is a differentiator.”

Robotic Perfection

Redesigned transitions of care and changing reimbursement models are only part of the equation for KentuckyOne’s total joint program. The addition of robotic hip and partial knee replacement is revolutionizing outcomes and has the potential to exponentially increase the lifespan of implants.

While robotic joint surgery has been around for several years, it has been slow to

The Mako robotic system uses pre-operative CT scans along with intraoperative tracking to allow surgeons to place implants perfectly ever time.

come to Kentucky. However, in December 2015, Jewish Hospital was the first in the area to launch a robotic joint replacement program with the MakoPlasty™ Interactive Orthopedic System, a product of Stryker®.

For Stryker, the Shea Orthopedic Group, part of KentuckyOne Health, was the fastest launch in company history in terms of the number of patients who had robotic surgery within the first 90 days.

Now six months into the robotic program, orthopedic surgeon Arthur L. Malkani, MD, who began Jewish Hospital’s total joint program in 1997 and is with Shea Orthopedic Group, says he and a fellow surgeon have done a total of approximately 65 robotic surgeries, about 50 of which have been hip replacements and 15 of which have been partial knee replacements. Robotic total knee replacements

were recently approved by the FDA, according to Malkani, and he hopes to have that technology at Jewish Hospital by the end of the year.

Using a pre-operative CT scan to map the patient’s anatomy, the Mako robotic system provides surgeons real-time information on correct implant size, position, and leg length to allow perfect placement every time. Malkani likens the robot to using GPS navigation in your car. “GPS is telling me where to go, but I’m driving the car,” he says. With the robot, “If I deviate, it just shuts off. It’s so precise. I can’t imagine doing this surgery without the robot now.”

One hundred percent of Malkani’s hip and partial knees replacements are now being done with the robot. For hip replacements, his preference is the direct superior approach, but he says the important thing to note is, “The robotic system can do hips from any position you want based on the patient’s needs and best interests.” With traditional partial knee replacement, the procedure is only perfect an average of 70 percent of the time. With the robot, precision jumps to 95 percent. “It takes the stress out of surgery when you have a system that’s extremely accurate in telling you what size you need and where to go,” says Malkani.

Very active 74-year-old Paula Hammer had a total knee replacement done by Malkani in 2010 before the Mako robot was available. She returned to Malkani because of pain in her other knee, and he opted to do a robotic partial knee replacement in January 2016. While Hammer admits she babied her first knee after surgery, she was walking the Masters Tournament three months post-op.

This time, however, her results were even better. “The other knee I woke up and I was groggy and ISSUE#101| 11

COVER STORY

uncomfortable. This one I woke up and I was ready to party. It was a totally different experience,” Hammer says. She was home two days after the robotic partial knee and walked up the stairs to bed. “Yes, there was pain, but it was nothing like before,” says Hammer. Now she is back to exercising and playing with her grandkids just like she did before.

Logan Mast, MD, is the newest member of Shea Orthopedic Group, having joined in September of 2015. A Louisville native, Mast attended medical school and residency at the University of Louisville and did a sports orthopedics fellowship with Andrews Sports Medicine group in Birmingham, Al. A self-proclaimed generalist, Mast has a patient population that is half orthopedic patients and half sports medicine patients, a good representation of the breadth of surgical options available at Jewish Hospital. He also assists Raymond Shea, MD, with the care of the U of L football team.

Mast is certified to do Mako robotic surgery but has not yet performed surgery with the robot. “The implants are similar or the same as the implants we’ve used in the past. It’s the reproducibility of the robot that allows us to be more consistent with placing the implants in the correct position for a given patient, that allows us to hopefully maximize the life of the implant itself, and therefore the length of benefit that the patient will see from that partial knee replacement,” Mast says.

Sports Medicine = Arthroscopy, Not Just Athletes

Often misunderstood, sports medicine is a surgical subspecialty of orthopedics.

However, there is also a new breed of primary care sports medicine physicians, a subspecialty of family practice, who focus on non-surgical treatments. KentuckyOne Health employs both to meet the comprehensive needs of its patient base from weekend warriors to collegiate athletes to aging patients with arthritis.

When it comes to sports medicine sur12 MD-UPDATE

BUNDLING PAYMENTS, IMPROVING OUTCOMES On July 1, 2015, KentuckyOne Health opted in to the Centers for Medicare and Medicaid (CMS) Bundled Payments for Care Improvement (BPCI) initiative in orthopedics for lower extremity joint replacements.

Explains Greg Rennirt, MD, orthopedic surgeon and physician market leader of the West Market (Louisville area) for KentuckyOne Health, “It’s a way of bundling orthopedic services to control costs for CMS, but what it does is it actually allows us to spend money to try to improve outcomes to drive down costs. Instead of just chasing cost reductions, it actually allows us to spend money to try to make our patients safer, and to cut down on complications, which in the end will result in cost savings.”

KentuckyOne Health initiated the program at six of its facilities and has the only CMS orthopedic bundled payment program in Kentucky.

As part of the program, KentuckyOne launched a Joint Academy. Pre-op counseling was offered

to orthopedic patients prior to the bundled payment program, but the Joint Academy is now a mandatory educational class for any patient having an orthopedic procedure. The class is led by a KentuckyOne Health nurse navigator and discusses all aspects of pre-op and post-op care, including discharge planning.

While all orthopedic surgery patients attend Joint Academy, only Medicare patients are part of the orthopedic bundle at this point.

As part of the bundle program, those patients also meet with a KentuckyOne Health Partners orthopedic health coach at the Joint Academy class.

KentuckyOne Health Partners, a division of KentuckyOne Health, is a care management company with a clinically integrated network of providers, facilities, and ancillary services that collaborate to ensure high quality, costeffective care.

“We feel the value of Joint Academy is that patients go into surgery knowing exactly what to expect, knowing exactly where they are going to go at discharge, and they have met their orthopedic coach that is

a KentuckyOne Health Partners Health Coach who follows them for 120 days post-operatively,” says Ann Spencer, KentuckyOne Health Partners regional director for Care Management.

"We’ve seen great success at lowering readmissions due to that relationship that starts immediately in that classroom setting.” Case in point, KentuckyOne readmissions for elective hip and knee replacement were 17 percent before the program. Now they’ve been reduced to 10 percent across the health system.

Another advantage of the bundle program is that KentuckyOne has obtained a waiver from CMS so patients can be sent home on day one or two post-op rather than staying for the otherwise obligatory three nights, allowing patients to start the healing and therapy process earlier.

Spencer also says physicians have been instrumental in developing consistent evidence-based protocols and standardizing care across the continuum to improve quality and reduce inconsistencies across the market.

“It’s been a real win for patients and for the system,” she says. ◆

LEFT Dr.

Logan Mast is the newest orthopedic surgeon to join Shea Orthopedic Group, part of KentuckyOne Health, and has a practice that is half orthopedics and half sports medicine.

BELOW Dr. Paul McKee is a primary care sports medicine physician specializing in non-operative sports medicine who has been instrumental in creating a walk-in after-hours clinic for sports medicine injuries.

gery, Mast says, “As sports orthopedists, we don’t only treat athletes, but also weekend warriors and the general public, alike. Some of our procedures are done through a scope in a minimally invasive manner, called arthroscopy. The ability to treat many problems through a scope is one of the defining features of a sports orthopedist.”

A large portion of Mast’s practice is hip arthroscopy. “Recently we’ve been able to treat problems like labral tears in the hip that were untreatable before or at the most extreme were treatable with open surgery only. Now we can do them as an outpatient procedure through small incisions that require less risk of bleeding and infection,” he says.

Rennirt, who joined KentuckyOne in 2010 because he was looking to be a part of a large multispecialty group, says his sports medicine and shoulder practice has evolved as he has gotten older. He no longer participates as an on-the-field physician but sees more rotator cuff injuries, osteoarthritis patients, and worker’s compensation shoulder injuries.

Arthroscopy continues to be the center of his practice, but he says new advancements in devices are improving the patient experience. “In shoulder replacements, newer implants help to compensate for rotator cuff deficiencies, which used to be a contraindication to doing a shoulder replacement, and synthetic grafts for the shoulder, called Superior Capsular Reconstruction, treat people with irreparable rotator cuff tears,” Rennirt says.

The Healing Power of Biologics

When it does come to treating athletes, according to Rennirt the newest horizon is biologics. “The big field in sports medicine right now is osteobiologics, trying to harness the body’s healing capacity and concentrate it to heal an athlete,” he says.

Paul McKee, MD, is a primary care sports medicine physician who joined Shea Orthopedic Group in 2010 and specializes in diagnosing, treating, and managing nonoperative musculoskeletal injuries. McKee serves as the team doctor for the U of L baseball team and sees athletes from all sports on the U of L campus. He has a particular interest in biologics, such as platelet rich plasma (PRP) and bone marrow injections, which he has been using on athletes for years. “The focus is to try and promote healing and prevent surgery whenever possible. Ultimately, we try to get athletes back to sport safely and quickly,” he says.

A New Model for Emergent Musculoskeletal Care

McKee posits that access to care is one of the most frustrating and challenging things for patients in healthcare today,

particular orthopedic patients. For a patient who suffers a musculoskeletal injury after hours, the choices are limited – either urgent care centers that may not be trained in such injuries and ultimately refer you back to your doctor in the morning or emergency departments that can have long wait times as more acute medical emergencies take precedence.

That’s why McKee has been advocating for an after-hours walk-in clinic for years, and he’s finally getting his wish.

KentuckyOne Health is opening its first orthopedics and sports medicine walk-in clinic at Medical Center Jewish Northeast in Louisville, set to open in August 2016.

“The goal of the walk-in clinic is to provide a high level of musculoskeletal care in an after-hours environment, therefore increasing access to musculoskeletal care that is specialized, while at the same time providing it in a much more efficient manner,” says McKee. In addition to improved access and specialized care, the walk-in clinic is designed to be more cost effective than existing treatment options. “Instead of an emergency room charge that could be thousands of dollars, it would be a simple office visit charge, and you have follow up in the appropriate setting already pre-established,” offers McKee. The target audience for the clinic is any patient with a musculoskeletal injury who is at least seven years old. Staffed by a new primary care sports medicine physician, Neil Patil, MD, and sports medicine trained physicians who will rotate there a couple of days a week, the clinic will offer first floor walk-in access and a full range of imaging services, including X-ray, CT, and MRI. For any patient who needs a higher level of care, such as surgery, the clinic has access to all KentuckyOne Health facilities.

“We have an obligation as healthcare providers and as large hospital networks to provide care at a high level in an efficient way that is also fiscally responsible. This after-hours office is going to do all those things,” says McKee. ◆ ISSUE#101| 13

To Us, Seeing a Hero is a Daily Occurrence.

They are around every corner at Shriners Hospitals for Children – Lexington receiving compassionate care from our pediatric orthopaedic experts.

Providing a full range of services to children with conditions of the bones and muscles, from the simple to the very complex, in a family-friendly convenient location.

Relocating in 2017 to the UK HealthCare Campus! We’re moving, not changing who we are or our mission to provide care regardless of a family’s ability to pay.

General Information: 859-266-2101 or 800-668-4634 Referrals: 859-268-5675 or 800-444-8314 shrinerslexington.com 14 MD-UPDATE

SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

Video Game Vision, One Millimeter Accuracy

Greg D’Angelo, MD, uses Navio® robotic partial knee replacement technology to achieve greater accuracy for patients BY BOB BAKER When Greg D’Angelo, MD, was doing his master’s degree in mechanical engineering, robotic-assisted partial knee replacement was not on his radar, and the developers of the orthopedic robotic hand piece may not have envisioned an orthopedic joint replacement specialist who did his master’s thesis on three-dimensional motion imaging. Sometimes these things come together as if by fate, and good things happen.

D’Angelo, a joint replacement specialist, joined Bluegrass Orthopedics in Lexington as the third member of the practice in 1995, when all members of the group did general orthopedics. With the group now at 20 providers with 12 surgeons, each one can focus on a subspecialty with the assurance that at least one member of the group will cover the other areas. D’Angelo has been able to focus on joint replacement for several years now. During this time, D’Angelo reports that hip and knee replacement surgery has gone from being a big surgery with large incisions, blood loss, and an admission to the hospital, to being a much smaller surgery done in a surgery center with same-day discharge if the patient is in good general health. While there is no such thing as minor surgery, especially if you are the patient, the morbidity of joint replacement has steadily decreased as developments in materials, technology, surgical instrumentation, and minimally invasive surgical techniques have evolved.

D’Angelo obtained a bachelor’s degree in mechanical engineering from McMaster University in Hamilton, Ontario and then entered the MD program at the same university. His surgical internship was done at Mt. Sinai Hospital, followed by a residency in orthopedic surgery at the University of Toronto. He then returned to McMaster to complete the Masters of Mechanical Engineering program, followed by three one-year subspecialty fellowships, all in Toronto, beginning with arthroscopic surgery and sports medicine, then pediatric orthopedic surgery, and finally adult LEXINGTON

After incision the reflective tracking arrays are placed on the tibia and femur.

The reflective spheres communicate to the Smith & Nephew Bluebelt Navio unit.

D’Angelo stresses the range of motion of the knee to show the computer how much correction is possible and the tension in the patient’s tissue. The main benefit of the Smith & Nephew Bluebelt Navio technology is having a perfectly balanced knee through the range of motion.

The robot identifies where contact is made on the femur and tibial insert through the range of motion for proper tracking of the components and correction of the preoperative deformity.

PHOTOS BY GIL DUNN

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SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

reconstructive surgery. He immigrated to Kentucky in 1992 and to Bluegrass Orthopedics in 1995. He has been in that practice to the present.

For historical perspective, D’Angelo recounts that partial knee replacement was first tried in England about 40 years ago and has come in and out of popularity over the course of his career, becoming more successful as technology has produced better performing implants and now more accurately placed implants. Improvements in prosthesis manufacturing linked with better imaging techniques and computer analysis to assist prosthesis placement have all converged to produce the robotic devices that are now the cutting-edge of surgical care.

The greatest challenge of partial knee replacement has always been to fit the prosthesis into the knee so that it conforms to the remaining bones and ligaments of the knee in optimal anatomic alignment, as well as correcting existing joint deformity and range of motion to the maximum extent possible without over-stressing the soft tissue in and around the joint. This challenge is now met with a greater degree of success than might have been imagined even a few years ago.

This brings us to the two-part contribution of the Navio® robotic system. There is definitely a wow factor in this robotic device, but it is perhaps not the one you would first imagine. Since the most visible part of the system is the robotic hand piece, and it is an incredible instrument, it would seem it should get the all-star votes. But, the bigger wow in this system is that it can “see.” Not to push the anthropomorphosis too far, but as D’Angelo explains, this robot sees with the same technology that high-end video games, like the Xbox, used to let the gamer control the action on the screen – a wavelength of light not visible to the human eye sent to a computer via a detector.

For partial joint replacement, an array of reflective spheres is placed on the femur and tibia in the operating room after making an incision. The bone surfaces are 16 MD-UPDATE

STRIDE™ unicompartmental knee implants are specifically designed to pair with the Navio system.

D’Angelo uses the robotic hand piece tool to burr out the exact amount of bone for the implant of the prostheses.

D’Angelo implants the final femoral component with an impactor and mallet.

recorded using a 3D pointer. The system does not require a preoperative image such as CT scan or MRI. The computer controlling the robotic hand piece, known as the Smith & Nephew Bluebelt Navio, has already been programmed with the specifics of the prosthesis to be implanted.

D’Angelo then rotates the knee through several planes of movement and the computer calculates the relevant kinematics unique to that particular patient using the images of the reflective spheres attached to the bone.

The power of the computer is then used to replace the knee “virtually.” The components to be placed are chosen to fit the bone contours. The original cartilage surface can be made to match the new metal surface.

The range of motion is checked on the computer so that the two components articulate at the correct locations and that the knee is stable and balanced throughout the range.

If adjustments have to be made, the components can be rotated and shifted to onedegree and 0.5mm accuracy and rechecked on the screen before any bone is cut.

The robotic hand piece is used by the surgeon to cut the host bone at the specified implantation bed, but only in that calculat-

The real question is: What can an experienced surgeon do with a computer-directed robotic hand piece that he couldn’t do without it?

- Dr. Greg D’Angelo ed bed because the robotic cutting tool will not remove bone outside of that prescribed area. If a movement of the drill is about to push outside the calculated area, the drill stops and will not cut again until brought back within the calculated area. This process is accurate to within one millimeter. So, when asked; “What can a robot do that an experienced and meticulous surgeon can’t do?” D’Angelo responds, “Wrong question.

The real question is: What can that experienced and meticulous surgeon do with the computer-directed robot system that he can’t do without it? That one-millimeter accuracy tolerance cannot be achieved without robotic assistance.”

At this time the robot is used exclusively for partial knee replacements. Very recently the FDA gave approval for the use of the

system in total knee replacements.

In discussing the theoretical ideal patient for joint replacement, D’Angelo gives an answer that is not intuitive to someone outside the field. The usual answer to that kind of question in most branches of medicine would be that the best patient would be diagnosed and treated very early in the disease process. D’Angelo tells us that many patients come in with that same concept; they want to get surgery right away before it gets to the point it can’t be fixed.

Basically, says D’Angelo, “You can’t damage a knee or a hip to the point that it can’t be fixed, so there is no rush.” In fact, the opposite should be observed. Specifically, the best patient for a joint replacement is one whose lifestyle has been destroyed by pain and immobility. These patients are so relieved by the procedure that they are willing to undertake the rehabilitation necessary and put up with some temporary discomfort in order to have their lives back.

“That’s the best part,” D’Angelo says, “having patients come back to get their stitches out, walking on their own, no wheelchair, no walker, no cane. That’s a good feeling for everybody.” ◆

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SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

Lexington Shriners Hospital Incorporates State-of-the-Art Technology in Pediatric Care

BY MEGAN WHITMER Time and time again in recent months, Shriners Hospitals for ChildrenLexington has demonstrated its commitment to being a leader in orthopedic care by incorporating cutting-edge technology to increase the quality and safety of the care provided to patients of the hospital.

LEXINGTON

Computer-Aided Design

Shriners Hospitals for ChildrenLexington’s Pediatric Orthotic and Prosthetic Services (POPS) department offers a full range of care, including upper and lower extremity prosthetic care, scoliosis bracing, and a wide spectrum of pediatric orthotic services.

MAGEC Growing Rods

Last September, Vishwas Talwalkar, MD, pediatric orthopedic surgeon, completed the hospital’s first implantation of the state-of-theart Magnetic Expansion Control (MAGEC) Spinal Bracing and Distraction System on Noah, an eight-year-old boy with scoliosis.

Growing rod surgery is used to treat scoliosis, a sideways curvature of the spine, in children TOP: Vishwas Talwalkar, MD, with curves at high risk explains the magnetic lengthening of worsening. Traditional device to his patient before growing rod surgery performing the procedure. involves the implantation RIGHT: After scanning a casting of the child’s leg, the orthotist of growing rods on either completes the orthotic design side of the spine. The rods digitally. are attached to the verteFAR RIGHT: The EOS Imaging brae with hooks or screws.

System allows the patient to stand The initial surgery coror sit inside the booth while the rects the scoliosis as much X-ray is taken. as possible, and then the child returns every six to eight months to undergo lengthening sur- videos while Talwalkar used an External gery as the child grows.

Remote Controller to communicate with MAGEC rods, approved by the FDA for the magnets in Noah’s back and perform use in the United States in 2014, are chang- the lengthening. ing treatment plans for scoliosis because “This new technology is one more they do not require surgical intervention to tool that allows us to provide high quality perform the lengthening procedures. After healthcare,” says Anna Gayle Parke, RN. the initial surgery to insert the MAGEC “Not only is it painless and quick, it also rods, lengthenings take place in the outpa- eliminates multiple episodes of anesthesia, tient clinic. “There’s a mechanism inside therefore reducing the risk of complication.” the rod that is controlled by an external Not all spinal curves can be treated with magnetic device,” Talwalkar explains. the MAGEC system; there must be a section Noah returned for his first lengthening of the spine straight enough to line up with procedure post-surgery in January. Rather the magnets. “This is a great option for some than undergo the lengthening surgery that of our patients who require growth instrutraditional growing rods require, Noah lay mentation,” says Talwalkar. “It remains to on an exam table and watched Star Wars be seen if we will use this on a regular basis.”

18 MD-UPDATE

PHOTOS PROVIDED BY SHRINERS HOSPITAL FOR CHILDREN-LEXINGTON

In March, POPS introduced 3-D scanning technology and incorporated computeraided design (CAD) to assist staff in the design of orthotic and prosthetic devices.

These technologies offer a high degree of accuracy and reproducibility to accentuate the current clinical skills needed for the intricate pediatric orthotic and prosthetic designs.

“Using our Vorum computer-assisted design program, we can either scan our patients in real time or scan a fiberglass cast taken during assessment. We then modify the scanned images and digitally send these files to our Twin Cities fabrication center for production,” says Eric Miller, CPO-L, Orthotics & Prosthetics manager.

“The most noticeable benefit is for our

patients with scoliosis,” Miller continues.

“The ability to scan allows us to capture a detailed image of the patient without any hands-on contact. The majority of our scoliosis patients are young females, and the scanning process makes it less awkward for that patient population.”

EOS Imaging System

In January, Dale Wallenius, director of Development, announced that he had secured funding to purchase an EOS Imaging System for the Shriners Hospitals for Children Medical Center (SHCMC) scheduled to open in 2017 on the UK HealthCare campus. EOS® is a unique, ultra-low dose X-ray system that utilizes Nobel Prize–winning technology to reduce the amount of radiation received during an X-ray procedure. The EOS system at SHCMC will be the first in Kentucky.

Radiation exposure to patients is 50 to 85 percent lower than standard digital radiography, and 95 percent lower than a computed tomography (CT) scan. This reduced radiation is an important benefit for patients with progressive conditions, such as scoliosis and other spinal deformities that require frequent X-rays to monitor disease progression. “EOS will primarily be used on patients with spine conditions and lower extremity conditions, affecting nearly 43 percent of our patients,” says Peggy Myers, director of Radiology.

Reducing a patient’s exposure to radiation from X-rays has been a top priority of the medical imaging industry, which has resulted in a best practice standard known as “ALARA.” This standard states that technology should use radiation doses that are “as low as reasonably achievable” (ALARA) without sacrificing the high-quality images

needed to make medical decisions.

EOS captures full-size, whole body images of a standing or seated patient in a single scan. Images are taken from multiple angles at the same time, reducing the number of X-rays and improving the surgeon’s ability to diagnose and plan for surgery based on three-dimensional views.

Frontal and lateral images of any length can be acquired simultaneously. Physicians are able to view all areas of the body with one image, rather than piecing together multiple images, as is done with digital radiology.

“The vision of Shriners Hospitals for Children is to be the best at transforming children’s lives by providing exceptional healthcare,” says Tony Lewgood, administrator. “Incorporating proven state-of-theart technologies in a compassionate, patientcentered environment helps us provide the highest quality care to our patients.” ◆

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SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

One Step at a Time

Kentucky Orthopedic Associates grows to provide general orthopedics and spine surgery to Central Kentucky communities BY ROBERT BAKER KY Michael R. Heilig, MD, was familiar with orthopedic techniques as early as 1969, the year of his birth, when he began treatment for his own clubbed feet.

At that time, the orthopedic management of his condition meant surgeries, casting, and bracing. Many individuals pursue medicine because of a personal medical problem or a condition severely affecting a loved one.

The majority of these people have changed their minds before the end of medical school. Not Heilig. His personal interest in club foot persisted, and rotations in medical school further convinced him to pursue an orthopedic career. Now, after 14 years in a very busy practice in general orthopedic surgery and the formation of Kentucky Orthopedic Associates in Winchester, Ky., he is quite happy with his early decisions.

Heilig grew up in Lexington and attended Brigham Young University for his BS degree. He took his medical degree from U of L’s School of Medicine, followed by an orthopedic surgery residency at Tulane University in New Orleans. After residency, Winchester was a good fit for Heilig because extended family members were close by and he had the desire to fill a service void in Eastern Kentucky. Furthermore, his friend through medical school and residency, G. Jeffrey Popham, MD, already had a private practice established in Winchester.

Popham encouraged Heilig to join him.

However, soon after beginning this partnership, Popham moved to Louisville to be closer to his family.

So, four months out of residency, Heilig found himself in solo practice, which he considered “somewhat daunting but it turned out to be a blessing because I was able to deliver all aspects of orthopedic care myself and became very comfortable doing so.”

Although he had no concrete business plan for expansion and the creation of a group practice, after four years, Heilig took on his first partner, Gregory F. Grau, MD. Grau, a graduate of UK College of Medicine, has been associated with Kentucky Orthopedic Associates for 10 years now.

WINCHESTER,

20 MD-UPDATE

PHOTOS BY GIL DUNN

About a year ago, the practice added James W. Rice, MD, a 2006 U of L School of Medicine graduate, who had been practicing spine surgery in Ashland, Ky. Rice’s addition filled a service need for spine surgery in the area. Nine months ago, at the end of 2015, David Waespe, MD, UK College of Medicine, joined the group after a fellowship in joint replacement surgery.

These four surgeons now make up Kentucky Orthopedic Associates in Winchester, with satellite offices in Georgetown, Richmond, Paris, Morehead, and Irvine. In addition to the medical staff, the practice employs five physician assistants – Jason Delong, PA-C, Brandon Embry, PA-C, and Kurt Schlenther, PA-C, who will be joined by Sarah Ervin, PA-C, and Michael Bradley, PA-C – plus physiotherapists, and has its own open MRI facilities at the Winchester and Richmond offices.

“To expand further we’d have to add additional providers,” says Heilig. “We stay very busy now with patients who

Dr. Michael Heilig is the founder and senior partner of Kentucky Orthopedic Associates in Winchester, Ky., with satellite offices in Georgetown, Richmond, Paris, Morehead, and Irvine.

come to us from outlying areas. Eastern Kentucky patients come to Winchester and Southeastern Kentucky comes to our Richmond clinic.”

Although Heilig continues to practice general orthopedic surgery, he has a special interest in abnormalities of the shoulder, including shoulder arthroscopy and shoulder replacement. “Diagnostics and pathology of shoulder repair is much improved over the last ten years.”

An additional area of interest for Heilig is repair of the anterior cruciate ligament of the knee. For this process, Heilig prefers the Arthrex© All Inside ACL Technique, an all internal procedure through four small incisional ports and no large incision. An allograft is placed with anchors to the tibia and femur that are drilled with a special pin drill developed by Arthrex. In addition to

these fairly high volume procedures, Heilig has maintained an interest in club foot, also known as Congenital Talipes Equinovarus (CTEV), which he treats non-operatively with manipulation and casting. While at Tulane he performed research on club foot using this non-operative approach with good results. Heilig uses an arthroscopic technique for hip surgery especially in young

people who need labrum repair or osteoplasty, a minimally invasive technique that only a few surgeons in Kentucky are doing.

Improvements in current orthopedic surgery employed by Heilig include a Smith & Nephew produced joint replacement material, Oxinium© that is an amalgam of steel and ceramic and has been approved by the FDA for at least a 30-year life span.

“Newer materials wear better and last longer. This has a significant effect on the decision to move forward with joint replacement in younger patients who previously might hold off on joint replacement in spite of debilitating pain and immobility,” says Heilig.

Heilig describes common misconceptions about orthopedic treatments such as people who think they will never work

again after joint replacement and new treatment of wrist fractures with low profile bone plating allowing repair without using casting and wire fixation. These wrist fracture patients can begin physiotherapy earlier and have less post-operative pain and stiffness. With X-ray, MRI, ultrasound, nerve testing and fluoroscopy available onsite at Kentucky Orthopedic Associates,

New materials wear better and last longer. This has a significant impact on the decision to move forward with joint replacement in younger people.

- Dr. Michael Heilig

Kentucky Orthopedic Associates has full X-ray, MRI, ultrasound, fluoroscopy, and physical therapy capabilities. Many procedures are now performed in-office.

many procedures that would have previously required hospitalization can now be done in-office, such as joint injections, particularly for the spine. Even spinal rhizotomies and kyphoplasties can now be done in office. “Having different diagnostic and treatment modalities all under one roof has greatly contributed to our continuity of care for our patients,” says Heilig. With the combination of a team of four surgeons, five physician assistants, physiotherapists, bracing experts, EMG diagnostics, and full imaging capability, Dr. Michael Heilig has turned a personal orthopedic difficulty into a fully capable state-of-the-art orthopedic facility. ◆ ISSUE#101| 21

SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

You Don’t Know What You’ve Got Till It’s Gone

Brandon Devers, MD, strives to restore the debilitating loss of patients’ hand function while thriving on the variety of the specialty BY ROBERT BAKER For many people, the convenience and function of their hands is not something they truly appreciate until it is gone. Brandon Devers, MD, hand and upper-extremity surgeon at Lexington Clinic Orthopedics – Sports Medicine Center, highlights the constant contributions of the human hand to our activities of daily living. “People arrive at our office daily saying, ‘I had no idea how debilitating it would be to lose the full function of my hand,’” says Devers.

It would be impossible to remain conscious of all the things our hands do for us over the course of a day. It goes without saying that anything capable of such diverse actions has to be both structurally and functionally complex. It was this complexity and the rich variety of anatomic, pathologic, and therapeutic entities that drew Devers to choose hand surgery as his subspecialty. He arrived at Lexington Clinic with his armament of diagnostic and surgical skills and joined the hand surgery team of Stephen C. Umansky, MD, and Michelle Derbin, PA-C. With a patient age range from one to 90 years, a day of surgery may include a fracture repair of the elbow, an endoscopic carpal tunnel repair, an extensor tendon repair, an injection of collagenase for a Dupytron’s contracture, and shortening of a congenitally long ulna. With Devers, any given day is a busy one.

But, Devers has always been a busy man. He played college football for Princeton and graduated with honors in 2005. This is an achievement that takes disciplined time management, an admirable intellect, elite-level athleticism, and dedication to a team. All of these abilities are called upon daily in Devers’ practice. After his undergraduate degree at Princeton, Devers attended medical school at Baylor College of Medicine and again graduated with honors and was elected to Alpha Omega Alpha in 2009. A residency in orthopedic surgery at Vanderbilt in 2014, was followed by a hand fellowship at the University of Cincinnati in 2015. With this superb training, it is likely Devers LEXINGTON

22 MD-UPDATE

PHOTOGRAPHY BY STEPHANIE NORTHERN

Dr. Brandon Devers is a hand and upper extremity surgeon with Lexington Clinic.

could have gone into practice anywhere he wanted, but he chose the hand surgery team at Lexington Clinic, which has the added bonus of allowing him to be back home with an extended family.

Since Devers’ arrival, the hand surgery team has grown their practice at a betterthan-expected rate and are seeing a wide variety of injuries. “There is no other area in our specialty where you get to do fracture work, joint replacement or reconstruction, micro-vascular surgery, nerve repair, and more. So, I know that every day I show up for work there is going to be a different set of problems than I saw the day before,” says Devers. You can find Devers in the

operating room two to three days a week doing three to eight cases a day depending on complexity.

Devers singles out endoscopic carpal tunnel repair as the most common procedure he performs. He is very comfortable with the single incision endoscopic technique, which he offers to all patients.

Understanding that all the various techniques have the same outcome at six to 12 weeks, Devers prefers the single incision endoscopic technique, as there is less pain and quicker return to work by two weeks as compared to the others. The benefit of faster recovery is common to several recent advances in surgical techniques.

More aggressive rehabilitation is possible now, which decreases the likelihood of adhesion formation, one of the most unwanted complications in any hand surgery.

Rheumatoid Arthritis (RA) is a condition that well illustrates the principle of maximum medical therapy before making the decision to operate, which Devers always adheres to. In the past, there were hand surgeons whose practice was primarily devoted to treating RA. Now, with the development of much more successful medical treatment, Devers estimates he sees only one or two patients with RA per month. Conversely, osteoarthritis (OA) continues to be a common condition affecting the hands and wrist. While osteoarthritic conditions may show advanced progression on imaging, Devers offers his patients initial conservative management with splinting, injections,

I don’t treat x-rays. I treat patients.

– Dr. Brandon Devers

and medications, which may lengthen the time before they have to undergo surgery.

“I don’t treat x-rays. I treat patients,” Devers often says.

One feature of Umansky, Devers, and Derbin’s practice that they want other physicians to know about is that there is always someone in the clinic to see emergent or urgent patients.

When Devers is in the operating room, Umansky or Derbin are in the clinic and vice versa.

Also, they save time in each clinic schedule for same-day referrals.

These openings are usually filled with trauma and fracture patients who would otherwise spend many hours in the emergency room and then still get referred to a surgeon.

Although Devers has been too busy

building his practice to start any new research, a look at his curriculum vitae will show that he has several research papers published in prestigious journals.

Recently, Devers traveled to the MidAmerica Orthopedics Association meeting to present some of his research findings from his fellowship. He looks forward to continuing his research efforts in the form of participation in multi-center clinical trials and beta-testing technological advancements as his practice matures.

These endeavors would be integrated with a patient-centered hand surgery practice where the primary focus will always be on providing the best individualized care possible for every patient. ◆

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SPECIAL SECTION  ORTHOPEDICS & SPORTS MEDICINE

Propelling Sports Performance to the Next Level Baptist Health has partnered with D1 Sports Training to open a new sports training facility in Louisville BY MEGAN WHITMER

Co-owned by professional athletes such as Peyton Manning, Tim Tebow, Chipper Jones, Chris Paul, and others, D1 Sports Training was established on the principle of delivering a full-service, prolevel training experience. Along with Baptist Health, former University of Louisville football players turned professional athletes Deion Branch, Breno Giacomini, Chris Redman, and Eric Wood are co-owners of the new facility in Louisville, D1 Sports Training’s 32nd location in the United States.

The premiere athletic-based training facility is the first of its kind in the Louisville area, with 17,000 square feet of training space, including an indoor turf field, a full-service physical therapy clinic, and common area lounge. “The facility itself is what sets D1 apart,” says Nick Sarantis, operations manager with Baptist Health Sports Medicine. “Our indoor field is 40 by 25 yards. You’re not going to find an indoor field of that size –with FieldTurf rather than AstroTurf – in many other places outside of a professional or collegiate sports environment.”

D1 has developed training programs for clientele ranging from youth to adult and amateur to professional levels with professional coaches and physical therapists offering a variety of services focusing on strength, agility, injury prevention, weight loss, and general health and fitness.

Programming is divided into group and personal training and includes Pro Training (collegiate, combine, and professional athletes); Adult Training (18+); Prep Training (ages 15-18); Developmental Training (ages 12-14); and Rookie Training (ages 7-11). “D1 has a general curriculum for athletes who wish to LOUISVILLE

24 MD-UPDATE

The indoor field at the D1 Sports Training facility is 40 by 25 yards and made of FieldTurf rather than AstroTurf.

D1 Coach Jon Esposito works with 11-year-old Luke Appling on his agility.

LEFT Christopher Pitcock, MD, primary care sports medicine physician with Baptist Health, says,”our partnership with D1 put us in a great position for any new opportunities that arise in the future.”

TOP

increase their overall fitness level, but that curriculum can be tailored to each patient’s specific needs,” says Christopher Pitcock, MD, primary care sports medicine physician with Baptist Health. “There’s a lot of

PHOTOS BY ROB DENSMORE AND BAPTIST HEALTH

individualization depending on the patient’s personal goals.”

Pitcock expects this partnership to have a positive impact on the health of the local community. “D1 is a first-class operation at the pinnacle of providing sports performance training for a variety of ages and sports,” he says. “Baptist Health has a physical therapy unit there as well, so if anyone wants an evaluation or treatment for an injury, there’s already a great connection in

Baptist Health physical therapist Danielle Cardinale PT, DPT performing joint mobilizations on patient Blake Stuart.

place between D1 and physical therapy.”

The physical therapy unit at D1 is a full service physical therapy office staffed by Baptist Health employees offering all the same services that patients find at Pitcock’s practice at Baptist Health Eastpoint. The sports performance programming at D1, however, is different. “Baptist Health Sports Performance is becoming smaller and more concise, shifting away from group and team training to more of a post-physical therapy environment,” says Sarantis. “Group and team training will take place at D1 under the guidance of D1 employees.”

Partnering with D1 Sports Training allows Baptist Health to continue to treat and prevent as many injuries as possible to allow patients to be at their best at whatever activity they choose to be involved in, while at the same time providing a new

ed,” states Pitcock. “The number of sports medicine patients we’re seeing has really increased over the last

two years. I expect this area to continue to grow, and our partnership with D1 put us in a great position for any new opportunities that arise in the future.” ◆

C E N T E R E D O N YO U

ELEVATE YOUR PERFORMANCE.

space for team and group training. Pitcock has already seen a few new patients that have been referred to him through D1, and he refers patients in turn, particularly those who feel the D1 location is more convenient and/or have a particular interest in sports performance.

“The sports medicine program at Baptist Health has grown a lot since we started, and faster than we’d anticipat-

AT BAPTIST HEALTH SPORTS MEDICINE, we’re centered on helping you elevate your performance – regardless of your fitness level or goals.

Besides offering the region’s most comprehensive sports medicine programs, which include clinical services and active fitness, we also provide the online tools and information you need to achieve your best.

Learn more by visiting BaptistHealth.com.

Corbin | La Grange | Lexington | Louisville | Madisonville | Paducah | Richmond

BaptistHealth.com

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ISSUE#101| 25 6/28/16 12:59 PM

SPECIAL SECTION ď ľ ORTHOPEDICS & SPORTS MEDICINE

Surgery on Sunday Provides Surgeries for 16 Patients in Need On Sunday, May 22, 70 volunteers, including physicians, surgeons, nurses, and administrative staff, gave their time at the monthly surgery date for Surgery on Sunday. The surgeries were performed at the Lexington Surgery Center at no cost for patients who were unable to pay for these essential outpatient procedures.

The physicians and surgeons volunteering their services included: Phil Hall, MD; Edwin Liem, MD; Paul A. Kearney, MD; Matthew Bailey, MD; Joseph Iocono, MD; Michael Lynch, MD; J. Martin Favetto, MD; John Stewart, MD; Ross Tekulve, MD; and Jennifer Harris, MD. The surgeries performed on Sunday included: mass excisions, gallbladder removal, hernia repairs, orthopedics, and colonoscopies.

LEXINGTON

Dr. Ross Tekulve performs a hernia repair for a Surgery on Sunday patient.

Dr. J. Martin Favetto performs a hardware removal for an orthopedic patient.

About Surgery on Sunday

Surgery on Sunday was founded in 2005 by plastic surgeon Dr. Andrew Moore, II. Moore was dedicated to a population of people so often overlooked in the healthcare industry and made it his mission to see the working poor receive outpatient surgeries they would not otherwise receive due to their inability to pay. Relying entirely on volunteers, Surgery on Sunday performs outpatient surgeries the third Sunday of each month at the Lexington Surgery Center utilizing volunteer physicians, anesthesiologists, nurses, social workers, and administrative personnel who have donated over 92,000 hours of volunteer service.

To date, nearly 5,700 patients have been served. â—†

Dr. Trevor Wilkes repairs a rotator cuff for a patient who had suffered with pain for over a year.

To become involved or support Surgery on Sunday, contact:

Anna L. Taylor EXECUTIVE DIRECTOR

859.246.0046 anna@surgeryonsunday.org www.surgeryonsunday.org

26 MD-UPDATE

PHOTOS PROVIDED BY SURGERY ON SUNDAY

Committed to Excellence dr. michael r. heilig dr. gregory F. grau

• Offices located Winchester, Richmond, Georgetown, & Paris • Only spine specialist from Ashland to Lexington • Physical therapy on site • Same and next day appointments available

859-737-5333

dr. james rice

www.kyorthopedicassociates.com

dr. david waespe

Kurt Schlenther, PA • BrAndon emBry, PA • JASon delong, PA

KOA-11x6_mailer.indd 1

6/29/16 9:03 AM

Open mri

KentucKy orthoPedic ASSociAteS

ppers Dr

Our state-of-the-art Hitachi ARIS II MRI system provides you with a comfortable, non-intimidating examination experience.

Our team of highly trained technologists and board-certified radiologists provide the highest level of diagnostic care.

OrthOpedics

When our patients have incurred a musculoskeletal injury or disease that compromises their ability to fully experience and enjoy life, our mission is to get them back to health as quickly and safely as possible. We are committed to providing excellent care to our patients with compassion, understanding and respect.

physical therapy

Recovering strength and mobility so that you can return to normal activity is our number one goal. Whether you’re getting back to competitive sports, recreational activities, or just being able to walk independently and maintain your home, we are here to help.

We look forWard to seeing you!

Winchester Clinic • 404 Shoppers Drive Richmond Clinic • 318 Highland Park Georgetown Clinic • 1140 Lexington Rd., Suite 201 Paris Clinic • 5 Linville Dr., Suite 105 KOA-11x6_mailer.indd 2

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Map data ©2016 Google

200 ft

ISSUE#101| 27

COMPLEMENTARY CARE

It’s In Her Sole Dr. Nicole Freels has literally followed in her grandfather’s footsteps

BY JIM KELSEY Doogie Howser she isn’t, but it is fair to say that Dr. Nicole Freels, FACFAOM, began her medical journey much earlier than most.

Her grandfather, Dr. Arthur O. Kelly, was a podiatrist in Portsmouth, Ohio. Freels grew up on a horse farm in nearby South Portsmouth, Ky., and spent much of her time at her grandfather’s office.

“I think I started helping when I was about 12 years old, sweeping up toe nails, rooming patients, doing everything, learning the entire process,” Freels says.

“I graduated into trimming toenails when I was about 15.”

Freels completed her undergraduate degree at the University of Kentucky before attending her grandfather’s alma mater, the Ohio College of Podiatric Medicine in Cleveland, Ohio. Freels began a comprehensive podiatric surgical residency with the first two years at James H. Quillen Veterans Affairs in Mountain Home, Tenn.

The third year was spent in Atlanta, Ga., learning from worldrenowned podiatric surgeons, Drs. Douglas H. Elleby and Alan Shaw, and leading wound care specialist and podiatric surgeon Dr. Michael K. Bednarz.

At that point, Freels and her husband Rob, who has an extensive business and entrepreneurial education, decided to start Lexington Podiatry on their own in the fall of 2008. “It was challenging at that time to get an unsecured loan to start a practice,” Freels said. “We found a small bank in Ashland. I had a 10-year old 28 MD-UPDATE

car and lived in an apartment but they gave me a start up loan of $100,000. That was the benefit of growing up in a small town.”

Lexington Podiatry was officially open for business in January of 2009. To build up her customer base, Freels went back to her roots cutting toenails in her grandfather’s practice. “I cold-called every nursing home in a 20-mile vicinity of Lexington and got 10 job offers,” she says of her efforts to drum up business. “I was a traveling toenail clipper.”

Today, Lexington Podiatry serves a much

Dr. Nicole Freels formed Lexington Podiatry in 2008 with her husband Rob.

larger patient population, seeing everyone from infants with ingrown toenails to diabetic patients to routine check-ins with nail care and calluses. But the marketing

TOP PHOTO PROVIDED BY LEXINGTON PODIATRY. BOTTOM PHOTO BY GIL DUNN.

efforts of Freels and her staff have helped them develop one core demographic. “We conduct free foot exams all over the state,” Freels says. “Now we work with many large corporations – Toyota, Sylvania, JIF, Amazon, and others. Manufacturing makes sense because the employees work on concrete and stand all day long.”

Freels takes pride in helping these patients, who often endure pain and discomfort on a daily basis to keep their jobs and support their families. “Often these patients have a difficult time maintaining a healthy lifestyle while working a job where they are taking 20,000 steps per day,” says Freels. “These people don’t feel like going for a run after work. They’ve been on their feet all day, so they have lack of movement and flexibility. We work to keep them on their feet.”

One of the most common complaints is plantar fasciitis.

Treatments include stretching, steroid injection, physical therapy, and custom orthotics. Freels notes that many patients diagnosed with plantar fasciitis actually suffer from tarsal tunnel syndrome.

Freels calls upon diagnostic neurophysiologist Dr. Mark Brooks, PT, DSC, ECS, OCS, who comes in every week to conduct nerve conduction velocity tests to determine if a patient has tarsal tunnel.

Whether treating plantar fasciitis, flat feet, heel pain, ankle sprains, or tendinitis, Freels prefers a conservative approach to treatment, avoiding surgery if possible. “I stopped doing surgery about six years ago

because I had so many patients coming to me with failed procedures,” Freels says.

“I feel like foot and ankle surgery has an underserved negative reputation. We do many more minor procedures that focus on shifting the bones and the joints, tailoring the treatment plan to the lifestyle of the patient.”

These people don’t feel like going for a run after work. They’ve been on their feet all day, so they have lack of movement and flexibility.

We work to keep them on their feet.

– Dr. Nicole Freels That said, Freels understands fully that there are times that surgery is necessary and wants to bridge the perceived communication gap between orthopedic foot and ankle physicians and podiatrists. “I strongly believe in a collaborative effort,” Freels says.

“There are patients who need surgery and there are times when non-surgical treatment is best. By working together, we’ll achieve the best outcome for the patient.”

Relationships are Key

Relationships are Lexington Podiatry’s specialty. Every part of the practice is designed to enhance the patient experience. Out-ofthe-box thinking and staffing has led to a focus on patient care and comfort that is central to the practice’s mission.

“Many of us used to be restaurant servers,” Freels says of herself and her staff. “We know about customer care. So here, you get a comfort menu when you walk in the door.

Older patients tend to get cold so we offer them airplane blankets. ‘Would you like something to drink’? People who are having injections—‘Have you eaten today? Let’s get you a snack.’ We bring the hospitality full circle. It’s not an office visit. It’s more of a

spa experience.”

Lexington Podiatry staff are hired based largely on personality with an understanding that most of the necessary office skills can be trained. One benefit to this comfortable patient environment is that Freels finds that she can communicate more effectively with patients when they are relaxed.

Another benefit of this model is that it is helping Lexington Podiatry find its niche in an age when smaller practices often find it difficult to compete. “Everyone in podiatry is looking to diversify. How we can be unique, like having the ped-spa. That’s not covered by insurance, but our patients love it.”

Following her grandfather’s lead and emphasizing patient experience? For Freels, it seems to be a step in the right direction. ◆

THE PAIN TREATMENT CENTER OF THE BLUEGRASS ABOLISHING THE T YRANNY OF PAIN

Ballard Wright, MD, PSC MAIN OFFICE:

SATELLITE OFFICE:

2416 Regency Rd., Lexington KY 40503 NEUROLOGY / NEUROIMAGING Peter D. Wright, M.D. Medical Director Director of Neuroimaging

110 Hardin Ln. STE 4, Somerset INTERNAL MEDICINE Anand Modadugu, M.D.

INDEPENDENT MEDICAL EVALUATIONS Ballard D. Wright, M.D.

ADDICTION MEDICINE Traci Westerfield, MD

PHYSICIAN ASSISTANTS Lois Wright, MBA, PA-C Celeste Christensen, PA-C Shari Pierce, PA-C Jing Ye, PA-C Barry Williams, PA-C

ANESTHESIOLOGY Ballard D. Wright, M.D. Founder and Medical Director Fred Coates, M.D. Dennis Northrip, M.D. PHYSICAL MEDICINE AND REHABILITATION Katherine Ballard, M.D. Lauren Larson, M.D Steven Ganzel, D.O.

Ambulatory Surgery Center 280 Pasadena Drive, Lexington

FAMILY PRACTICE Laura Hummel, M.D. BEHAVIORAL MEDICINE Narda Shipp, ARNP Kellie Dryden, LCSW Marie Simpson, LCSW

NURSE PRACTITIONERS Becky Moore, ARNP Teri Partin, ARNP Lynne Shockey, ARNP Jeff Eversole, ARNP

Joint Commission Accreditation, The Quality Distinction

A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include: Epidurals Intrathecal Pumps Spinal Cord Stimulation MILD Facet Blocks Vertebroplasty Neurolytic & Sympatholytic Denervation For further information on the region’s largest freestanding pain treatment facility, call: (859) 278-1316 ext 258 • Fax: (859) 276-3847 • www.pain-ptc.com ISSUE#101| 29

COMPLEMENTARY CARE

How to Deal with a Difficult Person…

Without Becoming Part of the Problem One of my extended family members died recently. When people offered their condolences, without hesitation I found myself replying, “It’s the kind of death that is a blessing.” I didn’t mean that she was relieved of suffering, either related to a disease or treatment for it. I meant that her death was a relief from her life … and relief for the family members that had struggled for decades to help her get to a better place in life and health.

My relative weighed 600 pounds when she died. She could not sit up and existed the last few years of her life lying on her right side.

As her weight and associated health issues increased over the decades, so did her resolve and refusal to be cared for in a nursing home.

Although there were many wakeup calls and second chances, she didn’t manage to take advantage of them. Over 10 years ago, a 60-pound mucinous ovarian tumor was removed at University of Louisville Hospital. No cancer, no chemotherapy. Life went back to “normal” for her.

My relative did not make it easy for people to provide care for her. Her “give her an inch and she’ll take a mile” approach to relationships left those around her frustrated, resentful, and often exhausted.

In their attempt to be caring, responsible family members, my relatives complied with her insistence that she could manage at home … until it was too late and the only option was a $5000 ambulance ride to a private pay facility in Illinois.

But that’s the way it is with enabling.

You think you’re helping. It feels like helping, and even thinking about doing anything else feels terribly wrong.

In other words, you’re no longer solving the problem — you’ve become part of it.

Chronically difficult people and situations can make us feel crazy — doing the same things over and over again, but expecting different results.

So how do people stop enabling, when it so feels like the right thing, the only thing to do?

The Alternative to Head-Banging 30 MD-UPDATE

So why do people keep banging their heads against the same wall? I’ll tell you why — doing something different is even harder.

Acknowledging the reality of a difficult situBY Jan Anderson, PsyD, LPCC ation involves some very unfamiliar, uncomfortable thoughts and feelings. Most of us don’t like discomfort. We avoid it as much as possible.

Once you’re in touch with that (usually painful) reality, you’re kind of obligated to do something about it. Sometimes you’d rather just keep your head in the sand.

But life and relationships have this annoying way of continually giving us opportunities to learn, grow, and do better.

Your creative problem-solving skills kick in and you find yourself thinking outside the box.

“Your internal dialogue sounds something like this: ‘The difficult person in my life does not think and act like me … It’s unlikely they will ever understand how I see things or agree with how I think things should be handled. Accepting that reality, what is the next right step for me to take?’”

CLIENT: “But what if it doesn’t work?

What if they don’t change?”

ME: “It’s very seldom that I don’t see at least some improvement in the situation.

There are no guarantees, but doing your own work not only benefits you, it also creates the best possible odds that the other person will respond better.”

CLIENT: “Those are pretty good odds.”

ME: “That’s as good as it gets. Ready to get started?” ◆

A Change of Heart, Mind, and Behavior — Yours

Here’s a typical CBT (cognitive behavioral therapy) exchange on the road from crazy to control of your life: CLIENT: “They’re the problem! Why do I have to be the one to change?”

ME: Because they’re the dysfunctional person. You’re the mentally healthier person … aren’t you?” Therefore, you’re the one with the most capacity to influence and possibly improve the situation.

CLIENT: “But it’s not fair. Why do I have to be the one do all the work?”

ME: “Because you’re the one with the most incentive. You’re the one experiencing the most negative effects. The difficult person is okay — at least more okay than you are — with letting things stay as they are. Why should they do anything different when they have little or no incentive?”

CLIENT: “What if all my effort doesn’t do any good?”

ME: “I can pretty much guarantee that your effort will do you good. The energy you previously used to try to change the difficult person is now freed up to get you moving. You start thinking more clearly and objectively.

Relationship and Life Strategy Expert Individual & Couples Counseling Relationship & Life Strategy Coaching Mindfulness-Based Cognitive Therapy

complimentary preliminary Consultation 502.426.1616 DrJanAnderson.com Jan Anderson, PsyD, LPCC

A sold-out event raised over $100,000 to preserve the Henry Clay Estate and legacy.

EVENTS

(l-r) Dr. Pearse Lyons, founder of Alltech and presenting sponsor of the 2016 Ashland Lawn Party with Gil Dunn, publisher of MD-UPDATE.

Ashland Lawn Party 2016

The 20th Annual Ashland Lawn Party was a smashing success. More than 400 attendees gathered to celebrate the legacy of Henry Clay, raising $105,000 to preserve Ashland, Clay’s beloved estate, and to support its exhibits and educational programs. The event sponsor was Alltech, Pearse and Deirdre Lyons. The honoree was the Garden Club of Lexington, celebrating its 100th anniversary.

Ashland, the Henry Clay estate, is a National Historic Landmark and a rare treasure in the heart of Lexington. Established in 1926, the Henry Clay Memorial Foundation, a 501c3 non-profit organization, is dedicated to preserving Ashland and operating its educational center. Generous individuals and corporations make the conservation of Ashland, and sharing the legacy of the Great Compromiser, Henry Clay, possible.

LEXINGTON

(l-r) Ellen and Dr. Michael Karpf, executive vice president for UK Healthcare, with Ashland Board Member Carol Russell.

(l-r) John Paul and Judy Miller, long-time supporters of Ashland, the Henry Clay Estate, with Gil Dunn, MD-UPDATE.

(l-r) Stephanie and Jim Morris, UK College of Law, 1994, enjoyed their first Ashland Lawn Party.

Classical music gave a timely background sound to the Ashland Lawn Party, an American and English tradition.

PHOTOS BY JOE OMIELAN

ISSUE#101| 31

EVENTS

Saint Joseph President Benny Nolen (far right, orange shirt) welcomes players to the Saint Joseph Mount Sterling Foundation’s 15th Annual Golf Tournament on June 16, 2016 at Old Silo. This was the largest outing ever held with 31 teams playing and raising over $22,000.

Wehr Construction fielded a formidable team with (l-r) Dale Berry, Brandon Berry, Chris Smyth, and Jim Dillon.

Saint Joseph Hospital Foundation Golf Tournaments

Saint Joseph Hospital Foundation’s 27th Annual Golf Tournament was held June 6, 2016 at the University Club of Kentucky. The event was presented and chaired by Mike Marnhout, the president of Bluegrass Oxygen. Marnhout has chaired this outing for 20 years.

This year the tournament benefits the Community Outreach Program that serves the Appalachian area. In total, this tournament has raised in excess of $2.1 million dollars over the last two decades.

LEXINGTON

Flying high was the team from Air Methods, (l-r) Bryant Shumate, Eric Cremeens, Brian Carpenter, and Bryan Lake.

Keeping close track of the score was the Vital Records team of (l-r) Mike Fox, Tim Leroy, Matt Dick, and Kevin Finley.

Playing for the Congleton-Hacker team and raising money for patient care were (l-r) Kevin Doyle, Seth Burrett, and Finley Lyons.

Obviously enjoying the day of golf was the Tremco team of (l-r) Kevin Hub, Chris Jaggers, Ken Arrington, and Greg Meegan.

The Cintas team included (l-r) Frank Morand, Blair Duckworth, Drew Brock, Denetrius Johnson, and coach Ryan Olukalns.

32 MD-UPDATE

PHOTOS BY GIL DUNN

Saint Joseph Foundation Board Member Greg Yeary made it a family affair playing the scramble with (l-r) Jackson Yeary, Greg Yeary, Jeff Yeary, and Bill Yeary.

Team work was the key for the Allied Communications team of (l-r) John Sims, Dan Dasher, Landry Fields, and Jeff Fields.

Lexington Medical Society Foundation

GolfPresented Tournament

by BB&T Wednesday, August 24, 2016 University Club of Kentucky shamble format

Proceeds from last year’s event went to Baby Health Services, Inc, Bluegrass Council of the Blind, Inc, Bluegrass Ovarian Cancer Support, Inc, Camp Horsin Around, Children’s Advocacy Center of the Bluegrass, Faith Pharmacy, God’s Pantry Food Bank, Institute for Compassion in Justice, Inc, LMS Physician Wellness Program, McDowell House Museum, Mission Lexington, Radio Eye, Inc, Ronald McDonald House Charities, Safe Kids Fayette County & Surgery on Sunday.

LMS FOUNDATION GOLF COMMITTE MEMBERS: John W. Collins, MD, Chairman Wendy G. Cropper, MD W. Lisle Dalton, MD Kenneth V. “Tad” Hughes, MD John H. Voss, MD Susan Potter, BB&T Gil Dunn, MD Update David Smyth, Family Financial Partners Patrick Cashman, SIS Betty Nolan, LMS Alliance John Maher

SPONSORSHIP OPPORTUNITIES: White Tee Sponsor Hole Sponsor + 4 players Hole Sponsor Foursome Beverage Cart Sponsor Individual Player

To sponsor or register: contact Cindy Madison (859) 705-0003, email cmadison@lexingtondoctors.org or go to www.LexingtonDoctors.org .

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