Lancaster Physician Spring 2024

EMPOWERING PATIENTS

to Take Greater Control of their Health & Care

LANCASTER COUNTY AND THE OPIOID EPIDEMIC

BY JON LEPLEY, DO, FAOAAM

CLIMATE CHANGE'S IMPACT ON ALLERGIES

BY LAURA FISHER, MD

TWEEN AND TEEN SKIN CARE TRENDS VS. THE TRIED-AND-TRUE

BY CHRISTINA LAWSON, MD, FAAD

2023/2024 BOARD OF DIRECTORS OFFICERS

Stacey S. Denlinger, DO President Highlands Family Practice & UPMC Wound and Hyperbaric Center

Sarah E. Eiser, MD President Elect Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

Robin M. Hicks, DO Vice President UPMC Supportive Care & Palliative Medicine

Christopher R. Scheid, DO Secretary College Avenue Family Medicine

Stephen T. Olin, MD Treasurer Penn Medicine Lancaster General Health

Laura H. Fisher, MD Immediate Past President Lancaster Family Allergy DIRECTORS

Robert

Marco

Lena

David

Anna

James

Karen

LancasterPhysicianis a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patientcentered care in an increasingly complex environment.

Here we are, well into 2024, and it’s time for the Spring Edition of our magazine! As my term as president of LCCMS ends in June, this is my final note to you all. Coming into this role, I had big goals for breaking down barriers of communication and depolarizing our community. I hope that at the very least I have brought awareness to members and supporters of the organization that we can disagree but still find mutual ground for having productive conversations that benefit the whole. All change starts with awareness, and the process is always slower than we would like it to be. I look forward to seeing our continued evolution and all the good our Medical Society can do for the community.

Most of LCCMS’s winter months were spent preparing programming for the year to come. We are looking forward to including artificial intelligence in health care as a focus for our Annual Dinner presentation. Many of us are interested in knowing how this technology can improve both the patient and physician experience, and we hope to get a lot of interest in this event. We anticipate sharing more on this subject in upcoming issues of the magazine, as we know it will affect the future of medicine. In addition to creating programs that offer interesting topics, we are working on generating a resolution to support expedited access and insurance coverage for fertility preservation consults for persons facing a cancer diagnosis/treatment that could impact fertility. This will hopefully be presented and accepted at our House of Delegates meeting in October 2024. If there are problems you face on a day-to-day basis in practice that you would like to see change, get involved or at least reach out to a board member. That is how we make an impact on a larger scale!

I love that this magazine provides information from our local physicians to the community about health care issues — both at the institutional and individual levels. You may not be aware, but we are one of a few societies still putting out a regular periodical. We have such a rich medical community in Lancaster and can continue working together to make the experience great for patients and their doctors.

Thank you for taking the time to read my messages. I hope they have provided an informative summary of the Medical Society’s activities and goals while eliciting some feeling of inspiration to be a part of something that is so important and bigger than each of us. The Oxford dictionary definition of the word society is “the aggregate of people living together in a more or less ordered community.” Let’s be on the “more” end of that definition! I challenge you to be curious, aware, and willing to challenge your own thoughts and assumptions.

Stay well!

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ALSO IN THIS SECTION

• With Health Care Violence On The Rise, WellSpan Takes Steps To Keep Teams Safe

• Practice Management Insights: A Perspective on Profit-Motivated Insurer Practices – The Impact on Health Care Providers and Patients

PENN MEDICINE LANCASTER GENERAL HEALTH’S New Specialized Physical Therapy Program Benefits Patients With Early-stage Parkinson’s or Other Movement Disorders

Most patients diagnosed with Parkinson’s disease or other related movement disorders share the same goals: preserve their quality of life and slow progression of the disease for as long as possible.

Research shows that early initiation of treatment, including a Parkinson’s-specific exercise program, may do both. However, many patients begin therapy and rehabilitation much later in their disease progression, only after they are experiencing a significant decline in function.

With Penn Medicine Lancaster General Health’s new Early Stage Movement Disorders program, a trained therapy team provides newly diagnosed patients and their caregivers with treatment, education, and support as they navigate care, as well as any changes in symptoms.

Parkinson’s disease is a neurodegenerative condition that profoundly affects movement, but many patients experience only mild symptoms at the time of diagnosis. J. Gabriel Hou, MD, PhD, an LG Health neurologist who specializes in movement disorders, said that physicians typically do not refer patients to physical therapy until their conditions are more advanced, leading to difficulties with balance or gait.

“We now know that in order to maintain function for as long as possible, patients should not wait to begin intervention,” he said. “We have found that providing early education, prescribing appropriate medications for symptoms such as tremor, rigidity and bradykinesia, and establishing an exercise program are highly beneficial.”

LG Health’s multidisciplinary team of specialists in Neurology, Neurosurgery, Neuropsychology and Neuro Rehabilitation — which includes physical and occupational therapists and speech language pathologists — works collaboratively

PARKINSON’S DISEASE IS A NEURODEGENERATIVE CONDITION THAT PROFOUNDLY AFFECTS MOVEMENT, BUT MANY PATIENTS EXPERIENCE ONLY MILD SYMPTOMS AT THE TIME OF DIAGNOSIS.

with the patient’s primary-care provider to ensure a comprehensive and well-coordinated approach to care. The team of therapists is certified in evaluation and treatment protocols specific to Parkinson’s disease and other movement disorders.

The team sees patients at LG Health’s Neuroscience Institute at 2150 Harrisburg Pike, as well as several outpatient offices throughout Lancaster County. Rehab supervisor and physical therapist Megan Martin said that following a physician referral, newly diagnosed patients are evaluated in order to determine their specific needs and design an individualized treatment plan that focuses on function, safety, and home care.

“In additional to physical therapy, an occupational therapist can help if they are having challenges with handwriting, computer work, or activities of daily living,” she said. “If they have difficulty with swallowing or speech, we can bring in a speech language pathologist. We can also refer patients to a neuropsychologist for cognitive assessment if needed.”

While most patients recognize that exercise will help them preserve function, they don’t know which specific exercises are most beneficial, she said. Over six to eight sessions, the team utilizes an evidence-based treatment approach to develop an individualized exercise plan that patients can follow at home or in the gym setting. The plan includes specific exercises that have been shown to be beneficial for people with Parkinson’s disease.

Many newly diagnosed patients are overwhelmed and struggle to come to terms with what their lifelong condition will mean for their future, Martin said. As an additional first step, the team connects patients and caregivers with community resources, including education, support groups, and activities.

The team assesses patients every six to 12 months to provide comparative data on objective changes that may require a follow-up physician visit for medication management, updated home exercise program, or consideration for other procedures. If patients are experiencing new symptoms, the team can help guide them to additional resources and make recommendations on when it is appropriate to engage with other rehab professionals.

“Parkinson’s is a chronic degenerative condition, and unfortunately, we know that eventually, it will progress,” Dr. Hou said. “Now, throughout the course of the disease, our patients know where to go, and that they have a team here to support them.”

WITH HEALTH CARE VIOLENCE ON THE RISE, WellSpan Takes Steps to Keep Teams Safe

Chaos erupted when a patient who had been sedated for a procedure was being taken to the recovery area at WellSpan Ephrata Community Hospital.

The patient awoke confused and combative, arms swinging, wailing, trying to climb out of a gurney in a hallway while being transported by Vic Strelkov, a registered nurse in the anesthesia department.

Strelkov hit a button on his Strongline badge, a small wearable device that summons help during emergencies.

“Three security guys were there in the next second,” Strelkov says. “I mean the next thing I knew they were standing right next to me.”

Vic Strelkov (left), a registered nurse in the anesthesia department at WellSpan Ephrata Community Hospital, used his Strongline badge to summon security officer Wilberto Torres and two other security team members when a patient had a combative wakeup from anesthesia.

Strongline badges have a button that, when pressed twice in quick succession, notifies WellSpan security teams of the badge holder’s name and location in a building, so the security team can quickly respond and offer assistance.

The badges are just one of the measures WellSpan has taken to ensure the safety of its team members, patients, and visitors. Additional measures include flags in medical records to alert team members to potentially violent patients, and team members at each hospital who are specifically trained in de-escalation for behavioral situations and can be summoned for help around the clock.

“Health care has seen a rise in violence toward team members and WellSpan is taking the steps to make sure team members are prepared and can quickly get help when faced with difficult situations,” says Bill White, senior director of security at WellSpan.

Violence against health care workers doubled from 2010 to 2020, according to the U.S. Bureau of Labor Statistics. Hospital workers were six times more likely to suffer a workplace violence injury than other professions in 2020. And while health care workers made up 12% of the U.S. workforce in 2020, they suffered 73% of nonfatal injuries due to workplace violence.

It’s imperative that health care team members feel safe at work, says Christy Kreider, clinical services director at WellSpan Ephrata Community Hospital, who, with White, chairs a WellSpan workplace violence committee.

“With the shortage of nurses across the nation, we need to take care of our workforce and make them feel protected and safe,” Kreider says. “This relates to retention and being able to have the staff we need to take care of our communities.”

Strongline Badges

Strongline is a Bluetooth-based alert system that features a small, individually assigned badge, with a button that team members can press for assistance. When pressed two times quickly in succession, the badge provides the security team with the staff member’s name and location in a building to expedite security or law enforcement assistance.

Since late 2022, WellSpan has issued the badges to team members who have contact with patients or visitors – with the goal to get them to about 90% of the 22,000 WellSpan team members, with the exception of those who work fully remotely.

In the past two years, WellSpan has issued badges to nurses, physicians, advance practice providers, dining room workers, housekeepers, lab workers, and office teams – anyone who has contact with patients or the public at a WellSpan site. The badges allow them to quickly summon help in dangerous or combative situations.

VIOLENCE

AGAINST

HEALTH CARE WORKERS

doubled from 2010 to 2020, ACCORDING TO THE U.S. BUREAU OF LABOR STATISTICS.

Last year, security team members helped to resolve about 80% of almost 900 Strongline alerts, with team members being able to quickly resolve 20% of them before security teams arrived.

At Ephrata, security officers Wilberto Torres and Charles Miller and security manager Nathan Roman helped to keep the patient safe on the gurney. At the same time, Vic and a colleague reoriented the patient, saying, “You just had a procedure. We are in the hospital,” calming and de-escalating the delirium that had been temporarily caused by the anesthesia. Aided by the visible presence of the three officers, who escorted the patient back to the recovery area, the situation ended calmly with no injuries to anyone.

“We felt supported and safe,” Strelkov says. “It is important to have the support and tools for patient safety.”

In this case, the team knew the patient had a history of being combative when waking up from anesthesia, Strelkov adds, so they were on the alert for potential challenges. This was due to another tool WellSpan teams use.

Violence Risk Assessments

Since 2021, WellSpan has used a screening tool called DASA (Dynamic Appraisal of Situational Aggression Assessment) to alert team members if they will be caring for someone with a potential for aggressive behavior.

The system works on the same principle of fall prevention, Kreider notes. Knowing that someone is at risk for a fall helps staff take steps to prevent a fall. So it is with aggressive behavior. Knowing someone is at risk for that sort of behavior helps team members prepare and take steps to potentially prevent that behavior.

Nurses do a DASA assessment on every patient who comes into the hospital, by completing a series of yes or no questions. These questions include: Is the patient

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GREATER CARING.

WE’VE EXPANDED OUR PROVIDER TEAM.

Lancaster Cancer Center is proud to announce its expansion of care with the addition of Roxana Ramos, CRNP. She joins the team of expert physicians and highly trained staff who are committed to providing the highest quality of cancer care in the county.

We make new patients and second opinions a priority with appointments available within 24 hours by calling 717.291.1313.

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irritable? Unwilling to follow directions? Easily angered when their requests are denied? Verbally threatening? Each yes gets a score of one point. Patients who have a score of four to seven are considered at high risk for aggression, and the information is included in the patient’s medical record.

“If someone screens as high risk, the teams have been educated on strategies and interventions to reduce that risk,” Kreider notes.

These interventions can include things such as allowing breaks between tasks, using consistent caregivers, reinforcing positive behaviors, and decreasing outside stimulus such as noise, lights, and crowds.

The preparation and training do not end there.

Response Teams

Since 2018, WellSpan has established a specially trained Behavioral Response Team (BRT) at each of its hospitals. BRTs are available around the clock to rapidly respond to de-escalate potentially violent situations.

A BRT typically includes nursing supervisors, critical care nurses, behavioral health nurses, and security officers. Trained in de-escalation, each team member has a role to play when they arrive at a potentially dangerous situation. The teams are part of WellSpan’s commitment to provide trauma-informed care, a more holistic approach to managing behavioral health incidents that focuses on an individual’s underlying mental health and any trauma history they have.

Last year, across the system there were 662 BRT calls, with 78.4% of them successfully de-escalated.

In 2020, WellSpan was awarded a Hospital and HealthSystem Association of Pennsylvania Achievement Award for its work with BRT.

With the addition of Strongline badges, staff are trained to know which situations are more appropriate for Strongline or BRT. The bottom line is that they have multiple options for emergency help, and they are prepared for potential problems through DASA.

“WellSpan has made a big investment with tools and personnel to ensure safety,” White says. “We want to go above and beyond for our employees.”

Hyatt P. (Tracy) DeGreen III, DO; Lena Dumasia, MD; and Roxana Ramos, CRNP

A Perspective on ProfitMotivated Insurer Practices

The Impact on Health Care Providers and Patients

BILL WEIK, CEO Orthopedic Associates of Lancaster, LTD

As a CEO overseeing a medical practice with hundreds of employees, I am troubled by the continued trends in the health care marketplace. Our providers of care are subjected to increasingly wasteful activity, creating inefficiency and increased costs. Our margins are squeezed by insurers, who try to leverage their increased scale while requiring processes that add nearly no value; hospitals continue to consolidate under banners of “quality” and “efficiency.” Well, these trends have been playing out for more than a decade, and I ask, “How is it going?” In my opinion, the answer is, “Not well. And it could be so much better.”

The recent lawsuit against Johnson & Johnson over prescription drug pricing and conflicts of interest in their health benefits plan has struck a particularly resonant chord with me. This case underscores a pervasive issue in the health care and insurance industries that I, too, have confronted firsthand: opaque and conflicted relationships.

The Johnson & Johnson lawsuit illuminates the broader implications of these conflicts. It is not merely about the excessive costs borne by employees for their prescription drugs; it is a glaring example of how the health benefits landscape is marred by arrangements that prioritize profits over people’s well-being. Markups on prescription drugs — costing participants significantly more through their insurance plan than if they were to pay out of pocket — paint a damning picture of a system that does not safeguard the interests of its most vulnerable stakeholders.

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One of the unique positions I find our company in re: employee benefits is each year when we get to the renewal phase, I sit at the table not only as an employer trying to save money on our employee benefits but also as a provider of health care services. Unfortunately, the providers are often the collateral damage of what the insurance companies do to create “perceived” methodologies to save employers money. Often, these come at the expense of the patient who needs care by their physician. Prior authorizations are probably the best example of a way to deter, delay, or negate care that is needed.

These processes put on providers for prior authorization and other inefficient methods employed by insurance companies often lead me to the conclusion that insurance companies don’t have relationships with their subscribers; they have them with their brokers, or producers, who sell their products.

If you use a broker, make sure you fully understand any financial incentives, rewards, etc., that are offered to place your coverage with a specific company. Almost every employer relies on a broker to manage their renewal. The discussions, analyses, and negotiations that happen throughout the process are mostly obscured from the view of the employer and create the opportunity to steer toward an outcome that maximizes financial incentives and commissions for the broker. There are so many articles available to read related to the relationships between insurance companies and brokers. I encourage anyone reading this article to look them up.

These findings underscore the critical need for a shift toward relationships grounded in transparency and fiduciary duty. The traditional brokerage model, with its opaque incentives and alignments, is clearly incompatible with our commitment to acting in the best interests of our employees. As employers, we are obliged to adopt a fiduciary standard in managing our health benefits, ensuring that our employees’ well-being and financial security are paramount and free from the distortions of conflicted interests.

The role of a broker or advisor should not be a transactional one, measured by

the commissions earned from insurers, but a fiduciary one, where the only metric of success is the well-being and financial security of the clients served.

Adopting a fiduciary standard in the choice and management of health benefits plans is not just an ethical imperative; it is a strategic one. Employers withstand most of the health care costs, a sizable part of which can be attributed to inefficient, opaque, and conflicted arrangements that inflate prices without corresponding value. By demanding transparency, accountability, and fiduciary responsibility from our advisors, brokers, and vendors, we can begin to dismantle these perverse incentives and realign the system with the interests of those it is meant to serve.

The impact on our community of health care providers goes beyond the perverse incentives of traditional insurance brokers. Government regulation and insurer administrative requirements have introduced a significant burden on both our practice and our patients. One example to illustrate this is the process surrounding visco supplement injections. Previously, a patient appropriately indicated for this service could be diagnosed and receive their injection in a single visit. However, insurers cause a cumbersome process involving the patient’s return home, the completion of prior authorization paperwork by our staff, and a return visit by the patient for the treatment. In some cases, a specialty pharmacy is the source of the injection when we have these items in our inventory. This not only diminishes patient satisfaction by wasting their time but also escalates costs and reduces efficiency within our practice. These impositions by insurance companies exemplify the need for systemic change to alleviate unnecessary burdens and restore focus on patient care and operational efficiency. I ask, “Where is the value in this process?” I assure you, the impact on cost is real. Our surgeons and staff spend a lot of wasteful time making sure they treat the insurance and not the patient. Fifteen years ago, neither physicians nor staff knew about the insurance coverage of a patient. Today, it is critical to make sure the correct visco is selected based on the deal the insurance company made with a particular vendor.

If you doubt whether these processes increase cost, ask any practitioner who has contracted with Infinx about their rationale for using this system. The rationale is entirely about coping with the scope and volume of prior authorization processes, for which we can find zero discernable clinical value. We could not manage the volumes of authorizations without such a system. Denials almost always get overturned, but the efforts required to overturn them are erroneous and disheartening for all involved. There is no added reimbursement for the physician’s office that incurs all this cost, but be assured if the insurance company’s costs increase, the employer group premium will go up to manage these increased costs.

The Johnson & Johnson case should serve as a watershed moment, prompting us to reflect on the structures and relationships that govern our health benefits plans. As business leaders, we must advocate for change, pushing for a health care and insurance ecosystem that runs with integrity, transparency, and fiduciary commitment to the individuals it serves.

To truly improve our health care system, we must focus on a model that prioritizes the well-being of every participant, especially patients. This goal demands a unified push toward breaking down the existing barriers that hinder efficiency and transparency. By adopting a fiduciary mindset across health care management, we align everyone’s goals with the health and safety of patients, fostering an environment ripe for innovation and streamlined services. As leaders in health care, we owe it to our communities to advocate for key stakeholders to support the pursuit of reforms that empower health care providers and enable a sustainable, patient-centered future.

It could be so much better.

A NEW CHAPTER FOR Health Care Education in Lancaster

JAMES H. CARTER, PHD Interim Provost, Saint Joseph’s University

The January 2024 merger between Saint Joseph’s University (Saint Joseph’s) and the Pennsylvania College of Health Sciences (PA College) marked a significant milestone for health care education in Lancaster and the surrounding area. Through this merger, Saint Joseph’s acquired more than 15 new nursing and allied health programs and introduced a bachelor’s-level nursing program to the University’s Hawk Hill location in Philadelphia. Additionally, Saint Joseph’s signed affiliation agreements with Penn Medicine Lancaster General Health (LG Health).

As Saint Joseph’s interim provost, I’m excited about the possibilities this merger holds for our students, faculty, staff, the local health care community and the future of health education in Lancaster.

As a Jesuit university, Saint Joseph’s recognizes that students are multidimensional individuals who need the freedom and encouragement to grow mentally, spiritually, personally, and creatively. Students are invited to be both reflective and active — in the classroom and the community. This whole-person education allows the student to develop the

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Healthy Communities

vital soft skills needed for the health care workforce — including problem-solving, critical thinking, empathy and self-care. PA College’s legacy will be preserved while students will be exposed to a broader educational experience, and the Lancaster health care ecosystem will be stronger than ever.

PRESERVING THE LEGACY, EMBRACING THE FUTURE

At the heart of this change lies the desire to steward the very essence of what made PA College the higher education institution it was: deep-rooted connections to the Lancaster community and a focus on creating personalized, student-centered learning experiences. These commitments will continue to be hallmarks of education at Saint Joseph’s University in Lancaster.

This focus has nurtured generations of exceptional health care professionals who have served the region with dedication and compassion at institutions such as LG Health, WellSpan Health, UPMC, Penn State Health, and beyond. The merger with Saint Joseph’s University assures the continuation of this 120-year legacy while opening doors to the vast resources of a larger university, including access to a wider range of academic programs, cutting-edge research facilities, a global network of partnerships, and over 110,000 alumni.

A BROADER EDUCATIONAL LANDSCAPE

This merger significantly widens the range of academic offerings available to students in Lancaster as Saint Joseph’s brings with it a diverse academic portfolio, including undergraduate and graduate programs across five schools in various disciplines. For example, students can now explore beyond traditional nursing and allied health programs, potentially pursuing degrees and taking classes in business, health administration, or science fields, as well as a full array of programs in the liberal arts.

The combined resources of both locations will also open doors to cutting-edge research collaborations for the advancement of health care knowledge. In addition, students will be able to learn from a broader pool of esteemed faculty and staff, gaining even more diverse perspectives and enriching their learning experience.

STRENGTHENED LOCAL HEALTH CARE ECOSYSTEM

Approximately 1.8 million health care occupation positions across the country are projected to be open per year between 2022 and 2032, according to the U.S. Bureau of Labor, and Pennsylvania expects to see a 10.4% growth in health care jobs by 2030.

With a larger pool of diversely skilled health care professionals graduating from the newly formed School of Nursing and Allied Health, local health care institutions will continue to benefit from a readily available talent pipeline. This can help address the growing demand for quality health care personnel in the region and ultimately lead to improved access to quality care for Lancaster residents.

Saint Joseph’s has expressed a strong commitment to collaborating with local health care providers to ensure the new School of Nursing and Allied Health meets the community’s specific needs. The existing partnership with LG Health is expected to grow stronger — providing students with access to a wider range of clinical placements and practical experiences, ensuring they graduate prepared to seamlessly integrate into the local health care community — while other partnerships will be explored.

Saint Joseph’s and LG Health are also committed to continually evaluating and adapting educational offerings to meet those needs, resulting in more opportunities for Lancaster residents to access high-quality health care education and potentially leading to a broader and more highly skilled workforce in the region.

More skilled health care professionals entering the field and the collaboration with local health care providers show the merger’s immense potential for the local health care ecosystem here in Lancaster.

CONTINUED COMMUNITY FOCUS

Saint Joseph’s has made a commitment to collaborate and have open communication with the Lancaster community. PA College’s longstanding dedication to community outreach and service projects, like free ultrasounds for pregnant community members and hosting high school students and their mentors for the

Lancaster Chamber’s “Discovering Paths” Programs, mirrors Saint Joseph’s commitment to service-learning and community engagement. This lends well to increased opportunities for students to participate in community-based projects and volunteer initiatives, further strengthening the bond between the University and the residents of Lancaster. The commitment to the Lancaster community remains paramount as Saint Joseph’s recognizes the unique identity and close-knit nature of the Lancaster community.

Furthermore, the increased visibility and resources associated with a larger university can attract a wider pool of talented faculty and researchers to Lancaster. This influx of expertise can benefit not just the University but also the broader health care community by fostering collaboration, innovation, and improved patient care.

LOOKING AHEAD

As this new chapter unfolds, one thing is certain: Saint Joseph’s University in Lancaster will continue to play a vital role in nurturing the next generation of health care professionals and contributing to the well-being of the Lancaster community.

This new chapter promises to offer a wider range of educational opportunities, contribute to a more skilled health care workforce, and further reinforce the ties between the University and Lancaster community.

Saint Joseph’s University in Lancaster represents a positive step forward for health care education in our area. As we move into this new era, I’m confident that Saint Joseph’s University in Lancaster will positively impact not only our students but the entire Lancaster health care community.

James Carter, PhD, is the interim provost at Saint Joseph’s University. Carter was previously the dean of the College of Arts and Sciences and has been a member of Saint Joseph’s faculty since 1999. He is also a leading and celebrated scholar on China’s modern history, having published three books on related topics and dozens of articles.

SYMPTOMS, PREVALENCE, RISKS, AND PREVENTION

NITIN PATEL, MD, MBBS

Medical Director, Infection Prevention, Penn Medicine Lancaster General Health Chair, Antimicrobial Stewardship, Penn Medicine Lancaster General Health

CHICKENPOX AND SHINGLES:

AN OVERVIEW

Varicella zoster virus (VZV) is a DNA virus of Herpesviridae family. There are two clinically distinct forms of the disease, varicella (or chickenpox) and herpes zoster (or shingles). Primary VZV infection (chickenpox) results in fever and diffuse vesicular rash. It is most common in children, but it can develop in adults, especially if they are not immunized. Herpes zoster (shingles), a reactivation of VZV that lay dormant in sensory ganglia, presents with localized rash without fever.

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Healthy Communities

PRIMARY VARICELLA ZOSTER VIRUS –A.K.A. CHICKENPOX

Chickenpox tends to be more severe if it is acquired later in life or in adulthood, which is now very infrequent. But because of decreasing use of the varicella vaccine, there is a risk that unimmunized children may acquire infection at a later age, and there is higher chance of a more severe primary infection. Encephalitis is the most serious complication of primary VZV infection. Patients with underlying malignancy, use of high dose steroids, HIV infection, solid organ transplantation, or immunosuppressive treatment are susceptible to developed disseminated varicella infection if it is acquired. The chickenpox vaccine has been administered since 1995 in the United States. It has significantly reduced the overall incidence of primary infection, severity of the infection, and hospitalizations required as a result of the infection.

Starting in the nasopharynx, where the susceptible host comes in contact with airborne droplets, chickenpox is highly contagious. Subsequently, the host

develops viremia, and the virus spreads throughout the body. Usually, there is an incubation period of 14-16 days prior to development of the vesicular rash. The rash will last for about a week, and then lesions will become crusted. During the vesicular rash stage of infection, the virus will infect nerve endings in the skin and then spread retrograde, finally reaching ganglia, where it establishes lifelong latency.

HERPES ZOSTER (HZ)

– A.K.A. SHINGLES

When VZV virus becomes reactivated it causes herpes zoster (shingles). Major risk factors for developing shingles include advanced age, immunosuppressive conditions (such as HIV infections) or the use of immunosuppressive medications (such as high dose steroids or TNF alpha inhibitors), and solid organ transplants. Age is the most important risk factor. After the age of 50, there is a dramatic increase in incidence of herpes zoster infection. It is estimated that one-third of individuals over age 50 and approximately half of individuals over age 85 will have an episode of herpes zoster infection. When there is

Journal of Infectious Diseases, Volume 226, Issue Supplement_4, 1 November 2022, Pages S470–S477, https://doi.org/10.1093/infdis/jiac255

Jessica Leung, Kathleen Dooling, Mona Marin, Tara C Anderson, Rafael Harpaz, The Impact of Universal Varicella Vaccination on Herpes Zoster Incidence in the United States: Comparison of Birth Cohorts Preceding and Following Varicella Vaccination Program Launch, The

reactivation of VZV, the virus will spread antegrade down from ganglia to sensory nerves and then to the skin, causing the typical rash.

The most common finding of shingles is a localized rash, which is erythematous, vesicular, painful, limited to sensory dermatomes with corresponding ganglia. The typical rash is ipsilateral (affecting one side of the body) and does not cross the midline. When it involves ophthalmic division of the trigeminal nerve, it is called herpes zoster ophthalmicus, which can result in acute or chronic ocular sequelae including vision loss. This is an urgent development requiring consultation with an ophthalmologist and immediate treatment to prevent vision loss. Selected patients may get corticosteroids or sometimes intravitreal foscarnet (an antiviral injection into the eye). Pain, including acute neuritis, is also among the most common symptoms in herpes zoster. Pain may last for several days up to a month.

In an immunocompromised host, shingles can be more severe, involve multiple dermatomes, cross the midline, and present as disseminated zoster. Disseminated zoster (a form of shingles that covers a more widespread area of the body) can be difficult to distinguish from chickenpox. Rarely visceral involvement can occur, causing rare complications, such as meningoencephalitis, pneumonitis, or hepatitis. Some of the other potential complications include bacterial superinfection of lesions, especially with Staph aureus and beta-hemolytic streptococcus. Some patients develop cranial or peripheral nerve palsy due to the shingles infection.

Herpes zoster infection, especially if disseminated, is contagious. Localized herpes zoster lesions should be completely covered until they are dry and scabbed. If the infection is disseminated or the patient is immunocompromised, then the patient should be on airborne and contact isolation until lesions have crusted.

Approximately up to 6% of individuals will experience a second episode of herpes

Source:

zoster. Recurrent shingles is more frequent in women and in immunocompromised hosts. Multiple antiviral treatments are available for herpes zoster infection. Most commonly used agents are valacyclovir, acyclovir, and famciclovir. They are more effective when used within 72 hours of the onset of clinical symptoms. There is no benefit to using them once lesions start crusting. Early antiviral treatment decreases the duration and severity of acute neuritis as well as prevents new lesions and hastens healing of cutaneous lesions. In the case of disseminated disease, intravenous acyclovir is used as initial treatment due to its more effective response. There are several adjunctive agents — such as steroids, gabapentin, and tricyclic antidepressants — in acute situations. But their role in improving outcomes is not very clear. No definitive data has suggested these adjunctive agents will prevent postherpetic neuralgia (PHN), one of the common complications from herpes zoster.

PHN is defined as persistent and significant pain after 90 days of the onset of the herpes zoster rash. It can occur in about 10-15% of patients with herpes zoster. This is secondary to hemorrhagic necrosis of the nerve cells and subsequent neuronal loss and fibrosis of nerve fibers.

Individuals older than 60 and those in an immunocompromised state run a heightened risk for development of postherpetic neuralgia. The herpes zoster vaccine is protective against development of postherpetic neuralgia.

Patients who develop postherpetic neuralgia will need an individualized approach to improve pain. There are several options available including: gabapentin, pregabalin, tricyclic antidepressants, antiseizure medications, serotonin norepinephrine reuptake inhibitors (such as duloxetine or venlafaxine), and neuro axial glucocorticoid injection. Some refractory cases may benefit from botulinum toxin injections and other treatment such as spinal cord stimulation or peripheral nerve stimulation.

Postherpetic neuralgia complication can be prevented by either early treatment of shingles or getting the zoster vaccine. Recombinant zoster vaccine (RZV), called Shingrix, is approved for immunocompetent adults older than 50 and immunocompromised adults age 19 and older. It has two doses, given two to six months apart. The vaccine should be given even if the patient has a prior history of shingles, had the previous live

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Chart by CDC. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm. Use of this chart does not imply endorsement by CDC in any capacity.

zoster vaccine (which is no longer available) or the chickenpox vaccine, or has a history of chickenpox. Shingrix should not be administered during pregnancy or an active shingles infection. It is a well-tolerated vaccine, with the most common complaints being injection site reactions. Some people develop tiredness, nausea, fever, or headache. It is not clear if the childhood chickenpox vaccine helps to prevent herpes zoster in adulthood, but the overall rate of herpes zoster has declined since administration of the chickenpox vaccine began.

REFERENCES

https://www.cdc.gov/shingles/hcp/index.html

Jessica Leung, Kathleen Dooling, Mona Marin, Tara C Anderson, Rafael Harpaz, The Impact of Universal Varicella Vaccination on Herpes Zoster Incidence in the United States: Comparison of Birth Cohorts Preceding and Following Varicella Vaccination Program Launch, The Journal of Infectious Diseases, Volume 226, Issue Supplement_4, 1 November 2022, Pages S470–S477, https://doi. org/10.1093/infdis/jiac255

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6112a4.htm

A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS ,Mayo Clin Proc. 2007;82(11):1341.

Minnie Taw, MD Board certified in Internal Medicine, Pediatrics and Obesity Medicine

Tween and Teen Skin Care

TRENDS VS. THE TRIED-AND-TRUE

WCHRISTINA LAWSON, MD, FAAD Dermatology Associates of Lancaster, Ltd.

ith the rapidly changing era of social media comes a new trend facing our tweens and teenagers — the intense focus on skin care products. Much of this fascination originates from the abundance of social media influencers available on the internet who strategically target the younger generation. Such videos and advertisements have the ability to influence our youth to incorporate a multistep skin care regimen at a very early age. For example, it is not uncommon during a patient encounter for a teenager to inquire about particular skin care products that they viewed on social media platforms such as YouTube, Instagram, TikTok, and Facebook.

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As with most trends, there are positive and negative viewpoints. The positive aspect is that our younger generation is becoming more proactive about caring for their skin at a much earlier age than previous generations. This can have a beneficial impact on their overall skin health since the use of sun protection at an earlier age helps reduce the risk of actinic damage and future skin cancer.

However, there are some true concerns related to the overuse of certain cosmetic products. The downside of this latest skin care trend targeting our tween population is that some younger patients are seeking the use of anti-aging products, which are not truly necessary in their particular population. These agents can include topical retinols and glycolic acid, which are used to exfoliate the skin and ultimately achieve a more youthful skin appearance. Without proper education and guidance, these products can increase the risk of skin sensitivity, presenting in the form of irritant or allergic contact dermatitis. Certain “at home” masks or peels can even cause abrasions or chemical burns on the skin. At a younger age, the skin barrier is more sensitive and easily aggravated by exfoliating agents. If left untreated, contact dermatitis can lead to a condition called post-inflammatory hyperpigmentation or hypopigmentation (PIH) which may take months or years to fully resolve. Furthermore, a multi-step skin care routine has the potential to “overwhelm” the skin, leading to further occlusion of pores which can exacerbate conditions such as acne vulgaris. In addition, a lengthy skin care regimen can interact with the medical treatment of common skin conditions in this population such as acne vulgaris, atopic dermatitis, and perioral dermatitis.

As dermatologists, we certainly want to encourage our tweens and teens to care about their skin, however, we want to emphasize the importance of “keeping it simple.” There are a variety of highly effective topical products that can be purchased over the counter at an affordable cost at most local retail stores. Below is an example of a simple daily recommended skin care regimen for tweens and teens to utilize:

The downside of this latest skin care trend targeting our tween population is that some younger patients are seeking the use of anti-aging products, which are not truly necessary in their particular population.

1. Wash the face with a gentle facial cleanser. Cleansing the skin with a gentle cleanser in the morning and evening helps to remove excess sebum, bacteria, and debris from the skin. Commonly recommended products include CeraVe Hydrating Facial Cleanser, Cetaphil Gentle Skin Cleanser, Neutrogena Ultra Gentle Daily Cleanser, or Vanicream Gentle Facial Cleanser.

2. Apply a daily facial moisturizer containing sunscreen. The use of sunscreen in a daily moisturizer helps combat cumulative damage from ultraviolet radiation and

also helps reduce the risk of skin cancer. A broad-spectrum sunscreen (protecting from both ultraviolet A and ultraviolet B rays) with a minimum sun protection factor (SPF) of 30 is advised. It is recommended to select a sunscreen lotion or cream that states “non-comedogenic,” which means it will not block pores. Examples include CeraVe AM Facial Moisturizing Lotion SPF 30, Neutrogena Clear Face Liquid Lotion Sunscreen SPF 30, or Vanicream Facial Moisturizer SPF 30.

3. Apply a facial nighttime moisturizer. After cleansing the face in the evening, a lightweight moisturizer applied evenly on the face helps prevent dryness and moisturizes the face for the night. Examples are Vanicream Moisturizing Cream or Lotion, CeraVe PM Facial Moisturizing Lotion, or Neutrogena Hydro Boost Water Gel.

4. Miscellaneous products can be added if necessary. In some cases, patients may have concomitant dermatologic facial conditions, such as acne vulgaris, atopic dermatitis, or seborrheic dermatitis. If there are signs of mild acne, there are over the counter cleansers containing salicylic acid that may be indicated based on evaluation by the dermatologist or primary care physician. For those with dry lips, adding a protective lip emollient such as Vaseline, CeraVe healing ointment, or Aquaphor healing ointment can be also helpful.

It is important to recognize that with the evolving access to social media, our younger patient population can be easily influenced by new popular trends. Therefore, as physicians it is critical that we carefully educate them on the necessary objectives for treating the skin at a younger age. At this stage, the goal would be to maintain a consistent, simple skin care regimen. With proper education, we aim not to discourage this generation from caring about their skin, but rather guide them to understand that a basic skin care approach ultimately achieves an overall healthy skin appearance and enhances positive outcomes.

CLIMATE CHANGE’S IMPACT ON ALLERGIES

Global warming and its effects on the health of the planet’s inhabitants is widely accepted now in the legitimate medical and scientific communities. From the spread of diseases to the effects of pollution and greenhouse gases, these changes have not been for the better and have affected numerous components of human health. In the field of allergy and immunology, there are numerous ways our changing climate has put patients at risk, including here in Lancaster County.

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LAURA FISHER, MD Lancaster Family Allergy

Air pollution, worsened by changing weather patterns and their consequences, has been associated with worsening pulmonary and cardiovascular health. Remember the massive western and Canadian wildfires of last summer, when we kept kids indoors and many asthmatic patients had flares? Increase in exposure to air pollution leads to increased development of atopy and food and environmental allergies, early in life. It leads to increased asthma development, flares, and mortality. Pollution affects skin barriers and leads to more atopic dermatitis in infants. Air pollution has been associated with generic modifications including methylation of FOXP3, increasing the risk of asthma diagnosis by age 7. Air pollution and smoke exposure increase respiratory viral and bacterial infections as well, which flare asthma. COVID-19 infections and inflammation have been more severe in vulnerable populations exposed to air pollution.

We have more pollen, which means more allergies, which means more asthma, rhinitis, and eczema. Ragweed especially lends itself to study. When I started practicing two decades ago, we would set our ragweed calendar to mid-August. Now ragweed-sensitive patients locally present to me with symptoms as soon as late July/early August. Changing weather patterns, moisture levels, storms, and longer and longer growing seasons, among other factors, have led to bigger plants, more pollen grains/plants, and longer pollination seasons. Other pollens, grasses, and trees have been studied with similar effects. You don’t need the groundhog to tell you, spring is coming earlier. This year was the second earliest cherry blossoming in Washington, D.C. on record.

With climate change comes more intense storms, including thunderstorms. Thunderstorms can release pollen and mold suddenly into the atmosphere leading to more asthma flares and deaths. Flooding leads to mold growth with development of sinopulmonary disease flares.

The above issues are exacerbated in vulnerable populations of patients — including

WE HAVE MORE POLLEN, WHICH MEANS MORE ALLERGIES, WHICH MEANS MORE ASTHMA, RHINITIS, AND ECZEMA.

children, the elderly, and pregnant women. There are inherent racial biases affecting Black and Hispanic health care. These populations are more heavily centered in warmer climates, along polluting highways, and with less support in climate disasters. Underserved populations are less likely to have access to air conditioning.

Air quality action days, once isolated events in the hottest and most humid days of summer, are now year-round events in Lancaster. A wonderful resource to monitor air quality for physicians and patients in Lancaster County is the following website: co.lancaster.pa.us/2837/Air-Quality-Index. Asthmatics and other vulnerable populations should limit outdoor time when the Air Quality Index is in the orange zone or above. Respirators and air filter recommendations are also on this site. Pollen counts can be followed for the area on pollen.com; limit outdoor exposure if your specific allergens are among the top reported. Allergy testing to identify allergens can be performed by an allergist/immunologist. Exercising before dawn or late in the day and avoiding windy days is recommended. Rinse off after spending time outdoors, and do not dry sheets, towels, or clothes outside. Wipe off pets that spend time outdoors with a damp cloth so they do not become little pollen bombs running through the home. Use air conditioning and resist opening windows even on beautiful spring and fall days.

Treatment strategies include nonsedating antihistamines for itching and sneezing. Fexofenadine does not cross the blood/brain barrier and should not cause any sedation. Topical nasal steroids help congestion/ rhinorrhea. For those with pollen allergies, allergy immunotherapy — thorough injections or sublingually for a smaller group of allergens — is available and a better longterm plan. Avoid using topical decongestants long term for eyes or nose because they can cause rebound symptoms.

Our patients need our advocacy to treat asthma and allergies. Climate change is in our lane.

It’s our pleasure to highlight a Lancaster City & County Medical Society member’s “passion outside of practice” in each issue of Lancaster Physician. Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature Allison Barrett, MD, and her passion outside of practice.

Tennis

Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?

I started playing tennis in 2022. I was encouraged by a friend to try a New to Tennis series at RCW Athletic Club. After completing the 6-week series, I was hooked. I enjoyed the combination of physical exercise, mental challenge, and social interaction. I have met so many wonderful friends through tennis these past two years.

How did you develop an interest in your passion outside of practice?

I started playing every week with friends and attending clinics. Within a few months, I also started playing in a United States Tennis Association (USTA) league with an amazing group of ladies. As my skills improved, my desire to play increased. I have made it a point to play two or three times a week, as it serves as my exercise for the week but also engages a different side of my brain from what I use during my work hours. The stress relief that

comes from playing a sport has also been very welcome.

How long have you been participating in this activity?

About two years.

Why is this pursuit special to you?

Being in medicine, we spend so much of our time with other health care providers, and that contributes a huge amount to my daily social interactions. When I began playing tennis, I was able to make friends with people outside health care, providing such a nice balance to my work life. I also enjoy the challenge of learning a new sport in my 40s! My body does not always do what I want it to do, but I find the task of training my body to move a certain way to be fun and engaging, though sometimes frustrating. I enjoy seeing myself improve and being able to make shots that I couldn’t make previously. Learning a new sport gives me satisfaction and pride in myself, while also being, at times, very humbling!

What else would you like readers to know about this passion?

When I’m not working or playing tennis, I spend time with my family. I have two young children and an amazing husband. In addition to being a physician, my husband is our family’s landscaper, handyman, and an excellent trampoline and swimming pool buddy for our kids. My husband and I are big Formula 1 racing fans. We are planning our second trip to see an F1 race this summer. My husband is Dr. Michael Deutsch, a colorectal surgeon at Hershey.

Allison Barrett, MD

Penn State Health Medical Group – Noll Drive

LANCASTER County and the opioid epidemic

Introduction

JON LEPLEY, DO, FAOAAM Medical Director of Addiction Medicine Penn Medicine Lancaster General Health

It is hard to overstate the devastation of the opioid epidemic in the United States. Since the turn of the century, more than one million people have died from unintentional drug overdose, and the majority involve opioids. The Centers for Disease Control and Prevention (CDC) described 63,632 accidental drug overdose deaths in 2016 alone — a number larger than the total of Americans who died during the decade-long war in Vietnam.

That was a staggering number at the time, yet enviable by current standards. The CDC reported 106,699 overdose deaths in 2021 (Figure 1), and the majority involve illicitly manufactured fentanyl — an opioid that is 100 times more potent than morphine. Most overdose deaths occur in people aged 25 to 55 with untreated or inadequately treated opioid use disorder (OUD).

This epidemic hit Lancaster County the hardest in 2017, with an average of more than three overdose deaths per week that year (Figure 2). The COVID-19 pandemic brought another surge of overdose deaths in 2020. Yet, in contrast to our nation, overdose deaths in Lancaster County have declined year after year since that spike in 2020.

Preliminary data for 2023 indicate that Lancaster will record the lowest number of overdose deaths in nearly ten years. The role of behavioral treatment and naloxone distribution for overdose prevention is well recognized. I will highlight three significant changes in Lancaster County that are underappreciated but undoubtedly contributed to this favorable public health outcome.

Buprenorphine Treatment for Opioid Use Disorder

Buprenorphine is an FDA-approved medication to treat OUD and reduces the risk of fatal overdose by 70%. The medication is commonly known by its brand name, Suboxone, although generic formulations have existed for more than ten years. Despite its effectiveness at preventing overdose deaths and availability since 2002, the medication was in scarce supply primarily due to regulations.

Until 2016, buprenorphine could only be prescribed by a physician. Additionally, these physicians were required to complete a government-approved training course before offering the treatment. Completing the course allowed them to apply for a “waiver,” which was an additional notation on their Drug Enforcement Agency (DEA) registration to prescribe controlled substances.

This registration always began with the letter “X” and quickly became known as the “X-waiver.” In this scenario, potential criminal prosecution was being “waived”

— prescribing buprenorphine to prevent a fatal opioid overdose was otherwise considered a possible violation of federal law. The X-waiver was the DEA’s tracking mechanism to monitor buprenorphine prescribing. The X registration needed to be written on every prescription for buprenorphine, and physicians were subject to routine audits by the DEA field agents who scrutinized their medical practice.

Unsurprisingly, only a few courageous physicians in Lancaster County opted to undertake this scrutiny and provide this treatment since buprenorphine became available in 2002. These early adopters prevented many overdose deaths but were insufficient in number to withstand the wave of fatal overdoses when fentanyl came to dominate the drug supply in the mid-2010s.

The federal government wisely and gradually rolled back these barriers to providing buprenorphine. In 2016, advanced practice providers could also apply for an X-waiver (though with more stringent training requirements). By 2021, the training requirement was eliminated, and in 2023, the X-waiver was eliminated. Currently, buprenorphine can be prescribed by any practitioner with DEA registration to prescribe controlled substances. Clinicians in Lancaster County made good use of these flexibilities.

The Pennsylvania Prescription Drug Monitoring Program (PDMP) interactive dashboard provides the public with county-wide data on controlled substance prescribing. This resource went live in 2016.

An examination of PDMP data in Lancaster County reveals an 80% increase in

buprenorphine prescribing compared to baseline numbers in 2016. By contrast, the rest of Pennsylvania shows a 30% increase in the same timeframe. The increased availability of this proven life-saving medication is likely the most significant contributing factor to Lancaster County’s overdose prevention achievement.

Recognizing the Complexity in Opioid Treatment for Pain

The contribution of the pharmaceutical industry and aggressive opioid prescribing in the 1990s and early 2000s is widely recognized by the public. This is primarily thanks to television, movies, and news story depictions. Simple narratives draw viewers, but a complete understanding of opioid prescribing requires more careful historical exploration.

The medical profession was widely criticized in the 1990s for failing to address pain when managing illnesses. A well-intentioned effort was undertaken to incorporate patient-reported outcomes to assess the quality of healthcare delivery. Querying patients about pain became an important measure and a typical health system focus. Asking patients to rate their pain on a scale of one to ten when measuring other vital signs became commonplace.

Opioids were a very effective and convenient way of improving this metric in the early 2000s. At the same time, the risk of NSAIDs came into sharp focus when two were suddenly removed from the market due to concerns about increased risk of cardiovascular events. Time constraints and poor reimbursement for alternative treatments all further cultivated an environment that

incentivized opioid treatment for chronic pain syndromes.

Many patients who began long-term opioid treatment (LTOT) in the 2000s for chronic pain still take these medications today. Tapering them off their opioid treatment is not the same as never having prescribed opioids to them in the first place. Studies show that periods of opioid tapering in such patients are associated with an increased risk of suicide and fatal overdose.

Additionally, LTOT patients who develop OUD must be offered buprenorphine treatment. Simply cutting them off from their prescribed opioid is not treatment. Instead, those measures push such patients toward the unsafe supply of illicit fentanyl in our community.

At Lancaster General Health, we have taken steps to educate our primary care workforce about the complexity of opioid prescribing. Minimizing exposure to opioids for those patients who have never taken them is very wise. Yet, LTOT patients must be treated differently. Dose reductions must be undertaken cautiously and with informed consent, and patients who develop problems with addiction must be referred to treatment. A nuanced approach has contributed to reduced overdose deaths in Lancaster during the 2020s.

Medication for Opioid Use Disorder at Lancaster County Prison

A Substance Abuse and Mental Health Services Administration (SAMHSA) national

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Figure 1: Data from CDC. Accessed March 15, 2024. https://www.cdc.gov/nchs/data/ databriefs/db457-tables.pdf#. Use of this data does not imply endorsement by the CDC.)

Figure 2: Data from Pennsylvania Office of Drug Surveillance and Misuse Prevention and Lancaster County Joining Forces. Accessed March 19, 2024. https://www.lancasterjoiningforces.org.

THE POINT AT 101 NORTH QUEEN

Patient Advocacy

survey suggests a 2% prevalence of OUD in the community. Yet, because drug use is criminalized in virtually every state, the prevalence of OUD in correctional settings may be as high as 20%. Paradoxically, people who are incarcerated for drug use are often denied treatment.

Health care providers commonly presume that lack of education and negative attitudes toward medication for addiction are the underlying causes. Like pharmaceutical influence over prescribing opioids for pain, that narrative is an oversimplification of the problem. The provision of medication for OUD can be a labor-intensive process, and jails and prisons do not receive adequate funding to provide the service to one-fifth of their inmate population.

The Social Security Amendments of 1965 disallow the use of Medicaid and Medicare funds to provide most types of medical care to incarcerated people. Local governments carry the burden of funding health care in jails and prisons. A political platform that promises to increase taxes to improve the health of incarcerated people would garner my vote but perhaps not the support of a majority of the voting public. Lack of funding may be the most substantial barrier to treating OUD in our county prison.

Thankfully, Lancaster County Commissioners voted to allocate opioid settlement dollars to fund some buprenorphine and methadone treatment at Lancaster County Prison. People who already received these medications when they entered the facility now continue to receive them during their time in the institution. Absent these medications, release from jail is associated with a tremendous increased risk of fatal overdose upon community reentry. This wise utilization of opioid settlement dollars contributed to the recent decline in overdose deaths in Lancaster County.

Conclusion

Though the opioid epidemic continues to rage across the US, Lancaster County represents an optimistic outlier. The willingness of primary care providers to prescribe buprenorphine is a major contributing factor. The same workforce is recognizing that a meticulous approach is required when treating patients who already receive long-term opioids for chronic pain. Thanks to improved funding, these changes extend to the healthcare workforce in our county jail.

Yet, more work is to be done. A careful examination of fatal overdoses in Lancaster County reveals the existence of substantial racial disparities — people of color experience fatal overdoses at higher rates than white people. Sadly, the same ethnic groups are disproportionately involved in the criminal justice system. Future direction in our county must involve a further understanding of the underlying causes of this disparity and expanded access to buprenorphine for all incarcerated people with untreated OUD.

HEMPOWERING PATIENTS

to Take Greater Control of their Health & Care

SUSAN SHELLY Writer

ealth empowerment — which refers to the process of enabling patients to take control of their own care and well-being — is considered a cornerstone of a patient-centered approach to health care.

Studies have shown that engaging patients in their care boosts health outcomes, improves patient satisfaction with the care experience, reduces costs, and provides benefits to clinicians.

Hailed as a “new paradigm in health care,” patient empowerment calls for a collaborative relationship between patients and providers, with providers giving patients the tools they need to participate in decisions concerning their health and care.

Those tools, which include education, access to personal electronic health records, telemedicine platforms, digital health tools, wearable devices, and others are becoming more readily available, enabling an increasing number of patients to be involved in their care.

Lancaster Physician reached out to the health care systems serving Lancaster County to learn what they are doing to encourage patient empowerment. We spoke with representatives from WellSpan Health, Penn Medicine Lancaster General Health, and Penn State Health.

WellSpan Health

Recognizing the benefits of patient engagement, WellSpan Health employs a robust set of digital tools to encourage patients to fully participate in their care.

“The utilization of digital tools can help people when they’re not sick, and also when they need care and treatment,” said Mark Kandrysawtz, Vice President, Chief Innovation Officer.

Kandrysawtz explained there are 47 health maintenance tasks patients should adhere to, ranging from home monitoring of blood pressure to

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Mark Kandrysawtz

preventative screenings such as colonoscopies and mammograms.

Reminding patients of those tasks and providing access to tools needed to achieve them makes it more likely they will do so, Kandrysawtz said.

For instance, a patient due for a colonoscopy receives a reminder, along with educational materials about the procedure. Included in the message is a feature enabling the patient to easily schedule an appointment.

If a desired appointment time is not available, a patient can join an automated wait list called Fast Pass that delivers a notification every time an appointment opens. In 2023, that feature resulted in 58,000 appointments being rescheduled to an earlier date, benefiting patients and providers.

“WellSpan has a history of being a leader in delivering a better customer experience through the use of digital tools,” Kandrysawtz said.

The use of the MyWellSpan app, a consumer-facing tool that enables patients to communicate with their providers, access educational materials, manage appointments, see and share vaccination status, view test results and imaging scans, look at notes from provider visits, manage payments, request prescription refills, and more, has revolutionized patient engagement, according to Kandrysawtz.

Use of the app has increased steadily over the years, with patients on average accessing it seven times a month.

“That shows us that patients value all the services contained in that app,” Kandrysawtz shared. “There’s a direct correlation between our efforts and how often people will use these tools.”

In another effort to engage patients, WellSpan recently redesigned its patient arrival experience to personalize it and accommodate those who require services such as a phone call reminder or translator.

“We did the redesign because we studied what our customers wanted and used that knowledge to improve the experience,” Kandrysawtz said. “At the end of the day, health care has an obligation to make

HEALTH EMPOWERMENT — WHICH REFERS TO THE PROCESS OF ENABLING PATIENTS TO TAKE CONTROL OF THEIR OWN CARE AND WELL-BEING — IS CONSIDERED A CORNERSTONE OF A PATIENT-CENTERED APPROACH TO HEALTH CARE.

people feel the systems are designed just for them.”

WellSpan has earned five MyChart Diamonds from software provider EPIC Systems and is the first health care organization in the world to achieve a 5-Star designation. A diamond is awarded to a health care system that demonstrates all key features in a particular area are turned on and widely used by patients.

WellSpan earned diamonds for the following areas: telemedicine, clinical basics, patient communications, clinical advance & care companion, and interoperability.

Another area of patient empowerment is the system’s Proxy Access, which gives parents or caregivers access to all information pertaining to a patient. A designated proxy can learn who a patient’s providers are and communicate with them, access care plans and discharge instructions, and view all information on the patient’s chart.

WellSpan will continue to move forward in engaging patients, giving them the tools they need to be active and involved in their care.

“That is now the consumer expectation,” Kandrysawtz said. “And we’re excited to be able to deliver on those expectations.”

John Wood, MD

Penn Medicine Lancaster General Health

John Wood, MD, Executive Medical Director, Primary Care and Population Health at Penn Medicine Lancaster General Health, asserts that patient empowerment is not a novel approach to medicine, but a key component of the Hippocratic Oath.

“The Hippocratic Oath tells doctors to first do no harm; however, a major component is to instruct patients, meet patients where they are, and link them to resources they need,” Wood said. “The word ‘doctor’ comes from the Latin root that means ‘to teach.’”

LG Health follows the direction of the Oath in a variety of ways, from increasing patients’ access to providers to providing blood pressure cuffs and other remote monitoring technology for patients to use at home.

The blood pressure monitoring program, called B.P. Pal, enables patients to measure their blood pressure at home and report results by text message to providers.

Another text-based program that addresses blood pressure, along with healthier eating, cholesterol, and smoking, is Penn Medicine Health Heart. Available to patients in Lancaster County, the program sends monthly text message reminders for patients to check their blood pressure, while also providing educational resources about related topics. Patients text their results to their provider and receive plans for controlling and improving blood pressure and cholesterol levels.

“This puts patients in control and gets them involved in improving their health,” Wood said.

LG Health also offers education and support groups for patients and caregivers living with Alzheimer’s disease, diabetes, and many other conditions.

“We work to connect patients with certain diagnoses with like patients through support groups,” explained Wood. “They can support

one another as we continue to provide support, as well.”

Working to increase patient access to primary care, the health system continues to grow its network of employer-sponsored primary care clinics, known as Penn Medicine HealthWorks.

According to this model, employers sponsor clinics at or near their workplaces and pay membership fees for employees to access convenient primary care services, with a focus on wellness and prevention.

Patients have no co-pays, and because they’re able to access care easily, they’re more likely to seek it out and establish personalized relationships with their providers, explained Wood. Those relationships foster discussion and sharing of decisions regarding care, thereby empowering the patient.

Another innovative program is LG Health’s Food Farmacy, which combines one-on-one meetings between a patient and a registered dietician with access to affordable, healthy food options.

Through the program, which started in 2019, patients meet regularly with a dietitian at a local food pantry, where they receive nutrition counseling and “shop” for healthy food for themselves and their families. Patients in the program have experienced weight loss as well as improvements in their blood pressure and cholesterol levels.

“We are working to meet people where they are and provide whatever they need to be healthy,” Wood shared. “LG Health has committed itself to being physically present to all patients in Lancaster County.”

Technology plays a big role in empowering patients, Wood explained, with wearable devices, easily accessible electronic records, virtual appointments, online educational materials, and other features enabling patients to become more informed and involved.

“All those technologies make providers much more accessible to patients,” Wood said.

Helping patients become more empowered in their care has changed the way care is delivered, as patients increasingly want to be part of the

decision-making process. It’s common for his patients to have lists of questions for the doctor when they arrive for appointments, Wood said, and providers must be prepared to spend time not only explaining, but listening and asking patients what they want to do.

“The days are gone when a physician says to do something and the patient follows in lockstep,” Wood said. “And I think that’s a good thing.”

Penn State Health

Obstetrics and gynecology providers at Penn State Health Lancaster Medical Center are working closely with patients to tailor and personalize health care for women of all ages.

Women are encouraged to participate in all aspects of their care to assure they receive the treatment they deserve and expect, explained Vanessa McDonald, MD, a physician at the medical center.

“We work hard to create trust with every patient and let them know we’re listening to them,” McDonald said. “Women’s health care is an intimate experience that requires interaction between patients and their doctors.”

Obstetric patients in particular are encouraged to get involved in their care by expressing their expectations for prenatal care, labor, and delivery. Patients can write out a birth plan, which providers carefully review with expectant mothers and their partners to assure mutual understanding.

“We’re making a special effort to hear patients out and make sure their birth plan is followed through on,” McDonald said.

The concept of birth plans was introduced in the 1980s as a way for women to voice and clarify their wishes during a period in medicine when they often were not encouraged to do so. Many providers viewed birth plans as problematic and were hesitant to accept patients who wanted their wishes to be known and respected.

Those attitudes have changed, and now many doctors are eager to partner with patients and accommodate their wishes if they do not affect health outcomes for the mother or baby.

A birth plan, for which templates are available online, may specify that the mother wishes to cut the umbilical cord, delay the cutting of the cord, labor in a different position, receive an epidural if appropriate, and express other wishes. It may describe the role of the mother’s significant other or include other instructions.

“Being able to state those wishes allows a person autonomy in her health care,” McDonald said. “It makes her feel heard and know her wishes will be respected.”

While patients are in no way required to formulate a birth plan, those who want to are happily accommodated. Most expectant parents are aware of the concept of birth plans, and many initiate using one.

“If that’s what a patient wants, we’ll make sure the entire staff is aware of the plan,” McDonald said.

Many patients preparing for a birth have had past birthing experiences that were far from optimal, explained McDonald. They may have not been told what to expect or were not consulted regarding their care.

“We really want to work as a team with our patients,” she shared. “Most of our patients have been very pleased with the care they are provided.”

Penn State Health Lancaster Medical Center is working to restructure its expectant parent classes, which McDonald said are important in providing necessary tools and education.

Prenatal classes give women a chance to ask questions, receive support from other expectant moms, share their expectations, and lessen anxiety regarding labor and delivery. Women are encouraged to tour the hospital’s private delivery rooms and are told what to expect when they arrive to give birth.

“Our goal is to give patients the best experience possible by partnering with them and empowering them in their care,” McDonald said. “We let patients know that we’ll be working with them to make this the optimal experience.”

Vanessa McDonald, MD

LEGISLATIVE UPDATES SPRING 2024

In February, a group of ten Pennsylvania Medical Society (PAMED) members attended the AMA’s National Advocacy Conference in Washington, D.C. This year the PAMED physicians had meetings with legislators or staff from 14 offices of the PA congressional delegation, including Congressman Dan Meuser and Congressman Glenn Thompson. Among the issues and legislation discussed was the critical need to reverse the Medicare physician payment cuts that took effect on Jan. 1, 2024, and the importance of increasing the number of graduate medical education training slots.

As part of the National Advocacy Conference, PAMED Board Member Michael Suk, MD, led a panel discussion about the impact of Medicare cuts to rural health care. As part of the panel, Dr. Suk was joined by PAMED Board Vice Chair Lorraine Rosamilia, MD, who demonstrated the need for Medicare reform to ensure that those in rural settings can continue to receive important care in their communities.

In Pennsylvania, PAMED participated in a hearing on challenges surrounding rural health care for the Senate Majority Policy Committee and a joint hearing with the House Professional Licensure Committee and the House Health Committee on improving access to health care. Former PAMED Board of Trustee David Csikos, MD, was among the panel to testify on challenges to rural health care.

With the legislature quiet the beginning of this year, the PAMED Government Relations team was on the move, visiting different districts in Pennsylvania. They were recently part of a legislative forum held by the Lycoming County Medical Society with Senator Yaw, Rep. Jamie Flick and Rep. Joe Hamm. There they discussed legislation on noncompete agreements and POLST.

PAMED has seen notable movement on three key issues:

Amending Medical Practice Act (Senate Bill 559 & Senate Bill 560) – On March 18, the PA Senate passed Senate Bill 559 and Senate Bill 560 to amend the Medical Practice Act and the Osteopathic Medical Practice Act regarding athletic trainers. The legislation would allow athletic trainers to

perform certain specified procedures with the direction of a licensed physician and pursuant to a written protocol.

The bills would also amend the definition of a “physically active person” to include anyone that participates in an individual or team sport, an athletic competition, a performing art, a recreational activity, or a military exercise. The bills have now been referred to the House Professional Licensure Committee for consideration in the House.

Telemedicine Service Insurance Coverage (House Bill 1512) – On March 25, the PA House Insurance Committee considered House Bill 1512, legislation which would require health insurers to cover and pay for health care services provided via telemedicine. Unfortunately, the legislation does not address the issue in a comprehensive manner and only covers the insurance question.

PAMED has been engaged in negotiations over several legislative sessions regarding telemedicine and fully supports Senate Bill 739, a more comprehensive telemedicine bill currently waiting consideration in the Senate Appropriations Committee.

PAMED informed the House Insurance Committee that it supports moving House Bill 1512 forward in the legislative process to continue momentum on this issue, but we continue to press for an amendment encompassing the already-negotiated comprehensive provisions contained in Senate Bill 739.

Prohibit Noncompete Agreements

(House Bill 1633) – On March 27, the PA House Health Committee overwhelmingly approved House Bill 1633, legislation which would prohibit all non-compete agreements in employment contracts for health care practitioners. PAMED supports significantly restricting the geographic reach and duration of a hospital or health system’s non-compete agreements, but we also believe legislation on this issue needs to recognize the needs and concerns of small independent physician practices that require protection against predatory poaching of established community physicians.

PAMED is working with the prime sponsor and Committee Chairman to develop an acceptable amendment that balances these concerns. We have communicated to the Committee we support moving House Bill 1633 forward in the legislative process as we continue our negotiations on final language.

This year is an election year! The primary elections for Pennsylvania are Tuesday, April 23. To see a full list of important dates for the 2024 Pennsylvania elections, visit vote.pa.gov/About-Elections/Pages/ Upcoming-Elections.aspx.

PAMED members are encouraged to meet with and develop relationships with their local state representatives and state senators. Building these relationships helps PAMED achieve the legislative goals for physicians and patient care.

THE GREENFIELD RESTAURANT &

MD

Situated at the corner of the Greenfield Corporate Center, The Greenfield Restaurant & Bar has been a longtime (and completely booked at times) fixture of the Lancaster County restaurant scene. My wife and I enjoy stopping in for a light bite at the bar or a delicious dinner for two (or with friends).

They offer a wide variety of culinary options and always seasonal additions. On our most recent visit, I chose the Pan-Seared Georges Bank Scallops (fresh diver scallops, served with corn risotto), while my wife enjoyed a dinner special featuring lamb loin and roasted vegetables. While the restaurant is known for its seafood offerings, you can find almost anything to interest you on the menu. We often select a “midplate” salad and add a protein for a lighter dinner at the bar.

The scallops are a favorite mainstay on the menu. They are always perfectly prepared and simply delicious. A solid wine list is offered, and there is always a knowledgeable staff member to guide you on a perfect pairing for your dinner choice. Our servers have been friendly and attentive, making recommendations when we ask.

There is a seasonal outdoor eating area, which is arguably the prettiest in Lancaster. Gorgeous hanging plants and planters adorn the patio with convenient overhead ceiling fans. There is enough shade to keep the patio comfortable, but also enough sunshine to let you know you are outside! It is the perfect spot for brunch or an outdoor evening meal.

They also offer live music on certain nights for a more lively atmosphere. If you haven’t been there in a while, I highly recommend you revisit. You won’t be disappointed.

THE GREENFIELD RESTAURANT & BAR

595 Greenfield Road | Lancaster, PA 17601

thegreenfieldrestaurant.com | 717-393-0668

Pan-Seared Georges Bank Scallops

Glimpses of the indoor (above) and outdoor (left) ambiance at The Greenfield Restaurant & Bar

FOUNDATIO N A N NOUNCES

2024/2025 Medical School Scholarships

TUITION ASSISTANCE AVAILABLE TO LOCAL STUDENTS

The Lancaster Medical Society Foundation has opened its application process for scholarships for the 2024-2025 academic year. Eligible students must be a Lancaster County resident, accepted at or continuing a medical degree at an accredited medical school. Applicants must also demonstrate academic achievement, exhibit good character and motivation, and show financial need.

“Due to the on-going generosity of our contributors, we are pleased to be able to continue our commitment of investing in the future of medicine in Lancaster County,” shared executive director Beth Gerber. “With our growing and aging population, the demand for quality health care in our community is only increasing. It is our hope that our scholarship recipients consider returning home to serve the residents of Lancaster County when they begin their careers.”

According to the American Medical Association, medical student-loan debt, a figure that on average reaches about $200,000, looms large in many life decisions that physicians make.

“We know the debt many students must take on is daunting. It is our hope that we can help relieve that burden, if just a bit, and allow them to focus on their training and education,” said Gerber.

Supported by the Lancaster County medical community, including local hospitals/health systems, group practices, individual Medical Society members, various businesses, and the general public, the Foundation has awarded more than $294,000 in funds since its establishment in 1991.

Penn Medicine Lancaster General Health Care Connections

By the time we meet some of our patients, the path to good health has been marked by confusing medical terminology, disruptions in health care, and frequent hospital and ER visits. Their medical journey may also have led to missed time with loved ones, loss of enjoyable activities, and challenges in navigating community resources, such as housing, transportation, and even food.

Over the past decade, Care Connections has listened carefully to the stories of nearly 1,000 patients facing chronic, complex medical issues. As a primary care practice and ambulatory complex care team, our patients receive care from our team of primary care providers, pharmacist, RN case managers, social workers, patient navigators, and clinical support staff. Visiting our patients at home and accompanying them at specialty care visits gives a unique perspective, more fully allowing us to understand their needs, and how best to help them navigate the complicated world of social safety net benefits and community supports needed to stabilize their situations.

Patients join Care Connections on a voluntary basis and are attributed to our primary care practice for nine to 12 months on average. Focus is placed on improved management of chronic medical conditions, coordination of care, and closure of health maintenance gaps. The team works to remediate patients’ health-related social needs and aligns them with behavioral

health supports when needed. The ultimate goal is successful graduation, returning patients to their prior primary care provider with better coordinated care, improved understanding of their conditions, and supports in place to manage social determinant factors that can destabilize them in the community.

This National Doctors’ Day, Care Connections honors Wendell Kellum, MD, who has been critical to the success and growth of our practice. Dr. Kellum has been a key driver behind much of our programmatic development and has even moved the innovation of Care Connections into the research arena. More broadly in the health system, Dr. Kellum’s skills and alignment with the Epic build team led to the roll out of enhanced billing codes based on visit complexity and improving transition of care documentation and accuracy. He is now actively engaged in the development of the Penn Medicine Healthy Heart program.

Care Connections is entirely grateful for the opportunity to learn from our patients every day. It is through humble learning that we become better care providers. We thank Dr. Kellum for his dedication to high-quality care for some of our community’s most vulnerable patients and for always motivating our team to continue learning and growing.

The Care Connections team Wendell Kellum, MD

Kent Meldrum, MD

May-Grant Obstetrics & Gynecology

Where do you practice and why did you settle in your present location or community?

I was a bit of a late bloomer to medicine. During my undergraduate education, I realized that I loved the sciences, especially biology, and I enjoyed serving others in the community. I thought that medicine would be a great melding of these two interests. Being married and having a child already, I signed on with the US Air Force to take advantage of the Health Professions Scholarship to pay for medical school at Michigan State. Being on active duty for 10 years allowed me to complete residency in California (Travis AFB), and practice as an attending in Maryland (Andrews AFB), and England (RAF Lakenheath). I was able to experience different work environments, and my family and I had many travel opportunities both in the US and Europe. We loved our time in Maryland and were looking to settle in the Mid-Atlantic states when I separated from the USAF. I wanted a larger, independent practice that could support my clinical interests (and need for sleep), but NOT in a big city. And my wife had her own list of requirements, including good schools, local universities, cultural events, and driving distance to a major city (or better yet, three to four cities). We were so excited to find that Lancaster and May-Grant OB/GYN had all of these and more!

What do you like best about practicing medicine?

I love being at May-Grant. Being independent and able to mold our practice to fit the needs of our patients and employees is a real blessing to me. Having lab, ultrasound, and mammograms in-house has really simplified and streamlined our patients’ visits. I have the privilege of working side by side with our midwives and nurse practitioners, day and night. I love the collaboration with the other

physicians, both those who are more experienced and the freshly trained. They all have so much knowledge and experience that lend to best practices, and I appreciate working in that environment knowing we have each other’s backs.

Every day of work is different! Some days I spend in the office with routine or problem visits, some OB patients, and some procedures. Some days or nights, I am on call at the hospital or in surgery. I love the variety and know that every day and every patient is unique. I am not aware of any other specialty that has the variety OB/GYN has in our patient care: preventative care, procedures, surgery, and obstetrics (cesarean sections are amazing!).

My favorite part of medicine is sitting toe to toe with patients and their families and finding ways to maintain or improve their quality of life. I am in awe of the level of advocacy, sacrifice, and compassion my patients have regarding their families and their well-being. Obstetrics and gynecology really impresses on me how amazing and complex women’s health is and how much trust patients place in their providers. Working with women to address their concerns and issues and making a plan together is energizing. I also love surgery and the opportunity to treat conditions in a minimally invasive way.

Are you involved in any community, non-profit, or professional organizations?

I am very involved in my church, and I work closely with youth groups in Lancaster and York. I am a member of the AMA and ACOG and am grateful for their work on women’s health issues.

What are your hobbies and interests when you’re not working?

My wife (Alyson) and I have raised four children, who all graduated from Hempfield School District. We recently became empty nesters and may have overcompensated a bit by traveling EVERY month that first year. That was an exciting transition, and we are now learning to pace ourselves. My other passion is board games and I have assembled quite a collection. I enjoy spending time with family and friends together around a table and a game. My motto: “If you don’t like board games, you just haven’t played the right one.” I also enjoy running and soccer, and have recently felt very young as I have started playing pickleball at the local gym.

For what reason(s) did you become a member of the Lancaster City & County Medical Society and what do you value most about your membership?

Practicing mainly at Penn Medicine Lancaster General Health Women & Babies Hospital, I do not get a lot of interaction with other local physicians outside my specialty. LCCMS does a great job at getting physicians together socially and facilitating collaboration on local and regional issues that affect us all. I still feel like a newbie after being here just 13 years, so it is nice to take advantage of opportunities to interact with the amazing providers in this area. I feel that this organization’s efforts to foster cooperation, not competition, between physicians has really benefited our community.

IN REMEMBRANCE

LOUIS A. MAROTTI, JR., MD, PhD, FAANS

Louis A. Marotti Jr., 51, of Lititz, PA passed away suddenly after a brief illness on March 22, 2024. Lou was born in New Haven, CT and grew up in East Haven, CT. He graduated magna cum laude from Yale University in 1994, and went on to attend the Yale School of Medicine where he earned his MD and a PhD in Neuroscience. Following his residency in Neurosurgery at Yale, Lou completed a spine surgery fellowship at New England Baptist Hospital in Boston, MA. In 2010, Lou joined the practice of Argires & Marotti Neurosurgical Associates of Lancaster, as a partner. For the past fourteen years, he has touched the lives of countless patients and colleagues. Lou was a member of the American Board of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the Pennsylvania Neurosurgical Society, and the American College of Surgeons. He was Board Certified in Neurological Surgery and was the Chief of the Division of Neurosurgery at Lancaster Regional Medical Center.

Above all things, Lou loved his family. He met the love of his life, Jill, in 2005 and they have two boys, Louis, 8 and Bailey, 6. Lou loved his devoted parents, Rita, and Lou, and was so grateful for their love. He was also very close with his brothers and sister and spoke of them always with love and admiration. Lou cared about people and gave himself to everyone, if even to his detriment. He always took time with his patients and made sure to listen and teach them about their conditions. His humor and lighthearted nature will be remembered fondly. Lou has made such a tremendous positive impact on the lives of so many it can honestly be said that he made the world a better place. Lou will always be remembered as an excellent surgeon, amazing father and husband, and the best son, brother, and brother-in-law anyone could ever ask for. He will be sorely missed by his family and friends, and by all who ever knew him.

He is survived by his wife, Jill Marotti (Vasi), and sons, Louis A. Marotti, III and Bailey Marotti, as well as his parents, Louis A. Marotti and Rita Marotti, his sister and brother-in-law, Neisha and Michael Scinto, his brothers, Joseph A. Marotti (Ashlee Marotti) and Matthew A. Marotti (Maria Marotti), his Motherin-law, Joyce Bailey, father-in-law, Mark Vasi, brother-in-law, Bret Vasi (Krista) and Sister-in-law, Tara Vasi (Matthew) and his nieces and nephews, Noah Marotti, Mya Scinto, Audrey Marotti, Leo Vasi, Eva Vasi, and Maeve Sorenson.

FRONTLINE GROUPS SPRING 2024

Frontline Practice Groups have made a 100% membership commitment to LCCMS and PAMED. We thank them for their unified support of our efforts in advocating on your behalf and facilitating an environment for physicians to work collaboratively for the benefit of the profession and patients.

Argires Marotti Neurosurgical Associates of Lancaster

 Avalon Primary Care

 BestFit Virtual Health + Wellness PLLC

 Carter MD Aesthetics

 Community Anesthesia Associates

 Community Services Group

 Conestoga Eye

 Dermasurgery Center PC

 Dermatology Associates of Lancaster Ltd.

 Dermatology Physicians Inc

 DermDox Dermatology Centers PC

 The ENT Center

 Eye Associates of Lancaster Ltd.

 Eye Health Physicians of Lancaster

 Family Eye Group

 Family Practice Center PC – Elizabethtown

 Glah Medical Group

 The Heart Group of Lancaster General Health

 Hospice & Community Care

New Members

Isma Ali, MD

Nicholas Bertoni, MD

WellSpan Ephrata Community Hospital

Logan Lawson, DO, resident Penn Medicine Lancaster General Hospital

Jessica Miller, MD, resident Penn Medicine Lancaster General Hospital

Rachel A. Morales Fan, MD

Penn Medicine Lancaster General Health Physicians Family Medicine Twin Rose

Jeffrey T. Trost, MD

Penn Medicine Lancaster General Health Physicians Family Medicine Buck

 Hypertension & Kidney Specialists

 Lancaster Arthritis & Rheumatology Care

 Lancaster Cancer Center Ltd.

 Lancaster Ear Nose and Throat

 Lancaster Family Allergy

 Lancaster Radiology Associates Ltd.

 Lancaster Skin Center PC

 Manning Rommel & Thode Associates

 Nemours duPont Pediatrics Lancaster

 Neurology & Stroke Associates PC

 Patient First – Lancaster

Penn Medicine

Lancaster General Health Care Connections

Penn Medicine

Lancaster General Health

Physicians Diabetes & Endocrinology

Penn Medicine Lancaster General Health

Physicians Family Medicine Lincoln

Penn Medicine

Lancaster General Health

Physicians Family Medicine New Holland

reinstatements

Brian T. Brislin, MD

Penn Medicine Lancaster General Health Physicians Orthopaedics

Emily Elizabeth Brown, MD

Penn Medicine Lancaster General Health Physicians Comprehensive Care

Mark F. Cohen, DO Lancaster Family Health

Lori Cory, MD

Penn Medicine Lancaster General Health Physicians Gynecologic Oncology

Robert A. Faizon, MD

Penn Medicine Lancaster General Health Physicians OB/GYN

Alina Ivashchuk, DO CHOP at Women & Babies Hospital

Mark Jarowenko, MD

David Johnson, MD

Penn Medicine Lancaster General Health Physicians Urgent Care

Charles J. Lancelotta, III, MD

Penn Medicine Lancaster General Health Physicians Anesthesiology

Jared A. Nissley, MD

Penn Medicine Lancaster General Health Physicians Family Medicine Downtown

Edward J. Skicki, II, DO

Penn Medicine Lancaster General Health Physicians Trauma & Acute Care Surgery

Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco

Penn Medicine Lancaster General Health Physicians Family Medicine Susquehanna

Pennsylvania Specialty Pathology

 Retina Associates of Lancaster

Surgical Specialists—UPMC

 Union Community Care – Duke Street

 Union Community Care – Hershey Avenue

 Union Community Care – Kinzer-Church Street

 Union Community Care – New Holland Avenue

 Union Community Care – Water Street

 UPMC Breast Health Associates

 UPMC Heart and Vascular Institute

 WellSpan Ephrata Cancer Center

 WellSpan Family Health – Georgetown

 WellSpan Surgical Specialists – Ephrata

LCCMS EVENTS 2024

Wednesday, June 26

The Inn at Leola Village Casa di Fiori

At UPMC, our team of dedicated spine providers and nurse navigators guide you to the right care. Working together, we diagnose your back and neck pain and customize treatment plans with you — including non-surgical treatment, rehabilitation, and pain management — all so you can get back to doing what you love. And, our experienced spine surgeons are here for you with the most advanced surgical techniques and innovative technologies.

To schedule an appointment, call 717-791-2630 or visit UPMC.com/SpineCareCPA. For expert neck and back care, choose UPMC.