NJ Physician Magazine August 2013

JULY 2013 2012 AUGUST Visit us now online at

www.NJPhysician.org

Jerry Bagel, MD of Windsor Dermatology Home of the Psoriasis Treatment Center of Central New Jersey Restoring Quality of Life for Psoriatic Patients Throughout NJ and Beyond Also In This Issue: Gov Christie Agrees to Ease Some Rules on Medical Marijuana For Kids, But Conditionally Vetoes Bill New Jersey Physicians Report Divergent Outlooks For Their Practices The Medical Malpractice Insurance Industry: Time For a Check-Up? New Jersey’s New Steroid Prescribing Regulations Provide Clarity-And a Warning-To Prescribers

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Publisher’s Letter Dear Readers, Welcome to the August issue of New Jersey Physician magazine, providing crucial information to the state’s medical community.

Published by

A study of physicians practicing in New Jersey was conducted by Brach Eichler recently. Entitled “New Jersey Physicians Report Divergent Outlooks For Their Practices, Many Considering Changes in Structure”, it reveals mounting financial pressures and confusion over ACAs and ACOs. Sixty two percent of the physicians surveyed stated the outlook concerning their medical practice was either favorable or neutral. Thirty eight percent held an unfavorable view. Nearly half of the physicians surveyed said they were considering changing their practice structure.

Montdor Medical Media, LLC

When is the last time you reviewed your medical malpractice coverage?

The market is changing with insurance companies realizing significant profits but simultaneously losing premium dollars. Is the market oversaturated? Brian Kern comments on the state of medical malpractice in New Jersey.

Carol Grelecki

New Jersey has issued new steroid prescribing regulations you should be aware of. Once best known for the illicit use of bodybuilders, the drugs are now gaining popularity as anti-aging treatments. New Jersey has taken strong action to provide clarity to legitimate steroid prescribers and a warning for any who might seek to prescribe these drugs without an adequate medical basis.

Robin Lally

Governor Christie has agreed to ease some rules on medical marijuana for kids, but has conditionally vetoed the bill until a provision of the measure is changed to his satisfaction. He wants the provision requiring referrals from a pediatrician registered in the program and a psychiatrist to remain, which the bill as originally presented removed, allowing only one physician’s approval to permit the patient to obtain medical marijuana.

Montdor Medical Media, LLC.,

Psoriasis is a physically discomforting disease which can also result in disability. Jerry Bagel, MD of Windsor Dermatology has devoted his professional life to the study and treatment of psoriasis with significant success. The Psoriasis Treatment Center of Central New Jersey and Dr. Bagel are recognized by the National Psoriasis Foundation as the nation’s leading recruiter of psoriasis patients. Dr. Bagel has been an investigator on more than 75 clinical trials in the past 25 years and has been appointed to four three-year terms as a member of the NPF Medical Advisory Board.

Additionally he contributes to several prominent peer review journals regarding the treatment of this difficult disease. Please come inside our pages and visit with this most dedicated physician.

Send Press Releases and all other information related to this publication to

With warm regards,

Michael Goldberg Co-Publisher

New Jersey Physician Magazine

Co-Publisher and Managing Editors Iris and Michael Goldberg

Contributing Writers Iris Goldberg Michael Goldberg John D. Fanburg

Keith J. Roberts Mark Manigan Dan Goldbergt Kelly Heyboer Susan K. Livio

Michael B. Zerres

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Contents

Jerry Bagel, MD of Windsor Dermatology Home of the Psoriasis Treatment Center of Central New Jersey

4 Restoring Quality of Life for Psoriatic Patients Throughout NJ and Beyond CONTENTS

9 11 12 14 16 18 20 22 27

2 New Jersey Physician

BRACH EICHLER MEDICAL MALPRACTICE STEROID PRESCRIBING HEALTH LAW UPDATE STATEHOUSE HOSPITAL ROUNDS RUTGERS LEGAL MATTERS FOOD FOR THOUGHT

Where does insurance fraud end in New Jersey?

NJInsuranceFraud.org

Cover Story

Jerry Bagel, MD of Windsor Dermatology Home of the Psoriasis Treatment Center of Central New Jersey

Restoring Quality of Life for Psoriatic Patients Throughout NJ and Beyond photography by Michael Goldberg

By Iris Goldberg To say that psoriasis is a challenge to treat is an understatement. An immunemediated disease that affects the skin, psoriasis is typically a lifelong condition.

The disorder is chronic, recurring and varies in severity from minor localized patches to complete body coverage.

Plaque psoriasis is the most common form, affecting 80 to 90 percent of all patients with psoriasis. In plaque psoriasis skin rapidly accumulates and typically appears as raised areas of inflamed skin covered with silvery white scales. These plaques frequently occur on the skin of the elbows and knees but can appear on any area including the scalp, palms of hands, soles of the feet and genitals.

Fig. 1

Dr. Bagel Serves As:

at Windsor Dermatology, has spent almost 25 years investigating promising treatments in a continuing mission to improve the quality of daily life for those who are afflicted with psoriasis. Honored by the National Psoriasis Foundation (NPF) as the nation’s leading recruiter of psoriasis patients, Dr. Bagel has been an investigator on more than 75 clinical trials to find innovative treatments for psoriasis and other skin conditions. Additionally, he has been appointed to four three-year terms as a member of the NPF Medical Advisory Board. Dr. Bagel is renowned as an expert on psoriasis, who contributes to several prominent peer review journals (see Fig. 1) and often speaks at dermatology conferences worldwide to share current developments.

To understand how Dr. Bagel came to choose improving psoriasis treatment as the centerpiece of his work within the field of dermatology, it is important to go back 30 years to the early 1980s, when he was a dermatology resident at Columbia University. The program required that he spend six months on an in-patient service following patients who needed hospitalization for up to a month in order to clear their psoriasis.

Associate Medical Editor of the Psoriasis Forum Medical Editor of Practical Dermatology Peer Review of: British Journal of Dermatology Journal of the American Academy of Dermatology

“They would be in tar baths for an hour or two a day, get moisturizing treatments every day and be exposed to increasing amounts of light because light decreases the proliferation of the epidermis. And so after about a month of this, they would go home, stay clear for eight or nine months and then would eventually have to come back to the hospital,” relates Dr. Bagel.

Psoriasis can be associated with significant physical discomfort of itching and pain as well as some disability. Approximately 25 percent of psoriatic patients develop inflammation in their joints, known as psoriatic arthritis. Psychological distress caused by feelings of self-consciousness and embarrassment may lead to significant depression and even selfimposed social isolation.

Fortunately for psoriatic patients in New Jersey and surrounding areas, Jerry Bagel, MD, who is the founder of and director of the Psoriasis Treatment Center of Central New Jersey (PTCCNJ)

4 New Jersey Physician

“For every FDA-approved drug for the treatment of psoriasis – ENBREL®, HUMIRA®, STELARA® – and those that came before, we have been involved,” Dr. Bagel strongly states. Dr. Bagel, who is no less than passionate about finding new and more effective treatments for psoriasis, shares that the involvement of PTCCNJ is ongoing. “We have more people in registries than anywhere in the country,” he reports, adding that the FDA requires patients who are enrolled in trials to be followed for at least five years. Furthermore, Dr. Bagel explains that PTCCNJ’s role in fighting the disease carries over to the creation and organization of support groups to help psoriatic patients cope with the many issues associated with their condition.

Dr. Bagel examines the elbow of a patient who is a candidate for an upcoming clinical trial.

When he began his own practice, Dr. Bagel located his office just a few miles from where he was raised because he knew there was not an adequate dermatology practice or psoriasis treatment facility in the area. He acquired the necessary

UVB is also an extremely effective treatment for appropriate patients and does not require light-sensitizing medication.

UVB phototherapy penetrates the skin and slows the growth of affected skin cells by exposing the skin to an artificial UVB light source for specific intervals of time on a regular schedule. Narrowband UVB maximizes efficacy and safety. At PTCCNJ both PUVA and narrowband UVB phototherapy, supervised by on-site photo-therapists, are used depending upon the individual needs of each patient.

Unfortunately, when Dr. Bagel first began treating psoriatic patients, the time required for effective treatment was significantly longer and many patients did not have enough time to devote to coming in on a daily basis. Also, most insurance companies were unwilling to cover the treatments.

Patient is receiving phototherapy. There are numerous lightboxes on-site at PTCCNJ. equipment to treat patients with moderate to severe psoriasis in his office in order to spare them a hospital stay.

“I wanted psoriasis treatment to be one of the mainstays of my practice. I brought in light boxes and we started doing psoriasis day care here in the office and back then people actually would stay for six hours a day, five days a week to get phototherapy, tar baths and moisturizing creams,” he recalls.

In 1982, Dr. Bagel did extensive research and published his findings on phototherapy, which involves exposing the skin to ultraviolet light on a regular basis under medical supervision.

Phototherapy has been and continues to be an integral part of psoriasis treatment, often inducing a remission of psoriasis symptoms. Ultraviolet light A (UVA) and ultraviolet light B (UVB) are found in sunlight. UVA is relatively ineffective unless used in combination with psoralen, a light-sensitizing medication.

This process, called PUVA, slows down excessive skin cell growth and can clear psoriasis symptoms for expansive periods of time. Severe plaque psoriasis and psoriasis of the palms and soles are most responsive to PUVA therapy.

In 1990 things changed significantly when Dr. Bagel had the opportunity to collaborate with Merck Pharmaceuticals researching cyclosporine, an antirejection medication originally used in the 1980s for those undergoing kidney transplant. It was found that in kidney transplant patients who also happened to have psoriasis, taking cyclosporine caused the psoriasis to clear.

target specific parts of the immune system by blocking the action of immune cells called T cells or by blocking proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha) or interleukins 12, 17 and 23. It is these cells and proteins that are majorly involved in the development of psoriasis and psoriatic arthritis.

Dr. Bagel is pleased to report that as a result of clinical trials with pharmaceutical companies over the years, there are now medications that can significantly improve the quality of life for psoriatic patients. For example, he points to STELARA® by Janssen Pharmaceuticals.

“With one injection every three months that’s only four times a year – 75 percent of psoriasis patients can walk around almost clear,” he happily states. “This is a real breakthrough compared to what was available ten years ago,” Dr. Bagel adds.

At PTCCNJ trials to investigate promising immunosuppressant medications are continuously ongoing to determine their effectiveness on manipulating the immune system. Dr. Bagel discusses the significant benefits derived by appropriate patients who participate in

“It was then they realized that psoriasis was an immunologic disease,” Dr. Bagel explains. “For some reason, in a genetically pre-disposed individual, the white blood cells are producing chemicals that make the epidermis grow too quickly,” he elaborates.

After first researching cyclosporine as a medication for psoriasis, in the early1990s, Dr. Bagel became involved in clinical trials researching other biologic agents that might hopefully diminish the immune system’s ability to produce the chemicals that speed up epidermis growth. Although these did not come to fruition, in 1997 he began clinical trials with a medication called AMEVIVE®. This was the first of the biologic agents to show real promise in treating psoriasis.

Biologics are protein-based drugs derived from living cells cultured in a laboratory. Used mostly for patients with moderate to severe psoriasis, Dr. Bagel explains that instead of impacting the entire immune system as is the case with traditional systemic drugs, biologics

Here a patient uses special light boxes designed to treat psoriasis of the palms of the hands and soles of the feet.

August 2013

5

The dramatic results that can be achieved with biologic agents is evident in before and after photos of a patient who has undergone treatment at the Psoriasis Treatment Center of Central New Jersey.

clinical trials. “In some cases, they get five years of medical care and medication for free. They don’t have to deal with their insurance companies to get drugs approved. They don’t have to deal with copays,” Dr. Bagel points out.

“Now we’re developing newer IL-17 (interleukin 17) drugs where we’ve seen people with a significant percent of their bodies covered with psoriasis become clear in a few weeks. So the scientific research and the impetus from pharmaceutical companies and clinical trial development for psoriasis over the last ten years have been phenomenal and the improvement in the quality of life has been significant,” relates Dr. Bagel.

For Dr. Bagel it’s all about bringing a better quality of life to those who suffer the physical and psychological trauma

of living with psoriasis. He offers a hypothetical scenario involving a young girl with psoriasis:

of suicidal ideation and in fact, there is an increased frequency of suicide,” he informs.

“Imagine being a 16 year old girl with psoriasis on your elbows and forehead on a beautiful summer day. You’re meeting your best friend at a public pool.

You both approach the water and you’re told you cannot go in because you might have something contagious. You cry and you go home. Now imagine how this affects your self-esteem and increases your depression,” Dr. Bagel asks.

In addition to the overwhelming psychological problems that detract from their quality of life, psoriatic patients suffer much physical discomfort. “Psoriasis is very itchy and patients lose sleep at night,” Dr. Bagel reports. There’s also pain and bleeding from the excessive scratching.

So there’s itching and pain and times when psoriatics have go to work tired from lack of sleep,” he states.

In fact, as Dr. Bagel states, psoriatics have a significantly higher incidence of depression compared to the normal population and use anti-anxiety medications with significantly more frequency. “So you have depression, which is severe, increased frequency

Dr. Bagel goes on to share the results of a Harvard study which he collaborated on, that was reported this month at the American Academy of Dermatology meeting, held in New York City. It revealed that when asked, the average psoriatic patient would agree to relinquish five years of his or her life to have normal skin.

Ironically, as Dr. Bagel further reports, the average psoriatic actually lives five years less than the normal lifespan because of underlying risk factors associated with psoriasis.

“It has been found out over the past six or seven years that psoriasis is not just a disease of the skin,” reveals Dr. Bagel.

“First of all, 25 percent of all people with psoriasis also have psoriatic arthritis. The same inflammation that appears on the skin is present within the joints. When left untreated, that destruction of the joints becomes irreversible,” he explains. Since the initial presentation of psoriasis usually precedes the development of psoriatic arthritis by ten years, Dr. Bagel emphasizes the importance of early diagnosis and intervention by the dermatologist.

Dr. Bagel uses an excimer laser to treat the elbow of a psoriatic patient.

6 New Jersey Physician

Besides the risk of developing psoriatic

arthritis, as Dr. Bagel discusses in great detail, recent studies have confirmed that young people with psoriasis have increased risk for developing a heart attack or stroke. This is primarily due to the fact that people with psoriasis tend to have a greater incidence of those conditions that put one at increased risk.

“People with psoriasis have an increased frequency of obesity, have an increased frequency of diabetes, have an increased frequency of metabolic syndrome and in addition, have an increased frequency of depression,” Dr. Bagel specifies.

“I think we have to look at psoriasis much like we look at diabetes. When an ophthalmologist looks at the retina of the eye and discovers vasculopathy, he or she tells the patient to see an endocrinologist to be evaluated for diabetes,” he states.

“When you, as a dermatologist, see a patient with psoriasis, you need to tell that person to consult with a cardiologist or at the very least, an internist to be evaluated for lipids and possible cardiovascular problems,” Dr. Bagel strongly advises.

On the brighter side, Dr. Bagel reports on some preliminary data which suggests that when psoriatics are treated with the newer biologic agents, especially TNF inhibitors, the incidence of heart attacks and strokes decreases. “Not only does the psoriasis go away but you’re decreasing the entire inflammatory load,” explains Dr. Bagel. “By decreasing the body’s inflammation, you’re decreasing the amount of psoriasis, you’re decreasing the amount of atherosclerosis in the blood vessels and you’re decreasing the incidence of heart attacks and stroke,” he reiterates.

Dr. Bagel makes a point of emphasizing that for patients with mild psoriasis affecting less than 10 percent of the body, going to a traditional dermatology office and receiving a prescription for a topical ointment is probably sufficient most of the time. However for those patients with moderate to severe cases of psoriasis, the resources of a dedicated psoriasis treatment center are crucial for the ability to provide the most optimal level of care in each case.

“If you’re not involved with all the bells and whistles of a psoriasis treatment center, it’s hard to make a go of psoriasis if you’re just writing prescriptions for biologic agents or topicals,” asserts Dr. Bagel. “You need to be doing other things like phototherapy

25% of people with psoriasis also have psoriatic arthritis as can be seen on the hand of this patient.

This patient is a participant in a clinical trial investigating one of the newer biologic agents. His psoriasis has cleared significantly after only a few weeks of treatment.

Dr. Bagel and the clinical trials team at PTCCNJ meet regularly to discuss each patient’s progress. and clinical trials in order to have that infrastructure which allows you to really provide optimal care to psoriatic patients,” he strongly believes.

Without the success of Windsor Dermatology, Dr. Bagel acknowledges that the Psoriasis Treatment Center of Central New Jersey would not have been able to thrive and evolve into the haven

for psoriatics that it is today. He built Windsor Dermatology on the foundation of providing the highest level of care for a myriad of medical skin conditions in addition to psoriasis, including skin cancer.

Today, Windsor Dermatology also offers the most innovative cosmetic and laser procedures. Here is an overview of the medical and cosmetic treatment services available: August 2013

7

MEDICAL DERMATOLOGY •

Annual skin cancer check-up

•

Eczema

•

Hair loss

•

Hives

•

Hyperhidrosis (excessive sweating)

•

Moles

•

Molluscum

•

Port wine stains

•

Rosacea

•

Skin allergy/contact dermatitis

•

Skin cancer/Mohs surgery

•

Skin tags

•

Sun-damaged skin

•

Warts

Besides Dr. Bagel, five board-certified dermatologists comprise Windsor Dermatology’s staff of expertly-trained physicians (see below). Most recently, Windsor Dermatology has added a licensed and accredited aesthetician to recommend personal skincare treatment customized for each patient’s needs.

The Physicians of Windsor Dermatology

Jerry Bagel, MD

Judit Stenn, MD

David Nieves, MD

Wendy Meyers, MD

Brian Keegan, MD, PhD

Theresa Zwada, Windsor Dermatology’s aesthetician, performs a facial treatment..

COSMETIC and LASER •

Botox and Juvederm for wrinkle correction

•

Skin rejuvenation lasers to treat skin laxity, blotchiness, sun spots, scars and superficial blood vessels

•

Hair removal laser to treat unwanted hair

•

Sclerotherapy to eliminate unsightly leg veins

•

Skin tag removal

8 New Jersey Physician

Dr. Bagel makes a point of mentioning the priority placed on making sure that patients treated at Windsor Dermatology have a positive experience. First and foremost, he cites the impressive qualifications of the physicians. “We really try to maintain a high level of expertise,” says Dr. Bagel. “We have smart people who went to excellent schools.”

Additionally, patient surveys are undertaken often to identify problems and correct them. “We’ve gotten to the point where we are very patient-friendly and service-oriented,” Dr. Bagel shares.

Matthew Halpern, MD

“It’s taken some time but this is something we have really tried to develop with no nonsense,” he emphasizes.

Certainly, for anyone within New Jersey or surrounding areas who is suffering with moderate to severe psoriasis, Dr. Bagel and the staff at the Psoriasis Treatment Center of Central New Jersey offer real hope for a dramatically improved quality of life. For other medical and/or cosmetic dermatology patients treated at Windsor Dermatology, the results will be no less exceptional. Dr. Bagel wouldn’t have it any other way.

Windsor Dermatology and the Psoriasis Treatment Center of Central New Jersey are located at 59 One Mile Road Ext, Suite G. For more information or to schedule an appointment, please call (609) 443-4500 or visit www.WindsorDermatology.com

Brach Eichler

NEW JERSEY PHYSICIANS REPORT DIVERGENT OUTLOOKS FOR THEIR PRACTICES, MANY CONSIDERING CHANGES IN STRUCTURE

Brach Eichler’s Annual New Jersey Health Care Monitor Reveals Mounting Financial Pressures, ACA and ACO Confusion When asked about their outlook concerning their medical practices in the coming year, New Jersey physicians appear to be evenly divided among favorable, unfavorable and neutral perspectives, according to Brach Eichler’s 2013 New Jersey Health Care Monitor.

Brach Eichler conducted the annual survey among nearly 150 physicians statewide, including solo practitioners, members of a group practice or employees of a health care facility, in July 2013.

The Brach Eichler survey revealed that: - More than 26% said their outlook concerning their medical practice was favorable; - Nearly 36% said they felt neutral, and - Nearly 38% held an unfavorable view.

In spite of their diverse outlook, nearly half (45.5%) of the physicians surveyed said they were considering changing their practice structure this year. Specifically, half of all those respondents said they plan to integrate with another health care organization such as another single specialty or multispecialty practice, an individual practice association, a hospital system or a joint venture.

Further: - Another 35.9% said they plan to hire other practitioners; - 18.8% said they will contract with a health care facility this year; - 15.6% plan to leave their practice to practice in another state; - 12.5% said they were leaving their practice to join another practice, and - 12.5% said they plan to retire.

These findings are consistent with Brach Eichler’s 2012 New Jersey Health Care Monitor which showed that 44.6% of New Jersey physicians were considering changing their practice structure in 2012.

“The health care environment is a dynamic one in New Jersey, characterized by tremendous competition and an increasingly complex regulatory environment,” said John D. Fanburg, managing member and head of the health care practice at Brach Eichler.

“For example, those respondents whose outlook was negative about their practice were quick to cite such reasons as increasing insurance premiums, declining reimbursements, increased competition and declining autonomy as among the most influential factors.

“In fact, more than 63% of respondents confirmed that their reimbursement rates decreased from last year. This has put a great deal of financial pressure on New Jersey physicians who cited the need to reduce expenses, increase cash flow, reduce operational efficiencies, bolster market share and compete more effectively with other organizations that are integrating with partners as reasons for changing their practice structure,” Fanburg explained.

ACA and ACO Confusion Among those who held an unfavorable outlook of their practice, many cited the Affordable Care Act (“ACA”) as a reason. Further, nearly 62% said that the 2012 election negatively impacted their outlook for their medical practice and more than 53% said that the mandate to purchase health insurance under ACA will actually hurt their medical practice.

According to Joseph Gorrell, a health care partner at Brach Eichler, “There is still quite a bit of misinformation and confusion circulating about ‘Obamacare’ among physicians. For instance, many assume that their patient loads will increase while their reimbursements will continue to decrease. It’s clear that more education is needed about the Act’s implications.”

According to Fanburg, under ACA, reimbursement will actually not decrease, but how physicians seek reimbursement will certainly change. “The system under ACA is geared to promote efficiency and quality; we expect that those physicians that run their practice efficiently and with a focus on quality will do well in this regard.”

The survey also revealed that a relatively small number of physicians (24.1%) have joined an Accountable Care Organization (ACO), and of those that have joined, the vast majority (95.2%) says they have not seen any benefits as a result.

“The truth is, we simply do not know yet whether there are any meaningful benefits associated with joining an ACO or whether we simply have not seen them yet,” explained Fanburg. ACOs are groups of health care providers and hospitals who come together voluntarily to deliver high-quality medical care to Medicare patients, reduce duplication of services, and spend health care dollars more efficiently.

August 2013

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“The New Jersey Health Care Monitor underscores the delicate balance that can be associated with practicing medicine here. While growing their practices and the desire to provide superior patient care are certainly top-of-mind goals for New Jersey physicians, the growing body of both state and federal regulations, coupled with the financial pressures associated with the practice of medicine today, are having a dramatic impact on the healthcare landscape.

“When ‘Obamacare’ finally kicks in in October, then New Jersey’s physicians will be in a better position to make decisions about the strategic direction of their practice.” Fanburg said.

The survey results can be found online at http://www.bracheichler.com/?p=5539.

About Brach Eichler LLC Brach Eichler LLC is a full-service law firm based in Roseland, N.J. With nearly 60 attorneys, the firm is focused in the following practice areas: health care; real estate; litigation; tax, trusts and estates; and business & finance. Brach Eichler attorneys have been recognized by clients and peers alike in Best Lawyers in America, Chambers USA and New Jersey Super Lawyers. Visit www.bracheichler.com.

Brach Eichler’s health care practice offers an array of services to clients across the health care field in such areas as physician and hospital contracts; corporate governance and compliance; health care mergers and acquisitions, administrative and judicial litigation; and state and federal regulatory advice. Clients reflect a cross-section of the health care industry, including large physician groups, individual practitioners, hospitals and hospital systems, medical staff organizations, physician specialty societies, health care trade associations, from long-term care facilities, home health agencies, and patients and providers seeking insurance coverage and proper reimbursement. The Chambers USA Guide to America's Leading Lawyers for Business included Brach Eichler as having among the five leading health care law practices in New Jersey.

Visit us now online at

10 New Jersey Physician

www.NJPhysician.org

Medical Malpractice

The Medical Malpractice Insurance Industry:

Time for a Check-Up?

The medical malpractice insurance marketplace is experiencing an unprecedented phenomenon: many carriers have realized significant profits over the past few years, but have simultaneously lost substantial premium dollars. Negative growth is rarely associated with increased profits – even in the insurance industry. The medical malpractice insurance sector though, concerned with its very survival, drastically increased rates shortly after the turn of the century. This high pricing led to high profits, which may now be masking the effects of an oversaturated industry.

The Profits When a perfect storm hit the medical malpractice insurance market, companies took several steps to try to weather it. In addition to increasing premiums, coverage was tightened up, and insurance limits were reduced (as an example, some physicians had to pay more for $1 million in coverage than they previously paid for $6 million).

Physicians facing stiff premium hikes took the fight to their respective legislatures, often achieving at least some level of tort reform.

New laws were created to add stricter requirements on using expert witnesses and more road blocks to bringing lawsuits. A common result was that the cost of filing medical malpractice lawsuits increased.

With the cost of litigation rising, and the return (insurance limits) for plaintiffs falling, a significant decline in claim frequency occurred.

High premium and low claim frequency translated into significant profits for the industry.

The Old Market Before price increases or tort reform, the market experienced heavy company casualties, causing a serious supply shortage. The lack of solid commercial carriers led a number of physicians to look towards the alternative risk market for new solutions, and some decided to form captives or buy into start-up companies or risk retention groups. Though a risky move, the drop in claim frequency has handsomely rewarded some of the risk takers.

The New Market News of the highly profitable med mal sector traveled quickly, and supply now exceeds demand. Prices have thus been dropping precipitously, and the newfound competition is putting heavy pressure on carriers. Healthcare consolidation has increased this pressure, as many physicians are joining large provider groups or systems that have only one insurance policy.

A look at three NJ carriers created in 2002 or 2003 helps illustrate the point. In 2007, the written premiums for these three carriers totaled $123,954,182; in 2012, the written premiums totaled $88,577,780 – a decline of nearly29%. For many businesses, this loss in “sales” would be devastating – and may be a red herring for things to come.

For now, many carriers can absorb the loss in premium dollars because of the profits they are still realizing from overpricing past policies. Since anticipated claims are not coming in, the money set aside to pay for such claims can be taken out of reserves and booked as profit. Carriers cannot live off of reserve “redundancies” forever though, so they must develop a viable long-term strategy.

M&A Activity Healthcare consolidation seemingly lends itself well to a medical malpractice insurance market consolidation, and merger and acquisition activity has picked up. The structure of insurance companies can vary significantly from one to another though, which may slow - or prevent - this logical evolution.

The success of the new healthcare delivery system and its new payment models will play a considerable role in the future of its professional liability insurance system. While some companies strategize about becoming financially strong players in the future, physicians should strategize about finding one now.

Brian S. Kern, Esq., is Co-Chair of the Professional Liability Division for Bollinger Insurance Solutions, one of the largest professional liability divisions in the nation. He can be reached at brian.kern@bollinger.com August 2013

11

Steroid Prescribing

New Jersey’s New Steroid Prescribing Regulations Provide Clarity – and a Warning – To Prescribers Eric T. Kanefsky Director, New Jersey Division of Consumer Affairs

Once best known for their illicit use in bodybuilding, not to mention their harmful side effects, testosterone and other steroids now are gaining popularity as purported anti-aging treatments.

Television ads, magazine articles and websites, mostly if not entirely paid for by drug manufacturers, are successfully promoting the awareness of “Low T” (low testosterone level, or hypogonadism) and blaming it for many common symptoms of middle and advancing age, such as decreased energy, muscle mass, or libido. Testosterone is promoted as treatment for Low T, although the symptoms may have other causes and less intrusive treatments.

This new public perception of testosterone corresponds with a dramatic, nationwide increase in testosterone prescribing. And this, in turn, raises new concerns about whether prescribers are truly weighing the known risks and benefits associated with steroid treatment, and whether they are making those factors known to their patients.

Fortunately, while this debate continues nationwide, New Jersey has taken strong action to provide clarity to legitimate steroid prescribers – and a warning for any who might seek to prescribe these drugs without adequate medical basis. The State Board of Medical Examiners in February 2013 revised and expanded its regulation for “Prescribing, Administering, or Dispensing Anabolic Steroids and Human Growth Hormone,” found at N.J.A.C. 13:35-7.9.

While the previous version of this regulation simply and clearly prohibited the prescribing of steroids to increase muscle mass in the absence of a true medical need, the new regulation expands the requirements for prescribing these potentially dangerous drugs. The Office of the Attorney General led the effort to develop New Jersey’s new regulation, in response to media reports about “a growing industry of doctors who will prescribe steroids and HGH (human growth hormone) based on bogus diagnoses,” according to October 2012 rule proposal for the new regulation, published in the New Jersey Register.

The new regulation explicitly states that a practitioner shall only prescribe an anabolic steroid or human growth hormone when there is a bona fide relationship with the patient, and when the physician has obtained the patient’s medical history, performed a full physical examination, and established a valid medical indication and necessity for such drugs.

The regulation also goes a step further, by codifying three specific categories of steroid prescribing.

The first category includes those areas in which it is clearly permissible to prescribe steroids or human growth hormone, thanks to the established findings of clinical trials and medical research. This category includes, for example, cases in which there is a documented diagnosis of adult hormonal deficiency due to muscle wasting disease associated with HIV/AIDS. The second category includes cases in which steroid prescribing is strictly forbidden, such as when desired by persons in good health, who wish to use steroids to improve their performance in sports.

The third category includes cases in which steroid prescribing may be permitted, so long as the physician takes very specific steps to ensure patients are informed of the risks and benefits of long-term and short-term steroid treatment, as well as its less-intrusive alternatives, and obtains patients’ documented consent. The doctor also must obtain and maintain documentation of the appropriate clinical data and lab tests undertaken prior to the start of steroid treatment that support its medical indication and necessity. He or she must also provide and maintain documentation of proper follow-up at appropriate intervals during the course of treatment, and must adhere to monitoring protocols consistent with professional standards.

Cases for which steroid prescribing may be permitted under such conditions, include diagnoses of congenital or acquired hypogonadism; a record of treatment of delayed puberty in males; a female patient’s documented need for palliative treatment of breast cancer; anemia accompanying renal failure, where such may be helped by steroid therapy; and others.

New Jersey’s new steroid prescribing regulation is a commonsense approach, focused on protecting the well-being of patients and the public. It ensures that when doctors licensed in our State prescribe steroids, they will do so based on a documented medical necessity and while appropriately monitoring the patient’s health and the patient’s response to treatment.

The effort to create this rule began when the State Board of Medical Examiners, acting on a recommendation by the New Jersey Attorney General’s Steroids Study Group, convened a panel of medical experts to review existing rules governing the use of these drugs. The panel consisted of eight physicians with expertise including endocrinology, integrative medicine, obstetrics and gynecology, sports medicine, internal medicine and pulmonary disease. Based on their recommendation, the new regulation will remain relevant and applicable even as chemical science evolves and emerging molecular structures result in new products.

The Board enforces this regulation with the support of the Office of the Attorney General, the Division of Consumer Affairs and its Enforcement Bureau. These efforts are enhanced by the New Jersey Prescription Monitoring Program which tracks the prescription sale of controlled dangerous substances (CDS) including anabolic steroids such as testosterone, and of human growth hormone (HGH).

Nationwide prescribing trends make it clear that we established this regulation in New Jersey not a moment too soon. In June 2013, JAMA Internal Medicine published the results of the largest study to date of testosterone prescribing patterns, involving nearly 11 million men who were tracked through a major health insurer. The study found that the number of older and middle-aged men who received steroid prescriptions has tripled since 2011, with men in their 40s representing the fastest-growing group of users.

Disturbingly, the report found that a quarter of men did not have their testosterone levels tested during the 12 months before receiving the steroid. Of those men who were tested, it is unclear what proportion actually had results showing a hormone deficiency.

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Meanwhile, a recent Bloomberg News report cited a forecast that sales of testosterone replacement drugs are expected to triple to $5 billion by 2017.

Here in New Jersey, the State Board of Medical Examiners has had to take recent disciplinary action against doctors, due to allegations and concerns related to their prescribing of testosterone.

Among the most egregious allegations are those in the case of Dr. Roger Lallemand Jr., an Old Bridge physician whose license the Board revoked in January 2013. The Attorney General’s complaint, citing federal and state investigations, alleged among other things, that Lallemand prescribed testosterone while failing to consider less risky treatments, prescribed excessively high doses, failed to monitor patients’ reactions to treatment, and that his records failed to reflect he adequately informed patients of the serious risks of testosterone treatment. Meanwhile, the State alleged that some patients’ testosterone levels flew off the charts, dangerously exceeding the acceptable upper limits by as much as 79 percent for a male patient and 570 percent for a female patient.

Less egregious examples include the Board’s February 2013 reprimand of a doctor who is the co-founder and medical director of a self-described health and wellness center in Bergen County. The center advertises “anti-aging” therapies including hormone treatments.

The facility’s medical director was found to have hired a medical school graduate – not a licensed physician – to participate in patient care and treatment. The Board also found that the medical director failed to adequately ensure proper patient treatment involving the prescribing of hormones including steroids. The Board allowed this physician to continue practicing medicine and directing the health and wellness center, so long as he complies with its order of reprimand. The Board required that he complete an ethics course and a course on identifying and addressing basic issues in blood analyses and physical examinations. He also was ordered to pay the State $40,000 in civil penalties and costs.

The purpose of New Jersey’s new steroid regulation, and these enforcement actions, is not to put a chill on lawful medical practice in our state. Doctors are entrusted with the authority and professional judgment to prescribe as they see fit. The point is to ensure that, when doctors prescribe these high-risk and increasingly popular drugs, they stand firmly on the foundation of their own medical training and ethics.

They must tailor the treatment to the patient’s actual medical well-being and established need. They must fully inform the patient of the risks and benefits of short- and long-term treatment, and about other methods that may be available. They must fully assess the patient’s health and the appropriateness of treatment, before the treatment begins and regularly throughout the course of treatment. And they must do all of this consistent with professional standards.

None of these requirements is truly new. They are explicitly detailed in our steroid prescribing regulation in order to provide abundant guidance and a clear reminder about each licensed doctor’s primary responsibilities to protect the health and welfare of the public while prescribing these potentially dangerous drugs.

Eric T. Kanefsky, esq. is the Director of the New Jersey Division of Consumer Affairs, within the Office of the State Attorney General. Director Kanefsky is responsible for managing and overseeing the Division's Office of Consumer Protection, Bureau of Securities, Office of Weights and Measures, and 47 State professional licensing boards including the State Board of Medical Examiners, which licenses and regulates more than 38,000 active medical practitioners in New Jersey.

Friendly, Compassionate Staff to Serve the Urban Patient The Smith Center for Infectious Diseases and Urban Health was developed to address infectious diseases in the inner city.

This non-profit center, which is initially focusing on HIV, recognizes that inner city patients face many unique challenges in their daily lives. These challenges interfere with treatment of infectious diseases and foster an environment where infectious diseases are easily spread.

When you treat a person with HIV, you greatly reduce the chances of transmission and treat the whole community. In the past 10 years there have been incredible advances in HIV treatment. We at the Smith Center believe that by using novel approaches we can rid New Jersey of HIV. We have designed programs to incentivize patients to continue their medications. We have created a personal atmosphere, where each patient is known by her or his first name. We work with our patients to ensure that we are providing the best service possible.

Dr. Stephen Smith - named a Top Doctor of New Jersey by Castle Connolly 310 Central Avenue, Suite # 307 • East Orange, NJ 07018 Phone: 973-809-4450 Fax: 973-395-4120 • www.smithcenternj.org

August 2013

13

HEALTH LAW Update Health Law Update

GAO Calls for Action to Address Higher Use of Pathology Services by Self-Referring Providers The Government Accountability Office (GAO) recently reported the findings from a study of Medicare reimbursement expenditures in connection with anatomic pathology services, in a report titled Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer (GAO-13-445). The report covers expenditures for the years 2004 through 2010, and distinguishes between self-referred and non-self-referred pathology services.

The GAO concluded that from 2004 through 2010, expenditures for self-referred anatomic pathology services increased by approximately 164%, whereas non-self-referred expenditures for the same services increased by approximately 57% during the same time period. Stated in terms of dollar amounts, self-referred anatomic pathology services grew from $75 million in 2004 to $199 million in 2010, while non-self-referred services grew from $473 million to $741 million in the same years. The GAO went so far as to state that CMS does not have policies in place to address the impact of self-referral on utilization of and expenditures for anatomic pathology services. The report also identified the three specialties in which most providers that self-refer for pathology services practice: dermatology, gastroenterology and urology. The GAO suggested that CMS amend its reimbursement forms and policies to reduce financial incentives for providers to self-refer for anatomic pathology services.

For more information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com

Medicare Proposes Revisions to Clinical Laboratory Fee Schedule The Centers for Medicare & Medicaid Services (CMS) published proposed changes to the Clinical Laboratory Fee Schedule (CLFS)to address the rapid technological changes in clinical diagnostic labs.

Since 1984, Medicare has paid for most clinical diagnostic laboratory services based on the CLFS. The CLFS methodology sets payment rates at the lesser of (1) the amount charged for the test, (2) the fee schedule amount for the state or local geographic area in which the service was performed, or (3) the national limitation amount, which is either 74% or 100% of the national median fee schedule, depending on the test.

With the exception of inflation adjustments, payment rates set under the CLFS do not change. As a result, payments are unable to be adjusted based on changes to the cost of the test.

CMS is now proposing a process that would allow for the systematic examination of payment amounts to identify those codes that have undergone “technological changes� affecting the price of the test. CMS notes that advances in equipment and testing techniques, and the proliferation of advanced information technology, have made testing more efficient and automated. Accordingly, CMS expects that most payment amounts will decrease.

Under the proposal, CMS would review all CLFS codes over a five-year period, reviewing a portion of the total codes each year and making appropriate adjustments. After the initial review of the codes, CMS will allow the public to nominate codes for review as long as the codes have been on CLFS for at least five years.

The American Clinical Laboratory Association has raised concerns about the proposed changes, which will likely decrease payment amounts. Specifically, payments for pathology codes performed by independent laboratories would be severely reduced.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com

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Pending Bills May Impact NJ Health Care Providers A4302, an act concerning clinical laboratories and amending and supplementing P.L.1975, c.166., was introduced to the Assembly on June 27, 2013, and referred to the Assembly Health and Senior Services Committee. This bill would require a licensed clinical laboratory that is providing services for an accountable care organization (ACO) to establish a clinical laboratory testing advisory board. The board would be tasked with making recommendations to the ACO. A4307, an Act concerning the privacy of certain health information and supplementing Title 2C of the New Jersey Statutes, was introduced to the Assembly on June 27, 2013, and referred to Assembly Health and Senior Services Committee. The bill, if passed into law, would provide that a person who knowingly obtains or discloses personally identifiable health information, as defined in 45 CFR § 160.103, in violation of the federal health privacy rule (HIPAA), as set forth at 45 CFR Parts 160 and 164, is guilty of a crime of the third degree (which is punishable by imprisonment for a term of three to five years or a fine of up to $15,000, or both).

A4324, an Act requiring certain health care facilities to be equipped with generators, supplementing Title 26 of the Revised Statutes, and amending P.L.1974, c.80., was introduced to the Assembly on June 27, 2013, and referred to the Assembly Homeland Security and State Preparedness Committee. This bill requires that certain health care facilities be generator-ready while allowing health care facilities to qualify for certain loans for the cost of generators.

S2291 (identical to A3546), an Act concerning health insurance coverage for students at institutions of higher education and amending P.L.1991, c.187., was signed into law as P.L. 2013, c78 on July 5, 2013. Initially eliminating the requirement that full-time students at community colleges maintain health insurance coverage, this bill was revised before passage in response to a conditional veto by Governor Christie, and now removes the requirement for all full-time students at any institution of higher education in New Jersey.

S2461 (identical to A4345), an Act concerning physical examinations of children and supplementing Title 26 of the Revised Statute, passed the Senate on June 27, 2013 and was thereafter received in the Assembly. As amended, this bill would require that an annual medical examination of any child under the age of 19 include questions contained in the “Preparticipation Physical Evaluation� form developed to screen students seeking to participate in school sponsored athletics.

For more information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com

August 2013

15

NEW JERSEY Statehouse

STATEHOUSE

Christie agrees to ease some rules on medical marijuana for kids, but conditionally vetoes bill

TRENTON — Gov. Chris Christie agreed today to make it easier for severely ill children to participate in the medical marijuana program, but said he would not go along with one provision of the measure and sent it back to the state Legislature.

The bill was inspired by the plight of 2-year-old Vivian Wilson, who has been diagnosed with a potentially lethal form of epilepsy known as Dravet syndrome, for which a rare strain of marijuana in Colorado has helped reduce symptoms for in several dozen other sick children.

In giving lawmakers much of what they wanted, Christie agreed to provisions allowing marijuana cultivators to produce more than three strains of the drug, and to sell edible products that children would be able to consume.

But he let stand a provision that requires referrals from a pediatrician registered in the program as well as from a psychiatrist; if the child's pediatrician is not registered, then a third doctor's approval is required.

“I believe that parents, and not government regulators, are best suited to decide how to care for their children,” Christie in his conditional veto of the bill. “Protection of our children remains my utmost concern, and my heart goes out to those children and their families who are suffering with serious illnesses."

The statement went on: "Today, I am making commonsense recommendations to this legislation to ensure sick children receive the treatment their parents prefer, while maintaining appropriate safeguards. I am calling on the Legislature to reconvene quickly and address these issues so that children in need can get the treatment they need.”

But Christie said he disagreed with limiting the number of doctors involved, noting that "the need for children to benefit from additional specialized review must be maintained."

Brian Wilson of Scotch Plains, Vivian's father, said he and his wife Meghan were "confident the Legislature will resolve the conflict and hope that the Department of Health implements these changes swiftly and with good faith of the intent of the law."

"However," Wilson added, "we are disappointed that the governor decided to make it so difficult for parents, who are already enduring tremendous pain and heartache, to get approval for such a safe and simple medication. We think that the next course of action is for the legislation to draft a bill to require a three doctors to sign off for pediatric prescriptions of opiates, barbiturates, benzodiazepines, steroids and methamphetamines, which are all liberally prescribed with little oversight or doctor-to-parent education."

Christie, who frequently criticizes the medical marijuana law he inherited from Gov. Jon Corzine 3-1/2 years ago, initially said he was not comfortable allowing children to consume the drug without more evidence it won't cause harm. He said he also feared any easing of the rules that would enable people to abuse the drug for recreational purposes.

The Wilsons organized a letter-writing campaign that drew 2,200 responses urging the governor to sign the bill, (S2842). Other families came forward whose children also suffer from seizure disorders to demand that he support the measure.

Meghan Wilson said that even if the governor signs the bill, she predicted it would take another year before the kind of medicine Vivian needs will be available. For now, only one dispensary, in Montclair, is open, and it does not sell the strain of marijuana Vivian needs with the precise amount of cannabidiol, or CBD, content that is low in THC (tetrahydrocannabinol).

The bill now goes back to the Legislature. The Senate has a voting session scheduled for Monday, but it is not known if it will take up the measure.

State Sen. Nicholas Scutari and state Assemblywoman Linda Stender (both D-Union), said they were disappointed the governor did not support the entire bill and did not know how they would proceed. In order for the bill to become law, it must go back to the legislature to approve Christie's changes.

“Our number one priority is to provide relief from suffering for children like Vivian so we will take a close look at the governor’s proposed changes to see if we can work with them to still accomplish that goal," Stender said.

“It’s unfortunate that these families were forced to wait nearly two months while this legislation languished on the governor’s desk and now he is prolonging their suffering by telling them they must wait even longer," Stender added.

Keeping the multiple doctor requirement "continues to present a significant hurdle for families to get relief," Scutari said. "I want to consult with the family who is most affected and the sponsors. But I am pleased (he approved) the other two aspects."

Obamacare dollars: N.J. to receive more than $2 million from feds to help enroll residents

By Dan GoldbergThe Star-Ledger Five New Jersey organizations will share more than $2 million in federal funding to help with enrollment in insurance exchanges under the new health care law, the U.S. government announced today.Star-Ledger file photo Five New Jersey organizations will share about $2 million of federal money to help with enrollment in insurance exchanges under the new health care law, the U.S. government said today.

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Health and Human Services Secretary Kathleen Sebelius said a total of $67 million in Obamacare funding was awarded 105 "Navigators" across the country.

Navigators are supposed to help uninsured individuals sign up for the health care exchanges when enrollment begins Oct. 1. They are available to walk people through the process of picking and applying for a plan as well as explaining the law's new rules and mandates, and where residents can apply for Medicaid and the Children’s Health Insurance Program.

In New Jersey, four companies — Aetna, AmeriHealth, Horizon and Health Republic Insurance of New Jersey — have applied to sell health insurance on the exchange.

“Navigators will be among the many resources available to help consumers understand their coverage options in the Marketplace,” Sebelius said.

“A network of volunteers on the ground in every state – health care providers, business leaders, faith leaders, community groups, advocates, and local elected officials – can help spread the word and encourage their neighbors to get enrolled.”

This money is an addition to the $3.4 million 20 New Jersey health centers were awarded in July. That money is meant to hire 69 employees who will also help state residents navigate the new exchanges, a cornerstone of the Affordable Care Act. "Today's announcement is another step forward in implementing the Affordable Care Act and ensuring that New Jerseyans will be able to access high quality, affordable health coverage in the marketplace starting in October," U.S. Sen. Robert Menendez (D-N.J.) said. "These five organizations will help provide individuals and families throughout our state with unbiased, clear information – not only about the marketplace plans, but also their Medicaid and CHIP options."

The Navigators awarded grants in New Jersey are: • Center For Family Services Inc.: $677,797 The nonprofit human services agency will cover seven southern counties — Camden, Burlington, Gloucester, Salem, Atlantic, Cape May and Cumberland.

• The Urban League of Hudson County: $565,000 ULHC will partner with the Urban League for Bergen County, the Urban League of Morris County and the Urban League Union County to assist consumers in enrolling in the Marketplace.

• Public Health Solutions: $400,583 Public Health Solutions is based in New York City but plans to partner with community-based organization in New Jersey to reach Hudson and Essex Counties.

• FoodBank of Monmouth and Ocean Counties Inc.: $137,217 The FoodBank intends to reach out to the uninsured who visit their pantries.

• Orange ACA Navigator Project: $239,810

Task force recommends heavy smokers be screened for lung cancer even before symptoms arise

By Dan Goldberg The Star-Ledger A little-known panel has offered a recommendation that could save tens of thousands of lives every year, doctors say.

The U.S. Preventive Services Task Force is urging heavy smokers to receive an annual CT scan, regardless of any prior symptoms.

The proposal is critical because Medicare and private insurers typically cover procedures recommended by the task force. And under the Affordable Care Act, preventative screenings like this are covered without co-pays.

Previously, the screening could cost as much as $300, said Jean-Philippe Bocage, a thoracic surgeon at Somerset Medical Center.

That meant many patients went without these screenings, which can detect lung cancer in its infancy.

"It's a big problem," Bocage said. "Lung cancer, by the time it's discovered is usually an advanced disease. If it is small when it is found, you have a chance of being cured. It's cure versus control."

Lung cancer is the third most common cancer and the leading cause of cancer death in the United States. The most important risk factor for lung cancer is smoking, which results in approximately 85% of all lung cancer cases in this country.

These screenings would result in a 14 percent reduction in lung cancer deaths, the task force report said.

This draft Recommendation Statement is available for comment through Aug. 26. After the comment period, the task force will make its final recommendation.

The test is for heavy smokers — those over 55 who have smoked a pack a day for 30 years, or those with a family history of lung cancer.

"By the time lung cancer becomes symptomatic, the cat is out of the bag," Bocage said. "If you pick it up at Stage One your chances of being alive in five years are 85 to 90 percent; if it's Stage 4, your chance of being alive in five years is zero."

Visit us now online at www.NJPhysician.org August 2013

17

Hospital Rounds

HOSPITAL

ROUNDS Rutgers University President Robert L. Barchi and 164 Other University Leaders Call on Congress and President Obama to Close Innovation Deficit

University community launches national effort to urge Washington to restore investments in research and education that ensure America’s role as Innovation leader, power the economy, create jobs NEW BRUNSWICK, N.J. – Deeply concerned about major federal budget cuts to research and higher education at a time when other nations are steadily increasing investments in those areas, Rutgers University President Robert L. Barchi today joined 164 other university presidents and chancellors in calling on leaders in Washington to close what they call the “innovation deficit.”

In an open letter to President Obama and Congress published as an advertisement today in the influential Washington, D.C. publication, Politico,Barchi and his fellow university leaders wrote that closing the innovation deficit – the widening gap between needed and actual investments in research and education – must be a national imperative. The higher education leaders noted that investments in those areas lead to the types of innovation and new technologies that power the nation’s economy, create jobs, and reduce the budget deficit while ensuring the U.S. maintains its role as global leader.

“Throughout our history, this nation has kept the promise of a better tomorrow to each generation,” Barchi and his colleagues wrote.

“This has been possible because of our economic prosperity based in large part on America’s role as global innovation leader. Failing to deal with the innovation deficit will pass to future generations the burdens of lost leadership in innovation, economic decline, and limited job opportunities. We call upon you to reject unsound budget cuts and recommit to strong and sustained investments in research and education. Only then can we ensure that our nation’s promise of a better tomorrow endures.”

Economists agree that more than half of U.S. economic growth since World War II is a consequence of technological innovation, much of which results from federally-funded scientific research conducted at U.S. universities. Such groundbreaking research, the university leaders noted, has led to life-saving vaccines, lasers, MRI, touchscreens, GPS, the Internet, and many other advances that have improved lives and generated entire new sectors of our economy.

The university leaders pointed out that over the past two decades, China, Singapore, and South Korea have dramatically increased their investments in research and higher education, having seen the enormous benefits such investments have had for the U.S. economy. The rate of growth of U.S. research and development investments has been outstripped by those of China, Singapore, and South Korea by two to four times during that period.

The university leaders’ initiative comes as Congress faces critical budget decisions in the coming months. Annual funding bills, the debt limit, and measures to eliminate or modify the deep across-the-board spending cuts forced by sequestration could all be taken up this fall. While the legislative path for those measures remains unclear, the presidents and chancellors noted that targeted investments in research and higher education can and should be made regardless of overall funding levels because they would be key sources of long-term economic growth and fiscal stability.

“Because the innovation deficit undermines economic growth it harms our nation’s overall fiscal health, worsening long-term budget deficits and debt,” Barchi and his colleagues wrote. “Investments in research and education are not inconsistent with longterm deficit reduction; they are vital to it.”

The 165 universities represented in the letter are all members of the Association of American Universities and/or theAssociation of Public and Land-grant Universities. University of Anywhere is a member of both.

The open letter, including a list of all of its signers, can be seen here www.innovationdeficit.org..

Somerset Medical Center to merge with Robert Wood Johnson University Hospital

By Dan Goldberg The Star-Ledger SOMERVILLE —Somerset Medical Center announced today that it plans to merge with Robert Wood Johnson University Hospital in New Brunswick, continuing the state-wide trend of healthcare consolidation.

The move comes at a time when hospitals across the state are looking for strategic partners or buyers to help them manage the changing financial landscape.

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"As our nation’s healthcare system continues to evolve into one which ensures the health of entire populations rather than focus on delivering episodes of care, this new strategic partnership with Somerset Medical Center better enables us to care for the people of the region,” John Lumpkin, chairperson of the Robert Wood Johnson University Hospital Board of Directors, said in a press release.

The two hospitals have talked about a merger since the fall of 2011.

The merger will be subject to state and federal regulatory review.

Barnabas Health to consult in the management of University Hospital The Star-Ledger

By Kelly Heyboer and Dan Goldberg Barnabas Health has been contracted to advise the board of University Hospital, according to press releases from both institutions.

Barnabas is the state's largest not-for-profit health care system and has recently expanded its portfolio, striking a deal last month to take over Jersey City Medical Center in Hudson County.

University Hospital is currently affiliated with the University of Medicine and Dentistry of New Jersey but will become independent on July 1 because of the law merging UMDNJ with Rutgers and Rowan University.

Barnabas, in agreeing to provide consulting services for University, committed to keeping the hospital financially stable.

“We are very excited about the opportunity to assist University Hospital,” said Barry Ostrowsky, President and Chief Executive Officer of Barnabas Health. “Barnabas Health is committed to ensuring the long-term viability of University Hospital and in partnership with University Hospital to provide consulting services in a manner that best positions University Hospital to continue to meet the healthcare needs of the Greater Newark Community.”

The deal will now undergo a 60-day review process, which includes a review by the New Jersey Commissioner of Health.

Raritan Bay Medical Center is last N.J. hospital to ink deal with for-profit company

By Dan Goldberg and Susan K. Livio For-profit companies continue to advance on the New Jersey healthcare market, staking yet another claim to a struggling, nonprofit hospital.

Raritan Bay Medical Center announced yesterday that it had signed a letter of intent with Prospect Medical Holdings, a California company, which is making its first foray into New Jersey.

A letter of intent is just the beginning of the process and it would be months before a sale is complete, but the move highlights how hard it is becoming for stand-alone hospitals to survive a changing healthcare marketplace, and how attractive New Jersey is to for-profit companies.

The Affordable Care Act and changes in the Medicare and Medicaid reimbursement rates have created incentives for smaller hospitals to become part of larger health systems, Joseph Jankowski, chairman of Raritan Bay’s board of directors, said in a press release.

The law, also known as Obamacare, comes with a host of new mandates that can be expensive for a hospital to implement. Hospital systems have the advantage of scale and can better comply with the law.

Partnering with such an organization gives RBMC the resources it needs to continue to meet the obligation to the communities it serves, Jankowski said.

Prospect Medical is the latest for-profit company to show an interest in New Jersey.

In just the last year, Prime Healthcare, also based in California, has reached deals with St. Mary’s in Passaic, St. Michael’s in Newark and St. Clare’s Health System, which has three hospitals in western New Jersey.

Prime was also a bidder for Raritan Bay, according to two sources familiar with negotiations who asked not be identified because they were not authorized to speak about the deal. CarePoint Health, which already owns Hoboken Medical Center, Christ Hospital in Jersey City, and Bayonne Medical Center, is also looking to expand its holdings in the state and bid for St. Clare’s.

Should the deal go through, Prospect Medical which owns five hospitals in southern California and two in the San Antonio, Texas, area’s will have more than 500 beds between Raritan Bays campuses in Old Bridge and Perth Amboy.

Senate Majority Leader Loretta Weinberg (D-Bergen) reacted with surprise that yet another for-profit company is buying up New Jersey hospitals.

"What is it about New Jersey that issuing for-profit health care companies so comfortable?"

"This shows more than ever why we need the hospital transparency bill," Weinberg said, referring to legislation she sponsored and Gov. Chris Christie vetoed that would require for-profit hospitals to disclose the same financial information nonprofits must disclose publicly.

"The idea we are providing so much healthcare through private nonprofits without any oversight is absolutely wrong," she said.

August 2013

19

RUTGERS Rutgers

Rutgers Study: Worms May Shed Light on Human Ability to Handle Chronic Stress Scientists question why some suffer and others are better able to cope

By Robin Lally

Put worms under stressful conditions and they can survive almost anything, including the 2003 Space Shuttle Columbia disaster.

New research at Rutgers University may help shed light on how and why nervous system changes occur and what causes some people to suffer from life-threatening anxiety disorders while others are better able to cope.

Maureen Barr, a professor in the Department of Genetics, and a team of researchers, found that the architectural structure of the six sensory brain cells in the roundworm, responsible for receiving information, undergo major changes and become much more elaborate when the worm is put into a high stress environment.

Scientists have known for some time that changes in the tree-like dendrite structures that connect neurons in the human brain and enable our thought processes to work properly can occur under extreme stress, alter brain cell development and result in anxiety disorders like depression and Post Traumatic Stress Disorder affecting millions of Americans each year.

What scientists don’t understand for sure, Barr says, is the cause behind these molecular changes in the brain.

“This type of research provides us necessary clues that ultimately could lead to the development of drugs to help those suffering with severe anxiety disorders,” Barr says.

What is so interesting to Barr is that when a perceived threat is over, these tiny creatures and their IL2 neurons transform back to a normal lifespan and reproductive state like nothing had ever happened. Under a microscope, the complicated looking tree-like connectors that receive information are pruned back and the worm appears as it did before the trauma occurred.

This type of neural reaction differs in humans who can suffer from extreme anxiety months or even years after the traumatic event even though they are no longer in a threatening situation.

The ultimate goal, Barr says, is to determine how and why the nervous system responds to stress. By identifying molecular pathways that regulate neuronal remodeling, scientists may apply this knowledge to develop future therapeutics.

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What is so interesting to Barr is that when a perceived threat is over, these tiny creatures and their IL2 neurons transform back to a normal lifespan and reproductive state like nothing had ever happened. Under a microscope, the complicated looking tree-like connectors that receive information are pruned back and the worm appears as it did before the trauma occurred.

This type of neural reaction differs in humans who can suffer from extreme anxiety months or even years after the traumatic event even though they are no longer in a threatening situation.

The ultimate goal, Barr says, is to determine how and why the nervous system responds to stress. By identifying molecular pathways that regulate neuronal remodeling, scientists may apply this knowledge to develop future therapeutics.

Lifesaving Rapid Test for Tuberculosis Developed by Rutgers Researcher Approved by FDA Diagnostic tool replaces technology that is more than a century old A health scourge once considered to be largely contained in the United States has made an alarming resurgence in parts of the country. Recent tuberculosis outbreaks – including an episode in South Carolina that infected 53 children – have brought renewed attention to the need to remain vigilant against that potentially deadly disease.

To combat the public health threat both here and especially around the world, a Rutgers New Jersey Medical School immunologist has developed a test that can rapidly diagnose and classify the disease in a fraction of the time needed by previous technology.

Experts agree that a speedy diagnosis can both limit infections and save lives.

Rutgers Today talked to David Alland, director of the Center for Emerging Pathogens at Rutgers New Jersey Medical School, about his many years of work developing the test – called the Xpert MTB/RIF Assay – endorsed by the World Health Organization in 2010. The Food and Drug Administration approved the new diagnostic tool in late July for use in the U.S. David Alland calls his rapid TB test a "laboratory in a cartridge." photo credit: John Emerson Rutgers Today: How does the newly approved test advance the diagnosis of TB? Alland: The existing technology is a labor-intensive system that involves examining separate samples of saliva on a series of slides under a microscope, and results may not be available for a week or more. Using the system we developed and the FDA just approved results come back within two hours. In addition to being quick, our system detects TB more reliably, while also determining whether the strain of TB found in a patient is drug resistant, something the old technology could not do.

Rutgers Today: Why is it so important to know whether a case of TB is drug resistant?

Alland: If you have multi-drug resistant TB and you don’t get the appropriate treatment for it, your chances of dying are about 50 percent, and of course you remain contagious. Fortunately, there are now some drugs that appear to work pretty well for strains of tuberculosis that might have been considered totally drug resistant just a few years ago. But those treatments are both toxic and lengthy, and it takes a lot of courage for a patient to endure them. They only should be used in patients who clearly need them, so getting an accurate diagnosis is critical.

Rutgers Today: Now that the FDA has approved its use in the United States, how will the test change treatment for patients suspected of having TB? Alland: Up until now, when TB has been suspected, patients have needed to be kept in hospital isolation wards for the several days that it takes for microscope testing to be completed. Not only is it extremely expensive to keep a patient hospitalized for that length of time, but patients in isolation rooms tend to be treated less attentively, and their conditions can easily deteriorate there.

With a quick diagnosis, in theory we can rule out TB for some patients in the emergency room before we even have to put them in isolation, and patients who are infected can start receiving appropriate treatment immediately. That helps both the patient and the health care system’s bottom line.

Rutgers Today: The test is already in use in much of the rest of the world. Has it proven itself?

Alland: Its ability to save lives has been documented. The World Health Organization (WHO) reports that for every 100 patients with HIV who are diagnosed with my test there is one more life saved compared with how TB was diagnosed before. People whose immune systems are compromised by HIV are especially vulnerable if they contract TB. With more than one million new cases of people with combined HIV and tuberculosis reported each year, if more people can be tested and then treated, the numbers of lives saved can be huge.

Rutgers Today: What’s next?

Alland: We are developing a new generation of the test that not only detects multiple drug resistance in TB, but will be able to pinpoint which specific drugs are resisted and which are not. Also, some of the techniques we’ve used for TB are now being used to develop a test for fungal sepsis, which is a major problem for debilitated hospitalized patients, including transplant patients and cancer patients. That test is looking very promising. We also have a panel of very sensitive tests for bioterrorism agents such as anthrax and tularemia that could be ready to roll out if this country is ever attacked with those agents.

August 2013

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Legal Matters

LEGAL MATTERS Nicholas v. Mynster

By Attorney Michael B. Zerres

Plaintiff brought this medical malpractice alleging that defendants, Drs. Mynster and Sehgal, provided negligent care by failing to refer the patient to a facility with a hyperbaric chamber for appropriate treatment of carbon monoxide poisoning. Dr. Mynster was board certified in emergency medicine and Dr. Seghal was board certified in family medicine. Plaintiff served an affidavit of merit signed by expert witness, Dr. Lindell K. Weaver., who was not board certified in either emergency medicine or family medicine, but instead, was board certified in preventive medicine with subspecialty certifications in undersea and hyperbaric medicine, and, who had a clinical practice in hyperbaric medicine and critical care, which included evaluating and managing patients with acute carbon monoxide poisoning.

Defendants moved to bar plaintiff’s expert and for summary judgment under the Patient’s First Act, asserting that, under N.J.S.A. 2A:53A-41 he did not have the credentials to testify as to the standard of care of defendants because he was not board certified in either emergency medicine or family medicine. The trial court denied defendant’s motion, finding that this deficiency went only to the credibility, and not the admissibility, of Dr. Weaver’s testimony. The court ruled that expertise in the treatment of the condition was sufficient even if the expert did not share the same medical specialty as the defendant physicians. The Appellate Division further denied defendants’ motion for leave to for an interlocutory appeal.

The Supreme Court, on a motion by defendant’s for leave to appeal, reversed (213 N.J. 463 (N.J. 2013)) , and held that N.J.S.A. 2A:53A-41 of the Patients First Act requires that plaintiff’s medical expert must “have specialized at the time of the occurrence that is the basis for the [malpractice] action in the same specialty or subspecialty” as defendant physicians. Therefore, because plaintiff’s expert, Dr. Weaver, did not specialize in either emergency or family medicine, he was barred from testifying as to the standard of care relating to the named defendants. Furthermore, because the Supreme Court disqualified plaintiff’s expert, the Court also granted summary judgment in favor of defendants because plaintiffs have no statutorily qualified expert who could render an opinion regarding the standard of care, or breach of same, applicable to the defendants

22 New Jersey Physician

McLean v. Liberty Health System

By Attorney Michael B. Zerres on July 22, 2013

The mother of a deceased patient brought this medical malpractice action against the hospital and emergency room physician, alleging that defendants had negligently failed to detect and treat an infection, causing patient to become paralyzed and die.

In preparation for trial, plaintiff consulted with and prepared to call at the trial five medical expert witnesses, two of whom were expected to testify on the standard of care in emergency medicine. However, the trial court had informally granted a defense pretrial motion that restricted each side to one expert witness on any subject or specialty relevant to the case. At this time, plaintiff’s attorney accepted the courts ruling and did not formally object to the limitation on the number of experts.

However, during opening statements defense counsel stated that, “no emergency room physician with a possible exception of Dr. Bagnell…would ever have thought…this is a patient with an infection.” This declaration prompted plaintiff’s attorney to move for reconsideration of the limitation on expert witnesses because the defense had essentially told the jury that no other expert in the world would offer testimony supporting plaintiff’s case besides Dr. Bagnell. When in fact, plaintiff’s second proposed emergency department physician expert, Dr. Schechter, had also offered a report which concluded that defendant emergency physician, Dr. Anwar Khan, deviated from the appropriate standard of care. However, the trial court denied plaintiff’s request to allow Dr. Schechter to testify because it concluded that the two expert’s testimony was “duplicative,”and during the trial plaintiff was only able to call Dr. Bagnell testify as to the standard of care of an emergency department physician.

After a jury trial, the Superior Court, Law Division, Hudson County, entered judgment on verdict in favor of defendants. Plaintiff appealed, asserting that several errors at the trial tainted the jury’s verdict, and also, that the verdict was against the weight of the evidence. The Appellate Division reversed and ordered a new trial. (430 N.J. Super.156 (App. Div. 2013)) Specifically, the Appellate Division held that the trial court erred in prohibiting plaintiff from presenting the testimony of a second expert witness on the subject of medical malpractice because his testimony would be duplicative. The Court went on to note that the trial court’s pretrial ruling was a mistaken exercise of its discretionary authority to control the presentation of evidence at trial under N.J.R.E. 611(a). Furthermore, the Appellate Division concluded that, in general, “a trial court would likely abuse its discretion if it imposed a limitation of only one [expert] witness for each side to testify on a factual matter that is vital to the resolution of a disputed issue.”

By Attorney Michael B. Zerres

Jarrell v. Kaul

In this medical malpractice action the Appellate Court confirmed a jury finding that defendant physician, Dr. Kaul, M.D., deviated from the standard of care when he performed spine surgery upon the plaintiff. Furthermore, the Appellate court also determined that the plaintiff’s treating physician could provide ‘causation’ testimony without having to be qualified in the same manner as a designated expert witness.

The Appellate Court, at 2013 N.J. Super. Unpub. LEXIS 469 (Decided March 1, 2013), rejected the defendant’s appeal, in which the defense claimed that the plaintiff’s treating neurosurgeon, Dr. Steinberger, was improperly permitted to testify that the plaintiff required surgery because “something” happened during the prior fusion surgery performed by defendant, Dr. Kaul.

The Appellate court agreed with the trial court that the plaintiff’s treating physician, Dr. Steinberger, was called as a fact witness and not as an expert witness. Therefore, because Dr. Steinberger was being called as a fact witness, he did not need to be qualified as an expert or provide an expert report.

Specifically, Rules 4:10-2(d)(1) and/or 4:17-4(e), which require that the plaintiff provide an expert report with a complete statement of the expert’s opinions, along with the bases of those opinions, did not apply. The Appellate Division affirmed that, as plaintiff’s treating physician, Dr. Steinberger may testify as to his diagnosis and treatment, including his opinion as to the cause of the patient’s medical condition.

Stagg v. Summit Medical Group

By Attorney Michael B. Zerres

In this matter. Surgery was performed on plaintiff at ambulatory surgical facility owned by Summit Medical Group. The surgery was a septoplasty, nasal reconstruction and inferior turbinate coblation to correct nasal deformity as a result of a fracture, causing difficulty breathing in plaintiff. The surgery was performed by Dr. Jeffery LeBenger (“LeBenger”), with anesthesia provided by Dr. Tony George (“George”). The surgery was reported as being without injury, although when plaintiff awoke, she reported sharp pain in her left arm, numbness and loss of motion. She was informed that her arm was pinched during surgery, caught between the mattress and rail. rehabilitation. Plaintiff then instituted an action for medical malpractice, claiming that she suffered from immediate compressive neuropathy and radial nerve palsy in her left arm and hand, resulting in constant pain and difficulty performing tasks August 2013

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due to a lack of strength in her left arm. During discovery, counsel for the defendant George amended his answers to interrogatories to indicate that he might call Mary Zimmerman, R.N. (Zimmerman ) as an expert to be relied upon at trial. George then submitted an expert report authored by Zimmerman. Plaintiff, therefore, also indicated that she would adopt Zimmerman’s report and rely on her testimony at trial. Defendant George objected to plaintiff’s intent to call Zimmerman as an expert witness to testify on behalf of plaintiff. Defendant George asserted that he had not yet determined whether Zimmermann would be called as a witness at trial and that he had the sole right to make that determination. Plaintiff argued that under Fitzgerald v. Stanley Brothers, Inc., 186 N.J. 286, 302 (2006) defendant has no right to withhold access to an expert witness simply because he supplied the witness.

The Trial Court ruled that when a party provides an expert’s identity and opinion to an adverse party, the original retaining party waives all rights to deem the information as privileged.. Similarly, it was held that Fitzgerald stands for the assertion that an adversary has the right to produce a willing expert at trial, regardless of the party who originally retained the witness, and, that absent a privilege, everyone has access to a witness. Lastly, in this case, since the expert witness was formally named, the plaintiff did not have to demonstrate the existence of exceptional circumstances in order to call her in plaintiff’s case in chief.

According to the Court, R. 4:10-2(d)(3) states, in relevant part: “A party may discover facts known or opinions held by an expert . . . who has been retained or specially employed by another party in anticipation of litigation preparation for trial and who is not expected to be called as a witness at trial only upon a showing of exceptional circumstances under which it is impractical for the party seeking discovery to obtain facts or opinions on the same subject by other means.”

The Fitzgerald exception provides that once the identity and opinion of an expert has been disclosed, all privilege is waived.

Opposing counsel is then free to rely on that opinion without a showing of exceptional circumstances. Further, the Court held that it was irrelevant that defendant George had not clearly indicated whether Nurse Zimmerman was to actually testify at trial. Moreover, Zimmerman would be free to decline to testify on plaintiff’s behalf if she so chose

24 New Jersey Physician

Visit us now online at www.NJPhysician.org 26 New Jersey Physician

Martine’s RiverHouse Food for Thought

By Iris Goldberg

New Hope, Pennsylvania

Why does summer always fly by? We were just celebrating the 4th of July, or so it seems and suddenly, weíre heading into September and the myriad of hectic autumnal activities. Although I enjoy all of the seasons for the unique gifts each has to offer, I am always somewhat saddened when shorter days and cooler weather force us back indoors to spend more of our time. It was on an especially glorious August morning, as I sat at my desk, that I realized how few of these days are left. Already busily working on the September issue of New Jersey Physician, I wanted to freeze time and preserve the ability to be outdoors and feel the heat, enjoy the breeze and the best part of summer for me to spend time near water. I looked over to Michael and said, ‘Let’s go out for lunch.’

It took him a few minutes to understand that I wasn’t talking about a sandwich at the local deli. As is usually the case, I get an idea in my head and Michael is the one who does the investigating and the planning and comes up with the perfect way to put my thought into action. He has never disappointed me in this regard and although we ended up modifying his original plan just a bit, this time was no exception.

Instead of heading to the ocean, as we usually do, Michael thought we might enjoy a river view. He consulted his collection of New Jersey restaurant guides and went on line as well. He found a couple of interesting possibilities on the Jersey side of the Delaware River in Lambertsville. We decided to get in the car and choose where to eat once we arrived and checked things out.

Lambertsville is a quaint tourist-oriented town with shops selling antiques, arts and crafts, jewelry and such. There’s a historic Presbyterian church with a graveyard in which more than one Revolutionary War hero was laid to rest. Despite the strong early afternoon sun, we marched around town to see the sights and eventually came across the two restaurants which Michael had found that advertised outdoor waterfront dining. Although each offered an interesting and eclectic menu, I’m afraid the water referred to was really an old barge canal, with the actual river being a short distance away but not in view from the outdoor eating areas. They were both lovely enough but Michael took one look at my face and knew that this little strip of water would never make me happy while the whole big, beautiful river was literally a short walk from where we were.

We walked to the bridge connecting Lambertsville to its Pennsylvania counterpart of New Hope, which is a charming town, well-known as a tourist attraction. Looking out across the water, we both noticed a line of colorful umbrellas on the opposite shore and could definitely see people dining beneath them. ‘Should we walk or drive?’ I asked. We got back to the car and drove across the narrow bridge to New Hope. We were able to find the restaurant immediately and pulled into the parking area. We shut the engine and before we could open the car door August 2013

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a young man came to the window and informed us there was a $5.00 charge to park. Michael explained that we were thinking about having lunch but wanted to take a look before committing. He agreed to allow us a peek before paying. Michael went up ahead and I sort of lingered behind, not wanting the attendant to think we were ‘pulling a fast one.’ Michael disappeared for a moment and came back out with his thumb up. We paid the parking fee and entered. After voicing our preference for outdoor dining, we were escorted to the deck and seated at a table for two along the railing, directly overlooking the river.

Martine’s RiverHouse was originally constructed by New Hope’s first prominent settler, John Wells, who operated the ferry for 20 years. In 1776 the Ferry Landing was the site of a redoubt built by the continental soldiers, who could observe any enemy activity on the New Jersey shoreline. The circa 1717 post and beam barn construction was restored and renovated beginning in late 2004 and Martine’s, which was formerly located a short distance down on Ferry Street, moved into the building in 2006. Sitting on that deck overlooking the Delaware River, on that splendid summer day, Michael and I were treated to one of the most picturesque views we had ever experienced. By the way, the food was great!

To start, we shared some pate, served with cornichon, red onion, tomatoes, grain mustard and mango chutney, accompanied by small slices of toasted French bread. Along with this we enjoyed a glass of Chardonnay. There were so many wonderful flavors and textures. We both agreed that our decadent summer lunch along the banks of the Delaware was off to a great start.

While we ate, we observed a family of ducks that possibly was hanging around waiting for some morsels of food to be thrown over the rail. We also spied a pair of fishermen in a small rowboat, holding their fishing rods in one hand and a bottle of beer in the other, allowing their vessel to be carried by the current.

For his main course, Michael had a salad of roasted duck breast with baby arugula, sliced Vidalia onions, cucumbers, goat cheese and a dried cherry pistachio vinaigrette. I chose a plate of chilled seafood including lobster, salmon and sushi-style tuna, composed with baby lettuces, marinated melon salad and a ginger lime dressing. Both of these dishes were excellently prepared; the duck and fish, perfectly cooked. We each thoroughly enjoyed our meal. From the looks of those dining at the surrounding tables, many of the dishes served at Martine’s are a hit. The lunch and dinner menus are diverse and creative, affording patrons the ability to savor much more than the view. For those spending a weekend in the area or perhaps, visiting for the day as we had, this place is a sure bet.

By the time we arrived home, the afternoon was completely gone and neither of us felt like going back to work. We rationalized that there would be plenty of days ahead when summer was over to hide indoors and eat lunch at our desks. For now though, summer still had several weeks of life left and we intended to enjoy every moment.

Martine’s RiverHouse Restaurant & Bar is located at 14 E. Ferry St. & The River, New Hope, PA 18938. (215) 862-2966

28 New Jersey Physician

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