NJ Physician Magazine August 2012

PROVIDING CRITICAL INFORMATION TO THE STATES MEDICAL COMMUNITY

JULY2012 2012 AUGUST

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Endoscopic Endonasal Surgery at the University of Medicine and Dentistry of New Jersey (UMDNJ)-University Hospital A Minimally Invasive Approach for the Removal of Skull Base Tumors Also In This Issue: Healthcare Reform for New Jersey, Now What?

Private Shared-Savings Deal Puts Half of Future Raises At Hospital System at Risk EHR Standards Get Tougher Under Finalized Meaningful Use Stage 2 Governor Christie Signs NJ Medical & Health Sciences Restructuring Act- forming forming the foundation of the new Rutgers School of Biomedical and Health Sciences, from the units of UMDNJ

Publisher’s Letter Dear Readers, Welcome to the August edition of New Jersey Physician, now reaching over 28,000 readers per month including our newest audience, who have requested to receive our issues each month digitally by email. If you would like to be included in this rapidly growing group, please send us your request.

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Co-Publisher and Managing Editors Iris and Michael Goldberg

The American economy is based on competition, and this is particularly true as states attempt to interpret the recent Supreme Court decision on the Affordable Care Act. What are the factors that make New Jersey’s needs different from other states and why do we need to create a system that meets them? Please see former Commissioner of Health and Senior Services Poonam Alaigh’s response to these questions inside.

Contributing Writers Iris Goldberg Michael Goldberg Poonam Alaigh Kevin M. Lastorino John D. Fanburg Emily Berry Charles Fiegl Hank Kalet

There are many questions regarding where health care is headed.

A recent decision in Hawaii affecting physician compensation is considered a significant shift away from fee for service. Is the answer shared risk, or shared savings contracts?

Kelly Heyboer Steve Strunsky Mary Barr Mann

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EHR standards are getting tougher under finalized meaningful use Stage 2. I recently was invited to a presentation by NJ HiTech to a group of physicians where clarification of the changes was offered.

It is certainly difficult to understand and we will be doing our best to assist you by having NJ HiTech start writing for us each month breaking each aspect of the new rules into understandable terms for you.

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We get to see some remarkable surgeries through our work with this publication, but one recent photo shoot stands out. A procedure that is approximately 100 years old, is making a come back using technology to perform endoscopic endonasal surgery for certain skull base tumors. One of the main centers offering this advancement in a forgotten technique is UMDNJ-University Hospital where the surgical team of Dr Eloy and Dr Liu are able to treat and remove pituitary tumors and many other difficult to reach tumors by entering through the nose and not having to remove a portion of the skull to obtain access. I congratulate this team for bringing this advancement to Newark and look forward to the future technologies that will allow less invasive surgical procedures that are developed by this department.

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Contents

Endoscopic Endonasal Surgery at the University of Medicine and Dentistry of New Jersey (UMDNJ)-University Hospital A Minimally Invasive Approach for the Removal of Skull Base Tumors

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CONTENTS

10 11 15 17 18 2 New Jersey Physician

HEALTHCARE REFORM HEALTHLAW UPDATE COMPENSATION ISSUES STATEHOUSE HOSPITAL ROUNDS

Cover Story

Endoscopic Endonasal Surgery at the University of Medicine and Dentistry of New Jersey (UMDNJ)-University Hospital A Minimally Invasive Approach for the Removal of Skull Base Tumors

By Iris Goldberg It sounds like something one could see in a science fiction movie – using a patient’s nostrils as a passageway to the center of his or her brain – but instead of a movie theater, this real-life scenario takes place on a regular basis in a unique speciallyequipped three dimensional surgical theater at Newark’s UMDNJ-University Hospital. Complex skull base tumors are removed transnasally, eliminating the need for a craniotomy and without any incisions on the face.

Through the collaboration of James K. Liu, MD, Director of the Center for Skull Base and Pituitary Surgery and Jean Anderson Eloy, MD, FACS, Director of Rhinology and Endoscopic Sinus Surgery and Vice Chair of the OtolaryngologyHead and Neck Surgery Department, appropriate candidates who opt for treatment at UMDNJ-University Hospital, can have their tumors removed using a minimally invasive procedure.

Endoscopic endonasal surgery does not involve cutting through the skull or the face, but rather, utilizes a 3-D endoscope that fits through the nostril to navigate a pathway to the base of the brain.

Dr. Liu shares that surprisingly, the origin of endonasal surgery was actually more than a century ago, when, in 1907, at the University of Innsbruck, Dr. Hermann Schloffer performed the first transsphenoidal (through the sphenoid sinus) surgery on a living patient harboring a pituitary adeoma. He did not go through the nostril but used a nasal route via a transfacial rhinotomy incision.

This procedure was groundbreaking in that it laid the foundation for future development and refinement of transsphenoidal pituitary surgery, influencing prominent surgeons such as Dr. Harvey Cushing, who is considered by many to be the “Father of American Neurosurgery.”

After operating on pituitary tumors with both

4 New Jersey Physician

the transcranial (through the skull) and transsphenoidal approaches, however, Dr. Cushing ultimately chose the former as the more efficacious, causing the transsphenoidal approach to suffer a brief fall into obscurity.

It was Dr. Cushing’s assistant, Dr. Norman Dott, who took his considerable experience with both procedures to the University of Edinburgh, where he began utilizing the transnasal approach as well as writing and lecturing in favor of this method, inspiring other neurosurgeons to use it. Eventually, Dr. Dott passed the technique on to Dr. Gerard Guiot in Paris, who then taught it to Dr. Jules Hardy in Montreal.

“The lineage of these three surgeons preserved the art of what we call

transsphenoidal surgery,” Dr. Liu notes.

“From there it became very popular and was soon the preferred route to remove pituitary tumors,” he continues.

Pituitary tumors cause a variety of hormone problems and can grow to be extremely large, compressing important nerves and arteries at the base of the brain. If the optic nerve is involved vision loss can ensue. When these tumors cannot be treated medically, surgery is needed to remove the tumor.

From the 1960s until early in 2000, the transsphenoidal procedure was performed with the use of a microscope and a speculum through the nose. “It was like looking through a dark tunnel,” offers Dr. Liu. Still, he explains, it allowed good access to pituitary tumors, which occur

Pituitary tumors cause a variety of hormone problems. They can grow to be extremely large, compressing important nerves and arteries at the base of the brain.

in one particular region of the skull base (sella turcica). The lack of adequate light and the narrow field of vision, however, made it impossible to access tumors in any other areas. Those still required the more invasive transcranial or transfacial approaches.

Within the past decade, or so, the emergence of the high-definition endoscope and also the three dimensional endoscope has provided surgeons with significantly more light as well as a panoramic view that includes a much larger area of the skull base.

The more flexible maneuverability and superior panoramic perspectives offered by the endoscope heighten the surgeon’s awareness of the vital structures that reside in and around the sella, greatly diminishing the likelihood of potentially irreversible complications.

Now in addition to pituitary tumors, endoscopic endonasal surgery is performed at University Hospital for the removal of skull base tumors including meningiomas, chordomas, craniopharyngiomas, schwannomas, esthesioneuroblastomas and other sinonasal cancers. It is also important to note that UMDNJ-University Hospital is the recipient of the 2012 HealthGrades Award for Excellence in Neurosurgery.

Dr. Liu emphasizes that because endonasal surgery requires no incisions and is accomplished through the nostrils, which are natural orifices, the speed of recovery is much quicker, there is less pain and other risks associated with more invasive procedures are also greatly reduced. “Patient satisfaction is much higher,” Dr. Liu is pleased to share.

In order to gain access to a skull base tumor through the nostrils, Dr. Liu, who received fellowship training in Skull Base and Cerebrovascular Surgery, which encompassed traditional, open micro-surgical approaches as well as endonasal approaches, teams with Dr. Eloy, who received his sub-specialized fellowship training in Rhinology, Sinus and Endoscopic Skull Base Surgery.

Dr. Eloy’s mentor was Dr. Roy Casiano. “He is a true visionary who figured out how to take sinus surgery to the next level,” Dr. Eloy shares. Dr. Casiano was able to remove sinus tumors that extended into the brain completely endoscopically,” he relates.

Prior to surgery, mapping of the tumor is done to establish the surgical plan.

Working extensively on cadavers, under the direction of Dr. Casiano, Dr. Eloy gained significant expertise with the endoscopic endonasal technique.

When he arrived at UMDNJ-University Hospital, Dr. Eloy was most interested in performing these procedures and began searching for a neurosurgeon to partner with, that specialized in endonasal removal of skull base tumors as well.

About a year later, Dr. Liu arrived on the scene and was introduced to Dr. Eloy.

“I knew immediately that James was amazing and hoped that he would come on board,” Dr. Eloy remembers. That was three years ago and the two have been operating on skull base tumors at UMDNJ- University Hospital, as a team, ever since.

Charles J. Prestigiacomo, MD, FACS, Professor of Neurological Surgery, Radiology, Neurology and Neurosciences, is now Chair of the Department of Neurological Surgery at UMDNJ-University Hospital, having been appointed to that position as of January 1, 2012. Even before that time he was involved in some of the aspects in the establishment of the partnering between Dr. Eloy and Dr. Liu. “What we had was a synergistic marriage between the two of them, which is based on mutual respect as well as the same level of energy and the same vision and

goals,” Dr. Prestigiacomo relates. “Both of them have very high academic goals as well as high clinical goals. And they both see themselves as pushing the edge of the envelope for what can be a very important technical skill development and as a way of improving overall patient care and safety, while also contributing to the academic mission,” he continues.

Dr. Prestigiacomo is pleased to point out the collaborative efforts as well the historical feeling of mutual respect and collegiality between the two groups

Charles J. Prestigiacomo, MD, FACS, Professor of Neurological Surgery, Radiology, Neurology, and Neurosciences is now Chair of the Department of Neurological Surgery at UMDNJ-University Hospital.

August 2012

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Fig. 1

Selected Publications : Mammis A, Eloy JA, Liu JK. Early descriptions of acromegaly and gigantism and their historical evolution as clinical entities. Neurosurg Focus 29 (4):E1, 2010 Liu JK, Christiano LD, Patel SK, Eloy JA. Surgical nuances for removal of retrochiasmatic craniopharyngioma via the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach. Neurosurg Focus 30 (4):E14, 2011 Liu JK, Christiano LD, Patel SK, Tubbs, RS, Eloy JA. Surgical Nuances for Removal of Tuberculum Sellae Meningiomas with Optic Canal Involvement Using the Endoscopic Endonasal Extended Transsphenoidal Transplanum Transtuberculum Approach. Neurosurg Focus 30(5):E2, 2011 Liu JK, Christiano LD, Patel SK, Tubbs, RS, Eloy JA. Surgical Nuances for Removal of Olfactory Groove Meningiomas Using the Endoscopic Endonasal Transcribriform Approach. Neurosurg Focus 30(5):E3, 2011 (selected for cover illustration) Choudhry OJ, Choudhry AJ, Nunez E, Eloy JA, Couldwell WT, Ciric IS, Liu JK. Pituitary tumor apoplexy in patients with Cushing’s disease: endocrinologic and visual outcomes after transsphenoidal surgery. Pituitary Sept 17, 2011 (Epub ahead of print) Eloy JA, Choudhry OJ, Friedel ME, Kuperan AB, Liu JK. Endoscopic Nasoseptal Flap Repair of Skull Base Defects: Is addition of a Dural Sealant Necessary? Otolaryngol Head Neck Surg 2012; 147(1):161-166.

Patel AA, Friedel ME, Liu JK, Eloy JA. Endoscopic endonasal resection of extensive anterior skull base sinonasal osteoblastoma. Otolaryngol Head Neck Surg 2012; 143(3):594-596.

Eloy JA, Murray KP, Friedel ME, Tessema B, Liu JK. Graduated Endoscopic MultiAngle Approach for Access to the Infratemporal Fossa: A Cadaveric Study with Clinical Correlates. Otolaryngol Head Neck Surg 2012; 147(2):369-378.

Liu JK, Eloy JA. Endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma. J Neurosurg 32 Suppl:E3, 2012 Liu JK, Eloy JA. Modified one-piece extended transbasal approach for resection of giant anterior skull base sinonasal teratocarcinosarcoma. J Neurosurg 32 Suppl:E4, 2012 Eloy JA, Choudhry OJ, Shukla PA, Kuperan AB, Friedel ME, Liu JK. Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: Is there an increased risk of postoperative cerebrospinal fluid leak? Laryngoscope 2012;122(6):1219-1225.

Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK. Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: Incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2012 April 23. doi: 10.1002/alr.21040. Epub ahead of print.

Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 32(6):E7, 2012 Choudhry OJ, Choudhry A, Patel SK, Baisre A, Eloy JA, Liu JK. Giant suprasellar Rathke’s cleft cyst mimicking craniopharyngioma: implications for a spectrum of cystic epithelial lesions of ectodermal origin. J Neurol Surg A Cent Eur Neurosurg 2012;73(5):324-329.

To view surgical videos of endoscopic skull base surgeries performed by Dr. Liu and Dr. Eloy, please visit our youtube channel at: http://www.youtube.com/user/SkullBaseMD/videos

6 New Jersey Physician

in the Departments of Neurosurgery and ENT at UMDNJ. He feels that the successful partnering of Dr. Eloy and Dr. Liu has further demonstrated the importance of this mutually supportive relationship, in clearly illustrating that one cannot grow without the other.

Also, Dr. Prestigiacomo credits the vastly important role played by the innovative 3-D technology that has been put in place for the performance of endoscopic endonasal surgery, as a key element in fulfilling not only the clinical mission of the two departments but also the educational mission in terms of training medical students and surgical residents.

Speaking of the work being done by Drs. Liu and Eloy from the research perspective, Dr. Prestigiacomo says, “This does move the fields of ENT and neurosurgery forward in providing safer and more effective care to patients. Being able to disseminate that at the national and international level is one of the things you expect of a tertiary academic institution,” he maintains. Further, he notes that both the Departments of Neurosurgery and ENT at UMDNJ are regarded as having one of the finest surgical training programs in the state.

Dr. Liu and Dr. Eloy are both pleased to share that word of their cutting edge work has spread far beyond the boundaries of New Jersey. They receive referrals of patients from many different parts of the country and are often invited to speak about their endonasal technique for the removal of pituitary and other skull base tumors. Also, they have published articles in various journals (see fig.1) describing the procedure and benefits thereof.

“Here at our Center for Skull Base and Pituitary Surgery, patients get the full complement of all the specialists that comprise a multidisciplinary skull base and pituitary team. This includes neurosurgeons, otolaryngologists, neuroophthalmologists, endocrinologists, radiation oncologists and so forth,” Dr. Liu points out.

One of the greatest sources of pride for Dr. Eloy and Dr. Liu, besides the volume of patients (children and adults) they have been able to help by accessing and removing skull base tumors through the nose, is the state-of-the-art operating theater in which they work. The Center for Skull Base and Pituitary Surgery at

“I know what he’s going to need,” Dr. Eloy states, referring to his job of creating and maintaining a pathway to the tumor, so that Dr. Liu can then remove it. “It’s gotten to the point that he’s almost reading my mind,” Dr. Liu interjects. It’s almost like a dance,” he says. “I move my left foot forward - he moves his right foot back.”

The procedure begins with Dr. Eloy. “If the tumor is primarily in the brain and the sinus anatomy is normal, then you have to know how to navigate through the sinus to make an opening,” Dr. Eloy informs. He explains that because of the vital structures nearby, such as the eyes on both sides and the part of the brain that is intact, it is his responsibility is to find a way to make a tunnel to gain access to the tumor without harming any of these.

The stereoscopic high-definition visualization system allows the surgical team to view the operation on a flat panel display screen.

UMDNJ- University Hospital has the distinction of being the first in New Jersey to have a complete three dimensional neurosurgical operative suite, specifically designed to use 3-D technology for the removal of deep-seated and challenging brain tumors.

With the Visionsense™ 3-D endoscope, the surgeons derive the benefits of an endoscope and a stereoscopic operating room microscope in a single device.

Depth perception is delivered without diminishing magnification and focus.

Stereoscopic 3-D images, like natural sight are provided in a miniature tool that allows Drs. Liu and Eloy to navigate the easiest access path and get a complete picture through the small opening of the nostril.

In addition to a state-of-the-art 3D endoscope, the surgical suite is equipped with the TrueVision™ 3DHD vision system for microsurgery. This stereoscopic highdefinition visualization system converts the optical view of the surgical microscope to a digital 3DHD image and displays the surgical field of view in real-time on a 3-D flat panel display screen.

This allows the surgical team to visualize the operation in stereoscopic 3-D without the need to be permanently attached to the microscope oculars. Over twice the depth of field compared to the microscope view and three times the resolution of standard definition is delivered, enabling the surgeon to successfully perform

microsurgery in a “heads up” position.

UMDNJ-University Hospital is one of only a handful of facilities within the tri-state area to have an operating theater with these innovative systems in place.

Once in the operating room, Dr. Eloy and Dr Liu proceed with a surgical sequence of events that has been finely honed and refined during the years in which they have been working as a team. Over time they have come to know each other’s surgical skills and styles so well, that they can often communicate without the need to speak.

Along with 3-D and high-definition scopes to navigate a pathway to the tumor, Dr. Eloy often employs a microdebrider to help remove surrounding tissue. Depending upon the specific type and size of the lesion to be removed, the time needed for Dr. Eloy to forge a suitable pathway through the sinus and into the brain at the base of the skull is usually 20 to 30 minutes. However, at this point, Dr. Eloy’s job is far from completed.

Once the access to the tumor is provided, Dr. Liu begins the process of removing it. As Dr. Liu operates it is crucial that he has perfect visualization. Therefore, the whole time that Dr. Liu is carefully

Over time, Dr. Liu and Dr. Elroy have come to know each other’s surgical skills so well that they can often communicate without the need to speak.

August 2012

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working to remove the tumor, Dr. Eloy is holding and navigating the endoscope.

“If I were to hold the endoscope that would leave me only one hand,” Dr. Liu states.“With him navigating the scope and positioning it at various angles, it allows me to be free to use both hands and to operate as if I would be doing an open microscopic surgery,” he adds. Again, because the surgeons have been working so closely as a team for the past three years, Dr. Eloy knows what Dr. Liu requires at each point during the procedure and navigates the scope accordingly. Dr. Liu has the utmost confidence that Dr. Eloy will provide exactly what is needed and can focus all of his attention on removing the tumor.

In order to bring the tumor out through the small opening of the nostril, Dr. Liu explains that it must be broken up into pieces. “It’s actually safer to do it that way,” he notes. Dr. Liu continues, “Usually, these tumors are surrounded by very critical structures, such as the optic nerve, the carotid artery, the pituitary stalk and so by making it smaller or de-bulking the tumor on the inside, that allows the outer shell of the tumor to become a collapsible balloon.”

Dr. Liu goes on to share that he then comes from the outside of the tumor and gently peels the shell away from the critical blood vessels and nerves. “You don’t want to apply force because that can cause injury to those structures,” Dr. Liu makes a point of mentioning. Therefore, this part of the procedure can be tedious and lengthy, especially with some of the more difficult skull base tumors, such as meningiomas, craniopharyngiomas and chordomas.

a complication that can occur as a result of endonasal skull base surgery. “We actually have one of the lowest CSF leak rates in the medical literature,” Dr. Liu is pleased to report.

Dr. Eloy explains that the brain needs to remain completely sterile at all times and sealed off from the nasal cavity at the end of the surgery. If there is a postoperative CSF leak, this can lead to an infection of the CSF (meningitis) or of the brain itself (brain abscess).

“You have to be extremely meticulous as you are closing the defect,” Dr. Eloy emphatically states. “You need multiple layers between the nasal cavity and the brain cavity and the naso-septal flap significantly helps. Again, we have been really, really successful with this,” he is grateful to inform.

“This is the part where you really need to take your time,” Dr. Liu adds. “There have been times that we’ve put all the layers together and we’ve already been there for twelve hours and I look at it and I’m not happy,” he relates. “That’s when we take it all down and re-do it,” Dr. Liu reveals.

Dr. Eloy nods in agreement. “He doesn’t leave the operating room if I’m not happy and I don’t leave if he’s not happy,” he strongly states. The two are teammates in every sense of the word. The true beneficiaries of this are the countless patients who have had successful removal of their brain tumors without having to undergo an open surgical procedure, or have any incision at all.

In fact, aside from a stuffy nose, most patients wake from the procedure without pain and feel remarkably well.

Their tumor is gone and they don’t have to face a grueling recovery period as would be the case after a craniotomy or transfacial surgery. Many patients refer to their surgical experience as a “miracle.”

For Dr. Liu and Dr. Eloy, it’s their job – one that each is extraordinarily passionate about.

For more information or for patient referrals, please call (973) 972-2323.

Photography by: Michael Goldberg

Dr. Elroy begins to open a pathway to the tumor.

After the tumor is completely resected, the surgeons have to close the defect that was created. Dr. Eloy relates that depending on the type and size of the defect, sometimes synthetic materials are used and other times grafts from the patient’s legs are taken as the initial covering. “If the defect is big, we then use something called a naso- septal flap, where we borrow natural tissue from the patient’s nasal septum and rotate it to cover all of the initial grafts,” Dr. Eloy further shares.

This technique has shown to be quite effective in minimizing the possibility of a cerebrospinal fluid (CSF) leak, which is

8 New Jersey Physician

Here the tumor is now visible.

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BROAD COVERAGE FORMS FINANCIALLY STRONG INSURANCE COMPANIES ADVANCED RISK MANAGEMENT SERVICES AND STRATEGIES HIGHLY COMPETITIVE PRICING

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To learn more about how Bollinger can help your practice, contact Brian S. Kern, Esq. 973-921-8497 or Brian.Kern@Bollinger.com

www.Bollinger.com/pro Coverage is subject to meeting eligibility requirements and company approval.

August 2012

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HEALTHCAREREFORM Healthcare Reform

Healthcare Reform for New Jersey, Now What?

The American economy is based on competition, and this is particularly true as states attempt to interpret the recent Supreme Court decision on the Affordable Care Act

By Poonam Alaigh, The historic Supreme Court decision on June 28, 2012 upheld the individual mandate, a key provision of the Affordable Care Act. It also ruled that the states had the right to choose their participation in the Medicaid expansion without any penalty or loss of federal match for the state Medicaid program if they wanted to opt out. No matter what our position is on the ruling, the reality is that the Patient Protection and Affordable Care Act of 2010 is the law of the land. We must seize this opportunity to look for ways to bring improvements and innovations to our current healthcare system. Many participants in the healthcare system -- consumers/patients, physicians/providers, hospitals, government agencies, policy makers, insurance companies, pharmaceuticals, and others will be impacted by this. It is going to be important that we work together in private-public partnerships to achieve our goal of high-quality, coordinated, cost-effective access to care, while ensuring that our system is not burdened with bureaucracy and regulatory control.

What are the factors that make New Jersey’s needs unique from other states and why do we need to create a system than meets them? New Jersey ranks third nationally in population diversity and is among the top 10 states with the number of residents age 65 and older. With advanced age we consume more medical care, thus the need to coordinate that care becomes even more important, and New Jersey can, and must, institute its own marketbased solutions. Well-designed pilots, such as Accountable Care Organizations (ACOs), High ER Utilizer programs, integration of behavioral health services and streamlining end-of-life care should be pursued and customized to support regional healthcare resources. In the area of long-term care, home- and community-based options that support independence, dignity, and consumer choice need to be expanded. They are more cost-effective than nursing homes, and are generally preferred among those in need of long-term care services.

What role can automation play? A 2006 RAND study found that the U.S. healthcare system could save more than $81 billion annually if Healthcare Information Technology (HIT) was widely adopted. Electronic Medical Records (EMRs) can ensure the availability of all relevant, patient-specific medical information at the point of clinical decision-making. The electronic sharing of disparate data can increase administrative efficiencies and help in the evaluation of new techniques and evidence-based medicine by providers. Existing, fragmented systems reduce effectiveness and cause harm, whereas efficient systems can and will save lives.

10 New Jersey Physician

Do we have enough providers? The best-designed healthcare system cannot work without the clinicians who provide the services directly to patients. In 2010, New Jersey dealt with a shortage of 945 physicians. This number is expected to triple in ten years, without taking into account the increased demand nationwide under reform expanding Medicaid populations. Of 860 doctors who complete residency in New Jersey each year, only 32 percent plan to practice medicine here. The numbers are similar for the other professionals who provide for patients.

Thus the environment in New Jersey must be created that will cultivate, retain and attract more healthcare professionals.

Medical school capacities, along with educational partnership opportunities, must be expanded. And new opportunities must be created for retired and volunteer healthcare professionals to increase much-needed access to care and correspondingly malpractice and tort system must also be fixed. The current system promotes frivolous lawsuits, encourages the practice of defensive wasteful medicine and results in physician exodus, exacerbating our physician shortage.

As a physician, previous health insurance executive and the former commissioner of health, I know our collective objective is to ensure access to high-quality healthcare for all New Jerseyans.

It’s no secret that our nation’s healthcare system has become unsustainable and that left alone it is on track to insolvency. So we should view the current situation as an opportunity to achieve a real and sustainable outcome that will provide the world-class healthcare system standard our patients and taxpayers deserve and can afford.

Indeed, our state policy makers, legislators, and the governor should carefully assess and evaluate all the critical factors involved to ensure the final outcome is void of cumbersome and undue burden on the Garden State taxpayers and business community while addressing the critical deficiencies in the status quo.

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www.NJPhysician.org

HEALTH LAWUpdate Health Law Update

CMS Will Be Accepting Additional Applications for Advanced Payment Model ACOs

The Centers for Medicare & Medicaid Services (CMS) announced that it will accept applications from Accountable Care Organizations (ACOs) to participate in the Advanced Payment ACO Model Program, with a starting date of January 1, 2013. The Advanced Payment Model is an initiative for organizations participating as ACOs in the CMS Shared Savings Program, to provide advance payments to the ACOs that will be repaid to CMS from future savings the ACOs earn. The Advanced Payment Model is intended to test whether advance payments to ACOs will increase participation in the Shared Savings Program and whether advance payments will allow ACOs to improve care for beneficiaries, and generate Medicare savings more quickly and in greater amounts.

The Advanced Payment Model was intended for ACOs that do not include inpatient facilities and have less than $50 million in total annual revenue; or ACOs in which the only inpatient facilities are critical care access hospitals and/or low-volume rural hospitals, and have less than $80 million in total annual revenue. ACOs that are co-owned with a health plan are ineligible. The application scoring process favors ACOs with the least access to capital, ACOs that serve rural populations, and ACOs that serve a significant number of Medicaid beneficiaries. Applications are available through the CMS website at http://www.innovations. cms.gov/areas-of-focus/ seamless-and-coordinated-care-models/ advance-payment/, and are due between August 1, 2012 and September 19, 2012.

For additional information, contact: Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com

August 2012

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Private shared-savings deal puts half of future raises at hospital system at risk The Hawaii agreement, which will affect physician compensation, is considered a significant shift away from fee-for-service payment.

By Emily Berry A contract between Hawaii’s largest insurer and its biggest health system could prove a bellwether for contracting in other states, significant because so much of the health system’s payment — and compensation for its physicians — will depend on its clinical quality scores and the degree to which it can cut costs.

The shared-savings agreement between Hawaii Medical Service Assn. and Hawaii Pacific Health puts 50% the hospital’s annual pay increases over the five-year contract term dependent on achieving both quality improvement and cost savings thresholds.

HMSA President and Chief Operating Officer Mike Gold said he sees the arrangement as a model for payers and hospitals outside Hawaii that are dealing with the same dilemma: how to improve quality while cutting costs.

“The whole health care system and country will need to find a way out of this problem we’re in,” he said. “We think we have a good solution.”

Hospitals and payers across the country are moving to adopt shared-risk or shared-savings contracts like those authorized for Medicare under the Affordable Care Act. When large payers and hospitals adopt them, everyone is watching, said Carol Grelecki, a member of the New Jersey law firm Brach Eichler.

“The pressures are there to get involved in these,” she said.

Adoption “is going to turn on what the experiences are with these original ones.”

The scale of the at-risk pay under the Hawaii agreement is steep compared with private shared-savings models adopted in Massachusetts, another bellwether state in shared-savings agreements. The Alternative Quality Contracts that BlueCross BlueShield of Massachusetts introduced in 2008 included guaranteed pay increases to account for inflation, and a potential 10% bonus payment in recognition of clinical quality scores.

The Hawaii agreement will cover Hawaii Pacific’s four hospitals, 49 outpatient sites and care provided by its 1,300 affiliated

sicians. The arrangement takes effect in 2014.

Gold said the intervening time will give Hawaii Pacific a chance to ramp up some of the changes it will have to undergo to make the new shared-savings model work. Meanwhile, Gold said the two sides will finalize similar contracts that will cover Medicare and Medicaid patients.

The two sides’ current contract includes “pay for quality” as part of HMSA’s transition away from fee-for-service payment. The new contract will keep those elements but will include shared savings so the more money Hawaii Pacific saves, the more HMSA will pay.

“It’s a step on the road toward a full ACO, although I’m not sure what a full ACO is anymore,” Gold said. “It’s been defined so many ways.”

HMSA’s payments to physicians already are partly dependent on HEDIS scores and other quality measures, but physicians’ compensation is likely to become even more dependent on quality scores and cost savings, Ken Robbins, MD, Hawaii Pacific’s chief medical officer and executive vice president, wrote in an e-mailed statement. Hawaii Pacific employs 350 physicians.

Gold said the health insurer and hospital system were able to work out the agreement because of a shared intention. “Support for the physician-patient relationship is the key to making the health care system work,” he said. “Our goal is to do everything we can to support that relationship.” He said he expects that all of HMSA’s contracts will eventually include pay-for-quality and shared-savings elements.

If the contract does not work as planned, HMSA and Hawaii Pacific would share in the financial losses. Gold said patients will at least not be any worse off than they are today in terms of cost and quality of care.

Both sides have every incentive to make sure the shared-savings model works, he said. “There is no contingency plan, except to go back to the way we were, and no one wants to do that.”

EHR standards get tougher under finalized meaningful use stage 2 Federal officials soften some proposed requirements and officially delay the deadline to upgrade to the next electronic health record phase, but doctors wanted more leeway.

By Charles Fiegl Washington Starting as early as 2014, physician practices will be required to achieve more difficult objectives to demonstrate meaningful use of electronic health records to earn federal bonuses and prevent future penalties.

The Centers for Medicare & Medicaid Services finalized its requirements for stage 2 of the EHR incentive program in an Aug. 23 regulation. The final rule mandates that doctors meet a larger number of core objectives — and stricter guidelines for some of those objectives already in place — during the next part of the three-stage program. Physicians also must adopt and demonstrate meaningful use of EHR systems by Oct. 1, 2014, or be assessed a 1% penalty from Medicare.

12 New Jersey Physician

Doctors who successfully adopt early enough can earn up to $44,000 over five years from Medicare, or up to $63,750 over six years from Medicaid. Demonstrating meaningful use of a paperless record will become required annually to prevent penalties that will take effect starting in 2015. CMS reports that about 55,000 physicians had earned Medicare incentives through June 2012 under the less-stringent stage 1. Slightly more than 34,000 had earned Medicaid bonuses.

Several organizations representing physicians and other participants have urged CMS to design the program to be more flexible so it encourages even greater EHR use. Organized medicine groups, including the American Medical Association,

for the administration to soften the stage 2 meaningful use requirements that it outlined in a proposed rule issued inFebrary.

Some measures that were optional in stage 1 of meaningful use requirements are mandatory in stage 2.

The AMA “has provided ongoing input since the inception of the EHR incentive program and has urged greater flexibility to make the program more reasonable and achievable for physicians,” said AMA Board Chair Steven J. Stack, MD. “In a comment letter submitted by the AMA and 100 state and specialty medical societies in May, recommendations were outlined to eliminate physician roadblocks and encourage greater physician participation.”

The Association and the other societies that signed onto the comment letter were reviewing the final rule, Dr. Stack said.

He said he hoped the review would find changes that promote adoption and meaningful use of EHRs by physicians.

Stages 1 and 2 each require meeting 20 total objectives, but stage 2 makes mandatory some EHR measures that are optional for stage 1, such as whether the electronic systems can

same but have higher thresholds, such as a requirement that EHRs send more than 50% of applicable prescriptions electronically, up from more than 40%. The number of required core set measures goes up to 17 in stage 2 from 15 in stage 1.

Physicians also must choose and comply with three out of six additional “menu” set measures, as well as report at least nine clinical quality measures.

Some additional time granted The effective date of stage 2 has been one of the most contentious issues for the program. After physicians and others complained that early adopters of paperless systems would be forced to meet the more stringent requirements sooner than those who waited a year, the White House floated a plan in late 2011 to set the earliest possible stage 2 deadline for doctors to 2014 instead of 2013. The final rule released in August makes that delay official.

Physicians who earned EHR bonuses in 2011 and 2012 would be required to meet stage 2 requirements starting in 2014. Doctors who start achieving meaningful use in 2013 or later would report under stage 1 rules for two years before moving onto

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stage 2, regardless of whether they incur any noncompliance penalties for being late adopters. Despite the effective delay for early adopters to 2014, a significant majority of comments on the proposed version of the rule said that deadline still was too aggressive. “Some commenters suggested that the time was insufficient regardless of resource constraints, while others suggested that currently vendors of [EHR systems] lack the necessary capacity to make the necessary upgrades to their products and implement them for their customers in time,” CMS acknowledged in the final rule.

The physician organizations specifically asked that CMS delay the start of stage 2 until 2015. The agency rejected the request, saying it “would have a ripple effect through the timeline of stages.” However, CMS did give physicians some more time to make the necessary changes to their systems by requiring only a three-month reporting period in 2014, meaning EHRs would not necessarily need to be upgraded by the start of the year.

Reporting periods for meaningful use will be three months long regardless of what stage an eligible professional is following, said Rob Anthony, a health specialist with the CMS Office of E-Health Standards and Services, during an Aug. 24 seminar. Also beginning in 2014, a physician group can submit a meaningful use attestation for all of its eligible professionals in one file, saving the practice from entering each individual’s information separately.

their own care, including secure electronic messaging,” CMS said. The agency did, however, reduce the reporting thresholds for those measures from 10% to 5% in the final rule. CMS also will exclude physicians from the requirements when they practice in areas without sufficient Internet access.

Some organizations reviewing the final rule lauded the agency for including some additional flexibility for incentive program participants.

“Extending the start for stage 2 until 2014 was a necessary step to permit medical groups sufficient time to implement new software,” said Susan Turney, MD, president and CEO of the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. “Permitting group reporting will reduce administrative burden, as will lowering the thresholds for achieving certain measures such as mandatory online access and electronic exchange of summary of care documents.”

Doctors can seek penalty exemptions Agency officials carved out several hardship exceptions to the noncompliance penalties, and some will require the reporting physician to complete an application prior to the penalty’s assessment. The exemptions are available for physicians who: • Have insufficient Internet access for any 90-day continuous period between Jan. 1, 2013, and July 1, 2014.

Demonstrating meaningful use during stage 2 will rely on patients interacting with physicians and EHR systems online.

For instance, CMS had proposed that eligible physicians send a secure EHR-based message to at least 10% of unique patients.

Another proposed measure directed doctors to provide half of their patients with the ability to view online information about their care and ensure that a minimum of 10% did so.

• Are new to Medicare.

Many commenters objected to these measures, because physicians would be held accountable for patient inaction on a measure. The AMA and other medical societies recommended the patient measures be made optional, but CMS did not follow the advice.

• Have a lack of face-to-face visits or other patient interactions, or the need to provide follow-up care.

“While we recognize that [eligible professionals] cannot directly control whether patients use electronic messaging, we continue to believe that [eligible professionals] are in a unique position to strongly influence the technologies patients use to improve their

• Encounter extreme circumstances outside the physicians’ control, such as practices closing, natural disasters, EHR vendors going out of business and similar scenarios.

• Practice in multiple locations and have a lack of control over the availability of EHR systems.

In 2014, CMS also will align reporting for the clinical quality measures component of meaningful use with the Medicare physician quality reporting system so doctors are not facing two different reporting standards. PQRS, a separate program from the EHR initiative, will penalize physicians starting in 2015 for not reporting certain quality measures to the government.

Visit us now online at www.NJPhysician.org 14 New Jersey Physician

Compensation Issues

Horizon NJ Health Slashes Medicaid Reimbursements for Home Healthcare Agencies argue that 10 percent cut may ultimately affect the quality of care they can deliver to clients

By Hank Kalet, A 10 percent reduction in Medicaid reimbursements from Horizon NJ Health has caused an uproar in the home health community, which fears that the cut in reimbursements will hamper agencies’ ability to handle more clients just when demand is expected to soar due to a change in how Medicaid is administered.

Horizon NJ Health, the largest of four managed care companies that administer the state’s Medicaid system, sent a letter to agencies that provide personal care assistance saying that it would cut reimbursement rates by 10 percent, from $15.50 per hour to $13.95 per hour, beginning October 1. Providers were told they had until September 4 to agree to the changes or they would have to leave the healthcare network. The deadline was later extended to September 14.

Providers say current reimbursements of $15.50 an hour are barely enough to cover salary and administrative expenses and that reductions would have to be passed along to home aides in the form of lower per-hour wages. That, they say, could lead to increased personnel turnover in an industry that already experiences high turnover rates.

Wages now range from $9 to $10 per hour for most homecare workers in the state, says Ken Wessel, president of the Home Care Council of NJ and executive director of the nonprofit agency, HomeCare Options. There are about 30,000 personal care assistants working for about 170 agencies.

The state moved about 155,000 clients from the Medicaid feefor-service program to the managed care system between July 1, 2011, and October 2011. Horizon represents 47.5 percent of these clients, who are part of the Medicaid/Children’s Health Insurance Program, according to the Department of Human Services. Amerigroup New Jersey, Healthfirst Healthplan of NJ, and UnitedHealthcare Community Plan represent the other 52.5 percent and are not cutting rates.

In September 2011, the state submitted a Comprehensive Medicaid waiver application to the federal Centers for Medicare and Medicaid Services seeking the ability to “bundle services that support integrated, coordinated health care to clients,” according to Nicole Brossoie, spokeswoman for the Department of Human Services. The application is pending.

Market Conditions Horizon says market conditions have forced it to lower its reimbursements.

“Horizon NJ Health has carefully analyzed the experience with Personal Care Assistant [PCA] services over the last year,” George Ingram, director of provider contracting and strategy for Horizon, said in the letter. “Our findings indicate utilization has been significantly higher than anticipated and the trend is not abating.”

Thomas Vincz, spokesman for Horizon Blue Cross Blue Shield of

New Jersey, the parent company of Horizon NJ Health, called the reimbursement reductions “difficult decisions,” but said that they “demonstrate the realities of today's healthcare in having to do more with fewer resources.” Horizon is seeing a reduction in the rates it receives from the state to administer “various government health programs,” Vincz said, while “benefit utilization” and overall costs were growing.

“As a result, Horizon NJ Health must work within its budget and manage its costs responsibly to ensure that its resources are sufficient to protect its members, meet the needs of the provider community, and at the same time, ensuring financial stability of the plan,” he said. “Horizon NJ Health continues to work with the state and the provider community to ensure a sustainable program.”

Representatives from several homecare agencies said the cuts would force them to reduce wages to employees, which could leave patients with less experienced aides or agencies willing to cut corners to save money.

“As they push down the wages of the home health aides, the only agencies that are going to survive and service Horizon clients are the ones who will take people off the streets as aides, cut corners on services or cut corners on training,” said Ken Wessel, president of the Home Care Council of NJ and executive director of the nonprofit HomeCare Options.

Brossoie said via email that the state is speaking with both Horizon and representatives from the home-healthcare/ personal-care industry “to learn more about the reimbursement decision.”

“While the state does not have to approve these reductions,” she said, “we do monitor closely all health plan changes to ensure that members' care and access to the care is not disrupted.”

Disruptions Ahead Industry officials, however, say that disruptions seem likely.

Robinson Joseph, president of HomeHealth First in Elizabeth, said the cuts will cause quality of care to suffer because they will drive the better-performing aides out of the industry -- and possibly force some agencies to close. He said that even at $9 to $10 an hour in home health aide wages, it currently costs an agency about $13 per aide per hour in wages and state and federal taxes, which does not include administrative costs and other overhead.

“To stick with the plan, as proposed, the only way to do that is by reducing the salary of the aides,” Joseph said. “We will just have to pass it along by cutting the salary of the aides because everything is stretched to begin with."

“If, at the end of the day, your reimbursements cannot cover your expenses, then it would be a no-brainer to get out of the business completely,” he said.

The reimbursement cut is the second one in just over a year, August 2012 15

Wessel said. The first one -- 65 cents per hour -- came when the state outsourced Medicaid to the HMOs. His company and most of the state’s nonprofits did not pass that cut along to their employees, but he said it is unlikely they will be able to avoid doing it this time.

Justin Braz, political coordinator for 1199 SEIU-United Health Care Workers East, which represents about 830 personal care assistants in central and northern New Jersey, criticized both the Horizon cuts and the potential that agencies would pass them along to workers.

Overworked and Underpaid “We’re talking about workers making less than $10,” he said.

“They are already overworked and underpaid and this doesn’t make much sense to us. They are the most important assets to these companies.”

The money they earn -- which translates into less than $20,000 a year for full-time work -- rarely includes health coverage or other benefits, and most have to pay for their travel between clients out of their own pockets, Braz said.

“They are doing hard, backbreaking work. They are creating relationships with clients that mimic those of family members.

They take care of family members and a lot of them are working second or third jobs. There is only so far you can cut their wages.”

Wessel agrees. Some nonprofits cover the cost of travel between clients, and some provide scholarships and vacation and sick time. That, plus the general overhead, “adds up to more than the new $13.95 rate,” Wessel said.

“Then you have to provide supervision by a registered nurse.

16 New Jersey Physician

regulations in New Jersey and pay a decent wage -- and I’m not saying $10 is decent wage because you can’t live on it -- it costs a lot.

“Not everyone is willing to go into people’s homes,” he added.

“It is unpleasant. The people who want to do that are people who care about people. Horizon is literally taking money out of their pocket and they will be left with providers who, in a Darwinian way, will be left with agencies who are least common denominator.”

The Horizon cuts come at a time when the state is trying to move people from nursing homes into homecare to save money, an effort that could be placed in jeopardy by the cuts.

“The whole state strategy of keeping people at home and out of nursing homes comes down to the aides,” Wessel said “Once you cause them to go to McDonalds or Burger King for better wages, they won’t come back and agencies like ours might not be around.''

“They are messing with something the state rightly has pride in -- reducing the number of people in nursing homes and keeping people at home in a quality way. The state has washed its hands of this by handing it over to a private enterprise and the patients are going to suffer.”

Joseph called the move away from nursing homes a “win-win” for the state.

“Instead of keeping clients with some needs in a nursing home, those folks can live in their house with some assistance for personal care and you are saving so much money,” he said. “You can’t compare the cost of a couple of hours of home services to cost of institutional or nursing-home living.”

Statehouse

NEW JERSEY STATEHOUSE ASSEMBLY, No. 559

STATE OF NEW JERSEY 215th LEGISLATURE PRE-FILED FOR INTRODUCTION IN THE 2012 SESSION Sponsored by: Assemblywoman CONNIE WAGNER District 38 (Bergen and Passaic) Assemblyman HERB CONAWAY, JR. District 7 (Burlington) SYNOPSIS Allows gross income tax deduction for first $200,000 earned by certain new physicians in their first seven taxable years of practice in New Jersey.

CURRENT VERSION OF TEXT Introduced Pending Technical Review by Legislative Counsel A559 WAGNER, CONAWAY AN ACT allowing a gross income tax 1 deduction for certain income derived by certain new physicians in their first seven taxable years of practice in New Jersey, supplementing Title 54A of the New Jersey Statutes.

BE IT ENACTED by the Senate and General Assembly of the State of New Jersey: 1. a. For the first seven taxable years of a qualified New Jersey practice, a qualified new physician shall be allowed to deduct from gross income the first $200,000 of income derived from the qualified new physician’s qualified New Jersey practice. The total amount a qualified physician may deduct for all of the first seven taxable years of qualified New Jersey practice pursuant to this section shall not exceed $200,000.

As used in this section: “Qualified New Jersey practice” means engaging in the following activities within the State as a qualified new physician: providing medical diagnoses, exercising medical judgments, communicating medical judgments and diagnoses to patients and other healthcare providers and the performance of medicals tasks such as, but not limited to, physical examinations and surgical procedures.

“Qualified new physician” means a taxpayer that is a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners pursuant to R.S.45:9-1 et seq., who has not engaged in the practice of medicine and surgery as a licensed doctor in New Jersey in a prior taxable year.

2. This act shall take effect immediately and apply to taxable years beginning on or after January 1, 2010.

STATEMENT This bill provides a gross income tax deduction for the first $200,000 earned by certain new physicians in their first seven taxable years of practice in New Jersey. The purpose of this bill is to encourage new physicians to begin their practice in New Jersey so as to prevent shortages of physicians in the State and to realize the economic benefits associated with the establishment of new August 2012

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Hospital Rounds

UMDNJ- University Hospital Surgeon Reaches Milestone Using the da Vinci® Surgical System (NEWARK, NJ) – Justin Sambol, MD, Chief, Division of Cardiothoracic Surgery at UMDNJ-The University Hospital, has become a certified robotic thoracic surgeon by successfully performing more than 20 major thoracic procedures using the da Vinci® Surgical System. The system, used by surgeons to offer patients a minimally invasive option for complex surgical procedures, is an alternative to open surgery.

Dr. Sambol, a resident of Livingston, uses the da Vinci® Surgical System to perform many complex surgical procedures in the chest and lung. By reaching the twentieth surgery milestone, he is recognized as an experienced surgeon using this system.

In addition, Dr. Sambol is now among only a handful of robotic cardiothoracic surgeons in New Jersey listed on davincisurgery. com. In July 2011, the site, geared towards patient education, began generating a database of surgeons nationwide who have completed at least 20 surgeries using the da Vinci® Surgical System.

“There are many benefits of this system, including smaller incisions and quicker recovery time,” said Dr. Sambol.

For example, he said, patients with autoimmune myasthenia gravis (MG), a condition that causes the muscles to weaken, can undergo a thymectomy (thoracic surgical procedure to remove the thymus) to decrease the severity of MG. In the past, this surgery required a large incision in the middle of the chest.

With the da Vinci® Surgical System, it can now be completed with smaller incisions. This leads to a faster recovery and better cosmetic result.

“In an open surgery, thymectomy patients require a 5-7 day stay in the hospital,” he explained. “Using the da Vinci® Surgical System, the length of stay is reduced to 1-2 days.”

Interviews with Dr. Sambol, as well as with patients who have had surgeries using the da Vinci® Surgical System, may be arranged by calling Tiffany L. Smith at 973-972-1025.

The University of Medicine and Dentistry of New Jersey (UMDNJ) is New Jersey’s only health sciences university with more than 6,000 students on five campuses attending three medical schools, the State’s only dental school, a graduate school of biomedical sciences, a school of health related professions, a school of nursing and New Jersey’s only school of public health.

UMDNJ operates University Hospital, a Level I Trauma Center in Newark, and University Behavioral HealthCare, which provides a continuum of healthcare services with multiple locations throughout the State.

UMDNJ-The University Hospital is one of the United States' premier university medical centers and the principal teaching hospital for University of Medicine and Dentistry of New Jersey (UMDNJ)-New Jersey Medical School (NJMS). Located in the Central Ward of Newark, the hospital offers the highest quality of care across many medical specialties.

18 New Jersey Physician

Dr. Justin Sambol

New Jersey Medical School researchers develop DNA sequencing tests for hereditary diseases Reduces costs, improves effectiveness and turn-around time for diagnosis

NEWARK—Scientists at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School (UMDNJ-NJMS) have developed new DNA sequencing tests that hold significant promise for decreasing costsassociated with diagnosing cancer and hereditary diseases, including cysticfibrosis.

Officials at the New Jersey Department of Health approved the use of the new Cystic Fibrosis (CF) Carrier and Diagnosis Test, which was created at the Institute for Genomic Medicine at UMDNJ-NJMS. Using a semiconductor mechanism that was developed by San Francisco-based Ion Torrent, the microchip tests the entire gene for mutations. IGM now offers this certified Clinical Diagnostic Laboratory service for hospitals as well as obstetrics and gynecology practices throughout the Garden State.

According to the Cystic Fibrosis Foundation web site, “More than 10 million Americans are symptomless carriers of the defective CF gene.” This chronic disease impacts the lungs and the digestive system. It occurs when a child inherits one defective CF gene from each parent.

“We believe the adaptation of this new sequencing technology will drastically improve our ability to analyze genetic disorders,” said Marvin N. Schwalb, PhD, director of the Institute for Genomic Medicine. “Traditional CF sequencing testing costs thousands of dollars making the test unavailable for carrier screening. This new test costs less than $200. Most importantly, the genetic carrier test we developed improves the diagnosis rate to 98 percent. While the test provides significant improvement for all populations, the improved rate is particularly valuable for minorities because current carrier screening methods only detects approximately 65% of mutations in these populations.”

The new technology provides many advances including the ability to test as many as 96 samples on a single platform and the fact that the equipment cost 1/10 as much as the previous technology.

IGM has developed another test, which was also approved by the NJHSS, for mitochondrial DNA. Mutations in mitochondria cause a wide variety of diseases, such eye and neuromuscular system disorders and possible cancer.

Schwalb, a professor of Pediatrics, Microbiology and Molecular Genetics at NJMS, said, “We are proud of the fact that the IGM is a world leader in the advancement of genetic diagnosis. DNA sequencing will keep us very busy for a while. In the state of New Jersey, there is nothing thatcompares to this advancement and this is just the beginning.”

To arrange an interview with Dr. Marvin Schwalb, contact Kaylyn Kendall Dines at 973-972-1216.

About NewJersey Medical School: Founded in 1954 as the Seton Hall College of Medicine and Dentistry, UMDNJ—New Jersey Medical School was the state's first medical school. Today, it is part of the University of Medicine and Dentistry of New Jersey. NJMS has four mission areas: education, research, clinical care, and community outreach. It has 22 academic departments and more than 60 centers and institutes. In addition to offering the MD degree to its students, NJMS also offers, MD/PhD, MD/MPH, and MD/ MBA degrees through collaborations with other institutions of higher education.

About the Institute for Genomic Medicine (IGM) at NJMS: The Institute for Genomic Medicine at New Jersey Medical School was created 21 years ago to provide leadership in the field of molecular genetics. IGM remains the largest provider of clinical genetic services in the State of New Jersey. In addition to IGM’s general clinic, additional specialty areas include: craniofacial, Sickle Cell, neurogenetics, and metabolic disorders.

Cory Booker: Newark, North Jersey score 'great victory' in UMDNJ takeover

By Kelly Heyboer and Steve Strunsky/The Star-Ledger NEWARK — The University of Medicine and Dentistry of New Jersey began preparing for the beginning of the end Monday.

After more than four decades as the state’s health sciences university, the Newark-based school is slated to be broken up under higher education restructuring legislation approved in Trenton last week. Most of UMDNJ’s schools will be taken over

by Rutgers University.

UMDNJ’s interim president joined Newark Mayor Cory Booker and Assembly Speaker Sheila Oliver (D-Essex) at a press conference on the Newark campus Monday where they put a positive spin on the takeover.

They said the changes, including some last-minute provisions slipped into the legislation at the request of Essex County

ticians, will help Newark and North Jersey in the long run.

"We knew we had a crisis, but we also knew we had an opportunity," Booker said. "We were able to achieve a great victory."

The legislation — called the New Jersey Medical and Health Sciences Higher Education Act — was approved by both houses of the Legislature on Thursday. It still needs to be signed

by Gov. Chris Christie, who supports the plan. Rutgers’ Board of Governors and Board of Trustees, which are still calculating what the merger will cost, must also sign off on the changes.

The act calls for Rutgers to take over nearly all of UMDNJ, including two of its medical schools, its dental school and most of its campus in Newark. UMDNJ’s schools will become part of August 2012

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University Hospital, UMDNJ’s teaching hospital in Newark, will remain a teaching facility. But it will separate from the university and become its own state-run entity. In South Jersey, UMDNJ’s School of Osteopathic Medicine in Stratford will be taken over

by Rowan University in Glassboro.

• The Rutgers-Newark campus will have more transparency in its finances. The state will appropriate money directly to RutgersNewark instead of relying on Rutgers’ main administration in New Brunswick to decide how much money goes to the campus.

Denise Rodgers, UMDNJ’s interim president, sent students, professors and members of the university community a letter last week detailing the takeover, which is slated to begin July 1, 2013. It will involve all 7,000 of UMDNJ’s students, as well as professors, staff, schools, buildings and the university’s debt.

• A new Rutgers-Newark advisory board will be created to help choose Rutgers-Newark’s chancellor, propose building projects and advise the Rutgers Board of Governors on the budget.

"As we move forward, we also recognize there are questions concerning the direct impact on each of you," Rodgers wrote to the community. "First, it is important to note that all of the schools, institutes and clinical units of UMDNJ will remain intact in this process."

• Amendments were added to the legislation to ensure University Hospital will continue to provide charity care for lowincome patients.

This is the third time state lawmakers have attempted to merge UMDNJ and Rutgers. The previous two attempts, under the McGreevey and Corzine administrations, failed partly because Essex County lawmakers fought to keep UMDNJ intact.

• The new chancellor overseeing the Rutgers School of Biomedical and Health Sciences will be based in Newark.

The original restructuring proposal had the backing of George Norcorss, the South Jersey Democratic power broker who helped push it through the Legislature because it would help build up the universities in Camden.

This time, UMDNJ officials did not resist the idea. North Jersey lawmakers were part of the intense last-minute negotiations to make changes to the restructuring bills in exchange for their support.

Oliver, the highest-ranking Democrat in the Assembly, threw her support behind the reorganization bill after the sponsors consented to some of the Newark changes. At Monday’s press conference, she rejected the notion that North Jersey lawmakers had merely made the best of a statewide restructuring plan designed to benefit South Jersey.

Among the concessions they won:

"No," Oliver said. "This is not turning lemons into lemonade."

UMDNJ–The University Hospital Pioneers Integrated High-Definition 3D Neurosurgical Operative Suite in New Jersey TrueVision® 3D High System, a teaching tool designed to improve patient safety, is the first of its kind to use both state-of-theart 3D microscopic and endoscopic systems to treat complex neurosurgical diseases.

NEWARK—Ana Cores, a 54-year old Hackensack resident, worried about how a sudden loss of peripheral vision would impact the quality of her life. After undergoing MRIs, eye exams and many diagnostic tests, Cores opted to visit UMDNJThe University Hospital where Dr. James K. Liu, a skull base neurosurgeon, and Dr. Jean Anderson Eloy, an otolaryngologist, used a new three- dimensional endoscope to remove a brain tumor through her nose that was pressing on her optic nerve and causing her to go blind.

The operating room (OR) at UMDNJ-The University Hospital is the first location in the state of New Jersey where both the TrueVision® 3D Surgical Visualization System and the Visionsense Vsii 3D Endoscope System have been installed.

This unique integrated 3D Neurosurgical Operative Suite is the first of its kind to use both state-of-the-art 3D microscopic and endoscopic systems to treat complex neurosurgical diseases.

Traditionally, during a neurosurgical procedure, only one or two surgeons observed the surgical field through the microscope in three-dimensions. Now, neurosurgical residents and other members of the operating room staff wear 3D glasses to view the surgical field on high-definition monitors in real time.

According to Charles J. Prestigiacomo, MD, FACS, chair of the Department of Neurological Surgery at New Jersey Medical School (NJMS), “This 3D technology is a valuable system for surgeons at The Neurological Institute of New Jersey, who are

20 New Jersey Physician

faculty members at New Jersey Medical School. Improving the surgeon’s depth of perception helps increase the level of precision. When it comes to training up-and-coming residents in neurological surgery, having the capability to demonstrate the depth of field when approaching complex surgeries and videotaping the procedure certainly has significant educational benefits.”

The TrueVision® 3D Surgical Visualization System is a real-time, stereoscopic, three dimensional high-definition visualization system that attaches to microscopes to display the surgical field of view on 3D flat panel (1080p) digital display monitors in the operating room. The advanced technology is used for microsurgery and to stream live video of the surgical field, making it an unparalleled teaching tool. The Visionsense Vsii 3D Endoscope allows the surgeon to perform 3D removal of skullbase tumors through the nose.

James K. Liu, M.D., a noted neurosurgeon and director of the Center for Skull Base and Pituitary Surgery at the Neurological Institute of New Jersey, is renowned for his treatment of complex brain tumors and skull base lesions. In addition to serving as one of Cores’ doctors, he is an active researcher, and an extensively published author of journal articles and textbook chapters. Liu, who has lectured throughout North America and has taught numerous hands-on courses in skull-base surgery, said, “TrueVision’s 3D high-definition technology provides me with an enhanced view of the surgical field that allows residents and operating room staff to see what I see, enabling them to anticipate my needs during a surgical procedure. This software and technology allow me to integrate the data collected before

faculty members at New Jersey Medical School. Improving the surgeon’s depth of perception helps increase the level of precision. When it comes to training up-and-coming residents in neurological surgery, having the capability to demonstrate the depth of field when approaching complex surgeries and videotaping the procedure certainly has significant educational benefits.”

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Nearly Half of All New Jersey Physicians Are Considering Changing How They Practice Medicine, Says Just-Released Survey

BY BRACH EICHLER New Jersey Health Care Monitor Reveals Practice Integration is the Choice for the Majority of New Jersey Physicians

September 24, 2012 (Roseland, NJ) -- The desire to reduce expenses and increase cash flow rank among the most important factors driving physicians in New Jersey to merge or otherwise modify their practice structure this year. According to Brach Eichler’s New Jersey Health Care Monitor survey, nearly 45% of physicians are considering changing how they practice medicine in 2012. The semi-annual survey was completed by more than 400 physicians statewide, including solo practitioners, members of a group practice or employees of a health care facility, in July and August 2012.

Specifically, 52.8% of respondents said they plan to integrate with another health care organization, whether it be another single specialty or multispecialty practice, an individual practice association, hospital system or joint venture. Another 33.9% said they plan to hire other practitioners, 12.8% said they will contract with a health care facility this year, 11.9% plan to leave their practice to either join another practice or work under contract with a hospital, and 14.7% said they plan to retire. Worth noting, 11% said they were leaving New Jersey to practice medicine elsewhere.

“Changing reimbursement rates, increasingly complex regulatory requirements and mounting competition from other states that offer a more physician-friendly business environment are all factors weighing on practitioners here in New Jersey. As a result, physicians are not only looking for ways to grow their practices, but simply to remain competitive,” explained John D. Fanburg, managing member and head of the health care practice at Brach Eichler.

“The move to integrate with another practice or other health care organization has become a very viable option for physicians looking to remain competitive, bolster market share and achieve greater purchasing power in the face of reduced reimbursement rates, and we are seeing more and more in our practice. What IS disappointing, however, is seeing that nearly 25% of practitioners either plan to leave New Jersey or retire, according to our survey. In today’s environment, unfortunately, a physician may feel greater pressure to retire because the business side of practicing medicine has become an overwhelming task,” Fanburg explained.

According to the survey, reducing expenses was the reason cited most often (31.7%) for merging or modifying their practice, while 25.1% cited the need to increase cash flow, 19.1% cited the need to bolster market share, 13.6% stated that they are pressured by competing organizations that are already integrating, and 10.4% cited the need to reduce inefficiencies as the reason for their desire to integrate their practices.

In addition, the New Jersey Health Care Monitor revealed that one-third of practitioners are taking a wait-and-see approach with regard to the Patient Protection and Affordable Care Act of 2012 in terms of how it will impact their practice. Less than 10% see its potential impact as favorable or very favorable, while nearly one-third have an unfavorable or very unfavorable outlook about its impact on their practice.

Worth noting, however, is the fact that a number of respondents

22 New Jersey Physician

Worth noting, however, is the fact that a number of respondents said they expected the Act’s mandate to purchase health insurance would lead to increased patient volume, and their practices would be busier as a result. Nearly the same number of respondents also expressed concern that this mandate would negatively impact reimbursement rates and revenue.

“More than anything, these divergent views underscore how much education is needed to help practitioners sift through yet another layer of regulation so that they can make sound decisions about how to maintain and build their practice,” noted Fanburg.

Other findings from the New Jersey Health Care Monitor include: - Nearly one-third of practitioners are currently considering or have already joined an Accountable care Organization (ACO).

- Income last year remained nearly the same over the prior year, with 47.8% of physicians confirming this. More than 36% said their income declined last year and approximately 16% said it actually increased.

- Nearly 30% of practices do not yet have a corporate compliance plan though they will shortly be required to have one as the Affordable Care Act. - The majority of New Jersey physicians (57.2%) would not recommend to a family member that they pursue a career in medicine.

“In 2013, we expect to see accelerated reductions in reimbursement rates. As a result, more small group practices and solo practitioners will look to affiliate themselves with either hospitals or other group practices in an effort to survive,” said Fanburg. “Sadly, too, we will surely see more physicians leaving New Jersey or the practice of medicine altogether as a result of these regulatory and competitive pressures, which will also impact patient choice and the delivery of care. New Jersey has long prided itself on its internationally-recognized health care practitioners and institutions. It would be terrible to lose some of these phenomenal resources.”

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.

Medicare Cuts Could Have NJ Healthcare Hemorrhaging Jobs Automatic reductions in the federal budget, scheduled to kick in this January, could do some serious damage to the state's hospitals and private practices

By Hank Kalet New Jersey could lose more than 14,000 jobs next year and nearly 22,000 jobs by 2021 if a 2 percent cut in Medicare spending mandated by a 2011 federal budget bill goes into effect.

That projection comes courtesy of a recent report produced by consulting firm Tripp Umbach for the American Hospital Association, the American Medical Association, and the American Nurses Association. It looked at baseline figures issued by the Congressional Budget Office that placed the total cuts to the Medicare program at $10.7 billion next year, climbing to $16.4 billion in 2021.

The cuts are mandated by the federal Budget Control Act, a compromise measure passed by Congress that ended a stalemate over increasing the federal debt limit. The bill created a set of budget caps to cut federal spending by $1 trillion over a 10-year period ending in 2021 and created a joint committee charged with cutting the federal budget deficit by an additional $1.2 trillion.

jobs in the real estate industry and 21,865 in food service.

New Jersey would see the 10th highest loss in jobs, according to the report, which does not break down state figures by business sector.

In addition, McKnight’s, a magazine that focuses on the longterm care industry, says that sequestration would cost skilled nursing facilities $782.5 million in 2013. The cuts to nursing facilities, outlined in an analysis by Avalere Health and the Alliance for Quality Nursing Home Care, could cost the industry about $9 billion over 10 years. New Jersey would see the sixthhighest loss in funding, according to the report.

Direct Impact on NJ Healthcare Kerry McKean Kelly, vice president for communications and member services for the New Jersey Hospital Association, said the reimbursement cuts and job losses would have a “direct impact on healthcare services.”

The Joint Select Committee on Deficit Reduction -- known as the Supercommittee -- reached an impasse in November 2011 and has not been able to agree to cuts. That means a set of automatic cuts, known as sequestration, is scheduled to be triggered in January.

The report shows that there will be “resulting job losses, which creates an access-to-care problem for patients and then a significant downstream impact to the economy,” she said. “The big concern is that these cuts come on top of big cuts industry is already forced to absorb from the Affordable Care Act.”

The across-the-board cuts include 8.4 percent in most nondefense discretionary programs, 7.5 percent in defense, 8 percent in mandatory programs other than Medicare, and 2 percent in Medicare provider payments.

The ACA, the health-reform law passed in 2010 and upheld over the summer by the U.S. Supreme Court, imposed spending reductions on Medicare between 2011 and 2020. The savings come in the form of reduced payments to providers through Medicare Advantage and by cracking down on waste and fraud.

The Tripp Umbach report focused solely on the Medicare cuts and said they would have a direct impact on the healthcare sector and an indirect impact on other sectors of the economy.

• Direct Impacts, which include job cuts in the health sector and those caused by the loss of spending by health agencies, employees, and consumers, such as the purchase of office supplies, uniforms, and food service and money spent on rent;

“Hospitals just can’t take the added burden of deficit reduction cuts that we are looking at,” McKean Kelly said. “Under the Affordable Care Act, the whole premise is that we need to do something very different to make healthcare sustainable for the future. There is a big emphasis on efficiency, quality of care, and insuring more people. If we do those three things well that will produce the savings.”

• Indirect Impacts, or jobs lost regionally caused by reduced spending by those firms that do business with the health sector; and

Hospitals are adopting models to meet those goals, she said, by integrating into larger systems, moving to electronic medical records, and finding ways to better coordinate care.

• Induced Impacts, which is the overall response within the economy to job and income losses.

“But under the sequestration cuts, there is no balancing act,” she said. “It is a flat-out cut, and it is hard for organizations that are trying to work very lean to cut any further.”

The report breaks the impacts down into three categories:

According to the report, 211,756 jobs across the U.S. will be lost in 2013 as a direct effect of the Medicare cuts, with another 88,453 in indirect effects, and 196,222 in induced effects, for a total of 496,431 lost jobs.

The Burden on Hospitals The greatest impact would be felt by hospitals, with 92,984 jobs being lost nationally in 2013, while medical offices are projected to lose 40,220, nursing facilities 38,115, and medical labs and other outpatient services likely to lose 38,350.

Losses in nonmedical sectors are projected to include 22,705

Consumer groups also are concerned about the Medicare cuts.

Jeff Brown, policy director for New Jersey Citizen Action, said the report’s findings “are not really surprising.” The sequestration cuts, he said, balance the federal budget “on the backs of seniors and working families.”

“It is proof that cutting Medicare is not only bad for seniors, but it is bad for the economy,” he said. “Medicare is one of great policy achievements in American history, and I hope it is a priority of both parties to preserve it."

August 2012

23

NJ Physicians Look to Join ACOs, Large Group Practices

Decreasing reimbursement, complex regulations drive need to merge

By Mary Barr Mann Some New Jersey physicians may not think all that favorably of the Affordable Care Act, but they are looking to one of its mechanisms to deal with rising overhead, changing reimbursement rates, and other issues.

That's one of the findings of a survey of more than 400 Garden State physicians published by the New Jersey Health Care Monitor.

The survey documents the various ways that the ACA is affecting in-state physicians who are solo practitioners, members of a group practice, or employees of a healthcare facility. These trends include merging with other practices, deciding to practice in another state, and signing on with Accountable Care Organizations (ACOs) -- regional consortiums that team doctors and hospitals to improve patient healthcare and reduce wasteful spending.

Who's Afraid of the ACA? Nearly half of the respondents (48 percent) have a very dim view of the ACA. That tally includes 14 percent that want to see it repealed.

About 10 percent regard the legislation favorably.

What may be most surprising is that almost 33 percent of respondents are taking a wait-and-see attitude toward a law that will directly affect their professional (and possibly their personal lives). Another 6 percent are "not sure" what effect the ACA will have on their practices.

Perhaps the most disheartening finding is that the majority of New Jersey physicians (57.2 percent) said that they would not recommend to a family member that they pursue a career in medicine.

Mergers and Changes According to the survey, the desire to reduce expenses and increase cash flow rank among the most important factors driving New Jersey physicians to merge or otherwise modify their practices this year.

Specifically, 52.8 percent said they plan to integrate with another healthcare organization -- such as a single-specialty or multispecialty practice, an individual practice association, a hospital system, or a joint venture. Another 33 percent said they plan to hire other practitioners; 12.8 percent said they will contract with a healthcare facility this year; 11.9 percent plan to leave their practice to either join another practice or work under contract with a hospital, and 14.7 percent said they plan to retire.

Saying Goodbye to Garden State The survey also reports that 11 percent of respondents said they were leaving New Jersey to practice medicine elsewhere.

John D. Fanburg, managing member and head of the healthcare practice at Brach Eichler, the Roseland law firm that conducted the survey, said that both Pennsylvania and New York hold advantages over New Jersey.

“In New York there are more payers, the reimbursement is

24 New Jersey Physician

Survey Conducted in July and August 2012.

pay less because it is perceived to not require or demand higher reimbursement, and in some geographical areas there are a lot of providers, so it’s a supply-and-demand issue.”

Fanburg continued, “Pennsylvania has tort reform law, but they do not have as many payers. However, the cost of living is less unless you are in the Pittsburgh or Philadelphia area. Overhead is lower, so the margin of profit is greater.”

Looking at ACOs Regardless of what they may think of the ACA, nearly one-third of practitioners are currently considering or have already joined an ACO. They're making this move for a variety of reasons: Some are reacting to increasing regulation and decreasing reimbursements. Others are looking to cut cost or believe that being a member of a team will boost their competitiveness.

Fanburg explained that ACOs -- according to the Affordable Care Act -- were not merely about containing costs. Rather, “the idea was to compel physicians to agree to reimbursement tied into the quality of care being rendered as opposed to the amount of care being rendered.”

“When you are in a larger group with horizontal and vertical providers, he noted, "you can have more impact on the course of treatment.”

“In a hospital setting you could see half a dozen different specialists. You need a physician who is overseeing the care of all the patients. There is a certain amount of coordination necessary in order to have a plan in place when patients leave the hospital, to keep the patients out of the hospital.”

Fanburg said that the ACO is supposed to provide “the mechanism to enhance and reward that kind of coordination with economic incentives.”

“We’ve been advising our physician clients to consider being with larger groups. It’s very hard for the solo or two-person practice.”

Guidelines for ACOs are outlined under the Medicare Shared Savings Program of the Affordable Care Act. Behind the Curve on Merging Fanburg said, “Physicians on the West Coast have been moving into larger groups for years,” but in New Jersey, “many physicians still operate in small group formats of five or fewer physicians in a practice.”

“Physicians really need to rethink how they practice medicine.”

Fanburg also indicated that initial New Jersey Health Care Monitor survey is a “baseline” survey and that Brach Eichler plans to perform the survey twice annually going forward.

“We’ve been doing more informal surveys over the years. But this is the first with specific questions [for physicians] and casting such a wide net throughout New Jersey.” The new survey focuses on the physician for a reason, he explained.

“We have some of the best healthcare offered on the planet in New Jersey, but it comes down to the doctor. For the first time in New Jersey, we are trying to think of the physicians.”

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