JULY 2012
JULY 2012
Visit us now online at
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Rotolo, Howard & Leitner Urologic Associates The Physicians of This Innovative Practice Speak Out on the PSA Screening Controversy and Other Timely Developments Within the Specialty
Also In This Issue: CMS Proposed Rule Would Increase Payment To Family Physicians Missouri Supreme Court Overturns Malpractice Caps- How Will This Impact NJ? How To Register For The New Jersey Medical Malpractice Program As A Provider
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Welcome to the July issue of New Jersey Physician Magazine, and thank you to those readers who have responded to “opting in” to receive your monthly copy by email. If you haven’t responded yet and do elect to get your copy digitally, please just send me an email at mgoldberg@njphysician.org and you will be added to the list.
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The Centers for Medicare and Medicaid Services have issued a proposed rule which would result in an increase of payment for family physicians by approximately 7% and between 3% and 5% for other practitioners. The potential increase would result from updated payment policies and rates under the Medicare Physician Fee Schedule for calendar year 2013.
John D. Fanburg, Esq.
In a case that will most likely affect every physician in the US, the Missouri Supreme Court ruled that the state Legislature’s $350,000 cap on noneconomic medical malpractice damages is an illegal violation of residents’ constitutional right to a trial by jury. A coalition of community and consumer advocates, labor unions and health insurers is calling on Gov. Christie to sign legislation requiring all hospitals in the state to disclose their finances as a condition for receiving charity-care payments from the state, a bill the hospital association says will prevent for-profit firms from buying failing hospitals. Interested in having the ability to prescribe medical marijuana? If so, you will need to file an application with the state. Directions for doing this can be found inside this issue. Our cover story this month features Rotolo, Howard and Leitner Urologic Associates. By incorporating the latest medical and surgical techniques and evidence-based practices, the physicians of Urologic Associates stay on top of emerging information regarding the most effective treatments for the entire gamut of urologic disorders. Additionally, we report on Dr. Rotolo’s thoughts regarding the USPSTF’s recent opinion regarding PSA screening. In short, he feels survivability of patients with prostate cancer is better now (90%) due primarily to earlier diagnosis, and not revolutionary changes in treatment.
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Contents
Rotolo, Howard & Leitner Urologic Associates
The Physicians of This Innovative Practice Speak Out on the PSA Screening Controversy and Other Timely Developments within the Specialty
CONTENTS 10 HEALTH LAW UPDATE 14 11
NATIONAL NEWS
15
12
STATEHOUSE
16
HOSPITAL NEWS / HOSPITAL ROUNDS
HOSPITAL ROUNDS / NJ HEALTH CARE NEWS
FOOD FOR THOUGHT ANGELONI’S RESTAURANT & PIZZERIA CALDWELL, NEW JERSEY
2 New Jersey Physician
Cover Story
Rotolo, Howard & Leitner Urologic Associates The Physicians of This Innovative Practice Speak Out on the PSA Screening Controversy and Other Timely Developments within the Specialty
Figure 1
By Iris Goldberg The good news is that we are living longer. A current concern, however, is whether our healthcare system can keep up with the ever-growing demand. As our population ages, many specialties are challenged to meet the needs of the increased number of older patients while continuing to provide exemplary care to younger patients as well. This is particularly true within the field of urology. Many urologic conditions such as prostate cancer, bladder cancer and urinary incontinence, to name a few, become more prevalent as we age. Yet problems such as testicular cancer, sexual dysfunction and infertility, for example, are still problems faced by some younger adults. For patients in Monmouth and Ocean counties, Rotolo, Howard & Leitner Urologic Associates continues to evolve in order to provide the highest quality of urologic care to men and women of all ages. By incorporating the latest medical and surgical techniques and evidencebased practices, the physicians of Urologic Associates stay on top of emerging information regarding the most effective treatment for the entire gamut of urologic disorders. (See Fig. 1) James E. Rotolo, MD, FACS, who is Chief of Urology at Ocean Medical Center, is the founder of the practice and has significant expertise in all aspects of urologic care. He was joined in 1997 by Michael L. Howard, MD, FACS, who treats the complete spectrum of urologic disorders and prioritizes the importance of developing skills to enhance communication with patients. Next to join Urologic Associates was Robyn R. Leitner, MD, FACS, who, in addition to practicing all areas of urology, specializes in female urology, urinary incontinence and pelvic prolapse. The newest member of the practice is Mark A. Perlmutter, MD. Besides his expertise in managing patients with
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Overview of Urologic Conditions Treated at Urologic Associates Adrenal Mass or Nodule
Overactive Bladder
Bladder Stones
Pelvic Pain Syndromes
Bladder Tumors
Penile Cancer/Disorders
Bladder Prolapse
Prostate Cancer
Circumcision
Prostate Enlargement (BPH)
Hematuria
Prostate Infections
Hydrocele
Sexual Dysfunction
Hydronephrosis
Testicular Infections
Hypogonadism (Low Testosterone)
Testicular Mass
Interstitial Cystitis
Testicular Pain
Kidney Cysts
Urinary Incontinence
Kidney Infections
Urinary Retention
Kidney Stones
Urinary Symptoms/Problems
Kidney Tumors
Urinary Tract Infections
Male Infertility
Vasectomy
Neurogenic Bladder
Vasectomy Reversal
Dr. Rotollo, Chief of Urology, Ocean Medical Center and founder of Urologic Associates, in surgery.
all urologic conditions, Dr. Perlmutter underwent specialized training in robotic surgery at Henry Ford Hospital in Detroit, Michigan under the direction of Dr. Mani Menon, who is one of the pioneers and foremost authorities on robotic surgery worldwide. Perhaps one of the most controversial discussions taking place in today’s healthcare arena, concerns the recommendations on PSA screening for prostate cancer. The most recent statement from the United States Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer, citing that “there is a very small potential benefit and significant potential harms.” This refers to the risks associated with aggressively treating prostate cancers, especially those that could effectively be managed with a “watch and wait” approach. While Dr. Rotolo agrees that some prostate cancers are over-treated, he strongly disagrees with the idea of eliminating routine PSA-based screening. “I’ve been around long enough to remember treating prostate cancer patients in the prePSA era,” he shares. “At that time it was not unusual to see patients dying painful, slow, miserable deaths. Nowadays, if you’re diagnosed with prostate cancer, your curability rate is over ninety percent,” Dr. Rotolo adds. He believes, that to a great extent, survivability is better, due primarily, to heightened public awareness and earlier diagnosis, rather than to revolutionary changes in treatment regimens.
Dr. Rotollo performs the GreenLight procedure to alleviate symptoms of benign prostate disease (BPH).
“PSA testing itself should not be controversial,” Dr. Rotolo adamantly states. “PSA testing is simple, it’s safe and along with a digital rectal exam, it markedly improves screening for prostate cancer. PSA testing does not necessarily lead directly to treatment for prostate cancer and that’s
of 6 or lower and no core with greater than 50% involvement, is a good candidate for active surveillance, during which the PSA is followed closely along with periodic repeated biopsies to see if there has been an upstaging of disease.
GreenLight uses laser energy to remove enlarged prostate tissue, resulting in an open channel for urine to flow through and a quick return to a life that’s free of BPH symptoms.
where there is a communication breakdown,” he points out. When PSA test results are concerning, Dr. Rotolo explains that a biopsy would most likely be performed to determine if there is cancer. Then the biopsy results can provide the information to determine if the cancer should be treated and if so, how it should be treated. “What a lot of people fail to grasp is that prostate cancer is a very heterogeneous disease,” Dr. Rotolo remarks. “Prostate cancer comes in many different grades and stages and to presume that it is not necessarily worth treating before having all of the information is very dangerous,” he strongly warns. Dr. Rotolo discusses the evolving prostate cancer treatment philosophy embraced within the medical community today. “We’re using the protocols of watchful waiting and active surveillance much more today than we have in the past,” he says. PSA screening does not necessarily lead to treatment. PSA screening may lead to a biopsy and the biopsy is what will help us to determine whether and how to treat the patient,” reiterates Dr. Rotolo.
For those patients who don’t qualify for active surveillance, the treatment options are hormonal therapy, radiation therapy or prostatectomy (surgery to remove the prostate). A metastatic work-up, including CT and bone scans may be needed to ascertain whether or not the cancer has spread beyond the prostate. When a patient is found to have a low volume and low to moderate grade of clinically localized disease, the only treatments that are potentially curative are radiation therapy and surgery. For older patients who want to avoid surgery, radiation is certainly an appropriate option. When a patient who meets these criteria is comparatively young, fit and in good health, however, Dr. Rotolo almost always recommends surgery over radiation therapy. Even though radiation therapy can eradicate the cancer, Dr. Rotolo reasons that in a younger man, who is obviously predisposed to prostate cancer, it could be a mistake not to remove the entire prostate. If a new prostate cancer develops 10 or 15 years down the road, radiation therapy could not be repeated. Furthermore, performing surgery on tissue that was previously irradiated is much more difficult than operating on virgin tissue, as he explains. “With a well done prostatectomy, whether it’s done open or robotically, if the margins are negative at the time of surgery, the patient’s prostate cancer is essentially in his rear-view mirror, Dr. Rotolo states. “He has very, very low risk of recurrence,” he adds.
Upon receiving biopsy results that are positive for prostate cancer, Dr. Rotolo and the other physicians at Urologic Associates use the information to make a treatment decision based on the grade and stage of the disease in that particular individual. “Someone with minimal volume of low to moderate grade disease may not need to be treated at all,” informs Dr. Rotolo. He goes on to explain that a patient with 2 or fewer positive cores out of the 12 or more that were tested, a Gleason’s score
Dr. Perlmutter, seated at the controls of the daVinci robot performing a prostatectomy.
July 2012
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The daVinci system translates Dr. Perlmutter’s large hand movements into precise, minute movements inside the patient. It provides 3-D imaging, along with minimal blood loss which allow for maximized, clear vision of the surgical field.
Prostate cancer patients at Urologic Associates who opt for the robot-assisted laparoscopic prostatectomy have their procedures performed by Dr. Perlmutter, an expert in da Vinci™ robotic surgery. In fact, all robotic surgeries at Urologic Associates are currently performed by Dr. Perlmutter. The da Vinci system translates the large hand movements of the surgeon into precise, minute movements inside the patient. It provides 3-D imaging, along with minimal blood loss which allow for maximized, clear vision of the surgical field. Dr. Perlmutter, who was trained in both open and robotic surgery and is quite comfortable with either, discusses both approaches for prostate removal. “Overall, the outcome in terms of the cancer is the same for both. The survival rate, the positive margin rate, the recurrence rate are all equivalent between the two,” he reports. “The overall urinary continence rate and erectile function postoperatively, are also similar between the two,” Dr. Perlmutter has found. “The main advantage of robotic surgery is there is significantly less blood loss. There is a significantly lower risk of needing a blood transfusion. There is also significantly less pain, post-operatively and there is a significantly faster recovery time,” he distinguishes. Dr. Perlmutter utilizes the da Vinci technology to perform other urologic surgeries, as well. One procedure which Dr. Perlmutter explains is tremendously beneficial over the open surgery, when done robotically, is partial nephrectomy for the treatment of kidney tumors. He relates that the traditional open approach is a complex and invasive procedure. “The traditional procedure requires a
6 New Jersey Physician
large incision along the rib cage on the patient’s flank that is extremely painful and requires hospitalization for a number of days,” Dr. Perlmutter shares. “Traditionally, surgeons sometimes would even remove a portion of the rib to do that procedure and it is not uncommon to create a small injury into the lung cavity during that traditional open surgery,” he continues. “Robotic surgery completely avoids all of those risks. The pain is minimal. In fact, I’ve had patients tell me that they really have no pain and I’ve had to actually caution them to slow down after surgery,” states Dr. Perlmutter.
In these images of robotic ureter reconstruction, the blue vessel loops are around the ureter both above and below the area of ureteral injury. Note the metal surgical clip in the middle of each picture. The metal instrument coming from the bottom of 3 of the 4 images is pointing towards the metal clip. This was the surgical clip placed directly across the ureter by another surgeon that had caused the injury. Dr. Perlmutter was able to repair it robotically by dissecting the ureter both above and below the injury. He then resected the injured ureter and reattached the healthy edges of ureter directly.
and invasive when performed with an open approach that, when done robotically, is a minimally invasive procedure. “Doing these procedures laparoscopically, without the robot, would be very challenging, technically,” Dr. Perlmutter confides. “Robotics allows all of these complex procedures to be performed minimally invasively, with all of the advantages associated with that,” he is pleased to share. Besides prostatectomy, partial nephrectomy and pyeloplasty, another procedure that Dr. Perlmutter performs robotically is total nephrectomy in which the entire kidney is removed. Also, he was one of the first in the state of New Jersey known to do a ureteral reconstruction robotically for ureter trauma. The addition of the robot to enhance the surgeon’s ability to perform certain urologic procedures, such as radical prostatectomy, with a minimally invasive laparoscopic approach has certainly become increasingly more prevalent. There are times, however, when handassisted laparoscopic surgery might be performed by the physicians at Urologic Associates.
Robotic pyeloplasty is another procedure that is far less risky than the traditional open surgery. Pyeloplasty is indicated for an obstruction of the uteropelvic junction (UPJ), which is the portion of the collecting system that connects the renal pelvis to the ureter. The blockage, usually caused by scar tissue or a crossing blood vessel, prevents the urine from draining properly. This can lead to progressive dilation of the renal collecting system and can ultimately result in deterioration of kidney function. To treat this condition, Dr. Perlmutter incorporates the robot to remove the diseased portion and then reconstruct the ureter and re-connect it to the kidney to allow proper drainage of urine. He points out that this is another example of a surgery that is extremely complex, painful
Dr. Leitner views the monitor while performing cystoscopy on a patient with recurrent bladder cancer.
When cancer is found in the bladder it is resected at the time of the finding. Unfortunately, the recurrence rate for bladder cancer can be as high as two out of three. In one out of three patients, the cancer can actually progress to a higher grade and stage of disease. Therefore, the physicians at Urologic Associates employ various strategies to help reduce the recurrence rate and also to help find the recurrences at a very early stage.
Dr. Howard uses laser technology to remove a large stone located in this patient’s bladder.
The set-up, anesthesia and equipment are the same in a hand-assisted laparoscopic case as in a pure laparoscopic case. Blood loss, length of hospital stay and recovery time is similar as well. The difference involves the creation of a small incision just large enough to place the surgeon’s hand. A gel port is placed in this incision. It creates an air tight passageway for a surgeon’s hand. This addition allows the surgeon the best of both worlds. Laparoscopic magnification and instrumentation may be used in combination with a hand in the operating field. Dr. Howard discusses using this technology (which is appropriate when comparatively larger specimens require removal), to perform partial and total nephrectomies, where the entire kidney can be pulled out through the incision where the surgeon’s hand is placed. “Using a hand and one laparoscopic instrument as opposed to a purely laparoscopic approach really allows the procedure to happen a little more quickly and safely,” Dr. Howard explains.
ers, is a significant concern within that population. Also, increased incidence of bladder cancer has been found in some diabetic patients who are taking the medication ACTOS. At Urologic Associates, the physicians employ the most current modalities to diagnose and treat bladder cancer in order to achieve excellent longterm outcomes. Dr. Rotolo shares that when microscopic hematuria is present in two out of three urinalyses, or when there is any gross hematuria, the patient should be evaluated. At Urologic Associates, this would include a renal ultrasound to show the contour of the kidneys, followed by cystoscopy and retrograde pyelogram for direct visualization of the bladder and inspection of the entire urothelium (epithelial lining of the urinary tract, including bladder, ureters and kidneys).
Typically, patients who have had bladder cancer will go on a protocol in which they will undergo cystoscopy every three months for a period of two years. If they remain cancer-free after two years, they will be scoped every six months for two years. If after that period of time they are still cancer-free, they will have cystoscopy annually with periodic retrograde pyelograms. “If a patient is diagnosed with multiple tumors, a large tumor or a high grade or stage tumor, then what we do additionally, is begin treatment with BCG, which is a living but weakened strain of the tuberculosis bacteria,” explains Dr. Rotolo. “It is inserted into the bladder in six weekly treatments and it causes an immune reaction in the bladder that helps to reduce the recurrence rate as well as the progression rate,” he elaborates. Occasionally, additional treatment measures may be employed, such as instillation of Interferon, for refractory, localized bladder cancers. While many patients are treated by the physicians at Urologic Associates for cancerous conditions, a great number of patients suffer from non-cancerous disorders that also diminish the quality of
He goes on to share that when there is a tumor in the ureter, hand-assisted laparoscopic surgery can be used to perform nephroureterectomy, in which the ureter, kidney and a cuff of bladder are removed in order to minimize the chance of recurrence. This allows for a smaller incision and quicker recovery without sparing the quality of the result. With more senior citizens alive today than at any other time in our history, bladder cancer, which usually strikes those over the age of 60, especially former smok-
Cystoscopy provides the surgeon with direct visualization of the bladder.
July 2012
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Interstim modulates sacral nerves with mild electrical pulses.
one’s life. Urinary incontinence and/or significant symptoms of urgency or frequency are devastating, to say the least. At Urologic Associates the physicians offer the latest advancements in technology to treat patients and help them get back to enjoying life again without the constant worry of bladder control. InterStim Therapy involves the placement of a small neurostimulator in the patient’s upper buttock during a minimally invasive same-day procedure. The sacral nerves, which are located near the tailbone, control the bladder and muscles related to urinary function. If there is miscommunication between the brain and the sacral nerves, normal bladder function is interrupted. InterStim modulates the sacral nerves with mild electrical pulses. This helps restore communication between the brain and the nerves, allowing the bladder and related muscles to function properly.
as well. Dr. Leitner, who is, quite possibly, the only female urologic surgeon practicing within Monmouth and Ocean Counties, sees a significantly large number of female patients and many women who struggle with this problem.
the depletion of vaginal estrogen. “Estrogen keeps the pelvic floor healthy and I see a lot of women who think they have a urinary tract infection when actually it’s just a post-menopausal lack of estrogen,” Dr. Leitner reveals.
“I do a lot of incontinence work with women and this has become one major focus of my practice” Dr. Leitner reports. She performs the InterStim procedure and also provides medical therapy for her patients who suffer from over-active bladder. For women who have stress incontinence, Dr. Leitner often uses the SLING, which is actually a small strip of tape material that she places underneath the urethra to provide support when a woman coughs or sneezes.
Dr. Leitner is thrilled to report that currently the numbers of male and female urology residents are about equal. She feels certain this will positively impact on the experience that women will have when being treated for urologic conditions. In fact, Dr. Leitner is quite optimistic about the developments in urology in general.
Pelvic floor prolapse is another condition that affects some women as they age. Dr. Leitner explains that when there is a defect in the support tissue that keeps the bladder, uterus and rectum up, there can be some protrusion. “There is excellent support tissue repair today that is minimally invasive and provides maximum benefit,” Dr. Leitner is pleased to share. She relates that patients need only one night in the hospital after the procedure, which is virtually painless. Presently, male urologists outnumber female urologists by far and Dr. Leitner agrees that some women may not feel comfortable discussing certain issues with a male physician. She cites the problems
“I think it is a very good time right now. We have a lot to offer both men and women who are having urological issues. Whether it’s medication-based or surgery-based, we have a lot to offer nowadays that we didn’t have even ten or fifteen years ago. It’s just a really nice time to be in urology right now,” she remarks. Dr. Rotolo, Dr. Howard and Dr. Perlmutter could not agree more and share Dr. Leitner’s extremely positive outlook. Undoubtedly, present and future patients who are treated at Urologic Associates will benefit, not only from the expertise that the physicians have amassed but also, from their delight in helping patients regain health and a better quality of life. For more information or to schedule an appointment, please call (732)223-7877 or visit www.newjerseyurologists.com
Dr. Howard was one of the first urologic surgeons in the area to offer the InterStim technology to patients. “There are benefits for males and females for frequency and urgency, who do not respond to medical therapy, as well as unobstructed urinary retention,” Dr. Howard offers. “So for example, a diabetic patient who has lost bladder function as the result of diabetes would traditionally have been offered an in-dwelling catheter or intermittent catheterization. InterStim has really been very effective for a large portion of that population in getting them to better empty their bladders,” he shares. Stress incontinence and over-active bladder are often experienced by women, especially as they age, although overactive bladder can occur in young women
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Interstim therapy involves the placement of a small neurostimulator in the patient’s upper buttock.
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July 2012
9
HEALTH LAWUpdate Health Law Update
CMS Proposed Rule Would Increase Payment to Family Physicians
CMS Will Be Accepting Additional Applications for Advanced Payment Model ACOs
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 6, 2012, which would result in an increase of payment for family physicians by approximately 7% and between 3% to 5% for other practitioners. The potential increase would result from updated payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013. Under the MPFS, Medicare pays more than one million physicians and non-physician practitioners providing vital services to Medicare beneficiaries.
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 proposed rule would change several quality reporting programs associated with the MPFS – the Physician Quality Reporting System (PQRS) and the Electronic Prescribing Incentive Program (eRx) – as well as the Medicare Electronic Health Records Incentive Pilot Program which promotes the use of health information technology. The PQRS proposal includes simplified, lower burden options for reporting and aligns quality reporting across the various programs in support of the National Quality Strategy. CMS will accept comments on the proposed rule until September 4, 2012, and will respond to them in a final rule to be issued by November 1, 2012. For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com
Visit us now online at
www.NJPhysician.org 10 New Jersey Physician
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-andcoordinated-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
National News
Mo. Supreme Court overturns malpractice caps By Joe Carlson Overturning decades of prior legal rulings, the Missouri Supreme Court ruled this week that the state Legislature's $350,000 cap on noneconomic medical malpractice damages is an illegal violation of residents' constitutional right to a trial by jury. A divided court on Tuesday overturned (PDF) the court's own 20-year-old decision to uphold caps on noneconomic damages, ruling that "while this court always is hesitant to overturn precedent, it nonetheless has followed its obligation to do so where necessary to protect the constitutional rights of Missouri's citizens." The court ruled that the mother of Naython Watts, who was born in 2006, was entitled to the full $1.45 million in noneconomic damages that a jury awarded her after concluding that physicians for Cox Medical Centers provided negligent care that led to disabling brain injuries in the child. A trial court judge reduced the verdict to $350,000 after the jury decision, as required by state law. Mother Deborah Watts appealed, saying the caps violated the state constitution. Attorneys for Cox Health argued in court that a 1992 decision from the Missouri Supreme Court, Adams By and Through Adams vs. Children's Mercy Hospital, had already
upheld the constitutionality of 2005 tort reforms limiting medical malpractice awards for claims such as pain and suffering. But writing for the majority on Tuesday, Chief Justice Richard Teitelman said Adams was wrong and overruled it, citing similar court decisions to overturn legislative malpractice damage caps in states such as Washington (1989), Oregon (1999), Alabama (1991) and Florida (1987). Specifically, Teitelman said, the state's 1820 constitution grants citizens an "inviolable right" to a trial by jury for noneconomic damages in medical malpractice cases, and the cap on damages violated that right by removing a jury's ability to decide the magnitude of damage done to a litigant. In an e-mailed statement, Cox Health officials said they were disappointed in the decision. "Nearly every physician and every hospital in the state will be adversely affected by this ruling," Cox Health said in the statement. "Our greatest concern lies with how this will affect physicians in our state."
July 2012
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Statehouse
NEW JERSEY STATEHOUSE Will Governor Sign Hospital Financial Disclosure Rules? NJHA opposes the law saying it would chill purchases of failing NJ hospitals by for-profits By Hank Kalet, A coalition of community and consumer advocates, labor unions and health insurers is calling on Gov. Chris Christie to sign legislation requiring all hospitals in the state to disclose their finances as a condition for receiving charity-care payments from the state, a bill the hospital association says will prevent for-profit firms from buying failing hospitals. Advocates say the legislation, S782/ A2143, would level the playing field for non-profit and for-profit hospitals by making profit-making hospitals play by the same financial disclosure rules already in place for the non-profits. The Health and Allied Employee union, which represents hospital workers, is asking people to sign a petition showing their support for the bill. The New Jersey Hospital Association opposes the bill. “From a consumer accessto-care perspective, this would have a chilling effect on new hospitals coming into the state,” said Kerry McKean Kelly, vice president of communications and member services. The legislation, called the “New Jersey Hospital Disclosure and Public Resource Protection Act,” ties charity-care payments to disclosure of financial and governance information. The bill, which has passed both houses of the state Legislature and awaits action by the governor, requires all hospitals that receive charity care to report their funding sources and revenues, their expenditures, the vendors they deal with, and who sites on corporate boards to the state Department of Health and Senior Services. Non-profits already submit this information to the federal Internal Revenue Service, but not to the state. For-profit facilities have no such requirement.
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Seven of the states’ 72 acute care facilities have been taken over by for-profit firms, with five of these transfers occurring within the last five years. Another three or four purchases are under consideration. All of them are taking over existing facilities. Advocates say the growing presence of for-profit hospitals, coupled with the lack of transparency, leaves public officials in the dark when making decisions about the use of public money and puts communities at risk. “The need is pretty simple,” says Jeff Brown, the policy and communications coordinator for New Jersey Citizen Action. “You have a situation in New Jersey where a lot of for-profit companies are coming in and buying up what were nonprofit hospitals in communities that need hospitals. They are using questionable business practices, questionable business models and they are not providing the same community benefit.” Public oversight is difficult because the for-profits are not required to disclose the same kind of information publicly required of the non-profits, he said. That’s why there is a need to require transparency. “We’re not looking to target for-profit companies,” Brown says. “We’re just asking that they be held to same standards as their non-profit brethren.” For-profit companies, he said, are “assuming valuable community assets that have built over time with community effort and funding and the public should be able to see if they are providing that community benefit.” The bill passed both houses of the state Legislature with bipartisan support -- 32-4 in the Senate and 49-22 in the Assembly.
It awaits action by the governor, who has until Aug. 16 to act. Sean Conner, a spokesman for the governor’s office, said the governor would not comment. “The governor’s office does not comment on legislation currently being reviewed by our counsel’s office while it awaits the governor’s action.” State Sen. Loretta Weinberg (D-Bergen), a prime sponsor of the bill, said she is optimistic that the governor would sign it into law, even though she has not talked with him about it. “We are seeing a growth in for-profit hospitals, which function with a large amount of taxpayer money in charity care, Medicaid and Medicare payments,” she said. “It seemed simple to level the playing field and to require you, as a for-profit, to give the same information that your not-forprofit brothers and sisters give.” Jeanne Otersen, policy director for the Health Professionals and Allied Employees union, also is hopeful that the governor will sign the bill. “The governor has talked over and over again about transparency and accountability for taxpayer dollars,” she said. “He has talked about how the government should be accountable in how it spends taxpayer money and transparent in how it is spent. Given everything he talks about, the governor should sign this bill to show he believes it.” Randy Minniear, senior vice president for government relations and policy, said the legislation would put New Jersey at a competitive disadvantage and could cost some communities access to hospital care. “This is a bill backed by the unions
and we wonder what their purpose for wanting this information is,” he said. “I am not aware of any other state having this level of reporting requirements for forprofit hospitals. I am told by our members who have affiliates in other states that this is pretty unique. “ The purchase of the then-bankrupt Bayonne Medical Center by IJKG Opco in 2008 may not have been possible had bill S782 been in place creating a disincentive, Minniear said. “If there were more obstacles for them to come into the state, you could have put quite a number of patients at risk of not having access to care,” he said. The hospital association -- and the industry, globally -- supports transparency, Minnier said. The disclosure bill, however,
does not provide the kind of information that the average patient desires -- data that describes patient care and cost.
cancel the insurance contracts and cut services, even though they have a captive market.”
Otersen said patients and policy makers deserve more. The growth in for-profits and the lack of information available on how they spend the public’s money leaves consumers in the lurch, she said.
All of this happens in the dark, she said, because the for-profit hospitals are not required to disclose their financial information in the same way that non-profits must.
“We are seeing the trend that, when you have an urban hospital facing financial difficulties, they swoop in looking like they are saving the day,” she says of the for-profit companies. “But in fact, they are setting up a very profitable business for themselves on the taxpayer dole.
“This bill is a step in the right direction,” she says. “It will allow the public to know how [the hospitals] are using taxpayer and public dollars. They are getting charity-care dollars, and they get it whether they are non-profit or for-profit. They get Medicare and Medicaid. We know where the non-profits are spending the money, but don’t know where the for-profits are spending it.”
“The infrastructure exists. The utilities, the customers, the docs, the providers are all in place, and the company gets all kinds of special deals to take over. Then they
How to Register for the New Jersey Medical Marijuana Program as a Prescriber Go to https://njmmp.nj.gov. • Select Physician Registration. • Provide your personal and office contact information. (as noted by the red asterisk) Note* only your name, office location, and phone number will be publically displayed on the participating physicians list. • Provide your CDS and medical license information. • Indicate that you have completed medical education in Addiction Medicine and Pain Management within the past 2 years. Please type the course title or presentation that you have attended. • Enter desired user access information. This information will serve as your login to the registry system. • Indicate that you adhere to the Physician Agreement and type your full name and title. • Select Submit. The MMP will review your application and supporting documents. All applications will be responded to via e-mail with further instructions for finalizing your application. Denied applicants will be provided instructions on amending your application. Questions regarding this process will be addressed by contacting the MMP Customer Service Unit at (609) 292-0424 or medical. marijuana@doh.state.nj.us.
July 2012
13
Hospital News
Hospital News
Casey resigns as Atlantic Health CMO By Andis Robeznieks Dr. Donald Casey has resigned as chief medical officer and vice president of quality, academic affairs and research at Morristown, N.J.-based Atlantic Health System. According to an e-mail from Atlantic President and CEO Joseph Trunfio, Casey left "to pursue another opportunity" at NYU Langone Medical Center. A representative from NYU could not be reached for comment. "Don's vision, leadership and commitment to improvement raised the bar for quality, clinical research and medical education at AHS," Trunfio said in the e-mail. "He will be missed." Casey, who joined the three-hospital Atlantic system in 2005, was a chief critic of the National Quality Forum's endorsement of a quality measure targeting hospital readmissions as well NQF's endorsement process.
"We have some real concerns about the readmissions measure, and we wanted to emphasize that we don't think it is ready for prime time," Casey told Modern Healthcare in June. The NQF board later voted to uphold its endorsement of the measure. Trunfio credited Casey with engaging the Atlantic board on quality and safety issues, standardizing quality processes across different system institutions, acquiring the system's first National Institutes of Health research grants, and integrating quality improvement and research into graduate medical education. While Atlantic looks for a replacement, Trunfio said Jeffrey Levine, director of academic affairs, will assume Casey's academic affairs duties; Dr. Eric Whitman will take over his research duties; and Dr. Jan Schwarz-Miller will handle Casey's qualityrelated responsibilities.
Hospital Rounds New Jersey hospital takes EHR to the soccer arena Bernie Monegain, Clara Maass Medical Center, a 445-bed hospital in Belleville, N.J. will provide emergency medical services at Red Bull Arena, a new 25,000 seat soccer stadium in Harrison, N.J. The medical center will use its emergency department medical electronic health record on-site to ensure secure exchange of patient information from the arena's medical center to the hospital when needed.
During the first stadium event, an elderly man, enjoying the game with his sons and grandson, experienced shortness of breath and began to pass out, Fontanetta recounts. Security and the EMTs brought him to the first-aid room. Fontanetta, the physician on staff, quickly diagnosed him with congestive heart failure and administered a complete set of medications to stabilize and treat that man's condition.
Medical personnel from Clara Maass Medical Center (CMMC), an affiliate of the Saint Barnabas Health Care System, will be available at each arena event, including the New York Red Bulls' soccer games.
The CMMC medical team was then able to transfer the patient to the medical center's emergency room, where his care was expedited because the complete medical event record from the stadium, including drug therapies administered, was already in the system. The man was admitted to the hospital and released after four days, Fontanetta said.
CMMC's on-site first-aid room at the arena is staffed by a physician and a physician's assistant, as well as an ambulance and two emergency medical technicians for each event. Medical staff can access the electronic health record, a system developed by Livingston, N.J.-based healthcare technology company EDIMS. "Already, we are seeing the benefits of having a full electronic health record system at the stadium - better quality and expedited care," said John Fontanetta, MD, chairman of emergency medicine for CMMC.
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"Clara Maass Medical Center and EDIMS provide professional and state-of-the-art medical services for Red Bull Arena," said Red Bull New York Managing Director Erik Stover. Shane Hade, EDIMS' CEO says the EDIMS system helps clinicians make faster and more informed decisions at the point of care, and enables hospitals like CMMC drive ED quality, safety and efficiency to higher levels.
Hospital Rounds
N.J. hospital deals fizzle for Ascension joint venture By Melanie Evans St. Joseph's Healthcare System, Paterson, N.J., announced it ended acquisition talks with the Ascension Health Care Network, a joint venture between Ascension Health and a privateequity firm. St. Joseph's board rejected an asset-purchase proposal “following extensive analysis and careful consideration of all aspects” of the offer, a statement from St. Joseph said. Ascension Health Care Network said the decision ended its pursuit of St. Mary's Hospital in Passaic. “The agreement with St. Mary's was always contingent on the completion of deal with St. Joseph's Healthcare System,” said Leo Brideau, president and CEO of the Ascension Health Care Network, in a statement. A deal for St. Joseph “was
unfortunately voted down and now presents an uncertain future for St. Mary's Hospital.” Michael Sniffen, president and CEO of St. Mary's Hospital, said in a statement the 221-bed hospital would talk with state officials “to determine what role St. Mary's will play in continuing to deliver healthcare services” in the Passaic area. Talks with St. Joseph and St. Mary's were first announced in February. The Ascension Health Care Network was announced in February 2011 by Ascension Health, the nation's largest Catholic health system, and Oak Hill Capital Partners as a for-profit venture to acquire Catholic hospitals.
NJ Health Care News
Health Center in New Jersey is Integral to Botswana HIV Success Leaders of UMDNJ’s FXB Center attend International Aids Conference, July 22–27 The XIX International AIDS Conference in Washington, D.C., is bringing HIV/AIDS back into the spotlight. At the conference, leaders from the worlds of science, diplomacy, politics, and philanthropy will gather to discuss the strides made in the HIV/ AIDS prevention and treatment. The François-Xavier Bagnoud (FXB) Center at the University of Medicine and Dentistry of New Jersey–School of Nursing has been at the forefront of these initiatives since 1989. One of its success stories is its work to prevent mother-to-child transmission of HIV (PMTCT) in Botswana. “The FXB Center has worked closely with the Botswana PMTCT Program for nearly a decade. We have witnessed first-hand the resolve and dedication of the Ministry of Health staff, the nation’s nurses, and other health workers to overcome HIV,” says Carli Rogosin, Program Manager–Botswana, who has made several visits to Botswana on behalf of the FXB Center. “As the number of HIV infections in newborns and infants has declined, we take great pride in knowing that our technical assistance, including guidelines, job aids, and training workshops, has helped to counteract the epidemic and improve the lives of families andcommunities all over Botswana.” The southern African nation — which has one of the highest HIV rates in the world, with approximately 25 percent of all adults in the country infected — also has the most comprehensive and effective treatment programs on the continent. And part of the government’s plan begins with the country’s most vulnerable citizens, its children. Over the past decade, the nation has reduced the rate of transmission of HIV from infected mothers to their babies from 40 percent to under 4 percent.
Since 2003, the FXB Center has been integral in Botswana’s aggressive efforts. The FXB Center — which provides clinical care, education and technical assistance in the United States and globally to support capacity building to address the HIV/ AIDS epidemic — has collaborated with the Botswana Ministry of Health, the Botswana Institute of Health Sciences, CDC Botswana, University Research Co., and other partners to provide assistance in the following areas: · Development of PMTCT guidelines for care and treatment · In-service PMTCT training curricula for healthcare providers · Healthcare provider development and retention · Integration of HIV and reproductive health services The Botswana initiative is representative of the overall mission of the FXB Center, which has focused on clinical care, HIV prevention, provider training and technical assistance in the state of New Jersey and throughout the US since 1989 and for global partners since 1990. The FXB Botswana program is primarily funded by the Centers for Disease Control & Prevention to prevent mother-to-child transmission of HIV. Representatives from FXB Center attended the XIX International AIDS Conference (July 22–27) in Washington, D.C., where they presented a poster on the success of the FXB program in Guyana.
Visit us now online at
www.NJPhysician.org July 2012
15
Food for Thought
Angeloni’s Restaurant & Pizzeria Caldwell, New Jersey By Iris Goldberg
If you crave thin crust pizza and you live in Northern New Jersey, you’ve been to Star Tavern and you know the pizza is outrageous. If you’re interested in eating your thin crust pizza on real plates, in a lovely, yet casual setting that is not a bar, you should give Angeloni’s a try. Don’t get me wrong. I enjoy the raucous atmosphere at Star Tavern but sometimes it doesn’t suit the mood or the occasion. It was a Thursday evening and we were with our daughter and newborn granddaughter. We definitely wanted pizza but not the bar scene. I had heard about Angeloni’s while at the hair salon, where many of the stylists are Italian. In fact, some were born in Italy. They were raving about the pizza, praising the delectable and crisp thin crust. Located on a side street off of Bloomfield Avenue, Angeloni’s, which is BYO, used to be a local newspaper office, although you wouldn’t know it. The brick walls, curved archways and other charming accents of Italian décor create a perfect environment for a casual family meal or a cozy dinner for two. Angeloni’s is family-owned and operated, which might account for the warm greeting extended to all and the smiling faces of the staff. For those of you with babies and/or small children, Angeloni’s is a good choice. While Michael and I are still learning about all of the baby gear that is in vogue today, the staff at Angeloni’s is up to speed. Immediately, an appropriate sized chair was turned upside-down to accommodate the car/infant seat that young moms and dads carry from car to stroller base, to indoor destination. Also, a children’s menu is offered. While Angeloni’s serves everything you would expect to find at an informal Italian eatery - hot and cold appetizers, salads, pastas, hot and cold sandwiches, meats, seafood and of course, pizza - I will concentrate on the pizza and salads, which is what we ordered. We started with one Caesar and one arugula salad and shared. The Caesar salad was really good. I especially liked the croutons, which I am sure, were
16 New Jersey Physician
homemade. The arugula salad with cherry tomatoes was a special of the day. I was disappointed that it was made with baby arugula but the dressing was well-balanced and allowed the flavor of the leaf to come through. Why is it so difficult to get regular arugula these days? I miss the larger, more peppery leaf that used to be so abundant in the stores. The pizza selection at Angeloni’s is diverse with some options that I had never encountered such as “Nicky Boy’s Italian Hot Dog” pizza with potatoes, peppers, onions, hot dogs marinara and mozzarella, as well as “Grilled chicken Caesar salad “ pizza. After a somewhat lengthy discussion, the three of us agreed on two pies. First we chose “Michael’s” pizza, which is obviously named for someone in or close to the family that owns Angeloni’s. That pie comes with broccoli rabe, sausage, Parmigiana and mozzarella. The second pie, “Gina Marie,” also named for someone special, comes with tomato sauce, homemade mozzarella, Parmigiana, eggplant, spinach and garlic.
The pies arrived piping hot and super thin. The ingredients on both were fresh and delicious with a crust most crisp at the edges. My daughter and I easily finished two slices of each, while Michael had two of the “Gina Marie and three of the pie bearing his own name. He really enjoyed the sausage on that pie! I must confess I spent most of the meal staring across the table at Isabel who slept peacefully in her seat the entire time. I did notice, however that many tables were having regular meals. Many of the entrees that I saw looked to be generously portioned. The place was quite crowded and everyone seemed to be enjoying the food and the warm ambience. As we left, the woman at the front door (one of the owners, perhaps?) gave us a big smile as she admired Isabel. “What a beautiful baby,” she exclaimed. Honestly, I would have written the same critique even if she hadn’t said that but it was a sweeter ending to our meal than all of the cannolis on earth. Angeloni’s is located at 6 Brookside Avenue, Caldwell, NJ. (973) 226-1234
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