NJ Physician Magazine March 2014

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Richard Boiardo, MD, Cross County Orthopaedics Offering the Benefits of Advanced Robotic and Computer-Navigated Surgery Technologies While Preserving the Traditional Ideals of the Community-Based Sole Practitioner Also In This Issue: An Interview with Anthony Slonim, MD, PhD, Executive Vice President and Chief Medical Officer of Barnabas Health NJ Tops Nation in Percentage of Kids Diagnosed with Autism Spectrum Disorder Medicare to Reveal Payments to Doctors

Publisher’s Letter Dear Readers, Welcome to the March issue of New Jersey Physician magazine, reporting on the constantly evolving changes in the practice of medicine in New Jersey.

The premiere issue of our new sister publication, Affiliaed Practice (AP), has now been published. Focused on the changing world of medicine, AP targets the ACOs, Super Groups, Hospital owned practices, and Corporate owned practices. We also report on the latest trend towards physicians being able to retain ownership of their practice while outsourcing billing, reimbursement negotiation in larger numbers, staffing, coding and the other non-medical obligations facing physicians who would prefer to concentrate on the clinical side of healthcare while having expert management handling the other obligations.

If you would like to receive Affiliated Practice free of charge monthly, please send me an email and I will gladly add you to our list.

Anthony Slonim, MD, PhD, is the Executive Vice President and Chief Medical Officer for Barnabas Health. He was recently kind enough to share his expert insights with us regarding the current and future state of medical practice. I know you will find his thoughts most valuable.

New Jersey has topped the nation in the percentage of children diagnosed with Autism Spectrum Disorder, according to the US Centers for Disease Control and Prevention. Greater action is being called for by state representatives to determine both what triggers and how to treat a number of conditions within the autism spectrum.

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Co-Publisher and Managing Editors Iris and Michael Goldberg

Contributing Writers Iris Goldberg Michael Goldberg Colleen O’Dea Joe Carlson Andrew Kitchenman Joseph Conn Beth Fitzgerald Michael L. Diamond Emily Bader Susan K. Livio Meir Rinde

The federal government is about to reveal previously undisclosed information about doctors’ finances and performance. Under the Freedom of Information Act, Medicare will officially begin accepting requests from the public for doctors’ personally identifiable payment information. How many patients a doctor treats and what the government paid for the care will be disclosed.

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ICD-10 is now in a flux. Initially, the federal government announced the deadline for implementation will not be delayed, but action in the House of Representatives and upcoming action tomorrow in the Senate may very well extend the start of ICD-10 requirements for a year. Please stay tuned.

Livingston NJ 07039

Richard Boiardo, MD, of Cross County Orthopaedics is an unusual man.

He offers the benefits of advanced robotic and computer navigated joint replacement while he preserves the traditional ideals of the community-based sole practitioner. At the forefront of ongoing clinical research for robotically assisted joint replacement surgery, Dr. Boiardo maintains a solo practice, providing patients with one to one personalized care, ensuring a positive office experience as well as a positive clinical outcome. We are pleased to present him as our cover story honoree this month.

With warm regards,

Michael Goldberg

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Contents

Richard Boiardo, MD, Cross County Orthopaedics

Offering the Benefits of Advanced Robotic and Computer-Navigated Surgery Technologies While Preserving the Traditional Ideals of the Community-Based Sole Practitioner

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CONTENTS

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An Interview with Anthony Slonim, MD, PhD

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13

Medical News

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18

Hospital Rounds

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Affiliated Practice OIG Publishes Op-Ed Suggesting Mandatory Random Drug Testing For Health Care Professionals ACA News

The attorneys in the Health Care Practice Group at Giordano, Halleran & Ciesla, counsel clients on a broad range of issues, integrating traditional legal principles with the special body of federal and state law governing the health care field.

Our health care services include: Health

Care Reform Anti-kickback Law/Stark Law/NJ SelfReferral Law Professional Practice Formation and Related Agreements, such as Partnership Operating, and Shareholder Agreements Preparation and Negotiation of Contracts, such as Management, Employment, Physician Recruitment, Vendor, and Managed Care Contracts Purchase and Sale of Professional Practices and Practice Divorces Regulatory Compliance HIPAA and Confidentiality Issues Lease Preparation and Negotiation Joint Venture Formation Acquisition, Mergers and Considerations Physician Practice Management Issues Medicare and Other Reimbursement Issues Licensing Issues Litigation

Visit our Healthcare Blog for updates healthcare news, events, and legislation.

www.njhealthcareblog.com Giordano, Halleran & Ciesla PC | 732.741.3900 | info@ghclaw.com | www.ghclaw.com Follow us on Twitter: @GHCLawFirm

Cover Story

Richard Boiardo, MD, Cross County Orthopaedics

Offering the Benefits of Advanced Robotic and Computer-Navigated Surgery Technologies While Preserving the Traditional Ideals of the Community-Based Sole Practitioner

Surgical photography by Michael Goldberg

By Iris Goldberg In this emerging era of multiphysician practices, some with 20 or more affiliated physicians, it is rare to find a specialist in any field who chooses to practice alone. Certainly, the financial challenges of medical practice today sway many to seek strength in numbers. While physicians who select the large group models undoubtedly still prioritize excellent patient care, from the patient’s perspective, especially those who are older, the bygone days of the smaller, more intimate environment of the one or two-doctor practice are sorely missed. Still, prospective patients want to be assured that their physician is on top of the latest developments and technological advancements in his or her field.

For orthopaedic surgery patients in and surrounding Essex, Morris, Union and Hudson counties, Richard Boiardo, MD offers expertise in the most advanced surgical techniques, including a mastery of robotic and computer-guided systems designed to enhance the success of arthroplasty (joint replacement) procedures. At the forefront of ongoing clinical research for robotically assisted joint replacement surgery, Dr. Boiardo has published extensively and has presented at numerous conferences throughout his impressive career. In June, 2013, Dr. Boiardo was invited to present at the Annual Meeting of the International Society for Computer Assisted Orthopaedic Surgery.

With many years as an accomplished orthopaedic surgeon, Dr. Boiardo maintains a solo practice, providing patients, many of whom are older and suffer from degenerative joint disease, with one to one personalized care from him. His dedicated and highly skilled staff knows every patient well and can ensure a positive office experience, focusing on the individual needs of each.

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Dr. Boiardo and his surgical team at Saint Michael’s Medical Center.

Dr. Boiardo, who is Chief of Orthopaedics at Saint Michael’s Medical Center in Newark, has received statewide recognition for his advanced skills and has been prominently featured in many New Jersey newspapers, including The Star Ledger. Most notably, Dr. Boiardo led the surgical team that performed the first robot-assisted total and partial knee replacement procedures in New Jersey. He and his team at Saint Michael’s then went on to be among a handful of surgical teams nationally, to pioneer the first robotic total hip replacement surgery.

Dr. Boiardo candidly discusses why he chose to embrace robotics when that technology became available.

“You might ask why someone at my stage of the game who has a strong patient base with patients who have been coming to me for joint replacements for many years would look at a new technology,” he remarks.

In terms of the marketing success of

During MAKOplasty®, Dr Boiardo is provided with real-time visual, tactile and auditory feedback to facilitate optimal joint resurfacing and implant positioning.

this technology as validation of its benefits, Dr. Boiardo explains that the numbers speak for themselves.

Most importantly though for him, it comes down to the precision provided when the robot is added.

“Take a professional golfer like Tiger Woods. Some days his swing is great and other days it’s a little off,” Dr. Boiardo points out. “Surgeons are no different from professional athletes.

It’s all about hand-eye coordination,” he continues. “Some days you might be a little off. The robot is never off,” he states emphatically.

“Precision arthroplasty is going to be the mantra for the next era in joint replacement,” Dr. Boiardo predicts.

For patients who have been diagnosed with early to mid-stage osteoarthritis of the knee that has not progressed to all three compartments, partial knee replacement (resurfacing) has been an attractive option for many years.

During the procedure only the diseased portion of the knee is resurfaced, sparing healthy bone and surrounding tissue. An implant is then placed in the joint to restore natural movement.

With the assistance of the RIO® (Robotic Arm Interactive Orthopaedic System), developed by MAKO and classified as semi-active robotics, (the surgeon makes the cuts with guidance from the robot) Dr. Boiardo has taken this procedure to a new level. The RIO® system features three dimensional surgical planning. During the surgery, known as MAKOplasty®, the surgeon is provided with real-time visual, tactile and auditory feedback to facilitate optimal joint resurfacing and implant positioning. Optimal implant placement results in more natural knee motion post-surgically.

“With the technology of computer imaging and pre-operative planning, volumetrically, the amount of bone resected to achieve an excellent replacement is documented on a specialized CT scan and at the time of surgery it’s optically transmitted to the robot, which is in the surgeon’s hands, to achieve a precise cut and a precise orientation of components,” Dr. Boiardo elaborates. “So, no matter what happens with eye-hand coordination that day – you’re right there,” he adds, reiterating

Exactech GPS® Guided Personalized Surgery is an advanced surgical technology that provides the surgeon with real-time guidance and alignment data in total knee arthroplasty. the guaranteed precision he can count on since incorporating this technology.

When osteoarthritis of the knee has progressed to the point where all three compartments are diseased, total knee replacement is necessary. For appropriate patients Dr. Boiardo utilizes advanced technology in the form of passive robotics, which is basically computer navigation. Exactech GPS® Guided Personalized Surgery is an

advanced surgical technology that provides the surgeon with real-time guidance and alignment data in total knee arthroplasty.

Proper placement of the knee implant is critical to the long-term success of the operation. Ideal positioning allows for weight being transferred from the center of the head of the femoral bone down through the center of the knee joint and then to the center of the ankle.

The GPS® system enables Dr. Boiardo to confirm proper alignment of the implant.

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most important and common reason for post-surgical dislocation is component malposition,” he informs. Primarily, as Dr. Boiardo explains, an experienced surgeon operating with only the acuity provided by the naked eye alone, can actually be as much as 25 degrees off the correct component orientation, which can ultimately cause dislocation.

The addition of the robot eliminates this possibility. “You can have a patient standing on his head while you’re operating, figuratively speaking, and still get the correct component orientation,” Dr. Boiardo asserts, to sufficiently taut the benefits of robotic assistance for hip replacement surgery.

Small transmitters placed on the patient’s leg are tracked by an infrared camera.

Any deviation from this imaginary line, called the mechanical axis, could result in more weight-bearing stress being placed on one side of the knee, which could increase the risk of the implant loosening over time. With the use of the GPS® system, Dr. Boiardo can confirm proper alignment of the implant.

Dr. Boiardo places small transmitters on the patient’s leg. An infrared camera is used to track the movement of the transmitters via a computer that analyzes the positions and creates an anatomical drawing of the knee. Using this real-time graphic display, he makes cuts in the bone to ensure proper alignment on the mechanical axis for the implant. Again, maximum precision is the ultimate goal.

perform all hip replacement surgeries with robot assistance.

A preoperative CT scan of the patient’s hip is used to create a 3-D model of the hip, pelvis and femur. Dr. Boiardo uses the RIO® software along with the 3-D model to plan the surgery based on each patient’s unique anatomy.

During surgery, the software provides Dr. Boiardo with real-time information for precise implant positioning and alignment, while the robotic arm assists to prepare the socket and guide placement of the implants.

Medicare data reveals that 50 percent of complications after hip arthroplasty are mechanical. Dr. Boiardo shares that 80 percent of those are dislocations. “The

Of course, the most convincing endorsement of robotic assistance in joint arthrosplasty can be found in the successful outcomes as related by actual patients. Dr. Boiardo has performed more than 600 robot-assisted procedures since first incorporating this technology.

Although it was difficult to choose from the many former patients eager to share their joint replacement experience, here are just a few who exemplify the optimal results that can be achieved when advanced technology is embraced.

Fifty five year-old Roslind McGrady suffered with knee pain for years but resisted consulting with a surgeon. Finally, the discomfort became overwhelming, especially since she is also undergoing treatment for an unrelated cancer.

Fortunately, most of Mrs. McGrady’s knee

Today, more people than ever before, many of them baby boomers undergo total hip arthroplasty.

Whether from arthritis, injury or other causes of degenerative joint disease, patients as young as 50 who are living with chronic hip pain choose to have the surgery in order to get back to their active lives.

During the procedure the diseased hip joint is replaced by implants – a metal cup with a plastic liner to replace the acetabulum (socket) in the pelvis and a metal femoral stem and head.

As Dr. Boiardo explains, positioning the implants correctly is crucial to the success of the procedure and for the lifespan of those implants. Accurate alignment and positioning of implants can be challenging for a surgeon using traditional techniques. In order to achieve maximum precision, Dr. Boiardo relies on the MAKOplasty® system to

6 New Jersey Physician

Using real-time graphics, Dr. Boiardo makes cuts in the bone, ensuring proper alignment.

confidence in him. I trusted him with my life twice,” shares Mr. Maloney, who can once again supervise the basketball clinic he holds for ten and eleven year-old girls. “And I made the right choice!”

A pre-operative CT scan of the patient’s hip is used to create a 3D model of the hip, pelvis and femur.

was not diseased and she only required replacement of one compartment. Dr. Boiardo performed the procedure with the assistance of the MAKOplasty® System. Mrs. McGrady relates that she was pain-free almost immediately and in less than two months could walk unaided, without a limp and regained full range of motion in her knee.

When asked to describe her experience with Dr. Boiardo, her voice fills with emotion, “Not only is he an excellent and very skilled surgeon, he has such a warm spirit about him,” she says. “When he walks into the room, you just feel almost loved,” Mrs. McGrady describes.

“He’s so personable and so caring. And he knows my situation – that there is a burden on my husband since I’m out of work because of my illness. He works with us on that. Not all doctors would,” she notes.

When retired Newark police officer, Lawrence Maloney needed a total knee replacement in October of 2012, he knew just who to call. After undergoing total knee arthroplasty with Dr. Boiardo back in 1995 and having a good experience with the procedure and

with Dr. Boiardo, Mr. Maloney did not even consider having any other surgeon operate on his other knee.

Dr. Boiardo employed traditional arthroplasty techniques for Mr. Maloney’s first knee replacement.

This time around, Dr. Boiardo had the benefit of the Exactech GPS® passive robotic system. “There was no comparison,” Mr. Maloney firmly states. “I was up and around so much faster the second time,” he continues. More than a year later his knee feels great.

Mr. Maloney’s experience is certainly compelling as an endorsement for including robotic technology in total knee replacement. The surgeon, the patient and the procedure were the same both times. The addition of advanced technology for the second knee surgery may certainly have played a role in a significantly better experience for that patient, who, by the way, was 17 years older the second time around.

When asked what he thinks of Dr. Boiardo now, Mr. Maloney says, “He’s the best. “I have the utmost faith and

Warren Baker is a 68-year old schoolteacher who also works in a security position at NJ Transit.

Working seven days a week with excruciating hip pain, as a result of “bone on bone” arthritis, he and his wife consulted with Dr. Boiardo, who was referred by their primary physician. They had intended to get a second opinion as well but as Mr. Baker relates, after meeting with Dr. Boiardo, they both agreed that he was the one they wanted to perform the hip replacement surgery.

“You want to go to someone who is most familiar with what you’re having,” Mr. Baker states. He refers to the fact that Dr. Boiardo pioneered the MAKOplasty® robotic hip surgery.

“There’s no one who knows more about it than him,” Mr. Baker adds.

As far as the surgery, itself Mr. Baker could not be more pleased.

He spent one day in the hospital and two weeks in a rehabilitation facility.

Just six weeks after having the hip replacement surgery, Mr. Baker is able to walk unassisted in his home, drive a car and resume many of his other routine activities. Most important, Mr. Baker is totally pain-free.

When asked what he would tell others who are hip replacement candidates about Dr. Boiardo and robot-assisted hip replacement, Mr. Baker does not hesitate to respond. “He’s a fantastic doctor. All you have to do is just go and talk to him and he’ll give you the confidence you need,” Mr. Baker advises.

In terms of the procedure he says,

During hip arthroplasty, the software provides Dr. Boiardo with real-time information for precise implant positioning and alignment, while the robotic arm assists to prepare the socket.

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“The proof is in the pudding,” relating how when he went to see Dr. Boiardo just a few weeks after surgery, he put his walker aside and walked down the hallway towards Dr. Boiardo on his own. “He just shook his head and smiled,” Mr. Baker shares referring to the obvious pleasure Dr. Boiardo receives from helping patients regain their mobility.

Besides the significant appreciation from patients treated through Dr. Boiardo’s private practice in West Orange, who have been able to reclaim an active quality of life after undergoing joint replacement surgery, there are many others – those who are poverty-stricken and uninsured - whose gratitude goes even deeper.

In Newark, where he was born and worked during his high school

and college years, Dr. Boiardo has established a philanthropic program, called Operation Walk that provides free knee and hip replacement surgery for indigent and uninsured patients.

In fact, Dr. Boiardo was honored with the Humanitarian of the Year Award at the 22nd annual Newark Hall of Fame dinner held in October, 2010 as a result of this endeavor. The event was reported in detail in the Newark Star Ledger, where Dr. Boiardo was quoted: “There’s a great renaissance at work in Newark and I want to be a part of it medically. “The population has been underserved and disenfranchised by a level of poverty and I feel a strong commitment to the city to help change it.” He goes on to share, “The city was good to me and I want to give something back.”

Basically, when charitable donations do not cover the costs of the surgeries and hospital stays required, Saint Michael’s waives its fees and Dr. Boiardo and his team donate their services. To date many who would otherwise have continued to suffer the pain and disability of degenerative joint disease have regained their joint health and mobility. For some, this gift is an opportunity to be able to provide for themselves and their families once again.

Dr. Boiardo at work

Dr. Boiardo’s humanitarianism has not been confined to folks in New Jersey. He has traveled, along with other surgeons who feel a strong commitment to help the underprivileged, to places such as Vietnam, where he performed surgery without reimbursement. Also, Dr. Boiardo has visited countries such as Spain, Greece and Russia, where he attended educational lectures to present research introducing the latest advancements in joint replacement surgery.

An avid golfer who has devoted much of his practice to sports medicine throughout the years, Dr. Boiardo has received recognition for treating some of New Jersey’s well-known sports figures.

Before his death, fighter Arturo Gatti was a New Jersey hero.

In the early days of Gatti’s career, Dr. Boiardo performed fusion surgery on the fighter’s injured wrist, which was interfering with his ability to punch as hard as he needed to. After the surgery,

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Gatti regained the ability to hit hard and freely, which no doubt propelled his career.

Florida State football player, Josue Matias was a senior at Union City High when he suffered a potentially careerending injury. A patellar tendon avulsion complicated by a bone fracture is a rare and serious injury. After performing surgery, Dr. Boiardo was able to predict a total recovery for the young athlete.

For those of us who report on changing trends in healthcare, particularly as they apply to physicians, Dr. Boiardo is somewhat of an enigma. On one hand he is passionate about staying at the forefront of advanced technology as it emerges, relearning, if he must, in order to keep his skills aligned with new developments in his field. However, the solo practice model he continues to preserve would have some pundits label him as old-fashioned. Without a doubt, the countless patients in New Jersey whose lives he has touched and those he has yet to meet, are fortunate, indeed, that Dr. Boiardo has not yielded. In fact, the example he sets might serve well for those who would like the pendulum to swing a bit in the old direction as we move forward.

Dr. Boiardo is passionate about staying at the forefront of advanced technology as it emerges.

Cross County Orthopaedics is located at 769 Northfield Avenue, Suite LL-20, West Orange, NJ 07052. To make an appointment with Dr. Boiardo or for more information, call (973) 669-9595.

An Interview with

Anthony Slonim, MD, PhD

Dr. Anthony Slonim is the Executive Vice President and Chief Medical Officer for Barnabas Health and the President of the Barnabas Health Medical Group where he oversees all initiatives supporting the delivery of exceptional patient care. Dr. Slonim brings more than a decade of diverse healthcare experience as a practicing physician, professor, author and fellow.

Additionally, he is a Fellow and Member of the Board of Directors of the American College of Physician Executives and the College of Critical Medicine. He completed his Medical Doctorate (MD) at New York Medical College and his Master’s and Doctorate in Administrative Medicine and Health Policy from the George Washington University School of Public Health’s Center for Health Policy Studies.

Affiliated Practice: Barnabas Health has made numerous changes in its business model in the last couple of years-ACOs, Leasing and purchasing practices, a new insurance initiative that’s been talked about, other hospital affiliations. Can you tell us something about this in terms of the new business models that medicine seems to be heading towards.

Anthony Slonim, MD: Everyone understands that healthcare is changing. The focus is now on not only making sure that every patient who encounters the organization gets the best care they can from a quality perspective and a service perspective, but also that services are administered to them as efficiently as possible. Also, when the patient leaves your premises that interaction is not over. You still have ongoing responsibility to help assure that the patient maintains and improves their health. I think now is the opportunity to find out what those business models are to help us deliver on that vision of care. For one example, the accountable care organizations, and we have two of them here at Barnabas Health are precisely geared toward that model of care-improved quality of service and reduced expense and it’s a partnership method of engaging not only with other providers but with payers, and with doctors and with patients themselves because patients have to have a role in this as well. We want them to partner in living healthier lives as they go forward with their own care. I think that’s consistent with the model. We certainly have, as was announced last year, another hospital in our organization.

Jersey City Medical Center has joined us and that’s in part because in order to provide effective care to populations you want to have a reach into the population to make sure that you are overlapping areas to make sure the population is being served.

AP: Where do you see the small practices evolving to at this point. It seems as if Barnabas Health has been quite active in either leasing, purchasing or forming some kind of affiliation with many practices that have been with them before.

We are also seeing corporations that are forming either for more efficient management of practices or in some cases, just purchasing outright, single specialty type of situations. Where does Barnabas Health fit into that business model?

AS: We certainly have practices that we’ve purchased. I think that the bigger conversation is around integration. What are the ways in which physicians are further integrating with hospitals and health systems, a different group of providers to advance care for populations. That’s the conversation. It doesn’t much matter what the business arrangement is. The conversation is around integration. There’s a variety of three letter acronyms, there is a variety of these types of relationships

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but it is all about driving a relationship where you are partnering with people that share the same vision that you do in terms of the way you provide care.

AP: It seems as if the new models actually allow the physicians to be practicing medicine without the distraction of running a business as well.

AS: Exactly. And what we find is that many doctors are particularly interested in that because the business side of medicine has become quite cumbersome over the years. It’s not easy, essentially being a small entrepreneur and managing your small business. We’re finding to some extent, that at least what the literature suggests is that there may be some generational interests here as well where younger physicians are opting a better work/life balance than some older generations, myself included, might have previously opted for.

AP: We know of some physicians who have retired. The technology was overwhelming to them.

AS: Yes it’s really interesting. Not only has the business side become more difficult but the actual delivery of care with the technology has become more difficult. And I think what we’re going to find as we move forward if we take that to the next evolution, where I’m taking some time, thinking and focusing on our work at Barnabas, particularly on how we advance quality, which is one of my major responsibilities, is just like computer assisted surgery. We have to realize that in this arena the doctor has to be freed up from some of the more common decision making that could be done by other members of the team. Perhaps there are nurses or pharmacists that could liberate the physician from the burden of each individual independent decision. And we can use the doctor for the critical thinking skills when it becomes necessary. Otherwise we will continue, per the example of technology to overwhelm our physicians and we’ll never have sufficient resources on the doctors’ side to be able to provide the types of care at the population level that we’re talking about. It’s a matter of understanding what other disciplines can do for the patient and how we can partner together as health care workers to advance that model of care.

AP: Absolutely, where do you see this evolving in 5 years? There is some talk that the ACO is a temporary situation that will evolve more in line with something having corporations and hospitals run the healthcare industry. Do you see that as the direction in which things are going?

AS: I was recently asked by a graduating student at NYU who had received his MBA and he said to me “ Dr Slonim, I am sure that my career is going to focus on ACOs.” And I said to him, “I think then that it will be a really short career. I hope for you that you’re getting behind the proposition which is regardless of what you call it, ACO or other, the value proposition is here to stay. Improved quality and reduced expense. That’s the name of the game. And it’s about how we do that for more patients than we’ve been doing it previously.

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Medical News Medical News

NJ Tops Nation in Percentage of Kids Diagnosed within Autism Spectrum Colleen O'Dea CDC reports 1 in 45 children in Garden State has disorder marked by difficulties with communication and social interaction, repetitive behaviors New Jersey has the nation’s highest rate of autism among children, with 1 in 45 having the spectrum of disorders, according to new data released yesterday by the US Centers for Disease Control and Prevention.

The new study prompted two state representatives to call for greater action by both state and federal officials to determine both what triggers and how to treat a number of conditions in the the autism spectrum that are characterized by difficulties in social interaction, problems with verbal and nonverbal communication, and repetitive behaviors.

"It is a pandemic," said Rep. Chris Smith, R-4th, at a press conference with officials from the national organization Autism Speaks, following the release of the new CDC study.

Nationally, the CDC found 1 in 68 children with autism in 2010, based on a study of 8-year old students in 11 states, including New Jersey. That's 30 percent higher than the estimate for 2008 and 120 percent higher than the 2000 estimate. CDC officials said they don't know what is causing the increase in the prevalence of the condition, though some may be due to the ways in which children are identified, diagnosed and served.

New Jersey's rate of 1 in 45 is the highest ever recorded by the CDC. "It's not just disturbing, it's numbing," Smith said. "There is reason for alarm."

Several factors might explain why the autism rate in New Jersey is so much greater than in other states: The state’s relative affluence and high education levels mean parents have access to, can afford, and seek out a diagnosis and help for children exhibiting signs of autism.

"New Jersey has one of the best systems in the nation for identifying, diagnosing and documenting children with Autism Spectrum Disorders," said Mary O'Dowd, the state's health commissioner. "New Jersey is one of only four states with an Autism Registry that requires reporting by neurologists, pediatricians, nurses and other autism providers so children can be referred for resources and services. Approximately, 12,400 are registered and that has heightened awareness among parents and providers of indicators for Autism Spectrum Disorders."

Walter Zahorodny, an assistant professor of pediatrics at Rutgers New Jersey Medical School, has been a principal investigator for the CDC's studies from the beginning and told Rutgers Today there are no easy answers to the questions surrounding autism.

"This state does have some of the best resources anywhere for detecting and caring for autism, but if the higher documented prevalence were only due to better detection, sooner or later the numbers would plateau and other states would catch up. That hasn’t happened," he said. "In 2002, the prevalence in New Jersey translated to one child in 94. In 2006, it was one child in 57. The latest numbers show one child in 45. We need to start acknowledging that what once was a rare disorder now affects two percent of the state’s children, and unfortunately I think the numbers will continue to rise."

Zahorodny said there's likely nothing in the state's environment influencing the findings, but the state's demographics probably have something to do with its unenviable ranking.

"Many people here are more affluent and better educated than elsewhere, and those people tend to marry each other and have children later in life. It is considered a risk factor for autism if both the mother and father are older when the child is born," he said. "It’s also very likely that our findings apply beyond New Jersey. The same demographic profile exists in counties throughout the New York metro area, and I would expect that if those areas were monitored as closely as we have studied New Jersey, their autism prevalence would be found to be similar."

While the number of school children specifically labeled as autistic is likely too small -- children with autism may also be placed in a number of other categories, including specific learning disabilities or multiple disabilities -- it has nevertheless grown more than 250 percent between 2002 and 2013.

According to the CDC data, autism affects boys far more often than girls -- 3.4 boys for every girl -- and whites more than any other race or ethnicity.

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The new study did have one bright spot for parents, finding an increase in the percentage of autistic children with average or above average intelligence -- about least half of all those with autism spectrum disorders have an IQ of at least 85.

Numbers don't really tell the story of families struggling with children who have autism, though.

“Behind each of these numbers is a person living with autism,” said Autism Speaks President Liz Feld. “Autism is a pressing public health crisis that must be prioritized at the national level. We need a comprehensive strategy that includes the research community, policymakers, educators, and caregivers coming together to address our community’s needs across the lifespan.”

Sen. Robert Menendez, D-NJ, agreed. Speaking at the Autism Speaks press conference, he said the CDC report is "a clarion call for increasing efforts at the federal level" for autism funding.

“We must redouble our efforts and secure the funding needed to not only ensure critical autism programs aren’t shuttered but to find new diagnostic tools, early intervention techniques, therapies, and lifelong support and services to ensure individuals with autism can fulfill their God-given potential," said Menendez, author of the Combating Autism Act. Smith agreed, saying, "We need to be much more generous" in investing in autism research.

O'Dowd said that the Governor's Council for Medical Research and Treatment of Autism has provided nearly $25 million in research grants since 2008 and that the health department is at the forefront of supporting research, including a Center for Excellence at Montclair State University.

She urged parents to be vigilant in taking action when there is a suspicion of a developmental delay that could be due to an autism spectrum disorder. The department's Early Intervention System, funded by $135 million, provides early identification and referral, service coordination, evaluation and assessment, and services for children from birth through age 3 with disabilities.

"The earlier a child with Autism Spectrum Disorder or developmental delay is identified and connected to services, the sooner services can be provided to ensure the child is able to reach their full potential," O'Dowd said.

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

Medicare to reveal payments to doctors

By Joe Carlson Medicare doctors are accustomed to wearing the white coats and diagnosing others' problems. But in coming months they may feel more like they're the ones wearing backless hospital gowns, as the federal government reveals previously undisclosed information about doctors' finances and performance.

Today is the first day that Medicare will officially begin accepting requests from the public (PDF) under the Freedom of Information Act for doctors' personally identifiable payment information. The change comes just as drug companies and devicemakers are preparing to reveal payments to doctors, which is in addition to the growing transparency efforts at CMS' Physician Compare site.

The release of Medicare payment data to doctors is intended to tell the public how many patients an individual doctor treats, and what the government paid for the care—information that could shed light on physicians' competence in certain procedures as well as show patterns of fraud and overuse.

For the past 35 years, CMS officials have considered it a violation of physicians' right to privacy to tell the public how much Medicare pays individual doctors. But a federal judge in Florida ruled last year that doctors' privacy rights no longer trumped the public interest in making the data public. The decision followed the publication of news stories that used Medicare billing data to pinpoint physicians doing suspiciously high levels of Medicare work.

The Florida ruling set the stage for the case-by-case balancing test that CMS is launching today, under which it will consider requests for physician-identifiable Medicare data and determine whether the public's right to know the information outweighs the physician's right to privacy under an exception to the Freedom of Information Act. “The outcomes of these analyses may vary depending on the facts of each case,” CMS said in a Federal Register notice. “However, in all cases, we are committed to protecting the privacy of Medicare beneficiaries.”

In September, the CMS will begin publicly posting for the first time data showing how much money drug companies, devicemakers and other healthcare suppliers pay to doctors. The data will include almost any “transfer of value,” whether it's a $200 Mont Blanc pen, a $2,000 steak dinner or a $20,000 speaking engagement.

Those disclosures follow increasingly probing data available through CMS' Physician Compare website, which is phasing in publicly searchable information on individual physician's quality of care.

Both the Physician Compare changes and the industry payment data release were mandated by the Patient Protection and Affordable Care Act.

Medicaid Spending Would Climb While Other Health-Related Programs Get Less Andrew Kitchenman

Christie focuses on healthcare costs in proposed 2015 budget, boosting total expenditures to over $4 billion State spending on Medicaid would grow by $214.3 million in the budget proposed by Gov. Chris Christie yesterday, while other health-related spending would decline.

Christie, in his budget address, focused on changes in how the state delivers healthcare to low-income residents through Medicaid.

The increase in Medicaid spending, from $3.95 billion in the current fiscal year to $4.16 billion under the spending plan, is the biggest reason for an overall increase in Department of Human Services spending, from $6.49 billion to $6.64 billion.

State Department of Health spending would from fall from $371.3 million to $339.3 million, with much of the drop due to a onetime payment for Cooper Health Care’s new cancer treatment center.

While details of the budgetary impact of Christie’s proposal were still emerging yesterday, state officials highlighted some of the changes in a budget summary. They include $1 million to support the integration of substance-abuse treatment with employment services, $4.5 million to expand drug court treatment services, and $21 million more for children in New Jersey FamilyCare.

New Jersey Hospital Association President and CEO Betsy Ryan said she was encouraged by Christie’s focus on healthcare delivery and took a largely positive view of early budget details.

The budget includes $985.1 million in state hospital funding, which is unchanged from the current fiscal year although it shifts $25 million from Charity Care to University Hospital. Ryan said she wanted to learn more about the effect of that change.

Christie highlighted the state’s Medicaid comprehensive waiver, which is allowing the state to shift the focus of long-term care March 2014

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from nursing homes and other institutions to home- and community-based services. The budget includes a $125 million increase to support this approach.

“My philosophy is to allow older New Jerseyans to maintain their independence and receive care in the community in their homes for as long as possible,” Christie said. “This means better and more affordable care.”

Christie noted the high budgetary stakes of Medicaid, pointing out that the total state and federal cost for the program is $12 billion to serve 1.4 million New Jersey residents.

While Christie has been critical of President Obama and his signature law – the 2010 Affordable Care Act – the governor reiterated his support for expanding Medicaid eligibility in the state, a move made possible by the ACA. “I’m proud to have made the decision to expand Medicaid and provide greater access to healthcare for New Jerseyans in need,” Christie said, adding that the expanded access necessitates broaders reform of the healthcare delivery systems.

Christie focused on Medicaid and New Jersey FamilyCare -- the state’s Medicaid-funded state program – noting that a small number of Medicaid patients account for a large share of program spending.

“We need to take on the challenge of making the system more cost-effective so that we can protect Medicaid and FamilyCare for New Jerseyans who really rely on them,” said Christie, saying that 5 percent of the state’s Medicaid recipients – amounting to 70,000 residents – are responsible for 50 percent of the costs.

Christie called on Rutgers Biomedical and Health Sciences, which contains most of the former University of Medicine and Dentistry of New Jersey; University Hospital in Newark, and Rutgers-Camden to work with state officials to improve the efficiency of healthcare delivery in Medicaid and FamilyCare.

He cited two reform initiatives that are already moving forward in the state: a Medicaid Accountable Care Organization pilot program intended to improve healthcare coordination in areas with many low-income residents, and a federally funded Rutgers study on how to improve care for patients who frequently stay at hospitals.

Rutgers President Robert Barchi, a medical doctor, was on hand for the address and said he would work with state officials to help develop a program to reform Medicaid.

“One of the things that we can and should be doing as a healthcare entity and a great university is addressing the major problems of healthcare in this country,” including rising costs, Barchi said after Christie’s address.

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

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

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

16 New Jersey Physician

He said the state must think about how “episodes of care” begin with early symptoms and continue through follow-up care, and not just focus on hospitalizations.

Barchi said the state must rely more on teams of healthcare providers rather than relying just on doctors, “using approaches that focus on wellness as well as acute episodes of care, and we must think about how we manage chronic disease.”

Barchi added that the university is “absolutely committed to working with the governor on addressing this problem, especially in the most vulnerable populations” such as those enrolled in Medicaid in and around Newark and other cities.

Rutgers Center of Health Policy Director Joel Cantor, whose expertise may also be called on to contribute to the effort, said he was pleased that Christie issued “a call to action” on Medicaid delivery system reform.

“Medicaid costs, like all healthcare costs, keep going up, and that’s a real challenge in the budget,” said Cantor, an NJ Spotlight columnist.

Medical Society of New Jersey CEO Lawrence Downs said it’s appropriate to undertake a “full reform” of Medicaid now that program eligibility has been expanded, “to make sure that patients can actually access physician care.”

But important questions remain about how Christie’s budget proposal will affect healthcare in the state.

New Jersey Policy Perspective senior analyst Raymond J. Castro said of Christie’s call for Medicaid reform that “on the face of it, it sounds like a laudable goal,” but that “the devil is in the details – hopefully this is not a way to cut services.”

Castro also expressed disappointment that the state hasn’t committed to returning the savings from the Medicaid expansion – which resulted from the federal government taking on a larger share of Medicaid expenses – into programs that would strengthen healthcare access.

Castro cited two potential big-ticket programs as worthy projects: the state taking on the role of equalizing doctors’ Medicaid reimbursements with those that they receive from Medicare and the introduction of state subsidies to supplement federal subsidies to help low-income residents buy insurance through the federal health insurance marketplace. Castro said the federal subsidies won’t go far enough in a high cost-of-living state like New Jersey to cover the costs that residents with low to moderate incomes must pay in insurance premiums and out-of-pocket healthcare expenses. Sen. Joseph F. Vitale (D-Middlesex) agreed that the state should provide such subsidies once it has available funds, agreeing that marketplace insurance can still be expensive once out-of-pocket expenses like deductibles and coinsurance are taken into account.

But Vitale said he was encouraged by Christie’s overall healthcare emphasis.

“I think it’s good he’s thinking about more efficient ways to deliver care for all of New Jersey’s lower-income residents through Medicaid,” Vitale said, adding that the state effort should build oon Dr. Jeffrey Brenner’s work in Camden.

Dr. Poonam Alaigh, a former health commissioner in the Christie administration, said the governor’s focus on Medicaid was “very significant.” She noted that an expansion of Medicaid in Oregon resulted in an increase in emergency-department use, with many of those patients presenting a challenging combination of chronic health problems and behavioral health issues.

She predicted that the state’s Medicaid Accountable Care Organization pilot program -- scheduled to launch this year -- could be the key to aligning financial incentives to hospitals with positive health outcomes. She noted that Christie mentioned the program in his address.

“That’s going to be critical,” Alaigh said.

ICD-10 deadline won’t be delayed, Tavenner tells HIMSS

By Joseph Conn Providers, payers and claims clearinghouses can look for no relief from the looming, Oct. 1 compliance deadline for the nationwide conversion to the ICD-10 family of diagnostic and procedural codes, the head of the CMS said Thursday. But some case-by-case exemptions will be made for providers having a tough time meeting their Stage 2 meaningful-use targets, she said.

“There are no more delays and the system will go live on Oct. 1,” Marilyn Tavenner said during her keynote address at the Healthcare Information and Management Systems Society convention in Orlando, Fla., Thursday. “Let's face it guys, we've delayed this several times and it's time to move on.”

Similarly, there will be no rollback of compliance dates for Stage 2, Tavenner said, despite considerable pressure being applied to the agency to further delay compliance dates and add flexibility to its “all or nothing” requirements to meet meaningful-use measures.

For eligible hospitals, the starting date for Stage 2 was Oct. 1, 2013. Those hospitals have only two starting dates left in the program, which operates on a fiscal year, to commence 90 consecutive days of meeting the meaningful-use criteria: April 1 and July 1, 2014.

Physicians and other eligible professionals, whose EHR incentive programs operate on the calendar year, have a bit more time and three dates—the first days of April, July and October—to start their 90-day clocks.

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Regarding Stage 2 of the electronic health-record incentive payment program, which requires providers to electronically exchange healthcare records with others, Tavenner explained that “interoperability is a key step to everything going forward,” particularly CMS' value-based payment programs.

CMS has been sensitive to providers' concerns, Tavenner said, pointing out that the Stage 2 and Stage 3 start dates each had previously been pushed back a year. “Now is the time for us to start moving forward,” she said.

But, she acknowledged that some providers and health IT vendors may have legitimate issues, such as the late delivery of tested and certified software, or EHR vendors going out of business, that might preclude them from achieving timely compliance with Stage 2.

In those instances, Tavenner said, the CMS is willing, on a case-by-case basis, to entertain applications for “hardship exemptions.”

Even with the exemptions, she said, CMS expects all Stage 2 providers to fully meet all Stage 2 criteria by 2015 while still encouraging everyone else eligible to meet them this year.

Hospital Rounds

Barnabas to launch its own health insurance plan Program, coming in 2015, will serve individuals and small business employers

By Beth Fitzgerald Barnabas Health, the state's largest health care system, will launch its own health insurance plan in 2015, Chief Executive Officer Barry Ostrowsky told NJBIZ. Ostrowsky said the seven-hospital system will partner with a yet-to-be determined insurance company to offer the program, which will be pitched to both individuals and small employers.

The plan will begin enrolling members in late 2015, Ostrowsky said. And while he said Barnabas plans to offer the program on the health exchanges created by the Affordable Care Act, he said it would not be available on the exchange until 2016.

Ostrowsky said Barnabas Health is venturing into health insurance in an attempt to address what he feels is one of the biggest problems in the industry — the disconnect between financing health care and providing health care.

"It is one of the things that makes the health care delivery system intolerable," he said. "(Health care) is the only business where I deliver the service to the consumer and I charge somebody else. There is no other piece of commerce like that."

Ostrowsky hopes the plan can address another issue: keeping people healthy.

His vision, he said, is to offer a plan that helps lead the transformation of the health care system toward one focused on keeping people healthy, rather than just taking care of the sick.

"If we are going to sell this to a group of people, we are going to have to engage those people beyond just being consumers," Ostrowsky said. "I am going to want to encourage better lifestyles and (provide) encouragement to do the right things (health wise)."

He envisions a plan that coaches patients and coordinates the services they receive, rather than just allowing them to pay the premium and then do what they want.

"I desperately want to take a piece of the revenue that you collect and invest it in keeping people healthy — as opposed to reserving it and waiting for them to come to us when they are sick," he said.

Ostrowsky said the plan will be built around the Barnabas network of hospitals, doctors and other clinicians and outpatient facilities. He said it could offer members a two-tier network, in which members will have access to more affordable care if they remain in the Barnabas network.

Earlier this month, Freehold-based CentraState Health System announced it will launch a health plan targeted to small employers on March 1.

While CentraState is offering a self-insured plan managed by the health care network and claims administrator QualCare, the Barnabas plan will be a health insurance product. Ostrowsky said he has been in discussions with an insurance company partner that will be announced later.

Ostrowsky feels the Barnabas Health plan can have a big impact in the marketplace.

"It's going to be a big piece of the population," he said. "I would not want to quantify it, but this is not going to be a neighborhood plan."

18 New Jersey Physician

Kimball laying off 73 workers, including 62 nurses

by Michael L. Diamond Kimball Medical Center in Lakewood will lay off 73 employees by the end of April as part of its plan to consolidate with Monmouth Medical Center, according to documents filed with the state.

These new layoffs, coming at the end of April, will include 62 nurses, said Maria Refinski, president of New Jersey Nurses Union, Communication Workers of America Local 1091, which represents 274 nurses at Kimball.

Meantime, the union representing nurses has started a petition trying to stop the merger. An official said the low-income residents that Kimball serves will have trouble finding maternity care nearby.

“Those are services that that community really needs,” Refinski said. “It will be a hardship for the lower-income population.”

Kimball’s parent company, Barnabas Health, said in January it planned to make the Lakewood hospital part of Long Branch-based Monmouth Medical Center and change its focus. It plans to close the hospitals’ maternity ward. It plans to spend $11 million to make all of its inpatient rooms private. And it plans to change its name to Monmouth Medical Center Southern Campus.

Hospitals face mounting pressure under the Affordable Care Act, popularly known as Obamacare, to manage their business more efficiently. The 101-year-old Kimball, in particular, was in a perilous spot. About 80 percent of its patients are covered by Medicare, Medicaid and charity care, which reimburse providers at lower rates than private insurers. As a result, Kimball had an operating loss of $3.4 million in 2012, according to a financial report by KPMG. Barnabas officials said Kimball didn’t have an intensive care unit for births, prompting about half of all new mothers in Lakewood to go to Monmouth Medical instead. Only 16 percent of all Lakewood babies were born at Kimball, the said.

The company has said it is expanding the services it provides at offices outside the hospital setting, where it can offer care less expensively. And it is working with employees to find other positions within the Barnabas system.

The layoff notice, filed with the state Department of Labor and Workforce Development, was the first indication of the impact on Kimball’s work force. Barnabas has declined to discuss employment levels. Refinski said the hospital had a round of layoffs in January from ancillary departments. But she didn’t know how many employees lost their jobs that time.

It is forcing nurses to scramble to find new employment. Penny John has been a nurse in the maternity ward at Kimball for the past 13 years, and she said she would miss not only helping women through labor and birth, but also promoting healthy practices for new mothers and their families.

Finding a job in her current specialty might be difficult, she said, so she plans to expand her search. She returned to college to get a bachelor’s degree and might continue on for a master’s.

“Being able to take part in that wonderful experience (in the maternity ward) is just great,” said John, 40, of Waretown. “There’s nothing like it.”

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New list names top N.J. hospitals for

By Emily Bader Inside Jersey magazine and Castle Connolly Medical Ltd. produced a list of New Jersey's top hospitals for various medical conditions, as well as for overall care.

Medical centers in the state were divided into two categories based on size, one for hospitals with more than 350 beds and one for hospitals with fewer than 350 beds. Morristown Memorial Medical Center and Newton Medical Center earned the top honor in both categories.

The top five overall hospitals, plus the winners of each individual category, are listed below.

Here are the results: The top ranked hospitals overall (more than 350 beds): 1. Morristown Medical Center (Morristown) 2. Saint Barnabas Medical Center (Livingston) 3. Overlook Medical Center (Summit) http://www.case.edu/magazine/images/healthcare_lg.png 4. Hackensack University Medical Center (Hackensack) 5. Holy Name Medical Center (Teaneck) The top ranked hospitals overall (350 beds or fewer): 1. Newton Medical Center (Newton) 2. Bayonne Medical Center (Bayonne) 3. Jersey City Medical Center (Jersey City) 4. Palisades Medical Center (North Bergen) 5. Chilton Medical Center (Pompton Plains) Looking for specifics? The list has it covered. They ranked hospitals also based on specific treatment options.

For the treatment of breast cancer: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Newton Medical Center For the treatment of prostate cancer: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Bayonne Medical Center For the treatment of pediatric cancer: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: There were not enough hospitals with dedicated programs for this treatment.

For bypass surgery: More than 350 beds: Morristown Medical Center Fewer than 350 beds: Deborah Heart and Lung Center (Browns Mills)

20 New Jersey Physician

quality of care For hip and knee repair: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Bayonne Medical Center For the treatment of congestive heart failure: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Bayonne Medical Center For the treatment of strokes: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Bayonne Medical Center For high risk pregnancy: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Jersey City Medical Center For the treatment of neurological disorders: More than 350 beds: Saint Barnabas Medical Center Fewer than 350 beds: Bayonne Medical Center Although Inside Jersey and Castle Connolly understand that doctors' views are important, sometimes they don't tell the whole story. So, they partnered with IPRO, an independent not-for-profit health care consulting organization, to present post-discharge ratings of New Jersey hospitals by patients.

Patients highly satisfied: More than 350 beds: Valley Hospital (Ridgewood) Fewer than 350 beds: Deborah Heart and Lung Center Patient's room and bathroom kept clean: More than 350 beds: JFK Medical Center (Edison) Fewer than 350 beds: CentraState Medical Center (Freehold) Doctors always communicated well: More than 350 beds: Valley Hospital Fewer than 350 beds: Deborah Heart and Lung Center Registered nurses always communicated well: More than 350 beds: Valley Hospital Fewer than 350 beds: Deborah Heart and Lung Center Doctors were invited to participate in an online survey that ran from Nov. 11 to Dec. 8. More than 6,300 emails were sent throughout the state and regular mail to the chief executive offer, chief medical officer and the chief marketing officer at all hospitals in New Jersey, as well as to the state's county medical societies.

The hospitals were selected based on 33,880 total votes cast. The number of total licensed physicians participating was 2,076.

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East Orange General signs non-binding agreement with for-profit hospital

By Beth Fitzgerald Another for-profit hospital system may be coming to New Jersey.

The nonprofit East Orange General Hospital and the for-profit Prospect Medical Holdings announced Tuesday that they have signed a non-binding agreement to pursue a strategic partnership. The groups said the arrangement “will preserve and enhance essential health care services for the residents of East Orange and its surrounding communities.”

The non-binding letter of intent includes a commitment by the Santa Ana, Calif.-based Prospect to make a “substantial capital investment” in the hospital over five years, maintain East Orange General as an acute-care facility, and retain the employee and physician base.

Prospect will assume the hospital’s debt and provide several million dollars in new resources to enable the hospital’s Foundation to work directly with patients, families, physicians and community leaders to promote and improve wellness.

The development of a definitive agreement is ongoing and will require a review and approval process by the state.

“This strategic partnership with Prospect provides East Orange General Hospital with the very best opportunity to preserve and strengthen the public health safety-net we have maintained in this community for over a century,” East Orange General President Kevin J. Slavin said in a statement. “Prospect shares our core values, believes strongly in our mission, and will deliver the substantial capital investment we need to remain an essential part of our region’s economy and health care system well into the future.”

New Jersey has seen the acquisition of a number of struggling urban hospitals by for-profit hospitals companies in recent years.

CarePoint in Bayonne, for instance, acquired three such hospitals in Hudson County: Bayonne Medical Center, Hoboken University Medical Center and Christ Hospital in Jersey City.

Critics say for-profit hospitals are all about profits – which often come at the expense of the community. Proponents say for-profit hospitals are the only ones willing to serve these communities, keeping services available.

Prospect Chief Executive Samuel Lee said in the statement that his group is eager to make a difference.

“We are excited at this opportunity to build upon East Orange General Hospital’s strong presence in and commitment to its local community,” he said. “We are committed not just to helping preserve East Orange General Hospital as an essential community health care provider, but also to making sure it realizes its significant potential for growth.

“In this challenging health care climate and for the long term, Prospect offers a truly unique model of health care delivery that emphasizes cooperation and collaboration among hospitals, physicians, health plans and other providers, with one simple goal – ensuring that our patients receive the right care, in the right place, at the right time and at the right cost.”

The selection of Prospect follows an extensive review process facilitated by a request for proposal issued to more than two dozen hospitals and health systems by East Orange General in early 2013.

“The unique health care transformation fostered by the Affordable Care Act has led many hospitals to explore new, innovative partnerships,” Slavin said. “Our goal here was simple from day one; to identify the right strategic partner that will not only ensure financial viability for our hospital both today and tomorrow, but also embrace and improve our essential services, such as acute care, primary care, and behavior health. We have found that partner in Prospect.”

East Orange board chair Leonard Murray II agreed.

“Throughout our intensive process and open discussions with Prospect, it became clear that they were the ideal fit to join us in providing the best care possible for the populations we serve, both now and well into the future,” he said. “Their unquestioned record of strengthening urban, safety-net, mission-driven hospitals resonated greatly with us.”

East Orange General Hospital has served the community for more than a century, and recently expanded its services. Specialty areas include: same day surgery, physical and cardiac rehabilitation, behavioral health, family health and emergency medicine.

Prospect owns and operates eight hospitals, with a total of approximately 1,056 licensed beds, as well as clinics and outpatient centers. Prospect also manages the provision of health care services for over 210,000 patients enrolled in its networks of over 3,300 primary care physicians.

22 New Jersey Physician

Monmouth County hospital launches health plan

By Susan K. Livio In the latest sign that hospitals must do much more than treat sick people to compete in today's health care market, CentraState Health System in Freehold has launched its own health plan.

Since March 1, the CentraState Community Health Plan has been offered through Affiliated Physicians and Employers Health, a selfinsured benefits company that already covers 13,000 people from 800 businesses, according to a CentraState announcement.

The plan is aimed at cost-conscious physician practices with at least two employees, and any company that is a member of the Greater Monmouth, Howell, and Jackson Chambers of Commerce.

The premium rates in the CentraState Plan are about 17 to 19 percent less than Affiliated Physicians and Employers Health typically offers its members. CentraState's 175 physicians also have agreed to offer discounts to help make the plan more affordable, according to the announcement.

“As part of our mission to improve our community’s health, we were eager to assist our area businesses in finding a cost effective way to manage their health costs and ultimately the health of their employees,” said John T. Gribbin, CentraState's president and CEO. "This is New Jersey's first community-based product that will offer small and mid-sized businesses a health plan centered around a local health care system and its providers, while still providing these businesses with the full breadth of the expansive QualCare network," Dawn Wright said, a vice president for QualCare Alliance Networks of Piscataway, which manages the plan.

The partnership is another example of how the Affordable Care Act is changing health care. Hospitals took deep cuts in Medicare funding to help pay for the law. Hospitals also lose federal money if the rate of hospital readmissions among Medicare patients is high. The industry is looking for different ways to make and save money.

CentraState's business model is known as a Multiple Employer Welfare Arrangement Health Plan, called MEWAs. Meadowlands Hospital Medical Center in Secaucus created a similar plan.

This business model is not without risk, said Joel Cantor, director of the Rutgers Center for State Health Policy.

"These models are self-funded, meaning that the firms involved bear full financial risk, as opposed to having insurance companies bear risk," Cantor said. "In small groups, one or two catastrophic cases can lead to significant financial burdens on the sponsor."

The model offers another choice for business owners, which is good, but it might diminish the supply of relatively healthy people out of the insurance market, Cantor added. "To the extent that comparatively healthy small groups are leaving the insured market to form MEWAs, the average cost for the small businesses remaining in the market will go up."

By 2016, Obamacare will require businesses that employ 51 to 99 full-time workers must provide health coverage. Smaller companies are not obligated to offer coverage. Companies with 100 or more workers must comply next year.

Visit us now online at www.NJPhysician.org

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Affiliated Practice

HBCBS, JFK Medical Center form collaborative ACO

By Beth Fitzgerald

Horizon Blue Cross Blue Shield of New Jersey and Edison-based JFK Medical Center announced Monday the launch of a collaborative Accountable Care Organization aimed at improving medical care for over 5,000 Horizon BCBSNJ members.

Horizon will make care coordination payments to the JFK-affiliated physician practices to cover the cost of improved monitoring and coordination of population health. If certain clinical, patient satisfaction and cost goals are met, the practices will have the opportunity to share in the financial savings with Horizon.

This is the latest in a series of innovative medical care delivery programs that Horizon has launched through the state, which now cover about 500,000 of Horizon's 3.7 million members.

For the JFK ACO, more than 140 doctors practicing at approximately 50 practice locations in Central Jersey are participating, and the ACO is set to begin on April 1.

"This collaborative agreement with JFK is another important step in transforming the health care system in New Jersey with an eye toward delivering better patient care while containing costs," said Jim Albano, vice president of Network Management and Horizon Healthcare Innovations at Horizon.

"Our physician-led board of directors chose Horizon because it was evident they excelled in the qualities needed for the ACO to be truly successful," said William F. Oser, vice president, medical affairs and director of ACOs at JFK. ACOs are centered on primary care. Participating physician groups strive to create a healthier patient population through a coordinated approach to care among providers within the ACO. The ACOs are designed to achieve measured patient quality outcomes and decrease unnecessary and duplicate medical tests and treatments.

24 New Jersey Physician

Aetna, Atlantic ACO announce new agreement The agreement will cover more than 28,000 Aetna members in six N.J. counties

By Beth Fitzgerald The health insurer Aetna and the Atlantic Accountable Care Organization, a partner of the Atlantic Health System, announced Tuesday a new ACO agreement that will cover more than 28,000 Aetna members in six New Jersey counties served by Atlantic ACO physicians.

The goal of the new ACO is to improve the coordination and delivery of care to those Aetna members. Atlantic ACO, a group of health care providers who coordinate care and are accountable for cost, quality and patient satisfaction for the health care they provide, includes more than 1,700 primary care physicians and specialists.

The Atlantic ACO has already partnered with Medicare to improve care and lower costs in the federal health care program for the elderly. The Aetna program marks a further expansion of the ACO into the commercial insurance market, something a number of health insurers have been doing across the state.

According to Aetna and Atlantic ACO, Aetna members will experience more coordinated care, particularly those patients with chronic or complex conditions. They also will have enhanced access to appropriate care and will benefit from the improved flow of information to treating physicians in the Atlantic ACO. "Simply stated, when hospitals and health plans work together, health care improves for the people we serve," John Lawrence, president of Aetna – New Jersey, said.

"Aetna will work closely with the ACO physicians to identify specific areas where we can either develop or improve on the sharing of specific, useful health information. In turn, the physicians will use this information to improve care for patients, close gaps in care and reduce waste. We are creating a continuous loop of improved information to drive better care. By working together, we can bring better health, better care and better cost to thousands of Aetna members beginning this spring," Lawrence said.

"We are very excited to partner with Aetna, and together, offer patients well-coordinated care to live healthier, more productive lives," said Dr. David Shulkin, who is president of the Atlantic ACO and Morristown Medical Center and vice president of the Atlantic Health System. His hospitals also include Overlook Medical Center in Summit, Newton Medical Center in Newton and Chilton Medical Center in Pompton Plains. "We look forward to working with Aetna to deliver superior results for our patients."

Aetna members who've been treated by Atlantic ACO affiliated physicians over the last 24 months will become part of the ACO program. Their Aetna health plan benefits will not change, but they will receive highly coordinated, personalized care. Atlantic ACO employs a staff of care coordinators who will complement Aetna's care management programs to reduce hospitalizations and improve members' health outcomes.

The agreement includes a shared savings model that rewards Atlantic ACO physicians for meeting certain quality and efficiency measures such as:

•

The percentage of Aetna members who receive recommended preventive care and screenings;

•

Better management of patients with chronic conditions such as diabetes and heart failure;

•

Reductions in avoidable hospital readmission rates; and

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Reductions in unnecessary emergency room visits.

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Medical News

OIG Publishes Op-Ed Suggesting Mandatory Random Drug Testing For Health Care Professionals In an Op Ed article published in the New York Times), HHS OIG Daniel Levinson has called for mandatory random drug testing by hospitals for all health care workers with access to drugs. Citing recent cases involving drug diversions by health care workers that led to patient harm, the OIG indicated that since transportation or other safety-sensitive workers are already subject to random drug testing, health care workers should be subject to such testing as well. The OIG also called for the imposition of a requirement obligating hospitals to contact law enforcement if they suspect that a health care worker is stealing drugs. The OIG did not identify what vehicle would be used to implement these proposals. The Op-Ed piece leaves open the question of how the proposals would impact existing mandatory reporting obligations imposed on health care professionals by their professional boards, how mandatory reporting to law enforcement might impact referrals to professional assistance programs such as New Jersey’s Alternate Resolution Program, or issues raised in connection with collective bargaining agreements.

ACA News

ACA News

Co-Op Insurer Carves Out Unique Niche in NJ’s ACA Marketplace Meir Rinde Health Republic’s model calls for enrollees to eventually govern company while profits are used to improve coverage, lower premiums Three health insurers are selling policies on New Jersey’s marketplace under the Affordable Care Act, also known as Obamacare – and only one of them, Health Republic, plans to eventually be run by its members, with enrollees occupying a majority of the board seats, and with profits being put back into the company to either improve coverage or lower premiums.

Health Republic is one of 23 health-insurance cooperatives established across the country with start-up loans from the federal government. Unlike other insurers, a cooperative is governed by its members and reinvests surplus revenues in more services or cheaper premiums rather than seeking to make a profit.

It is making a point of targeting potential customers in urban areas, conducting recruitment campaigns aimed at commuters, and focusing on New Jersey residents who earn too much to qualify for Medicaid but are eligible for subsidies to help pay for coverage.

The two other insurers selling coverage through New Jersey’s federal health exchange are AmeriHealth and Horizon Blue Cross Blue Shield.

As they seek to establish a beachhead in the insurance market, executives at Health Republic admit enrollment has so far come in below expectations, due in part to the glitchy launch last year of the federal website Healthcare.gov.

The cooperative has not released enrollment figures, but CEO James Martin said he now hopes to reach 20,000 members by early in 2015, later than previously projected.

Health Republic has also had to navigate restrictions created by a Congress that was ambivalent about the cooperative concept, and the organization encountered some unanticipated hurdles as it crafted and began selling its health plans.

But Martin said he expects business to pick up as the Newark-based insurer focuses on enrolling self-employed workers, the uninsured and employees at small businesses who have been overlooked by other insurance companies. He also said potential customers, both on the individual exchange and in the small-business market, are attracted by Health Republic’s mandated mission of improving members’ health rather than on making a profit.

“We have a clause that was included in our federal government loan that was a mandate to innovate,” Martin said. “Not just to fund the startup of an insurance company, but to figure out other ways to improve the healthcare of those you're insuring. So that's part of what keeps us motivated to be optimistic about the future.”

Spurring competition Health Republic organizations in New Jersey, New York and Oregon were started with loan money applied for by the Freelancers Union of New York. The organizations maintain contacts but are independent from each other, Martin said.

Health Republic of New Jersey received a $107 million federal loan.

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The cooperatives were included in the ACA to ensure competition and a broader range of insurance plans after a proposal for government-run public option insurer faced opposition. A number of health insurance cooperatives opened around the United States in the 1930s and 1940s, and two large cooperatives have operated in Minnesota and Washington for decades.

But opposition from congressional Republicans and some Democrats led to a number of restrictions on the new entities sponsored by the ACA. The money was given out as loans rather than grants, and the initial funding of $6 billion was trimmed during later budget negotiations to about $2 billion, curtailing efforts to create more co-ops in other states.

In addition, the co-ops are allowed to sell only one-third of their policies in the lucrative large-employer market; they were given a special 501(c)29 nonprofit status that makes receiving grants and donations more difficult; and they are barred from using their federal loan money for marketing purposes, despite having entered a highly competitive industry with no customers or revenues.

The marketing restriction has been described as a major impediment for the co-ops, but Health Republic’s chief marketing officer, Cynthia Jay, said the nonprofit is allowed to used the loan funds for “education and outreach” as long as specific insurance plans are not being advertised.

That encompasses television and print commercials, a social media presence, and nearly daily enrollment events at hospitals and public libraries in North Jersey and Central Jersey.

Health Republic has also run into some of the same stumbling blocks other insurers have encountered. In particular, the rocky rollout of Healthcare.gov last fall made it nearly impossible for people to sign up for several weeks, pushing back Martin’s enrollment goals. He had previously projected enrolling 20,000 customers a year for the first three years and then starting to see revenues exceed expenses.

“Do we think we'll get there? Yes. The question is when,” he said. “Certainly not as aggressively as we had imagined.”

Through January, 54,805 state residents had used the marketplace to choose a plan from AmeriHealth, Horizon or Health Republic.

That does not include people who signed up directly with insurers or small-business customers.

Entering a complex market Another unexpected obstacle has been the sheer newness of health insurance to many potential enrollees, Martin said. Many of them are unfamiliar with terms like co-pay and co-insurance, and have trouble balancing the varying premium costs, provider networks, out-of-pocket limits and other options in health plans.

“You sit down and spend an hour to an hour and 15 minutes with somebody, going through all of their options -- and that's if they're prepared with correct information and have given some thought to what it is they want, what they can afford, how much out-of-pocket they can handle, how much health risk do they currently have, what's their current health status and what do they anticipate,” he said.

“Once you start running all that by people, we find this is not a quick and easy, ‘Oh, I like that one. I think I'll sign on,’ ” he said.

Jay noted that because Gov. Chris Christie opted to depend on the federal marketplace instead of creating a state exchange, New Jersey has not seen the influx of hundreds of millions of dollars to publicize and explain health insurance options, the way New York and some other states have. New Jersey also lost a $7.7 million grant to support the marketplace last month because federal officials turned down the state’s request to use the grant for purposes other than marketing.

Last year, Martin said, Health Republic hoped to boost enrollment by offering some of the lowest-cost plans in the marketplace.

However, an error in the way it calculated its benefit costs forced the cooperative to revise its plans, resulting in premiums that are no longer the cheapest available, he said.

The problem related to the out-of-pocket maximum, the amount a member must spend on in-network health costs before the insurer begins picking up 100 percent of those expenses. The cooperative initially used the federal maximum of $6,350, but later learned New Jersey limits the maximum to $2,500.

For customers with high health expenses, that means New Jersey insurers end up paying out more than they would under the federal rule. Health Republic realized it would have to charge higher premiums to make sure its health plans would not be money-losers.

“That meant we had to go back to the drawing board with our actuaries and everybody else” to recalculate the premiums, Martin said.

Jay noted that, as a new insurer, Health Republic does not yet have an archive of past cost and actuarial data to help it fine-tune its rates. It also is not in the huge large-employer market, where big insurance companies have revenues they can use to offset narrower earnings in the individual market, she said.

Higher premiums, but total costs vary The co-op’s revised plans ended up not being the least expensive in each level of New Jersey’s exchange. For example, for a March 2014

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27-year-old enrollee, Health Republic’s least expensive bronze-level plan is $298, while AmeriHealth offers one for $230 and Horizon’s cheapest is $286. Bronze plans cover about 60 percent of health costs, while the next tier of silver plans cover about 70 percent.

At silver, the level where many enrollees land, Health Republic offers three plans for about $330 a month while the other companies’ premiums range from $261 to $361. Its gold plans are similarly in the middle of the pack, and its high-coverage platinum plan is $414, below the one other platinum plan, AmeriHealth’s $479 option. Premiums at all levels may be higher for older enrollees.

Nationally, many of the 23 new co-ops are selling more of the expensive platinum plans than expected rather than bronze and silver plans, Kaiser Health News reported. The co-ops have enrolled close to 300,000 members so far, according to the National Alliance of State Health Co-ops.

Martin acknowledged that some people are signing up for the cheapest plan they can find. But as others in the industry have done, he cautioned that plans include many variables and in some cases the cheapest premium does not make for the lowest health costs overall, or what Jay called the “total cost of ownership.”

Such costs as higher deductibles and higher copayments are typical of plans with lower premiums, and other factors such as frequency of medical visits and which hospital groups are members of a particular plan also come into play, so the overall cost to the insured person could ultimately be higher despite the lower monthly bill.

And then there was the example of an East Windsor woman who reportedly planned to sign up for a more expensive Health Republic plan because she determined that it covers a drug she needs for just $30, compared to a cheaper plan that would cover only half of the $300 monthly cost, thereby making the high-premium plan more economical.

Jay also noted that the cooperative has not created cheaper plans with provider “tiers,” as Horizon and AmeriHealth have done.

People in those lower-premium plans pay less to use a specified subset of hospitals. But members who use nearby hospitals that are not in the top tier, or want to use an excluded hospital for another reason, will end up with higher overall costs.

Instead, all Health Republic members have the same provider access through QualCare Inc., a statewide network controlled by a group of hospitals. Qualcare has more than 100 hospitals and 20,000 physicians and other providers in New Jersey, New York and Pennsylvania, according to its website, and serves more than 800,000 members.

Reaching a target market As Health Republic seeks to build up its member base, it is targeting working people who do not have health insurance for various reasons and whose incomes are between 138 percent and 400 percent of the federal poverty level, making them ineligible to enroll in Medicaid but eligible for subsidies to buy insurance, Jay said.

To find those customers, staffers have done detailed research on the state’s self-employed and uninsured and visited promising areas, finding for example a large population of Korean small-business owners in the Fort Lee area who may not have insurance and may be interested in Health Republic’s plans, she said.

The cooperative is focusing on urban areas, where the populations of freelancers and the self-employed are densest, but enrolling members statewide. With a surge of enrollees expected before the marketplace’s open enrollment period ends on March 31, Health Republic’s 21 staffers are taking turns staffing tables at train stations to urge commuters to sign up, Jay said.

“We've been at PATH stations throughout the cities, handing out some of our information. We're getting ready to do a NJ Transit rail station campaign. I know nobody else is doing things like that,” she said. “It’s really thinking out of the box. We don’t have a lot of people and a lot of resources, but everybody chips in.”

The cooperative is also trying to establish a presence in the small business market through the insurance firms that provide coverage to small groups, Jay said.

“We’re building relationships with brokers out there,” she said. “We’re a newcomer, and what we’re finding is that they’re really interested in selling our products because we’re new. We’re trying to get them comfortable with us.”

Health Republic’s status as an upstart nonprofit is one of its biggest selling points, despite the challenges it has created, Martin and Jay said. Potential enrollees like the fact that surplus revenues will be reinvested in the business and that members will eventually make up at least 51 percent of the board, they said.

“They get excited about that, because they do hear, ‘We'll have a voice,’ ” Jay said. “The general co-op concept appeals to people, whether it's a food co-op, or a credit union, or just kind of a community. We’re new. It’s something that appeals to people.”

Health Republic’s plans do not envision it becoming a leading insurer in the state. Horizon, for example, has over 3 million subscribers. But Martin and Jay said they are expecting a bump in sign-ups ahead of the open enrollment deadline, more signups from small-group employers, and a steady flow of inquiries from people whose old “basic and essential” plans will be canceled through the end of the year because they do not meet the ACA requirements.

“There's an additional number of people who will be, after March 31, continuing to receive letters that say, ‘We can no longer offer you the plan that has been offered in the past,’” Martin said. “So it will cause them to be shopping and looking, and hopefully they will have heard about us in the process.”

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