M ay 2 0 12
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Didier Demesmin, MD
University Pain Medicine Center Comprehensive Interventional Pain Management Services that Bridge the Gap Between Conservative Therapy and Open Surgery
Also in this Issue • CMS Issues Proposed Rule on Increasing Payment for Primary Care • Health Care Disclosure and Transparency Act Appears Murky • NJ Insurers Say They’ll Retain Some ACA Reforms However High Court Rules
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Office of the Ombudsman for the Institutionalized Elderly to raise the visibility of state ethics committees that help families and nursing homes make tough, heartwrenching end of life decisions. These regional panels comprised of professionals from diverse backgrounds such as nursing, social work, long-term care and clergy can assist in working through the issues that sometimes put care facilities and
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University Pain Medicine Center is the focus of this month’s cover story. Didier Demesmin, MD and staff are incorporating innovative technology to provide minimally invasive interventions for a myriad of pain syndromes. In addition to treating disorders of the cervical and lumbar spine and other painful conditions
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such as diabetic neuropathy, Dr. Demesmin is dedicated to helping cancer patients live with less pain. With 5 office locations, including a beautiful brand new site in Monroe, University Pain Medicine Center is helping countless patients in central and southern New Jersey find relief from chronic and/or acute pain without undergoing an invasive procedure.
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Contents
Didier Demesmin, MD University Pain Medicine Center
Comprehensive Interventional Pain Management Services that Bridge the Gap Between Conservative Therapy and Open Surgery PHOTOs BY michael goldberg
9
Health Law Update
• CMS Issues Proposed Rule on Increasing Payment for Primary Care • STATE UPDATE – Health Care Disclosure and Transparency Act Appears Murky
10
Statehouse
• NJ Ethics Committees Mediate Crucial End-OfLife Decisions • NJ Insurers Say They’ll Retain Some ACA Reforms However High Court Rules • N.J. health department lets LHP-Hackensack joint venture proceed
14
Hospital Rounds
TAVR – New Treatment for Aortic Valve Disease Gives Older Patients New Option
15 16
he 4th Annual T NJ ASC Review
F ood for Thought
Town Hall Deli
Known as the Birthplace of the “Sloppy Joe”
South Orange, New Jersey
20
Diagnosis
• Famed Infectious disease specialist Leon Smith, MD has four more cases for you this month
COVER STORY
2
New Jersey Physician
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Cover Story
Didier Demesmin, MD University Pain Medicine Center Comprehensive Interventional Pain Management Services that Bridge the Gap Between Conservative Therapy and Open Surgery By Iris Goldberg
Chronic and/or acute pain is a fact of life for
• Cancer-related pain
Most recently, Dr. Demesmin is pleased
millions of Americans. Whether from a nerve,
• Migraines and other headaches
to share, in addition to interventional pain
spinal disc, joint or muscle, ongoing pain can
• Reflex sympathetic dystrophy (causalgia
management
interfere with normal function and greatly dimin-
or chronic regional pain syndrome)
University
Pain
Medicine
Center will also be focusing on physiatry and
ish the quality of one’s life. Finding a successful
• Arthritis
rehabilitative services. With the arrival of Jing
resolution can be challenging, to say the least.
• Phantom limb syndrome (post
Liang, MD and Manan Patel, MD, UPMC is
When conservative treatments such as oral med-
amputation pain)
ications and physical therapy fail - patients and
• Joint pain
referring physicians will usually opt for effec-
• Pelvic pain
tive, yet minimally invasive approaches before
widening its comprehensive umbrella. Although Dr. Demesmin and the staff at UPMC have successfully treated countless patients
considering an open surgical procedure. Inter-
As the field of pain management continues
with painful disorders involving the neck and
ventional Pain Management is a specialty that
to evolve, Dr. Demesmin is committed to the
back, there are other debilitating conditions
incorporates a variety of innovative procedures
constant research and exploration of new
that can be relieved at UPMC with a minimally
that successfully reduce pain and help countless
developments which enable him to most
invasive approach. “We treat many oncology
patients avoid open surgery.
effectively, yet least invasively help his patients
patients who are undergoing treatment
to live their lives with less pain. Within the
for various types of cancer.” Dr. Demesmin
For many in central and southern New Jersey,
attractive and relaxing setting of UPMC’s five
informs. “And we see pediatric cancer
Didier Demesmin, MD and the staff at
office locations, including a beautiful, brand
patients as well.”
University Pain Medicine Center (UPMC)
new site in Monroe, or its impressive same-day
including Sejal Patel, MS, PA-C and Margaret
surgical centers, Dr. Demesmin and staff work
Another example is women with chronic
Ahmed, MS, APN-C incorporate the latest
together to provide a full range of treatment
pelvic pain as a result of endometriosis or
technology to provide effective, minimally
services for those suffering from chronic and/
perhaps post-surgical scar tissue, neuromas or
invasive interventions for a myriad of pain
or acute pain.
nerve damage who are referred by their GYN
syndromes. At UPMC the goal is to expertly diagnose and treat painful conditions in order for patients to resume their everyday activities quickly, without having to rely heavily on medications. Some of these disorders include but are not limited to: • Neck pain (herniated or degenerative disc disease, radiculitis, whiplash) • Back pain (herniated or degenerative disc disease, radiculitis, spinal stenosis, sciatica) • Failed back surgery • Facet joint pain • Trigeminal neuralgia • Diabetic neuropathy • Post herpetic neuropathy (herpes zoster or shingles-related pain)
4
New Jersey Physician
p Reception area at UPMC’s beautiful new Monroe location. Intricate stonework is just one of the attractive touches.
Procedures Offered at University Pain Medicine Center Cervical Procedures: • Epidural steroid injections • Nerve root blocks • Diagnostic medial branch blocks • Radiofrequency rhizotomy (ablation) • Discogram • tellate ganglion/sympathetic blocks • Cervical disc decompression Thoracic Procedures: • Epidural steroid injections • Intercostal nerve block • Thoracic transforaminal epidural • Thoracic disc decompression Abdominal & Pelvic Procedures: • Celiac plexus block • Hypogastric plexus block • Prudenal nerve block Stimulators: • Spinal cord stimulator and implant • Lumbar & cervical Lumbar Procedures: • Epidural steroid injections • Nerve root blocks • Transforaminal injections • Facet joint injections • Diagnostic medial branch blocks • Radiofrequency rhizotomy (ablation) • Discogram • SI joint injections • Lumbar sympathetic block • Lumbar disc decompression • Endoscopic disc decompression Other Options: • Peripheral nerve blocks (occipital, ilio-inguinal, supraorbital, etc.) • All joints (hip/knee/shoulder) • Piriformis block • Intrathecal pump • Vertebroplasty Fig. 1
repair, it can actually form a scar embedding
Nerve blocks use local anesthetics, steroids,
the nerve within it, causing the painful result.
chemical
neurolytic
agents
or
thermal
neurolysis to produce small lesions in In terms of neck and back pain, however, Dr.
nerve pathways in an attempt to interrupt
Demesmin reports that UPMC does incorporate
the transmission of pain signals. Intraspinal
cutting edge and the most technologically
administration
current minimally invasive procedures for
efficiency of pain relief while minimizing
patients who suffer from these conditions as
systemic side effects. Spinal cord stimulation
well as the many other painful disorders that
involves the controlled application of pulsed
are successfully treated. “We cover the entire
electrical energy across neural structures to
gamut of innovative pain management,” Dr.
modulate painful signals, thereby producing a
Demesmin states. (Please see Fig.1).
reduction of pain.
One aspect of interventional pain management
Dr. Demesmin cites the recent example of a
that does not receive adequate recognition, is
patient with metastatic breast cancer to her
the crucial role it can have in the comprehensive
ribs, causing severe pain. He administered a
and multi-disciplinary treatment of some
couple of nerve blocks which did help for a
cancer patients. Cancer patients frequently
short while but unfortunately her pain returned.
of
medication
improves
have more than one cause and more than one location of pain. A significant number of
“We subsequently implanted an intrathecal
cancer patients, such as those with bone or
pump,” Dr. Demesmin relates. “This delivers
nerve involvement, cannot achieve adequate
local anesthetics and medication directly into
pain reduction or reach an acceptable balance
the intrathecal space to more effectively control
between analgesia and pain medication-
the pain on an ongoing basis,” he explains.
related side effects. These patients may benefit greatly from interventional pain management
The patient in question, Elizabeth Soos and
procedures that are therapeutic options for
her daughter, Helga Gherzan, feel strongly
managing cancer pain that is uncontrollable by
about sharing how having the pump implanted
conventional drug therapy.
dramatically improved the quality of life for Ms. Soos. “The pump completely changed my
Anesthetic techniques include nerve blocks
mother’s life,” Ms. Gherzan emphatically states.
and neuromodulation, such as intraspinal
“She suffered for months and couldn’t even get
administration of narcotics and/or other
out of bed. Now, with the pump she is able to
agents as well as spinal cord stimulation.
enjoy her life again,” Ms. Gherzan joyfully says.
physicians. “So we try to be as comprehensive as possible and don’t just focus on necks and backs,” he strongly emphasizes. Dr. Demesmin describes in some detail, an innovative, yet possibly less well-known procedure he performed recently on a woman who
developed
ilio-inguinal
neuralgia
following a hernia repair. Her pain was directly over the area where the mesh had been placed. “I placed two leads directly into the front where the inguinal nerve is in order to block her pain,” he relates. Dr. Demesmin goes on to explain that often when mesh is utilized to do a hernia
p Dr Demesmin and technician Jenna Main in the state of the art procedure room at the Monroe office. May 2012
5
We are so grateful to Dr. Demesmin. He is just wonderful! The support we
Using local anesthesia and light sedation, Dr. Demesmin restores the
get from him and the staff means everything to my mom,” she exclaims.
space in the spinal canal while maintaining structural stability by locating and removing only those portions of tissue and bone that pinch the spinal
“We also treat pain from pelvic tumors, such as GYN cancers of the
nerves and cause pain. The procedure, which takes about an hour to
ovaries,” Dr. Demesmin shares. “There are specific nerve blocks that we
perform and uses a minimal entry point about the diameter of a pencil,
do for these types of patients,” he reports.
requires no sutures. Patients return home the same day.
For pancreatic cancer patients UPMC offers splanchnic nerve block (SNB) and celiac plexus block (CPB) to control pain. Abdominal pain is a major symptom in patients with inoperable pancreatic cancer and may prove difficult to treat. SNB and CPB are safe and effective methods for reducing this pain, which involve the chemical destruction of nerve fibers that convey pain from the abdomen to the brain through the administration of fluoroscopically-guided injections. Dr. Demesmin is extremely dedicated to and involved with improving the quality of life for patients with cancer. He treats adult and pediatric cancer patients on an outpatient basis at UPMC and also those who are hospitalized at either St. Peter’s University Hospital or Robert Wood Johnson University Hospital. “This is very important to me on a personal level,” he shares, confiding that he has witnessed the suffering of many in his own family who have struggled with the pain from various
p Dr. Demesmin performs discography by inserting a guide needle through the anesthetized track to the annulus of the disc .
types of cancer. Chronic disabling lower back pain that can also involve the groin, It is unquestionable that unrelieved pain associated with cancer can
hip and/or leg is a problem that may be experienced by millions of
dramatically affect patients’ quality of life, including levels of physical
Americans at any given time. Sometimes, despite extensive conservative
activity, social interactions and attitude. Ultimately, poor performance
treatments with medication and physical therapy, patients continue to
status can negatively impact on treatment regimens. Dr. Demesmin
experience pain. When traditional diagnostic procedures such as MRI
works with oncologists and other healthcare providers to devise a
and CT myelogram have failed to elucidate the primary pain generator
multidisciplinary approach to treating cancer-related pain.
and a problematic disc is the suspected culprit, these individuals may benefit from lumbar discography.
Besides his work on the Cancer Committee at St. Peter’s University Hospital, where he confers with a multidisciplinary team of specialists
At UPMC Dr. Demesmin performs discography to definitively determine
to develop the most effective regimens of palliative care, Dr. Demesmin
whether a disc or discs in question are, in fact, responsible for the painful
recently attended the Cancer Pain Convention that was held in Arizona.
symptoms. It is only when this has been established that an effective
There, he was able to learn about some of the very latest modalities for
treatment plan can be formulated. Discography involves pressurizing
controlling cancer-related pain from renowned experts in the field.
discs with an injection of sterile liquid to induce pain in the affected disc or discs.
In addition to the innovative procedures offered at UPMC for those conditions that do not involve chronic neck or back pain, Dr. Demesmin
The patient receives local anesthesia and mild sedation but must remain
and staff do, in fact, treat many disorders of the cervical and lumbar
alert enough to provide feedback to Dr. Demesmin. Using fluoroscopy
spine. At UPMC cutting edge spine procedures provide relief to countless
to identify the correct location, he inserts a guide needle through the
patients.
anesthetized track to the outer edge (annulus) of the disc. Through this guide needle a much smaller disc needle is advanced towards and
For patients with spinal stenosis, which is a narrowing of the spinal canal
eventually into the center of the disc. This may be repeated for more than
that can compress the nerve and tissues causing pain, Dr. Demesmin is
one disc.
pleased to share a relatively new procedure, MILD (minimally invasive lumbar decompression). Often, patients with spinal stenosis eventually
Once all of the needles are placed, Dr. Demesmin pressurizes the
do not get adequate relief from physical therapy, medications and
discs, one at a time, with injections of contrast dye. With each injection,
epidural injections but do not want to undergo an invasive open surgery.
patients feel either pressure or pain. It is imperative for patients to tell Dr.
Dr. Demesmin explains that for these individuals, MILD is an extremely
Demesmin if the discomfort they are feeling when each disc is pressurized
desirable option.
is the same as or different from the pain they had been experiencing. If it
6
New Jersey Physician
Dr. Demesmin has shared his expertise in the performance of minimally invasive discectomy with pain management physicians worldwide. He has taught by demonstrating this technology in Brazil, China and Trinidad and has also lectured on this in Italy, France and in regional venues within the United States. Unlike open lumbar disc surgery, lumbar endoscopic discectomy involves no traumatic back muscle dissection, no bone removal and is accomplished through a small puncture site rather than a large skin incision. Dr. Demesmin uses fluoroscopic x-ray imaging and magnified video to guide an endoscopic probe through the skin of the back, between the vertebrae and into the damaged disc space.
p Once the needles are placed, Dr. Demesmin pressurizes the discs, one at a time, with injections of contrast dye.
is the same, this may indicate a diseased disc. After each level has been pressurized, pictures are taken with the fluoroscopic unit and the needles are removed. Typically, Dr. Demesmin will obtain a post-discogram CT scan to document the internal architecture of the disc. It is important to note that a disc which appears to be significantly abnormal may not actually be causing pain, while a minimally disrupted disc may be associated with severe pain. It is only when the information provided by the patient during the procedure is included that a painful disc can be definitively identified. When all of the information from the discogram has been evaluated a
p Dr. Demesmin uses fluoroscopic x-ray imaging and magnified video to guide an endoscopic probe into the damaged disc space.
suitable course of treatment can then be undertaken.
Tiny surgical attachments are sent down the hollow center of the probe
Lumbar endoscopic discectomy is a minimally-invasive, ambulatory
can also be used to push a bulging disc back into place or for the removal
surgical procedure that Dr. Demesmin, teaming at times with an endoscopic surgeon, performs for many of his patients when MRI, CT scan and discography document lumbar disc problems such as disc annular tear, disc bulge and disc herniation. During this procedure damaged disc material that is causing pain in the lower back is removed.
to remove a portion of the offending disc. The microsurgical attachments of disc fragments and small bony spurs. The amount of nucleus tissue removed varies but the supporting structure of the disc is not affected by the surgery. The access route to the disc consists of only the probe’s small puncture site, usually the size of a freckle. Therefore, the risk of complications from scarring, blood loss, infection and anesthesia that could occur with conventional open surgery is essentially eliminated. Many patients treated by Dr. Demesmin are seen because of chronic and debilitating pain which is caused by a problem in the cervical spine. Often this is the result of injury to one of the facet joints that are found on both sides of the spine that connect the vertebrae. Sometimes the cartilage inside the joint may be injured or perhaps only the connecting ligaments surrounding the joint are injured. Cervical facet joint pain can occur in any area from the head down to the shoulder blade. Radiofrequency ablation, which uses radiofrequency energy, is
p Dr. Demesmin and endoscopic surgeon Marc Cohen, MD, team to perform lumbar endoscopic discectomy.
performed by Dr. Demesmin to disrupt nerve function. When this is done to a cervical medial branch nerve, the nerve can no longer transmit pain May 2012
7
from an injured facet joint. This minimally invasive procedure, also called radiofrequency rhizotomy, involves inserting a needle-like tube called a cannula and positioning it near the irritated medial branch nerve. A fluoroscopic x-ray is used to position the cannula properly. A radiofrequency electrode is inserted through the cannula. Dr. Demesmin tests the electrode’s position by administering a weak electric jolt. If the stimulation recreates the pain without any other muscular effects, the electrode is positioned correctly. Dr. Demesmin uses the electrode to heat and cauterize the nerve. This disrupts its ability to communicate with the brain, blocking the pain signals. He may treat multiple nerves, if necessary. Although pain may increase initially, the patient usually has full relief from pain within a month. With his expertise in interventional pain management technology, Dr. Demesmin has helped thousands of patients treated at UPMC return to normal functioning and to regain a good quality of life. As the recentlyelected President of the Middlesex County Chapter of the Medical Society of New Jersey (MSNJ), Dr. Demesmin is significantly involved in that organization’s work as an advocate for patients throughout the state’s healthcare system. In addition to his efforts on behalf of patients, Dr. Demesmin is instrumental in providing advanced training for upcoming interventional pain management specialists. Working with Rutgers University and within the Physiatry Department of JFK Medical Center, Dr. Demesmin is an instructor who has helped to develop an A.C.G.M.E. (American
p Dr Demesmin uses an electrode to heat and cauterize the nerve, disrupting its ability to communicate pain signals to the brain.
College of Graduate Medical Education) - accredited fellowship program, which is one of only six, nationwide.
“This is something that is very important to me and I am extremely involved in helping to graduate fellows who have completed a fellowship program at this level,” Dr. Demesmin emphatically states. For the treatment of his patients and the advanced training of pain management physicians, Dr. Demesmin holds himself and others in the field to the highest levels of excellence. For more information or to schedule an appointment, call 732-873-6868 or visit www.upmcpainmedicine.com
University Pain Medicine Center locations are: Somerset (2 locations) - Towne Professional Park at Somerset 33 Clyde Road Suites 105 & 106 Somerset, NJ 08873 Monroe 294 Applegarth Road Suite G Monroe, NJ 08831
p Radiofrequency ablation involves inserting a needle like tube and positioning it near the irritated medial branch nerve
8
New Jersey Physician
Piscataway 234 Stelton Road Piscataway, NJ 08854
- 2 Worlds Fair Drive Suite 203 Somerset, NJ 08873
South Plainfield 1810 Park Avenue South Plainfield, NJ 07080
Health Law Provided by Brach Eichler LLC, Counselors at Law
CMS Issues Proposed Rule on Increasing Payment for Primary Care On May 9, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that seeks to increase Medicaid payments for certain primary care services. Among other changes, the proposed rule: • Implements the Affordable Care Act’s requirement that Medicaid reimburse primary care physicians for services CMS designates as “primary care services” at Medicare rates instead of state-established Medicaid rates (which often are lower) in calendar years (CYs) 2013 and 2014 • Grants states more than $11 billion in federal funds over two years to support Medicaid primary care delivery systems • Applies to primary care services delivered by physicians specializing in family medicine, general internal medicine or pediatric medicine, and related subspecialists • Provides guidance on identification of eligible primary care services and providers, implementation of increased payments and payment
Health Law Update
Update
STATE UPDATE
Health Care Disclosure and Transparency Act Appears Murky On May 10, 2012, a bill was introduced in the New Jersey legislature entitled the Health Care Disclosure and Transparency Act (A.2751) to clarify waiver, disclosure and payment issues for out-of-network (OON) benefits. While a laudable goal, the bill instead creates more problems than it seeks to resolve. Under the bill, if a provider furnishes OON services, the provider must make at least three documented good faith attempts to collect before waiving the patient’s financial responsibility. Waiver would then be permissible only if due to a medical or financial hardship, only if waivers are not routinely given, and only if the patient’s insurer is notified. This is generally consistent with current case law and regulatory guidance in New Jersey.
of vaccine administration fees under the Vaccine for Children
However, the bill also indicates that, if an OON provider furnishes
program.
services in an in-network licensed facility, the provider cannot bill the patient beyond the patient’s in-network co-payment, co-insurance or
The temporary increase in payment for primary care services will be paid
deductible. In essence, the OON provider would receive payment as if he
entirely by the federal government, with no state matching of payment re-
was in-network. Moreover, it is unclear whether the OON provider who is
quired. In particular, states will receive 100% federal financial participation
paid based on in-network rates would have any contractual protections
for the difference between the Medicaid state plan payment amount as
or rights against the insurer. Indeed, there would be no signed contract
of July 1, 2009, and the Medicare rates in effect in CYs 2013 and 2014 or, if
between the OON provider and the insurer. Additionally, it is unclear
greater, the payment rate that would be applicable using the CY 2009 Medi-
whether an OON provider can be forced to accept in-network rates that
care conversion factor. The proposed regulations also note that, “[a]s we
he never negotiated or agreed to. Furthermore, it is unclear whether the
move towards CY 2014 and the expansion of Medicaid eligibility, it is criti-
OON provider can bill, if at all, the in-network facility or the insurer for the
cal that a sufficient number of primary care physicians participate in the
difference between the in-network and OON rates.
[Medicaid] program,” and these rate increases “will encourage primary care physicians to participate in Medicaid by increasing payment rates.”
If enacted, the bill would also lead to providers having less leverage in contract negotiations with insurers.
Please visit us online at www.NJPhysician.org
The bill is being watched closely by physicians, ambulatory surgery centers and hospitals, all of which have voiced opposition.
May 2012
9
Call for Nominations
New Jersey Physician Magazine invites all medical practices to submit nominations for cover stories. Practices should include a brief description of what makes the practice special. Please contact the publisher Iris Goldberg at igoldberg@NJPhysician.Org
Statehouse
New Jersey Statehouse NJ Ethics Committees Mediate Crucial End-Of-Life Decisions Nursing homes encouraged to see help with medical, moral choices By Beth Fitzgerald
When a nursing home resident can no longer
McCracken wants to raise the visibility of these
and follows the patient from one care setting to
make decisions, someone else has to make the
ethics committees and encourage nursing
another, including home, ambulance, hospital,
tough ethical choices. Should the patient’s life
homes to call on them to mediate more often.
nursing home, and hospice.
be prolonged with a ventilator or feeding tube?
To do so, he is presenting this month training
Has the time come to remove life support?
sessions, “How to Make Ethical Decisions at the
POLST is designed to supplement the living will
What would this person have wanted? The
Bedside,” taught by clinical ethicist Dr. Helen
or advanced directive, which individuals typi-
family and the nursing home staff can wind up
D. Blank and designed for ethics committee
cally use to designate a healthcare proxy who
at loggerheads, unable to take the next step.
members and nursing home staff.
will make decisions when they are no longer competent to direct their own medical care. A
The state’s ethics committees are helping fami-
McCracken’s initiative comes at a time when
committee of the New Jersey Hospital Associa-
lies and nursing home staff make these tough
New Jersey is paying increased attention to
tion is expected to create a POLST form to be
decisions. The regional panels are made up
the quality and cost of end-of-life medical care.
used throughout the state by the end of the year.
of trained volunteer professionals with diverse
New Jerseyans tend to spend more time in
backgrounds, including nursing, social work,
intensive care units of hospitals and see more
When there is no clear directive, a state ethics
long-term care, and clergy. They work under
specialists in their final months of life, which
committee can step in to help families and
the direction of the state Office of the Ombuds-
is why the state’s end-of-life spending is among
nursing home staff tackle tough questions
man for the Institutionalized Elderly, which ad-
the highest in the nation.
by bringing “some fresh viewpoints, and people who have been trained to keep the
vocates for patients in long-term care facilities. A new law gives New Jersey residents the
conversation on track and keep it very neutral,”
The ethics committees “are available to people
final say on their medical care. The planning
said Jane Knapp, chairwoman of the Tri-county
to help them through an extremely difficult
document, called the “Physician Orders for Life
Regional Ethics Committee, serving Camden,
and hard time and help them critically think
Sustaining Treatment” or POLST, details the
Burlington, and Gloucester counties.
through issues and make decisions that are
individual’s wishes for the quality of life and
ultimately resident focused,” said ombudsman
medical intervention in their final days. The
There are 10 regional ethics committees, some
James McCracken.
document has the authority of a medical order
more active than others. Often the panels help May 2012
11
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Statehouse mediate discussion on what the nursing home
Amy Brown, an attorney with the ombudsman’s
or no evidence of the resident’s wishes, the
resident would have wanted. “If they have stated
office, said the work of the ethics committee
treatment could be withheld/withdrawn if the
to people that they want everything done, that
employs “a methodology that identifies the
burdens of the treatment outweigh its benefits
they are afraid to die, then we will advocate in
ethical principles that are generating conflict,
or if it is inhumane to continue it. Brown said
that direction, “ Knapp said. “We won’t just do
and then works through all the factors.” The
the court directed the ombudsman’s office to
what looks easy for the nursing home, or what
committee comes up with a recommendation,
handle complaints related to these cases. The
might be for the greater good of society. We are
which is not legally binding but is the
regional ethics committees were established as
trying to advocate for that particular resident.”
committee’s best assessment of what should
an extension of this mandate.
be done in that situation. “More often than In many cases, as the committee makes
not [the nursing facility does] follow the
“Each one of these situations is heart-
inquiries, it finds out that “people don’t want
recommendations of the ethics committee,”
wrenching,” said Margaret Nolan, a registered
to live on a respirator, a ventilator or a feeding
said Brown, who estimates that the committees
nurse and a nursing home administrator, who
tube -- they really don’t,” Knapp said. “But in
conduct 30 to 40 formal consultations per
chairs the regional ethics committee for Passaic
those cases that we can determine that the
year, and also field numerous calls seeking
and Morris counties. The committee alleviates
patient would have wanted it, we recommend
guidance.
the situation “by bringing the interdisciplinary
that they stay the course.”
team together, bringing the family together, and Brown said the regional ethics committees are
having everyone come to the table and find out
Knapp recalled a case several years ago of a
a response to the 1985 New Jersey Supreme
where the conflict is and how to work through
24-year-old man who suffered a catastrophic fall
Court ruling in the case of Claire Conroy,
it.”
from a high tree, and was in a skilled nursing
an 84-year-old nursing home resident with
facility on full life support. His father wanted to
severe cognitive impairments and physical
Paul Langevin, president of the Health Care
remove life support, but his mother could not
complications. She was receiving nutrition and
Association of New Jersey, whose members
do it. Her committee was called in, and listened
hydration through a feeding tube. She could
are nursing homes, said ethics committees
to family members, the doctors, the nursing
no longer communicate or express her wishes,
were more active and accessible in the early
home staff and the family priest.
and her guardian nephew went to court to have
1990s than they are today, and he welcomes
the tube removed, arguing she would not want
efforts by the ombudsman to reinvigorate this
“We provided a time and place for everyone’s
it. The state’s highest court ultimately ruled
network.
stories about the case to be told,” Knapp said.
that life-sustaining medical treatment can be
“What we were trying to do is figure out as
withheld or withdrawn for elderly residents
“I think the timing could not be better [as the
best as we could what the young man would
of nursing facilities with severe cognitive and
nation] starts to re-examine what it means not
have wanted. Not what his father or his mother
physical impairments who have limited life
only to have a good life but what it means to
wanted, but how would he have wanted to live?
expectancy.
have a good death,” Langevin said. “What kind
In the end, his mother was very much at peace
of things do they want to pursue to get better,
with the decision to withdraw life support after
In the ruling, the high court mandated
and when you cannot get better or recover,
the discussion was framed as ‘what would my
procedures to guide treatment decisions that
what kind of care should you be pursuing?
son want?’”
focus primarily in determining what the resident
Having an open, transparent conversation
would have wanted. Where there is limited
about that is the best approach.”
N.J. Health Department Lets LHP-Hackensack Joint Venture Proceed By Beth Kutscher
LHP Hospital Group, Plano, Texas, and Hackensack (N.J.) University
transaction next month, according to an e-mailed news release.
Health Network have received approval to take over ownership of Mountainside Hospital, Montclair, N.J.
Terms have not been disclosed. The parties first unveiled the takeover plans in February.
The New Jersey Department of Health and Senior Services signed off on the acquisition of the 245-bed facility, clearing the final hurdle in the
For-profit Merit Health Systems, Louisville, Ky., has owned Mountainside
deal. The LHP-Hackensack joint venture is scheduled to close on the
since 2007. May 2012
13
Statehouse
NJ Insurers Say They’ll Retain Some ACA Reforms However High Court Rules One of most popular provisions of ACA -keeping kids on parents’ health plan until they’re 26 -- needn’t be a constitutional casualty By Beth Fitzgerald
Perhaps the least controversial provision of the
company will continue to abide by the law’s
New Jersey adults have gotten coverage under
Affordable Care Act is the one that requires
ban on insurers seeking to rescind a policy,
the ACA’s age-26 provision, which went into
health plans to cover children until age 26 --
except in cases of fraud, and will abide by the
effect in late 2010. Nationwide, 2.5 million
and it’s been especially popular in this tough
legal requirement that members be given an
young Americans have taken advantage of it.
economy, as young people struggle to find
independent appeal process when claims are
good jobs with health coverage. This month
denied.
The health plans aren’t allowed to charge a separate premium for this extended coverage,
the Supreme Court will decide whether all or part of the ACA is unconstitutional, but at least
Aetna said in a statement: “A number of
which kicks in when a child ages out of the
two insurers operating in New Jersey, Aetna
provisions in the health reform law have been
dependent provisions of the family health
and UnitedHealthcare, will continue covering
woven into the fabric of our healthcare system,
plan, typically at 21 or when he or she finishes
kids until age 26, regardless. Another two,
bring value to customers and consumers, and
college. Although the ACA does not allow
Cigna and Horizon Blue Cross Blue Shield
should be maintained.” Thus, the company
health plans to charge an additional premium
of New Jersey, are awaiting the court’s ruling
will continue covering dependents to age
for the age-26 extension, the increased costs
before addressing the issue.
26, provide 100 percent coverage for some
generated by additional claims get built into the
preventive care, and provide an independent
premiums for health plans that cover children.
Michael
McGuire,
chief
executive
of
appeals process. A 2005 New Jersey law requires health insurers
UnitedHealthcare for New Jersey, said the company decided to allow parents to keep their
Horizon spokesman Thomas Vincz said the
to cover children up to age 31, but it’s not nearly
kids on their health plans until age 26, whatever
company “awaits the United States Supreme
as comprehensive as the federal law. New
the Supreme Court rules, because, “We really
Court’s decision on the Affordable Care Act. Our
Jersey’s statute only applies to state-regulated
just wanted to give people better certainty as to
primary goal is to best meet the needs of our
insurance plans, whose members tend to be
what potentially could happen. We don’t know
members in providing access to high-quality,
small- and mid-size employers, and does not
what will happen at the Supreme Court, but we
affordable healthcare. We will continue to work
apply to the self-insured plans that are standard
thought it was important that we said to our
closely with all stakeholders to transform the
for large employers and unions. An adult child
members: ‘No matter what the outcome here,
healthcare system to improve patient care and
who uses the New Jersey program is charged
there are certain things about the ACA that we
contain cost for our customers.”
a separate premium, and the employer does not have to contribute. In New Jersey, 13,500
think are important.’ We thought it was the right thing to do.”
Cigna spokeswoman Amy Turkington said
children are covered by the state program.
the company “believes in respecting the UnitedHealthcare said it will retain other ACA
court’s process. We remain focused on our
David Knowlton, president of the New Jersey
reforms, including the elimination of co-pays
global customer programs, and are prepared
Health Care Quality Institute, said of the Aetna
for preventive services like annual check-ups,
to proceed as appropriate on behalf of our
and UnitedHealthcare decisions to extend
diabetes and blood pressure screenings, and
customers when the court deliberations reach
some ACA reforms: “I’m pleased they are going
vaccinations. The company said it does not
their conclusion.”
to do that, and I’m not surprised. These are immensely popular actions, so I’m not at all
impose lifetime dollar limits on how much it will pay on a policy, and that practice will
According to the federal Department of Health
continue. Regardless of the fate of the ACA, the
and Human Services, more than 68,000 young
14
New Jersey Physician
surprised that that’s what they are going to do.”
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Hospital Rounds
TAVR – New Treatment for Aortic Valve Disease Gives Older Patients New Option
Elderly people who are suffering from the symptoms of aortic valve disease can now benefit from a revolutionary treatment that replaces their heart valve without surgery. A team of cardiac specialists at the Barnabas Health Heart Centers at Newark Beth Israel Medical Center and Saint Barnabas Medical Center has successfully performed several transcatheter aortic valve replacement (TAVR) procedures to implant the SAPIEN valve that restores the adequate circulation of blood through the heart. When you consider that in a 70-year lifetime, the average human heart valve opens and closes more than 2.5 billion times, it is not surprising that those valves may stiffen or weaken over the years. Aortic stenosis reduces the valve’s ability to open and close completely and can cause severe shortness of breath, chest pain and weakness. TAVR is a remarkable new technique that allows cardiac specialists to treat aortic stenosis in ways that were impossible before the SAPIEN valve was approved by the FDA in November 2011. The Barnabas Health Heart Center at Newark Beth Israel was the first in New Jersey certified to perform the new procedure. The SAPIEN valve is the only catheterbased treatment option for people with severe aortic valve disease who are not eligible for surgery. TAVR has been shown to dramatically improve a patient’s quality of life. “TAVR opens a new door for people who have severe valve disease but who cannot undergo heart surgery because of other medical conditions or advanced age,”
16
New Jersey Physician
explained Craig Saunders, MD, Chairman of Cardiothoracic Surgery at Barnabas Health. “Aortic stenosis is a serious ailment and, left untreated, is life-threatening.” It is estimated that 40 percent of people with severe aortic stenosis do not undergo valve surgery and may benefit from this new treatment option.
Team Approach “TAVR requires a deeply experienced, multidisciplinary team of cardiac interventionalists and cardiac surgeons as well as a state-of-the-art hybrid operating room in which to perform it,” said Marc Cohen, MD, Chief of Cardiology at Newark Beth Israel Medical Center. Dr. Cohen performs TAVR procedures alongside other leaders of the TAVR team that include Bruce Haik, MD, Medical Director of the Cardiac Catheterization Laboratories at Barnabas Health; Paul Burns, MD, Director of Cardiac Surgery at Saint Barnabas Medical Center; and Craig Saunders MD, Chairman of Cardiothoracic Surgery at Barnabas Health. “Combining catheter-based and open surgical procedures is the next step in the evolution of cardiac and vascular care,” said Dr. Cohen, who is internationally respected for his expertise in the field of interventional cardiology. “The more sophisticated procedures such as TAVR require cardiologists and surgeons to work side by side.”
Hybrid Operating Room The Hybrid Operating Room combines all the advantages of high resolution images of the heart with a modern, sterile operating suite. The $5 million, 1,450-square-foot futuristic space fosters collaboration among cardiac specialists in a room designed to
handle both catheter-based and open-heart surgical procedures. “Instead of a long incision that divides the chest, the SAPIEN valve is compressed on the tip of a catheter that is threaded from the groin into the heart,” explained Dr. Haik. “The technology provides extraordinary images of the heart that are necessary for the precise placement and deployment of the synthetic valve.” When the device is expanded, it pushes the leaflets of the diseased valve aside. The new valve begins to work immediately and patients can experience a considerable improvement in their overall health and ability to perform their daily activities.
About Barnabas Health Heart Centers The Barnabas Health Heart Centers offer a single comprehensive adult and pediatric cardiac program with locations throughout New Jersey. Our network of cardiac specialists treats patients close to home with advanced technologies and the benefits of cutting-edge cardiac research. From heart disease prevention programs and the finest emergency heart attack care to cardiac catheterization, minimally invasive valve and coronary bypass surgery and heart transplant, Barnabas Health Heart Centers are nationally recognized for excellence. Families seeking the most sophisticated care for children with congenital heart defects turn to the Children’s Heart Center and its pediatric cardiac surgery partnership with NYU School of Medicine. Our renowned heart transplant program ranks among the nation’s top three centers with long-term survival rates that consistently exceed national benchmark.
Barnabas Health Heart Centers are located at Children’s Hospital of New Jersey at Newark Beth Israel Medical Center, Clara Maass Medical Center in Belleville, Community Medical Center in Toms River,
Heart and Lung Specialty Center at Toms River, Kimball Medical Center in Lakewood, Monmouth Medical Center in Long Branch, Newark Beth Israel Medical Center, Saint Barnabas Heart Center at Hackettstown,
Saint Barnabas Medical Center in Livingston, and the Advanced Heart Failure Treatment and Transplant Center at Summit.
The 4th Annual
NJ ASC Review Once again, Brach Eichler presented its annual seminar on the latest regulatory and business developments affecting New Jersey Ambulatory Surgery Centers. This seminar provided an opportunity for national and statewide ASC leaders to come together and discuss the latest and hottest issues affecting the industry. Chaired by Mark Mani-
gan of Brach Eichler, and presented in a new venue, Ocean Place, on the beach at Long Branch, the conference was a huge success attended by over 300 of the ASC industry’s top management. Speakers included Jeff Shanton, Chairman of the NJ AASC Advocacy Committee, Larry Trenk, President of the NJ AASC, Matthew Fulton of Saint Barn-
abas, Richard Maglin of Maglin, Miskiv and Associates, Henry Bloom of The Bloom Organization, John Fanburg of Brach Eichler, Edward Hetrick of FDM, and many of the top decision makers of the New Jersey ASC community. A valuable experience was had by all who attended.
p The conference room was filled with over 300 people.
p Mark Manigan was the moderator for the event.
p The vendor area was quite busy during the breaks.
p Richard Maglin spoke on financial issues. May 2012
17
Food for Thought
Town Hall Deli
Known as the Birthplace of the “Sloppy Joe” South Orange, New Jersey By Iris Goldberg
I know there is some controversy regarding where the “Sloppy Joe” that we in New Jersey enjoy so much actually originated. Whether it’s a football Sunday or any other special occasion that calls for casual food, ordering a bunch of “Joes” is right up there with pizza and/or Italian subs.
For many in the towns surrounding
South Orange and I would suspect, for some living considerably further, the only place to get the original and by far the best “Sloppy Joe” is at the Town Hall Deli. As the story goes, back in the 1930s, the mayor of Maplewood at that time traveled to Havana, where he dined at a bar and restaurant called Sloppy Joe’s, which was named for the proprietor’s lack of neatness and order. He was
Russian dressing is a secret family
served a sandwich which he enjoyed so much
recipe that gives the Town Hall
that when he returned he asked the folks at the
Deli Joe its unique and wonderful
Town Hall Deli to re-create this masterpiece for
flavor.
him. In addition to the original Sloppy The original recipe calls for ham, tongue, swiss
Joe, Town hall Deli offers a
cheese, cole slaw and Russian dressing layered
variety of combinations using any
on three slices of thin rye bread. Town Hall
two meats and a cheese of your
Deli makes its cole slaw without mayo from
choice. Some examples are: roast
fresh cabbage that they brine for two days. The
beef, turkey and swiss; ham, turkey and swiss;
turkey, corned beef and swiss; and a dairy Joe consisting of tuna salad, egg salad and swiss. Although there are some tables for dining there, most of the Town Hall Deli’s orders are “to go.” In addition to the Sloppy Joe, they offer every type of food you would expect to find in a traditional delicatessen, plus they also have beer and wine. Just the other day, Michael and I were too busy to prepare dinner or to take the time to go out to eat. We called the Town Hall Deli and ordered one Sloppy Joe with roast beef, tongue and Swiss with some macaroni salad on the side. One Joe is quite large and easily
18
New Jersey Physician
feeds two. Michael picked the order up twenty minutes later and it was ready when he arrived, as promised. The sandwich is packaged perfectly in a long box that I am sure was created specifically for the Joe. We opened it up and dug in. I must say, it did not disappoint. Everything worked so well together – the fresh, tasty meats with the swiss cheese, delicious cole slaw adding great flavor and texture, the tangy Russian dressing – all embraced by the thinnest rye imaginable. It was a true feast and a welcome break from the piles of work that needed to be done. If you’ve never had a Sloppy Joe, I would definitely recommend the Town Hall Deli as the place to go. The Town Hall Deli is located at 60 Valley Street, South Orange, NJ 07079. (973) 762-4900. townhalldeli.com
Please visit us online at www.NJPhysician.org
May 2012
19
Diagnosis Food for Thought
D IAGNOSIS Famed Infectious Disease Specialist Leon Smith, MD has suggested we start a contest. He will submit symptoms and the correct diagnosis will win a New Jersey Physician T-Shirt, as well as getting honorable mention in our column. Here are this months cases for you. Case 1 22 year old white male who presented with MRSA rhinitis with purulent drainage. He had a febrile pain on touching the nose. Exam negative except for a large hole in the nasal septum. Case 2 A 20 year old female immigrant from Costa Rica was seen in the pulmonary clinic for many years and treated as asthma. She wheezed terribly and was short of breath. Therapy of inhalants and steroids were ineffective. The chest x-ray was negative as well as routine lab tests. The pulmonary function studies revealed an abnormal loop and the biopsy of the trachea and bronchi via bronchoscopy yield a diagnosis.
Case 3 32 year old police officer who patrolled on horseback developed a right upper lung mass on chest x-ray and CT. Tuberculosis and cancer studies were negative on biopsy.
Case 4 A 15 year old male student was thought to be a “whimp” by his father. The father loved to shoot wild animals. He took his son on a hunting event against the boy’s wishes. Indeed he shot a rabbit and the father made his son skin the rabbit. A few days later the young man had an ulcer on his finger an a large node in the axcilla
Rx
Please send responses to MGoldberg@NJPhysician.org 20
New Jersey Physician
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