a p r i l 2 015
Raleigh Neurosurgical Clinic
Looking back on 60 Years and Looking Ahead
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in This Issue
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“My Husband’s Heart Surgeon Said, ‘We Don’t Usually Do This Procedure On Victims Of His Type Of Heart Attack.’ I Asked Why. He Said, ‘They Usually Don’t Make It To Surgery.’ ” Debbie Woodruff Smithfield, NC
Gordon Woodruff with his lifesaving heroes Johnston Heath ER Nurses Lisa Johnson & Kenny Gooch
Around 9:00 a.m. June 24, 2013, Smithfield Attorney Gordon Woodruff felt heavy pressure in his chest while driving to court. He decided to divert to Johnston Health’s ER, a Certified Chest Pain Center. He told them,“I think I’m having a heart attack!” ER Nurse Lisa Johnson quickly assessed his condition. She and Chest Pain Coordinator Kenny Gooch administered initial treatment to stabilize and prepare him for transport to a cardiac trauma center. Kenny accompanied Gordon on the ambulance. Unaware he was experiencing a type of cardiac event known as the “Widow Maker,” Gordon called his wife Debbie from the ambulance.
2013 AHA Mission Lifeline Recipient
“I was alarmed, but relieved to be talking to him,” said Debbie. “He told me where they were heading, but then, as we talked, Gordon went into full cardiac arrest.” Kenny immediately had the EMS driver pull off the road, then administered CPR until they could get the defib unit on him. Gordon responded to the defib and they continued to the hospital where he had emergency procedures, installing two stents. “The fact that everyone at Johnston Health knew exactly what to do at every turn was so obvious to everyone, including my surgeon,” says Gordon. “Their actions and professionalism are the reason I am alive. Debbie and I are so very grateful.”
Two Accredited Chest Pain Centers
Healing Neighbors... It’s What We Do - It’s Who We Are! 509 N. Bright Leaf Blvd. Smithfield, NC 919-934-8171
www.johnstonhealth.org
2138 NC Hwy. 42 W. Clayton, NC 919-585-8000
COVER STORY
6
Raleigh Neurosurgical Clinic Looking back on 60 Years and Looking Ahead
a p r i l 2 0 15
Vol. 6, Issue 3
FEATURES
10
Women’s Wellness
Genetic Testing: Information Empowers Family nurse practitioner Makayla Downs talks about the power of genetics to better manage care.
14
DEPARTMENTS 9 Physician Spotlight – NEW
12 Physician Advocacy
Abdomino-Phrenic Dyssynergia: Effective Diagnosis and Management Dr. Douglas Drossman says hype boils down to correct diagnosis and management of a chronic
Organization Gives Voice to Independent Doctors
14 Practice Management
Gastroenterology
Get to Know Michael Paul Bolognesi
On Your Own or Part of a Larger Health Care System?
16 News “Shared” Health Care Delivery Company Gets Name and President
17 News
Welcome to the Area
condition. COVER PHOTO: The medical team within Raleigh Neurosurgical Clinic, this month’s cover story, includes: (from left) Russell Margraf, M.D., Ph.D.; Timothy Garner, M.D.; Ali Thomas, P.A.-C.; Charlotte Spangler, P.A.-C.; and Robert Allen, M.D.
2
The Triangle Physician
From the Editor
Keeping Pace It’s enlightening to pause for an inventory of strides that are made over time.
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
This month’s cover story on Raleigh Neurosurgical Clinic does that, with an overview of medical advances since 1954, when the practice opened. It was a time of limited medical understanding, on the cusp of the “Decade of Technology. Fast forward to today, and we’re worlds away. New cases of naturally occurring polio in the United States are practically none existent. Robotics and brain-machine interface are no longer figments of the imagination. Having kept pace with the advances, Raleigh Neurosurgical plans to continue to integrate the best of new patient care and treatment advances.
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Douglas Drossman, M.D. Margie Satinsky, M.B.A. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Creative Director Joseph Dally jdally@newdallydesign.com
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Also this month gastroenterologist Douglas Drossman tells us why abdominophrenic dyssynergia causes a lot of head scratching. Makayla Downs, a family nurse practitioner, helps educate patients and colleagues on the value of genetic testing options and the latest options. Another new contributor this month, association executive Marni Jameson describes the genesis and advocacy role of the relatively new Association of Independent Doctors. Practice management consultant Margie Satinsky discusses the decisions physicians face in making the switch from private practice to health system. Because professional perspective changes with medical advances, The Triangle Physician offers news and cutting-edge insight. So as your practice evolves to keep pace, let us know. Information in The Triangle Physician reaches more than 9,000 professionals within your medical community. Editorial space is available at no cost. Advertising rates are competitive. Please send information and inquiries by e-mail to info@trianglephysician.com. Respectfully,
Heidi Ketler Editor
4
The Triangle Physician
info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
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Cover Story
Raleigh Neurosurgical Clinic
Looking back on 60 Years and Looking Ahead Raleigh Neurosurgical Clinic has thrived for six decades, maintain-
search and technology that have led to the wide range of surgical
ing a commitment to excellence and incorporating the best in medi-
techniques available today.
cal science and practice. Today, sights are set on continuing a legacy. A look back reveals an amazing evolution. Interestingly, some conLeRoy Allen, M.D., founded the practice in 1954, a time when the
cepts that emerged since the 1950s are still important to this day.
field of neurosurgery was still in its infancy, and neurosurgeons were extremely sparse. In the 60 years since, neurology and neu-
Before the polio vaccine was introduced in 1955, the disease had
rosurgery have experienced a series of major advancements in re-
reached epidemic proportions. In the first half of the decade, neurologists spent most of their time treating polio patients, and it was not uncommon for them to perform whatever surgical procedures were needed. While spinal surgery was available, it only included a limited number of procedures and diagnostic tests, and surgeons still didn’t understand the cause of many common problems. At the time, Xrays and myelography were considered less reliable than a physical exam. Throughout the decade, neurosurgery experienced a number of dramatic improvements in the diagnosis and treatment of neurological problems. The angiography was introduced, and neurosurgeons began seeing many more patients with chronic neck and back pain, head trauma, headaches and disorders of the spine or peripheral nerves. The integrated circuit also was invented in the late 1950s, which paved the way for the introduction of automated and programmable computational machines. The ’50s may have experienced some major advances, but the techniques that truly revolutionized the field of neurosurgery were mostly developed in the 1960s. Sometimes referred to as the “de-
Robert Allen, M.D.
6
The Triangle Physician
cade of technology,” transformation occurred on many fronts for neurology and neurosurgery.
While NASA focused on putting a man
agement of a wide variety of neurologi-
on the moon, physicians developed
cal disorders. Research into both Par-
concepts that would lead to the first
kinson’s and Alzheimer’s disease was
computed tomography (CT) scanner
enhanced during the ’80s with landmark
and the first microscope to be used in
discoveries that would lead to improved
the operating room.
treatment methods.
Important surgical advances were made
The era – which witnessed the first re-
for lumbar fusion, and a number of new
ports of acquired immune deficiency
approaches were developed for treating
syndrome, identification of the prion
thoracic disc herniation. Microsurgical
in causing spongiform encephalopathy
techniques also were developed for the
and application of antiplatelet agents for
first time and would go on to become an
stroke – also saw greater understanding
essential component of neurosurgery in
of neuroimmunology. Finally, stereo-
the future.
tactic surgery experienced significant improvements of its own that would be
This momentum continued into the
expanded upon in coming decades.
Timothy Garner, M.D.
1970s, which were regarded as a period of tremendous growth in research, edu-
The 1990s were defined by a continu-
cation and patient care for neurology.
ing explosion in knowledge about the
By far the most significant discovery of
biology of neurological disease and an
this era for neurology – and one of the
increase in the application of many tech-
greatest discoveries in the field of medi-
niques that had only been studied in the
cine – was proliferation of neuroimaging
past. For the first time, a variety of new
technologies.
options became available for several neurological problems that had not yet
In 1972, G.N. Hounsfield produced the
been used. These included the first use
first prototype of the CT scan and intro-
of intraoperative imaging and the intro-
duced it to the market in 1973. Magnetic
duction of artificial discs to the United
resonance imaging (MRI) and positron
States, which had been used in Europe
emission tomography (PET) followed
previously.
in the next few years, and though they
In addition, though pharmacotherapy
were primarily used for research pur-
remained the most widely used means
poses only in their earlier days, their
of coping with illness, interest in deep
invention radically improved the ability
brain stimulation and pulsed radiofre-
of neurosurgeons to view the brain and
quency (PRF) lesioning experienced re-
spine. The decade also saw the devel-
surgence and soon began to be used in
opment of many important treatment
conjunction with pharmacotherapy.
Kenneth Rich, M.D.
modalities for various neurological disorders like stroke, epilepsy and muscle
Electrical stimulation of the brain us-
disorders.
ing fish (the electric ray) to treat headaches was first conceived in ancient
With the advent of neuroimaging, im-
times, according to Vittorio A. Sironi in
provements in neurosurgery continued
his study Origin and Evolution of Deep
on into the 1980s. CT, PET and MRI scans
Brain Stimulation. Since then, electrical
became commercially available during
stimulation has been used to modulate
this time, and they soon experienced
the nervous system and to treat some
widespread application throughout the
neurological disorders
entire country. Their introduction to clinical practice helped neurosurgeons
Today, deep brain stimulation uses an im-
exponentially in the diagnosis and man-
plantable pulse generator to deliver elec
Russell Margraf, M.D., Ph.D.
april 2015
7
trical stimulation to specific areas in the brain as a way to block ab-
to grow as neurosurgeons brave novel techniques never before
normal nerve signals that cause debilitating neurological symptoms.
thought possible.
Radiofrequency lesioning to block the transmission of chronic,
During the past 60 years, Raleigh Neurosurgical Clinic has wit-
debilitating pain is a variation of conventional continuous radiofre-
nessed these advancements in neurosurgery, and efforts have
quency (CRF), which has been in use since the mid-1970s. Todayâ&#x20AC;&#x2122;s
been focused on integrating the best in neurosurgical practices
CRF technology uses safer pulsed radiofrequency heat to create
into its services.
the pain-blocking lesions on nerve tissue. Today, Dr. LeRoy Allenâ&#x20AC;&#x2122;s son, Robert L. Allen, M.D., his partners Significant progress also was made in the treatment of spinal cord
Russell R. Margraf, M.D., and Timothy B. Garner, M.D., and Ken-
diseases and traumatic brain injuries, and campaigns continue to-
neth J. Rich, M.D., are continuing the practice with an unyielding
day to help increase public awareness about the dangers of these
commitment to excellence. This assures a new generation of pa-
problems.
tients can benefit from even more effective treatment as medical advances continue in the coming years and beyond.
Progress in the fields of neurology and neurosurgery has shown no signs of slowing down in the current century and into today.
Raleigh Neurosurgical Clinic is located at 5838 Six Forks Road.,
Breakthrough discoveries linked to molecular biology and genetic
Suite 100, Raleigh, 27609. For more information, call (919) 785-3400
engineering apply directly to the nervous systems and have helped
or visit online at www.raleighneurosurgical.com.
usher in a new understanding of many conditions with novel approaches to treatment.
References http://www.aans.org/Media/Article.aspx?ArticleId=10560
The fields of biology and technology have continued to merge and
http://cp.neurology.org/content/2/3/201.abstract
open up new possibilities in neurosurgery, like robotic surgery
http://www.sciencedirect.com/science/article/pii/
and the brain-machine interface and optogenetics, in which a light
S1878875012010169
source is used to activate certain neurons and inactivate others.
http://onlinelibrary.wiley.com/doi/10.1002/ana.1346/pdf
With continued innovations and technological advancements, the
http://www.neurosurgical.com/medical_history_and_ethics/
potential of neurosurgery in the years to come is only expected
history/history_of_spinal_neurosurgery.htm
Kenneth Rich, M.D.; Timothy Garner, M.D.; Russell Margraf, M.D., Ph.D.; and Robert Allen, M.D.
8
The Triangle Physician
Women’s Wellness
Genetic Testing Information Empowers By Makayla Downs, FNP-BC
Identifying those at risk of developing can-
A review of the patient’s family history
cer is an important part of effective risk
may include first cousins, nieces, neph-
management that increases the potential
ews, aunts, uncles, grandparents and great
of prolonging one’s life. Yet, the process
grandparents. Information about all can-
of genetic screening can be an emotional
cers on both sides of the family, includ-
endeavor.
ing what age they occurred, is necessary and may include such examples as: breast
With genomic technology advancing rap-
cancer before age 50 or multiple breast
idly, the ability to practice personalized
cancers in the same person, male breast
medicine and tailor patient care based on
cancer, ovarian cancer or colon cancer
individual risk is now possible.
before age 50.
Every person fits into one of three risk
We encourage the patient to gather this
categories for cancer: those that carry
information prior to the screening visit. At
sporadic, familial or hereditary cancer risk.
the screening visit we discuss family histo-
• Sporadic risk is also referred to as gen-
ry and evaluate whether a woman qualifies
eral population risk.
for genetic testing. If so, her family history
Makayla Downs is a board certified Family Nurse Practitioner at the Women’s Wellness Clinic. She earned her bachelor of science in nursing degree from Southern Illinois University Edwardsville and her master of science in nursing degree, Family Nurse Practitioner from the University of St. Francis in Joliet, Ill. She is dedicated to women’s health both for primary care and gynecology. Further, Ms. Downs has a focus on genetic cancer risk and the evaluation of a woman’s personal risk of cancer and her family’s risk of cancer.
• Familial risk is elevated beyond sporad-
of cancer and blood work are submitted to
ic risk due to the presence of personal
the genetic testing lab. A follow-up appoint-
or a family history of cancer.
ment is then made to discuss the results
Personalized medicine allows us to tailor
and management plan.
medical care (prevention, diagnosis, treat-
• Hereditary cancer risk includes the presence of a genetic mutation in a fam-
ment and follow up) to an individual’s
ily that increases the risk of cancer and
The genetic testing results include a man-
clinical, genetic and environmental back-
is the highest risk threshold.
agement tool that provides a personalized
ground. The goal is to make treatment as
cancer risk and management guide based
individualized as possible. Genetic testing,
Identifying which category an individual
on professional medical society guide-
such as myRisk, allows a precise diagnos-
fits into is necessary to correctly adapt
lines. If a genetic mutation is identified,
tic test to help focus management and en-
screening and management decisions.
recommendations will include more fre-
able patients, along with their health care
Additionally, a focus on family history and
quent screening visits and testing.
provider, to make the most informed deci-
risk stratification allows the opportunity to
sion possible.
detect those individuals who carry one of
Recommendations for those with a genetic
several genetic mutations that dramatically
risk of colon cancer, management may
It can be daunting to learn of one’s in-
increase their risk of developing cancer.
include earlier, more frequent colonosco-
creased risk for cancer. However, with
pies. Recommendation for those found to
proper education and counseling, a
In our practice, we offer the myRisk he-
have an altered BRCA1 or BRCA2 gene may
woman can have more control over her
reditary cancer panel, a 25-gene panel that
include breast magnetic resonance imag-
own health and life and, likewise, help em-
identifies elevated risk for eight different
ing and more frequent mammograms; in
power her children and family. We cannot
cancers: breast, ovarian, gastric, colorec-
addition to biyearly clinical breast exams
change a woman’s genetic makeup, but
tal, pancreatic, melanoma, prostate and
and an emphasis on monthly self-breast ex-
we can help her manage the devastating
endometrial. The genetic test includes a
ams. Our goal is to provide the resources
effects that a genetic mutation may have.
screening tool used to evaluate a woman’s
necessary for the patient to be successful
family history and potential genetic risk.
in reducing the devastating effects that cancer can have.
april 2015
9
Physician sPotlight
Michael Paul
Bolognesi Place of current employment: Duke University Department of Orthopaedics
Credentials: Associate Professor, Director of Adult Reconstructive Surgery Undergraduate degree: University of North Carolina-Chapel Hill, 1993 Medical degree and others: Duke University School of Medicine, 1998
Do you have a personal hero or mentor? James Urbaniak, Tad Vail, Jim Nunley, Aaron Hofmann Your advice to aspiring physicians: Work hard, enjoy what you do, do not take yourself too seriously What word describes you? Bolo.... My last name is not the easiest to pronounce so most people in the hospital uses this shorter version. What’s your extracurricular passion? My family What’s your favorite restaurant? Bin 54 What’s your favorite getaway? Wrightsville Beach
Residency: Duke University Medical Center, 1998-2003
Tell us something surprising about yourself, your practice or your medical specialty. I work at Duke but played football at UNC
Fellowship: University of Utah Medical Center, 2003-2004
Married Yes, Kelly Bolognesi
Special medical interest(s): Hip and Knee Replacement
Children 3 children - John (9), Rina (8), Julia (5)
Gastroenterology
Abdomino-Phrenic Dyssynergia Effective Diagnosis and Management By Douglas Drossman, M.D.
In September of 2013, The New York Times
physiological factors2. In addition, her con-
Magazine posted a case report of a 15-year-
stipation was due to incomplete relaxation
old, world-class gymnast who mysteriously
of the pelvic floor muscles, called pelvic
developed abdominal cramps, acute diar-
floor dyssynergia, which responded to bio-
rhea followed by constipation and an inex-
feedback treatment.
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment.
plicable swelling of her abdomen1. I am fascinated by the high level of public The article goes on to say that numerous
interest that leads this case to be featured
diagnostic tests, including magnetic reso-
in The New York Times. What is it that ren-
nance imaging scans and ultrasounds, and
ders so much attention? And what are the
trips to a half dozen hospitals that left gas-
problems with this kind of attention?
troenterologists, neurologists, urologists, psychiatrists, surgeons, physical thera-
There are several factors we should con-
pists, an endocrinologist and a cardiologist
sider: The diagnosis of a functional gas-
scratching their heads in wonder. No one
trointestinal (GI) disorder was made after
understood why the girl looked pregnant
many expensive and unnecessary tests
or why she couldn’t go to the bathroom
were performed and by exclusion. Irritable
without laxatives. When the tests kept
bowel disorders (IBS) and other functional
coming back negative the doctors began
GI disorders are positive diagnoses estab-
to suspect that, “there was nothing really
lished by the Rome Foundation (www.
wrong: it was in her head.” The young lady
theromefoundation.org).
Dr. Drossman is president of the Rome Foundation (www.theromefoundation.org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www. drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www. drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
was placed empirically on numerous treatments, including hypnosis, acupuncture,
To recognize and accept these conditions
Chinese herbals and prescription medica-
as real will lead to fewer unneeded studies
tions, all without benefit.
to exclude “organic disease.”
In the end, one pediatric gastroenterolo-
When diagnostic studies were negative, it
gist came to the conclusion that she must
was presumed that the patient had a psy-
functional GI disorders must often deal
have a functional gastrointestinal disorder
chiatric problem. This relates to the lack of
with a lifelong history of symptom relapses
(FGID). More specifically she had irritable
knowledge of the biopsychosocial model
and remissions. While we can hope for
bowel syndrome that was associated with
of illness and disease: “If the studies are
cure, the majority of patients need to ac-
a not uncommon condition known as ab-
negative then the symptoms must be in her
cept FGIDs as a chronic disorder with a
domino-phrenic dyssynergia.
head.”
goal of symptom reduction and improved
3
quality of life. Each year, about six to eight patients are
Once the diagnosis was made, the patient
referred to my practice with this condition,
had a miraculous cure to the treatment.
References
in which there is a paradoxical redistribu-
The article leads us to believe that the
1
tion of abdominal contents associated with
gymnast’s biofeedback treatment led to a
15/magazine/diagnosis-gymnast.html
descent of the diaphragm and relaxation
dramatic cure of all symptoms.
2
of the abdominal musculature leading to
http://www.nytimes.com/interactive/2013/09/ Accarino A, Perez F, Azpiroz F, Quiroga S,
Malagelada JR. Abdominal distention results
distension. This is not an increase of gas
Pelvic floor dyssynergia does respond to
or fluid in the abdomen; it’s an inappropri-
anorectal biofeedback, but the abdominal
Gastroenterol 2009; 136(5):1544-1551.
ate pushing out of the abdominal wall that
distension is a more complex physiologi-
3
can fluctuate during the day depending on
cal entity and should not respond to bio-
a Name? Gastroenterol 2005; 128(7):1771-1772.
stimuli like meals, pain, stress and other
feedback. More important, patients with
from caudo-ventral redistribution of contents. Drossman DA. Functional GI Disorders: What’s in
april 2015
11
Physician Advocacy
Organization Gives Voice to Independent Doctors By Marni Jameson
“Certainly, the only happy doctors I still
In 2000, well over half (57 percent) of all
know are all in private practice,” said the
physicians in the United States worked for
e-mail from a physician who works for a
themselves; as of last year, that number
large hospital system.
was closer to one in three (36 percent), according to a report out from Accenture.
The e-mail came in response to my news that I had left my job as senior health re-
The rest went to work for hospitals.
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or marni@aid-us.org.
porter of the Orlando Sentinel to run a national nonprofit trade association whose
And who can blame them? The lure to be-
contract much higher rates for the same
sole purpose is to represent the interests
come a hospital employee – the promise
services.
of independent doctors.
of more money, perceived job security, no
• Education – Patients, the community
more overhead, guaranteed referrals – is
and regulators need to know how this
As a reporter, when a hospital system
strong. But, as many physicians, including
trend affects access, choice and cost of
acquired a medical group, I interviewed
the author of the e-mail to me, learned,
care.
sources on all sides: doctors, hospital ex-
the move comes at a price.
ecutives, insurers, academics, patient ad-
• Camaraderie – Independent physicians want to work with a network of doctors
vocates, consumers and government offi-
The Association of Independent Doctors
who share their practice philosophies.
cials. I got a full-circle look at why more
(AID) was formed in April 2013, when two
• Autonomy – By working to reverse the
doctors were going to work for hospitals
certified public accountants in Winter
trend of medical practice acquisitions,
and the impact that had on patient care
Park, Fla., saw the impact that the acqui-
the association makes it easier for doc-
and health-care costs.
sition of independent practices by hospi-
tors to stay independent and enjoy
tals was having on not only doctors, but
greater job satisfaction.
I also saw that while the independent na-
also patients, local communities and the
ture of private practitioners was mostly to
nation. They wanted to create a trade as-
“Physicians have a tendency to not get in-
their advantage, in one important respect
sociation to stop the trend.
volved in critical changes affecting them
independence was contributing to their
and specifically avoid the political end of
undoing. Independent doctors are by
I covered the inaugural meeting for the
medicine,” said Orlando orthopedic sur-
definition not well organized as a group.
paper. About 120 doctors attended, and
geon John McCutchen, who serves on the
By not being allied, they didn’t have a col-
nearly everyone joined that night. (Indi-
executive committee for AID.
lective bargaining voice.
vidual physician memberships cost $1,000 a year.)
Thus, their numbers were shrinking.
“We no longer have the luxury of doing nothing,” he said. “If physicians don’t
Since then, AID has grown to include
want non-physicians telling them how to
Unless you have been living in a yurt off the
members in eight states. More doctors
practice, they need to get engaged.”
grid, you know that the rate at which hos-
and health care advocates join every day.
pitals have been buying doctors’ practices
Of course, the Florida Medical Associa-
has been brisk in the past several years.
Most join because AID stands for what
tion and the American Medical Associa-
Such roll-ups help hospitals capture market
they care about, but don’t have the time,
tion represent physicians, too. However,
share, channel referrals to their other em-
resources or clout to fight for:
because most of their physician members
ployed physicians and hospital-owned di-
•
Parity – Independent doctors receive
are employed or in academia, they are not
agnostic and treatment centers and receive
substantially lower reimbursements from
in a position to champion the unique in-
more money for same-day procedures.
payers, compared to hospitals, which
terests of the independent physician.
12
The Triangle Physician
“The future of health care is changing,
be heard.”
Drossman Gastroenterology
Dr. Snook, like other physicians who
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
919.929.7990
www.drossmangastroenterology.com
and we as independent physicians need to come together to steer the boat in the right direction,” said Pamela Snook, M.D., F.A.C.O.G., a Winter Park ob-gyn and AID member. “I joined because this is an avenue where I feel I have a voice that I don’t have otherwise. It’s a way to
have resisted hospital employment, wants to remain independent so her allegiance remains unequivocally to her patients. As the only national organization of its kind, AID has already established itself as a formidable, articulate force. Its founders have spoken on Capitol Hill, and the association was asked in the summer of 2014 to support the Federal Trade Commission in an important antitrust case involving a hospital’s purchase of a large medical group in Idaho. This past February, the U.S. District Court of Appeals for the Ninth Circuit
ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS
ruled as AID requested, that the merger
“He wanted his confidence back.”
between St. Luke’s Health System and Saltzer Medical Group violated antitrust laws and had to be unwound.
I REFERRED HIM TO SOUTHERN DERMATOLOGY AID was proud to have been part of this verdict, which sets an important precedent for others contemplating such mergers. AID’s involvement put the voice of independent doctors on the national stage, making them part of a debate whose outcome will impact every American. Thanks to the growing support of doctors, we can collectively do what individuals alone cannot. FOR THE MOST ADVANCED DERMATOLOGY TREATMENTS, REFER YOUR PATIENTS TODAY!
Next month, we will discuss the seven consequences of hospitals acquiring physician groups.
southernderm.com
919-782-2152
ROSACEA • HIVES • VITILIGO • KERATOSIS • WART REMOVAL • ALOPECIA
DER131_AD_Triangle Physican I Want 4.indd 2
april 20153:56 PM 13 3/18/15
Practice Management
On Your Own…
or Part of a Larger Health Care System? By Margie Satinsky, M.B.A.
“Should I open or retain my own private
Organization and Management
practice or become part of a larger health
If you own and manage your practice,
care system? That’s the question we’ve
you must thoughtfully address the way in
heard from 10 physicians during the past
which you set up your business and affilia-
six months.
tions with other health care organizations.
We’ve worked with three types of people:
Some physician clients have the interest
1) Physicians who are certain they want to
and skill to manage their own practices.
own their own practices and have the
Others don’t.
skills to make that happen; 2) Physicians who are carefully examining the issues; and
Will you be comfortable collaborating with
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She’s the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.
a professional practice administrator or
3) Physicians who have a sincere interest
manager, and if so can you afford to hire
health care system. “We received mixed
in running their own practices but lack
an individual that has the required knowl-
messages from the system administration.
the personal characteristics needed for
edge and experience? How will you di-
On the one hand, we were told that qual-
success.
vide administrative responsibilities among
ity and safety mattered. On the other hand,
physicians, your practice administrator/
the budget for those tasks was significantly
One size doesn’t fit all. Only you can de-
manager and external resources? Do you
reduced. Only when the threat of federal
cide. We’ve written this article to help
understand the role that strategic business
financial penalties became a reality did the
you address the appropriate issues with
planning, budgeting and marketing play in
administration restore the funds needed to
respect to your own personal readiness,
managing a successful practice?
get the job done.”
management, managing staff and external
If you work for someone else, you are not
Financial Management
resources, maintaining quality and out-
exempt from organization and manage-
When you own a medical practice or any
comes and compliance.
ment challenges. “Entangled” might be a
other business, it’s your responsibility to
more appropriate adjective.
develop operating and capital budgets that
organization and management, financial
support your strategic business plan. With
Personal Readiness First and foremost, what’s your personal
Given your personal and professional ob-
respect to reimbursement, you must under-
readiness to run a successful business?
jectives, can you work within a larger or-
stand both the public and private sectors.
ganizational structure without sacrificing Good intentions are admirable, but they
your needs and goals? If you want to par-
Government policies for reimbursement
won’t come to fruition without drive, focus
ticipate actively in managing your practice,
shift like sand. For example, CMS is quickly
and decisiveness.
can you learn to do that within the context
moving in the direction of payment for
of organizational priorities? Can you toler-
quality and value. In the private sector, you
When someone asks about setting up a new
ate decision-making processes that will
must deal with a variety of payers, each of
private practice or remaining in an existing
probably move more slowly than you per-
which has a unique approach to provider
one, we provide a long list of tasks to be done
sonally might like?
reimbursement.
hensive guidance, but only you know your
Here’s what one practice manager said
As a practice owner, you should regularly
personal strengths and weaknesses.
about his experience working for a large
renegotiate managed care contracts, so
or questions to be asked. We offer compre-
14
The Triangle Physician
you can maximize reimbursement. With
tice settings without providing adequate
for delivering care, but you are not the ul-
respect to billing and collections, ulti-
training. For example, in the practice from
timate decision maker about processes in
mately it’s your responsibility, even if your
which we sought care, the nurse had come
your office. If the organization is a midsize,
practice management system software
from a hospital department and didn’t
large medical group or an academic medi-
includes revenue cycle management or if
know how to request a Tier 3 prescription
cal center, it may have substantial financial
you outsource billing and collections to an
that required physician authorization. With-
resources and information technology to
external vendor.
out that authorization, the additional out-of-
support quality improvement programs.
pocket cost to the patient was $3,600/year!. On paper, it sounds as if quality of care is
When you work for someone else, you work within financial constraints. You may
With respect to outside resources, when
simpler in a large organization with signifi-
contribute to the development of an orga-
you own your practice, you decide if and
cant financial resources to devote to the ef-
nizational budget, but you don’t make the
when to seek outside assistance. You de-
fort. But here’s the caveat that we hear over
final decisions. Obtaining the resources
termine which professionals should be on
and over again: “Quality takes second place
that you would like may be more difficult
your team and you select them. After you
to expectations for productivity. Pushed to
because you are competing with other
identify one or more external consultants
see a large volume of patients each day, I
physicians who believe their priorities are
with whom you want to work, you must
have insufficient time to practice medicine
equally as important as yours.
sign a formal agreement and develop a
the way I think it should be done.”
strategy for overseeing the work. Compliance
We could write a book about our own negative experience with a medical prac-
When you work for someone else, you
The final area of practice management is
tice owned by a large health care system.
can still access outside resources, but the
compliance. Federal, state, and local laws,
The telephone system had limited hours,
decision may be somewhat complicated.
regulations and rules govern both adminis-
because the health care system, not the
Depending on your scope of authority and
trative and clinical aspects of health care.
practice, decided on the way in which it
your organization’s rules, you may have to
As a practice owner, you must be famil-
would work. From a patient perspective,
follow a list of specific steps to obtain the
iar with the concepts and requirements
the practice was inaccessible by phone.
help that you yourself want.
regarding antitrust, anti-fraud and abuse, Stark, HIPAA (Health Insurance Portabil-
Managing Staff and
Improving Health Care
ity and Accountability Act of 1996) privacy
Outside Resources
Delivery and Outcomes
and security and OSHA (Occupational
Physicians who own their practices devote
Regardless of whether or not you own your
Safety and Health Administration). You are
a great deal of time managing internal staff.
own practice, the delivery of care to patients
obligated to establish and maintain compli-
With guidance from legal counsel, you
and the outcomes that you achieve should
ance programs.
need to understand employment law. What
be the focus of your efforts. The practice of
questions can you ask/not ask during an in-
medicine demands attention to both quality
When you work for someone else, the or-
terview? How do you terminate an employ-
of care and quality improvement.
ganization creates the systems. Your job is to learn how the organization approaches
ee? Can you create a performance evaluation system, pay grades for your employees
When you own the practice, you and your
each area of compliance and to meet the
and a compensation system for physicians?
entire workforce have opportunities to cre-
requirements.
What about a personnel handbook and op-
ate processes that meet patient and clini-
erating policies and procedures?
cal needs. You can analyze your workflow
Conclusion
and improve what isn’t working well. You
So what’s your response to the question?
When you work for a larger health care
can decide how to use patient registries
Do you want to open or retain your own
system, systems for managing staff will al-
to benchmark your care. You can mea-
medical practice or become part of a
ready be in place. Your challenge isn’t the
sure the impact of the changes you have
health care system? We can tell you what
creation of systems, but learning the rules
made – provided you know how to do it.
ownership requires, but you know what’s
for systems that already exist.
Your decisions on supporting information
best for you. If you decide that owning your
technology can help with both delivery
own practice is the right strategy for you,
and outcomes.
be sure to order A Handbook for Medical
One common complaint from physicians
Practice in the 21st Century written by Mar-
who are part of large health care systems is recruitment. Larger systems often rotate
If you work for someone else, you have
gie Satinsky with Randall T. Curnow, MD,
employees from hospital to private prac-
some input to that organization’s method
now President of Mercy Health in Ohio.
april 2015
15
WakeMed News
“Shared” Health Care Delivery Company Gets Name and President An innovative health care delivery partnership continues to take shape, with the recent announcement of its name, Socius Health Solutions, and its president, Mark W. Tribbett, F.A.C.H.E. Owned by Vidant Health, Wake Forest Baptist Medical Center and WakeMed Health & Hospitals, the company is using a sharedservices approach to improve quality and affordability for patients across the state. The name “Socius” has Latin roots that mean – shared, associated, allied. It reflects the “individual health care systems’ similar missions, visions, values and strategic focus,” according to a press advisory. “Socius Health Solutions brings together the collective talents and best practices of three like-minded organizations while retaining independent structure, governance and local identity. The shared-services approach leverages each of the systems’ areas of expertise, both clinically and operationally,” the advisory said. The company will reportedly support health care reform initiatives − including Accountable Care Organization development and implementation, as well as care coordination for population health − and create business and clinical efficiencies. It also will assist in” meeting the challenges posed by reduced reimbursement rates as well as technological changes, while keeping patient-centered care at the forefront.” “Socius Health fits perfectly with our mission and goals of seeking preferred partners to deliver an exceptional level of health care service by sharing our strengths and resources,” said Donald Gintzig, WakeMed president and CEO as well as chair of the Socius Health Board of Directors. “Our organizations want to deliver the best care and value to our state’s citizens.” The company will be based out of Raleigh,
16
The Triangle Physician
which is central among the three organizations. The next steps for Socius Health are to refine areas of focus as well as initiatives and methods of tracking. Supply chain management, select information technology infrastructure and clinical protocols are among the sharable opportunities available for its member institutions. “We will be building on the work of clinical teams from last fall to codify best practices and spread them throughout our health systems,” said John McConnell, M.D., chief executive officer of Wake Forest Baptist Medical Center. “Some of the benefit from this work will come from identifying select specialty patients with the most commonly diagnosed conditions in the specialty across the three systems. This clinical work will benefit patients in today’s health care environment as well as prepare the health systems for population health.” At the helm of the new company, Mr. Tribbett brings with him more than 30 years of health care management, with extensive experience as a hospital administrator and consultant. As president of Socius Health, he will lead efforts to transform health care models and support infrastructure that improve quality, reduce costs and best meet the needs of diverse patient populations. “We believe Mark is the right leader, with the right credentials and a proven track record to help improve all of our health systems’ efficiencies and value in order to invest more in the care of our patients,” said Janet Mullaney, interim CEO of Vidant Health. Prior to joining Socius Health, Mr. Tribbett established AlphaHealth L.L.C., a health care innovations firm focused on strategic planning and the development of health care enterprises. As founder and president of AlphaHealth, he steered more than 100 major projects for more than 50 health care organizations, including strategic, facility and operations improvement plans. He also
developed new hospital models and provided executive operations leadership in this role. Additionally, Mr. Tribbett served in leadership positions within hospital and health care systems for 17 years. His career path includes a 10-year tenure with Novant Health and Presbyterian Healthcare System as executive vice president for the Charlotte region. He led hospital operations, the development of Presbyterian Matthews Hospital – a national leader in the patient-centered care model – and oversaw outpatient centers and physician practices. Mr. Tribbett earned a master’s degree in health care administration from Duke University. He also has a bachelor’s degree in business with a focus on marketing management from Virginia Tech. Socius Health Solutions operates as a separate limited liability company with a board comprised of representatives from all three health systems.
2014 Editorial Calendar May Women’s Health, Neurology, Infertility June Men’s Health, Pulmonary July New Imaging Technologies, Vein Diseases, Rheumatology August Gastroenterology, Nephrology, Sports Medicine September Bariatrics/Neonatology Advances in NICU, Obstetrics/Gynecology October Cancer in Women Wound Management, Dermatology November Urology, ADHD, Austism December Sports Medicine, Otorhinolaryngology Pain Management
News Welcome to the Area
Physicians
Anna Xuzi Hang, MD
Co-May Dang Pasdar-Shirazi, MD
Duncan Thomas Vincent, MD
Hassan Haissam Amhaz, MD
Otorhinolaryngology
Internal Medicine; Pediatrics
General Practice; Hospitalist; Internal Medicine
University of North Carolina Hospitals Chapel Hill
University of North Carolina Hospitals Chapel Hill
University of North Carolina Hospitals Chapel Hill
James Jones, MD
Eric Gon-Chee Poon, MD
Marcella Gevonne Willis-Gray, MD
Administrative Medicine; Internal Medicine
Gynecology; Obstetrics; Gynecologic Surgery; Gynecology - Critical Care Medicine; Endocrinology/Infertility
Anesthesiology - Critical Care Medicine
Duke University Medical Center Durham
Matthew Francis Baldwin, MD Pediatrics
Adolescent Medicine
Raleigh
Durham Medical Center Durham
Blue Ridge Pediatrics Raleigh
Elizabeth Nora Jovanovich, MD Physical Medicine and Rehabilitation
Joseph Michael Reardon, MD
Ethan Alan Bean, MD
University of North Carolina Hospitals Chapel Hill
Emergency Medicine
Psychiatry
Duke University Hospitals Durham
Raleigh II CBOC Raleigh
Martyn Knowles, MD Vascular Surgery
Molly Moriarty Rusin, MD
Michael David Brown, MD
Rex Vascular Specialists Raleigh
Pediatrics
Hospitalist; Pediatrics
Wake Med Raleigh
Sachin Basiq Malik, MD
Anna Jaclyn Conterato, MD
Duke Dept of Radiology Durham
Pulmonary Disease and Critical Care, Internal Medicine
University of North Carolina Hospitals Chapel Hill
Shaina Rose Eckhouse, MD General Surgery; Surgery
Duke Surgery, Division of Metabolic and Weight Loss Surgery Durham
John Walker Greene, MD Internal Medicine; Pediatrics
Duke University Hospitals Durham
Gaorav P Gupta, MD Radiation Oncology
UNC Chapel Hill Chapel Hill
Whitney Ivy Haddix, MD Pediatrics
UNC Pediatrics Education Chapel Hill
Diagnostic Radiology
Milica Margeta, MD Ophthalmology
Duke University Eye Center Durham
Shannon Marie Matthews, MD Emergency Medicine
University of North Carolina Hospitals Chapel Hill
Matthew Ramseur McDaniel, MD Anesthesiology
UNC Hospitals Chapel Hill
Robert George MorganJr., MD Pediatrics
UNC Pediatrics Residency Program Chapel Hill
Samilia Obeng-Gyasi, MD General Surgery; Surgery
UNC Medical Center Chapel Hill
Physician Assistants
University of North Carolina Hospitals Chapel Hill
Sarah Emily Schmitz, MD
Cara Marie Bailey, PA General Practice
Raleigh
Elizabeth Bee Goldbach, PA
Psychiatry
University of North Carolina Hospitals Chapel Hill
Orthopedic Surgery
Cary
Grace Chae-Wha Park, PA
Andrea Stallsmith Senter, MD
Oncology, Internal Medicine
Radiology
University of North Carolina Hospitals Chapel Hill
Robert Alan Van Der Vaart, MD Ophthalmology
University of North Carolina Hospitals Chapel Hill
Durham
Mariam Rashid, PA Cardiology; Emergency Medicine; Family Medicine; Hospitalist; Internal Medicine; Pediatrics; Urgent Care
Raleigh
Taja Walker, PA
Sreenath Vellanki, MD Anesthesiology
University of North Carolina Hospitals Chapel Hill
Dermatology; Emergency Medicine; Facial Plastic Surgery; Gynecology; Obstetrics; Orthopedic Sports Medicine; Orthopedic Surgery of the Spine; Reconstructive Surgery; Plastic Surgery; Student Health; Urgent Care
Ashok Venkataraman, MD
Cary
Abdominal Surgery; General Surgery; Surgery; Thoracic Cardiovascular Surgery
Mary Carol Younginer, PA
University of North Carolina Hospitals Chapel Hill
Cardiology; Emergency Medicine; Gastroenterology, Internal Medicine
Cary
Duke University Medical Center Durham
AUTISM
Awareness Month The Autism Society of North Carolina (ASNC) will kick off Autism Awareness Month with a celebration on Thursday, April 2. The World Autism Awareness and Acceptance Day event, from 10 a.m. to 4 p.m. at Camp Royall in Moncure, is open to the public.
Sporting Clay Course
• Open Tuesday–Saturday 8a.m. till 6p.m. • Sunday 1p.m. till 6p.m. •Monday by appointment only • Over a mile course • 14 Stations
Families and self-advocates will gather for fellowship and fun, with access to many of Camp Royall’s unique features, including the Snoezelen Sensory room and the zapline. The day’s activities will also include inflatables, music, arts and crafts, and a cookout. ASNC’s summer camp program was
• Covered 5 Stand • Wing Shooting- Quail/ Pheasant/ Chukar Hunts • Driven Pheasant Hunts • European Tower Hunts • Shooting Instructions • Gun Rental • Ammo Available • Dog Training
established in 1972 and is the nation’s oldest and largest summer camp program for individuals with autism. Last year, Camp Royall served more than 1,800 individuals with autism through its overnight camp and yearround educational and recreational programs.
• Fishing • Corporate Events/ Retreats/Team Building • Birthday Parties, Bachelor/ Bachelorette Parties • Church Groups , Individual Outings • Complete Packages Available
For more details about World Autism Awareness and Acceptance Day at Camp Royall, visit http://bit.ly/WAAAD2015.
april 2015
17
3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | Select Locations | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 30 minutes from check-in to exam completion