Maryland Physician Magazine Nov/Dec 2013 Issue

VOLUME 3: ISSUE 6 NOV/DEC 2013

WHY A DEMENTIA DIAGNOSIS MATTERS

HALTING 3 KEY INFECTIOUS DISEASES

ACCOUNTABLE CARE EXPANSION

Physic i anYOUR PRACTICE. YOUR LIFE.

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10 Diagnosing Dementias: Why it Matters16 Stopping Infectious Diseases

20 Accountable Care Expands With or Without an ACO

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 6 NOV/DEC 2013

3010 16

Cases | 9 | Dementia Case Study and Discussion

Policy | 24 | Medical Marijuana Commission is Launched

Living | 26 | Sites to See and Explore Across Brandywine Valley

Solutions | 29 | Five Ways the Taxpayer Relief Act Could Affect Your 2013 Taxes

Good Deeds | 30 | Thinking (and Working) Outside of the Medicine Box

On the Cover: Katherine Coerver, M.D., Ph.D., neurologist at The Neurology Center in Chevy Chase

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE COHEN ROTHPUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

MANAGER OF DIGITAL CONTENT & SOCIAL MEDIA

BUSINESS DEVELOPMENTJackie Kinsella

[email protected]

CONTRIBUTING WRITERTracy Fitzgerald

PROOFREADEREllen Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

Melissa Grimes-Guy, Location Photography, Inc.Kevin J. Parks, Mercy Medical Center

Randy Sager, Randy Sager Photography, Inc.

BUSINESS DEVELOPMENTEileen Nonemaker

[email protected]

Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified MinorityBusiness Enterprise (MBE).

Mojo Media, LLCPO Box 949Annapolis, MD 21404443-837-6948www.mojomedia.biz

Subscription information: Maryland Physician Magazineis mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948.

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Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and businessleaders in diverse practice, business and geographic scopesprovides editorial counsel to Maryland Physician. Advisoryboard members include:

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

HOLLY DAHLMAN, M.D.Greenspring Valley Internal Medicine, LLC

PAUL W. DAVIES, M.D., FACSKURE Pain Management

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

STACY D. FISHER, M.D.University of Maryland Medical Center

REGINA HAMPTON, M.D., FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

CHRISTOPHER L. RUNZ, D.O.Shore Health Comprehensive Urology

JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center

Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLCcannot be held responsible for opinions expressed or facts supplied by authors and resources.

When my dad first recognized hismemory “slips,” he would chuckle and say,“I’m losing my marbles.” He became very cleverat heading off what he grasped as memorylapses, coyly steering the conversation awayfrom a topic of recent history. Throughout thistime, his capacity to pull detailed memories

from his days as an infantryman in WWII or his house call days as an internist in theJewish ghettos of Milwaukee was incredible. Now, seemingly quite quickly, his dementiahas caused the mind of a once brilliant man and renowned pathologist to become ashadow of itself.

Yes, it’s sad not be able to share with him my sweet memories of my childhood or ofmy mom, who passed away several years ago. And he no longer recalls the names of hischildren and six grandchildren. Yet, my dad’s dementia has managed to provide treasuredmoments. One time, I commented on how nice he’d become since he’d “lost his marbles”and he replied, “I’d sure hate to run into my old self!”

I’d heard an NPR piece about how powerful music can be for dementia patients anddecided that it was worth a try. I downloaded a few songs from musicals that my parentslistened to. I pushed play, Richard Harris’ baritone came booming through my iPhoneand my dad and I enjoyed a few karaoke sessions of Camelot, ending with a resoundingrendition of “I've Been Working on the Railroad”.

Our cover story on dementia (page 10) spotlights why a diagnosis is important,discusses the limitations of treatments and underscores the impact of the disease onyour patient’s family as well as your patient. There’s hope for treating a disease thatnow impacts almost 5 million people in the United States – and surely, that number willbe escalating.

In our 2012 November/December issue, Managing Editor Linda Harder surveyed thestatus of Accountable Care Organizations (ACO). At that time, there were 154Medicare ACOs in 37 states (“Accountable Care Organizations – Can They Work forYou?”). That article has been one of our top-read articles since Maryland Physicianlaunched – clearly a hot topic. As this issue goes to press, there are more than 250Medicare ACOs in operation, as well as a growing number of commercial models. Inthis issue, Linda revisits how accountable care is growing with or without an ACOmodel, and why some providers choose to participate while others pass (page 20).

We’re entering a time of family gatherings and holiday rejoicing. With social mediaand other influences, time seems to be speeding up and keeping us in the present, oftencausing us to neglect the rich history and stories from our parents and elder loved ones.Relish the time you have away from your practice and take some time to really listento someone else’s memories. With that, I wish you and yours a joyful and peacefulholiday season.

To life!

Jacquie Cohen RothPublisher/Executive Editor [email protected]

@mdphysicianmag#mdphysicianmagEvents

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DISCUSSION: Family members maynot recognize that a loved one issuffering from cognitive impairmentuntil the symptoms are quite advanced.Couples will often compensate for oneanother’s deficits quite naturally, untilthe signs and symptoms of impairmentare pronounced. Likewise, if a formaltest of mental functioning is notperformed during the primary careoffice visit, the physician may miss thesigns of early dementia. Medicarerecently approved payment to primarycare physicians for an annual wellnessexam. This exam must include a formaltest of cognitive function for thephysician to obtain Medicare payment.

Once impairment is discovered onthe cognitive screening test, thephysician will look for potentiallyreversible causes. A complete medicalhistory and physical examination,including a detailed neurological exam,should be performed. Questions toinvestigate the possibility of depressionshould be asked. People who areexperiencing early dementia maydevelop depression in response to the realization they are experiencingdeficits. The depression may cause an accentuation of the cognitiveimpairment, so a trial of antidepressantmedication may be given. The physician will look for medicalproblems that might cause cognitiveimpairment, including hypothyroidismor certain vitamin deficiencies. Profound anemia or renal failure could cause reversible cognitiveimpairment. Certain prescribedmedications (such as tranquilizers,sleeping pills, pain pills and others) can cause cognitive impairment.Alcohol or prescription drug abuse canpresent as cognitive impairment.

The primary care physician may refer the patient to a neurologist to helpmake the diagnosis of dementia, anddetermine the specific type of dementia.

Although Alzheimer’s disease is themost common form of dementia, otherdementia syndromes are recognized,including Lewy body dementia,dementia associated with Parkinson’sdisease, vascular dementia, primaryprogressive aphasia, frontal lobedementia, Cruzfeldt-Jakob disease,normal pressure hydrocephalus,dementia pugilistica and others. Areferral to a neuro-psychologist mayhelp to clarify the person’s abilities invarious realms of mental functionthrough a battery of cognitive tests.

The person with dementia should beadvised not to operate a motor vehicleany longer. Referrals to elder lawattorneys may be advised to establish a financial plan for future care needs.Advance directives should be made. The use of medications to try toimprove cognition is generallyrecommended, but controversy existsabout their cost versus effectiveness.

Caregivers must be supported in their efforts to provide care andkeep the loved one in the homeenvironment as long as is safe andfeasible. The Alzheimer's Associationwebsite provides resources forcaregivers at www.alz.org. City andcounty health departments and theOffice on Aging (www.aging.maryland.gov) are also sources for caregiverinformation. Participation in a medicaladult day care program can help relieve the burden of family members.When the loved one’s needs exceed the caregiver’s capacity, many assistedliving or nursing facility options exist. Caregivers must be able toprotect their own health and spendmore quality social time with the loved one by enlisting others. It trulytakes a village.Rebecca Elon, MD, MPH AGSF serves as

chief medical officer of FutureCare Health

and Management Corporation. She may

be reached at [email protected].

Cases

Dementia Case Studyand Discussion

CASE: Mrs. Jones was asuccessful business-woman.After retirement at the age of65, she remained active withlocal volunteer groups. Afterher 79th birthday, her husbandbecame concerned because shehad dropped out of most of herusual activities. She had alwaysbeen a very outgoing person,but had become quiet andreserved. She started askingrepetitive questions. She alwaysenjoyed cooking, but recentlyhad trouble getting the mealsprepared. When a fire startedon the stovetop, she did notknow what to do to extinguishit. When they had gonetogether on a recent vacationcruise, Mrs. Jones got up in themiddle of the night and wastotally befuddled andfrightened. Now, even at home,she wants to be with herhusband all of the time. Mr.Jones dropped out of several ofhis activities, due to his wife’sneeds. The latest challenge isthat Mrs. Jones no longer wantsto take a bath. She has becomeincontinent of urine and doesn’tseem to be aware when sheneeds to change her clothes.Their three children all live outof state and there is no otherfamily nearby. Mr. Jones isexperiencing physical andemotional exhaustion. He isvery worried about the future.He asked his primary carephysician what he should do.

By Rebecca Elon, MD, MPH AGSF

WHY IT MATTERS


Diagnosingdementias

IS THERE HOPE FOR THOSE WITH DEMENTIA?While treatments are limited, Maryland neurologists and psychiatrists discussthe importance of a good history and exam, plus optimal supportive care.

LZHEIMER’Sdisease (AD) and other dementias affect a growing percent of our agingpopulation. About 60 to 80% ofdementias are due to AD, affecting morethan five million Americans. But theimpact of the disease spreads wellbeyond those affected, as over 15 millionfamily members are caring for someonewith AD at home, and the average costof caring for a patient with dementia in a long-term care facility approaches$50,000 per year. In Maryland alone,some 80,000 people are believed to have the disease.

Differentiating DementiasJerold Fleishman, M.D., LAc, section chief, department of neurology atMedStar Franklin Square Medical Center,notes, “Dementia is characterized byimpairment of memory and at least oneother cognitive sphere, such as aphasia,apraxia, agnosia or impairment ofexecutive function, that affects normalactivities of daily living. Memory issuesalone do not define dementia.”

He continues, “In AD, the typicaltrajectory is for short-term or recentmemory to be affected first, then long-term memory. Spatial orientation andreasoning often are next. Family memberstypically observe a slow, progressivedecline. In teaching our residents, I usethe acronym JOMAC – which stands forjudgment, orientation, memory, affectand cognition – to describe the typicalfunctions affected in dementia.”

“There is a strong association with depression in those afflicted with dementia,” says Dr. Fleishman.“However, in turn, major depressioncan behave similarly to dementia, which is important to differentiatebecause treatment and outcomes aresignificantly different.”

While AD is the most commondementia in our population, otherrecognized dementias include vascularor multi-infarct, frontotemporal (FTD)or Lewy body dementia (DLB). Mostcases have a mixture of pathologies inthe brain.

“Vascular dementias, a common form,tend to follow a more step-wiseprogression, rather than a linear one,”says Dr. Fleishman. “One should think ofthis diagnosis in patients with a historyof multiple strokes, known uncontrolledhypertensions or diabetes that may leadto multiple small-vessel bilateral lacunarischemic strokes. Over time, these tinystrokes may lead to impaired cognitivefunction if not controlled.”

DLB is increasingly recognized asanother common type of dementia. It is characterized by early impairment in attention and executive and visuo-spatial function, with memory affectedlater in the disease course. Visualhallucinations can be an early sign ofDLB and can be helpful in distinguish-ing it from AD, where hallucinationstend to be seen later in the disease.

FTD, usually seen in those aged 40 to70, has several variants – includingbehavioral variant (bvFTD), primaryprogressive aphasia (PPA) and motorneuron disease (FTD-MND). The morecommon behavioral variant may besuspected if the patient has ritualizedbehaviors or abnormal social behaviors,loss of executive function and problem-solving issues.

A Team Approach to DementiaConstantine Lyketsos, M.D., MHS,FAPM, DFAPA, director of the JohnsHopkins Memory and Alzheimer’sTreatment Center on the Johns HopkinsBayview campus, provides cutting edgetreatment and conducts research and

education about dementia. The centersees about 1,000 new patients a year – a large volume, though only a smallpercent of them are Maryland residentswith dementia. About half of the center’sreferrals are from physicians, with theother half referred by self or family.

An interdisciplinary group of 12neurologists, geriatricians andpsychologists staff the program. “The first visit can be with any of ourphysicians,” notes Dr. Lyketsos, “butthen we triage as appropriate to thephysician who is the best match for thepatient’s presentation. We meet weeklyas a team, and we have three RNs whoare experienced with memory care, andwork closely with other experts in thearea such as occupational therapists andneuropsychologists.”

Good Exam Critical to Accurate DiagnosisWhether in a private physician’s office or a specialized center, our experts agreethat the key to dementia diagnosis andtreatment is a comprehensive history and physical.

“It’s easier to predict outcomes whenwe have the best diagnosis,” KatherineCoerver, M.D., Ph.D., neurologist at TheNeurology Center in Chevy Chase, says.“In my workup, I first take a carefulhistory, perform a physical exam andneurological exam, including completionof a cognitive screen. When appropriate,neuropsychological testing should alsobe completed to help develop afunctional portrait of the brain.”

Dr. Fleishman concurs. “Historytaking is so important and shouldinclude asking about medications, over-the-counter supplements, any recentchanges in medications, increasedphysical or emotional stressors and asleep history, which are all imperative.”


BY LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

A


“You’d be surprised how many peoplewe see that have been started on a drugfor dementia without having a diagnosis,”Dr. Lyketsos exclaims. “Diagnosisshould be the first step.”

Dr. Coerver contributes, “As part of the history and physical, I try todetermine if a person has languageproblems or difficulties with attention or processing information. With this knowledge, I am able to startdetermining if the dementia is due toAlzheimer’s disease or frontotemporaldementia, which tends to manifest itselfin language and behavior issues.”

“The truth is that biologic tests arenot that useful, but we’re good atdiagnosing with a rigorous clinicalexam,” comments Dr. Lyketsos. “Wealso employ a cognitive battery thatincludes such tools as the Mini-MentalState Examination (MMSE) and theMontreal Cognitive Assessment (MOCA).

“These are comparable to getting a chest x-ray in that it allows you to rule in or rule out dementia, but notdetermine what causes it,” he continues.“That’s where tests become useful.Where appropriate, we use neuro-psychological testing, which is more like a chest CT.”

Additional Testing“I also order an EEG to detect possiblesubclinical seizures,” states Dr. Coerver.“I order a basic metabolic panel andliver function, B-12 levels andmethylmalonic acid (MMA) levels,because a high level can mask a B12deficiency. I also check thyroid functionand homocysteine levels, which are

associated with B12 deficiencies and cancause atherosclerosis, blood clots andpossibly Alzheimer’s disease.”

She continues, “Next, whenappropriate, I get a structural view ofthe head with MRI, or CT if MRI is notan option, to rule out slow-growingtumors or small strokes. I also look forevidence of atrophy on the scan.”

“Focal symptoms in the setting of adementia, such as falling, may indicatesome other process,” notes Dr. Fleishman.“In those patients, I’m more aggressivein pursuing a baseline non-contrast CTor MRI, as recommended by theAmerican Academy of Neurology (AAN).”

Dr. Lyketsos says, “Many people canbe diagnosed without needing imaging – in fact, we can in some cases concludewith 90% confidence that it isAlzheimer’s without MRI – but we useimaging where appropriate. Whatmatters is the pattern of the entirepicture.”

Biomarkers for DementiaWhile no validated biomarkers for ADcurrently are available, several are on thehorizon, including those for cerebrospinalfluid proteins, blood proteins, brainimaging and genetic risk profiling.

Dr. Coerver comments, “While alumbar puncture is not something Iroutinely order, research shows there is a good correlation betweenAlzheimer’s and lower levels of betaamyloid and higher levels of Tau proteinbiomarkers in the spinal fluid. I will use this test if I believe that there may bean underlying infection or inflammatorychanges contributing to a person’scognitive dysfunction.”

She continues, “Is testing worthwhilewhen effective treatments are limited?Yes, because you never know what you’llfind. Vascular dementia has a betterprognosis, and treatment is available forbrain tumors or subclinical seizures.Atrial fibrillation increases the risk forvascular dementia because, even withCoumadin, it can release numerous tinyblood clots into the system.”

Molecular imaging technologies,involving PET/CT and radioactive tracers,show promise, but are not yet covered bymost insurers and can not yet definitivelydiagnose AD. A study published in JAMAon January 19th, 2011 showed near-perfect correlation between Amyvid(florbetapir F-18) detection of beta-amyloid and amyloid levels on autopsy.

“You’d be surprised howmany people wesee that have

been started on adrug for dementiawithout having a

diagnosis.Diagnosis shouldbe the first step.”

– Constantine Lyketsos, M.D., MHS, FAPM, DFAPA

Constantine Lyketsos, M.D., MHS,FAPM, DFAPA, director of the JohnsHopkins Memory and Alzheimer'sTreatment Center

“If the first round of tests doesn’tprovide enough information,” says Dr. Coerver, “I may order a FDG-PETscan to differentiate Alzheimer’s fromfrontotemporal disease. Medicare willpay for this test, though private insurersmay not.”

“Molecular imaging such as PET/CTis nonspecific but helpful in about 10 to 15% of patients,” says Dr. Lyketsos.“Amyvid-PET can help to rule outAlzheimer’s, but Medicare won’t pay forit as a diagnostic tool, so it’s expensivefor patients.”

TreatmentTreatment options for those with AD are admittedly limited, and no break-through drug is on the immediatehorizon. Most FDA-approvedAlzheimer's medications – donepezil,rivastigmine and galantamine –function by inhibiting the action ofacetylcholinesterase, the enzymeresponsible for the breakdown ofacetylcholine, a key neurotransmitter. By contrast, memantine, (Namenda), an N-methyl-D-aspartate receptorantagonist, work by limiting thepotentially toxic effects of glutamate.Response to these medications varies.

“Some people tolerate one of theacetylcholinesterase inhibitors betterthan another, but they are similar,” Dr. Coerver observes. “Namenda can be used at all stages of dementia. While it has few side effects, somepatients experience dizziness, and a small number of my patients haveexperienced increased confusion. Anextended-release form is now available,which improves compliance.”

Dr. Fleishman is also an acupuncturistwho practices a more complementaryapproach with his patients. “Since the1990s, I’ve believed that low-gradeinflammation may play a role indementia and in other medicalconditions. Supplements such ascurcumin, Omega III fatty acids andCoenzyme Q10 may help. I also believethat lowering homocysteine levels ifelevated, with a combination of B6, B12 and folic acid may be helpful.”

Dr. Coerver has tried Axona, aprescription nutritional supplement thatmay increase brain metabolism. “I alsoadvocate a healthy diet, exercise for 30minutes three to four times a week, andkeeping blood glucose and hypertensionunder control.”

Advice to Physicians: Avoid a Nihilistic ApproachDr. Lyketsos cautions physicians treatingpatients with dementia against taking a nihilistic approach to treatment.“Treatment is more than prescribingFDA-approved medications. You needdisease management that understandsthe possible underlying causes, such ashypothyroidism, major depression, anddiabetes. If it’s Alzheimer’s, there’s nodirect treatment, but management ofblood pressure, glucose levels and otherco-morbidities is very important toslowing progression. Appreciate that

much can be done to help patients with dementias and their caregivers, and the earlier the better. There is a lotwe can do.”

Supportive Care is CriticalDr. Lyketsos believes that supportivecare for patients with dementia is critical– proper sleep, consistent routines,adequate hydration and nutrition.“Caregivers also need support. Thefamily should be educated to be goodproblem solvers – to get respite care asneeded and to be detectives who canpick up problems,” he advises.


Katherine Coerver, M.D., Ph.D.,neurologist at The NeurologyCenter in Chevy Chase


“Common issues are constipation,dehydration, pain, dental problems, and bladder infections. In the winter,respiratory infections are common andmuch more detrimental to the brain withdementia. The flu can throw a dementiapatient for a loop, and patients shouldget flu shots and pneumococcal vaccinesto prevent respiratory problems.

“The evidence is very solid that acutemedical problems lead to a fasterdecline,” he adds. “If the patient doescontract an illness, be aggressive intrying to return them to functioning. Ifthey stay in bed two to three days, oneor two weeks of physical therapy mightbe needed to reverse deconditioning.”

Physicians should also monitorpatients to manage neuropsychiatricsymptoms, such as apathy, sleepproblems, depression and agitation –over 95% of patients with dementiadevelop one or more of these symptomsover the course of illness. “You want tocatch and treat them early,” states Dr.Lyketsos. “If agitation emerges suddenlyin a person with dementia, it’s oftenrelated to a bladder infection or othermedical problem.”

The person’s environment also plays a key role in their function. “A newcaregiver or change in routine can causeproblems,” Dr. Lyketsos adds. “Youshould encourage activity, such as a daycare program, to help patients keepmentally, physically and sociallyengaged – and to give caregivers whoneed it some respite. If there are moreserious behavioral issues, involve aspecialist before prescribing anti-psychoticor other psychiatric medications, whichcarry significant risk for patients with dementia.”

Dr. Lyketsos recommends that

physicians guide family members toaddress safety issues. “In early dementia,we see issues with driving andmedication oversight. Later, nutrition,hydration and safety become more of anissue, especially when patients live alone.Don’t assume that, as the dementiaprogresses, a nursing home is the nextstep. When the patient needs more help,we can teach families to do much ofwhat the patient would get at a nursinghome to delay admission.”

Enroll Patients in Protocols “Primary care physicians are used tosending cancer patients for protocols,”concludes Dr. Lyketsos. “They need todo that early on for patients withdementia, too. We have 15 dementia-related protocols going on currently,including Venlafaxine for Depression inAlzheimer’s Disease, a preliminary studyon Carvedilol for treating AD and DeepBrain Stimulation for AD. Researchparticipation is key to finding cures andimproving care.”

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Katherine A. Coerver,M.D., Ph.D.,neurologist at The Neurology Centerin Chevy Chase, MDJerold H. Fleishman, M.D., LAc,section chief, department ofneurology and director of clinicalneurophysiology, MedStar FranklinSquare Medical Center; clinicalinstructor of neurology, JohnsHopkins HospitalConstantine G. Lyketsos, M.D.,MHS,FAPM, DFAPA, director, Johns HopkinsMemory and Alzheimer's TreatmentCenter and chair of Psychiatry, JohnsHopkins Bayview campus

Jerold Fleishman, MD, LAc, section chief, department of neurologyat MedStar Franklin Square Medical Center

HEPATITIS C: TEST ALL BABYBOOMERS What is the most common infectious diseasein the U.S. today? Perhaps surprisingly, it’snot HIV. Instead, it’s Hepatitis C, a diseasethat is estimated to affect about five millionpeople in the U.S., many of whom are babyboomers born between 1945 and 1965.Compare that to about one millionAmericans suffering with HIV and 1.5million with Hepatitis B.

“The first thing the average physicianneeds to know is that our diagnosis rates for Hepatitis C are miserable – about39%,” observes Anurag Maheshwari, M.D.,clinical assistant professor of medicine,University of Maryland School of Medicine,Institute for Digestive Health and LiverDisease at Mercy Medical Center. “That’s instark contrast to HIV, where the rate isabout 90%.”

The overall prevalence rates for HepatitisC are 1.6%, but in baby boomers, theprevalence climbs to 4 or 5%; among innercity baby boomer African American males it may be as high as 8%.

“The highest transmission rate peaked inthe 1960s,” Dr. Maheshwari notes. “That’s

largely attributable to needle sharing among recreational injection drug users and unsafe medical practices, includingblood transfusions and tattooing.Unprotected sex may also contribute,although the rate of sexual transmission of Hepatitis C is much lower than that for HIV. Unfortunately, some 20 to 35% of those infected don’t have identifiable risk factors.”

Hepatitis C TestingThat’s why, in 2012, the Centers for DiseaseControl and Prevention (CDC)recommended that all baby boomers gettested for Hepatitis C at least once in theirlifetime, even when they have no identifiablerisk factors. Physicians can order a simpleblood test, the enzyme-linkedimmunosorbent assay (ELISA), with 94 to98% accuracy.

Dr. Maheshwari urges primary carephysicians to make this assay a routine part of an annual physical for baby boomers who have not yet had the test.“Testing for Hepatitis C should be likegetting a colonoscopy for those over age50,” he advises.


InfectiousDiseases

STOPPING

Despite our ability tonearly eradicatemeasles and even toeffectively treat HIV, anumber of potentiallydeadly infectiousconditions are on therise. Our medicalexperts suggest thebest approaches tostop or treat them.


TESTING BABY BOOMERS, DECREASING ANTIBIOTIC USE ARE KEY

If Hepatitis C is detected by the ELISAtest, the next step is determining thequantity and type of the virus.

Unfortunately, abnormal liver functiontests are not a reliable way to test for thisvirus. “Patients can have significant liverdisease even when their liver function testis normal, so that test doesn’t necessarilyindicate that all is well,” Dr. Maheshwaricautions.

Changing Treatment Implications A liver biopsy will reveal the presence ofcirrhosis and/or the stage of liver disease.In the past, those with Stage 0 or Stage 1liver disease were recommended deferringtreatment, because interferon treatmenthas significant side effects that caninclude fatigue, anemia, rashes, nausea,mood swings and even severe depression.Instead, interferon treatment was reservedfor those with Stage 2 or higher.

However, with newer treatments thatdon’t involve interferon, theconventional wisdom for patients atStage 0 or 1 is changing.

“Patients worry about being able tokeep working when they take interferon,which is injected subcutaneously,” Dr.Maheshwari says “But thanks to newoptions, that’s changing. Interferontreatment used to be 48 weeks in length.

In the next six months, we will reducethat to three months of therapy. And inthe next 24 months, we should be able tocompletely eliminate interferon and usepills only. Then we can argue that everypatient with this virus should be treated.”

A recent Phase II trial conducted bythe National Institute of Allergy andInfectious Diseases and the NIH ClinicalCenter, published August 28, 2013 in theJournal of the American MedicalAssociation, found that patients –including those in difficult-to-treatpopulations – can achieve viral controlthrough all-oral treatment regimens.Patients who were given a 24-weekregimen of sofosbuvir along with weight-based ribavirin had a sustained virologicresponse to treatment of 68%. Anotherpreliminary publication funded by AbbotPharmaceuticals of a combination ofthree oral anti-viral medicationsdemonstrated cure rates of between 93-95% of patients in a small studypublished in the New England Journal(N Engl J Med 2013; 368:45-53).

“Some doctors and many patientsmistakenly think there’s nothing that canbe done to treat Hepatitis C,” warns Dr.Maheshwari. “That myth needs to bedispelled. It’s a curable, treatablecondition, and failing to treat it can leadto cirrhosis or liver cancer, with possibleliver failure and the need for a livertransplant as a consequence.”

No insurance company will provide lifeinsurance if you have Hepatitis C, so whyshould we physicians leave it untreated? Ipersonally believe that all patients withHepatitis C should receive treatment, butwe need options that are palatable.Thankfully, they’re around the corner.”

He concludes, “My dream is toeradicate this virus in the next 10 years.Physicians need to ensure that their babyboomer patients get tested, even thoselacking evident risk factors. It takes fiveto seven years to progress from one stageto the next, but treatment depends onthe patient’s personal preference and co-morbid conditions. A young, healthy50-year-old, for example, should takecare of their infection now.”

FECAL TRANSPLANTS FOR C. DIFFBECOME ACCEPTEDAs the number of U.S. cases ofclostridium difficile (C. diff) climbs fromroughly 150,000 /year in 2,000 to about500,000/year today, and as 15,000Americans now die from the infectioneach year, finding effective treatments for

refractive cases has become more urgent. The overuse of antibiotics has clearlyhelped fuel the rise of this disease.

Those over 65 and in long-term-carefacilities are at highest risk, while agrowing number of pregnant women and children suffer from C. diff. Inchildren, those most at risk haveinflammatory bowel disease (IBD), are immuno-suppressed due totransplantation or oncological diseases,or are in chronic-care facilities.

The CDC recently reported that 75% of patients with C. diff actuallywere already colonized with the diseasewhen they were admitted to a hospitalor nursing home. That flew in the faceof accepted wisdom that most patientscontracted the disease as a result of their stay in such facilities, andsuggested that efforts should focus onavoiding contamination from newlyadmitted patients.

Preventing C. Diff InfectionMaria Oliva-Hemker, M.D., professor of pediatrics and director of pediatricgastroenterology and nutrition at theJohns Hopkins Children’s Center,comments, “The problem with antibioticsis that they kill the good bacteria as wellas the bad. In an uncompromised host,there’s some evidence that usingprobiotics helps. Probiotics can be useful,but they only restore several species of thethousands that populate our gut. Andmost yogurt in the U.S. has a lowconcentration of probiotics – if any. Asphysicians, we need to make sure patientsare getting only the antibiotics they needand getting the right ones, though it’schallenging in an era where patients areconditioned to ask for them.”

New TreatmentsVancomycin and metronidazole havebeen the go-to treatments for years. In2011, the FDA approved fidaxomicin(Dificid, Dificlir) as an alternativetreatment to vancomycin ormetronidazole for treating thiscondition. Vancomycin is effective inpreventing relapse in about 75% ofcases. A recent study demonstrated that fidaxomicin’s relapse rate is only15%, but it is expensive and far from a panacea.

Diverting loop ileostomy with colonicvancomycin lavage is being tested toreplace colectomies in some patients.

Gaining acceptance as anothertreatment approach is stool (fecal) trans-


Anurag Maheshwari, M.D., clinicalassistant professor of medicine,University of Maryland School ofMedicine

plantation. The concept dates back toancient Chinese in the early first century,and to Western usage in the 1950s.However, only recently has it gained realtraction, as studies demonstrate its value. While only about 500 published cases ofthe procedure exist worldwide today, thesuccess rates with stool transplants havebeen sufficiently impressive to launch itsreconsideration.

A randomly-controlled trial publishedin the New England Journal of Medicine(NEJM) on Jan. 17, 2013, found that theinfusion of donor feces was significantlymore effective for the treatment of recurrent C. diff infection than the use of vancomycin, at least in an adultpopulation. The trial was stopped earlyas a result of the far greater efficacy offecal transplantation (81% resolved afterone infusion vs. 31% receivingvancomycin alone).

Fecal transplants are now being triedas a treatment approach in children.“Some 20% of children with C. diff will have recurrence of their diarrheafollowing vancomycin treatment, and 40 to 60% of these will have a secondepisode. Fecal transplant should beconsidered for children who don’trespond to two standard courses ofantibiotics,” Dr. Oliva-Hemker states.

Fecal Transplants Extend to ChildrenWhile several area hospitals have performed the procedure in adults, theJohns Hopkins Children Center is one of a handful of pediatric hospitals in thecountry to offer this therapy. Earlyresults are promising, though Dr.

Oliva-Hemker expects a relatively small number of cases in the pediatric C. diff population.

Dr. Oliva-Hemker notes, “Theprocedure has no published short-termside effects, but we don’t know about thelong-term. Could the transplant of donorstool lead to obesity, for example? So

caution is still the rule. However, thetruly exciting aspect of this treatment isthat, in the future, it may be useful fortreating ulcerative colitis, Crohn’sdisease and other digestive diseases.”

“The more we know about the microbiome, the more we respect it,” she concludes. “It’s integral to ourimmune system.”

The ProcedureThe procedure involves identifying asuitable donor, often the parent. Afterextensive screening (similar to that

undertaken for a blood donor) and stoolanalysis determines that the donor is alow infection risk, the child is scheduledfor the procedure. Within 12 hours ofthe procedure, the donor provides astool sample. It can be introduced in thepatient’s digestive tract through a nasal-gastric tube, a colonoscopy, or an enema.

According to Dr. Suchi Hourigan, a pediatric gastroenterology fellowinvolved in the Hopkins protocol, “Weuse a colonoscopic approach exclusively,which has the advantage of allowing usto view the colon at the same time.”

A number of companies are seeking to replace donor stool with culturedorganisms. RePOOPulate is one suchproduct. “The science is not there yet,but when we know what part of themicrobiome works, this could be aviable approach. It would allow the procedure to be more standardized,”concludes Dr. Hourigan, who isinvestigating the microbiome changesthat occur in fecal transplantation.

MRSA: A BALTIMORE EPIDEMIC?When examining MRSA (Methicillin-resistant Staphylococcus aureus) trends,you have to be careful how you look atthe numbers. While the organism –caused by a strain of staph bacteriathat's become resistant to the beta-lactam antibiotics such as methicillin,oxacillin, penicillin and amoxicillin –is becoming more prevalent, the rate of MRSA infections is on the decline.

The CDC reports that the number ofhealthcare-associated (HA) MRSA casesclimbed from 22% of staph infections in 1974 to 64% in 2004. A nationalsurvey in 2010 also documented thatMRSA prevalence was higher in 2010than in 2006.

However, compared with 2006, therate of MRSA infection has decreased at the same time that the rate of MRSAcolonization has increased. The mostrecent CDC data showed that over62,000 severe MRSA infections occurredin 2011, and more than 11,000 peopledied. However, life-threatening HA-MRSA infections have been decliningsince 2005, especially for those withbloodstream infections.

Further, the proportion of HA-MRSAhas decreased as CA-MRSA hasincreased. Perhaps nowhere is that moretrue than in Baltimore. Bruce Gilliam,M.D., medical director of the Institute ofHuman Virology clinic at the Midtowncampus of the University of MarylandMedical Center, believes that Baltimore


GET SMART ABOUTANTIBIOTICS WEEKSince 2008, the CDC has worked

with other government and private

partners to promote public and

provider education about the

appropriate use of antibiotics. Their

efforts include an annual Get Smart

About Antibiotics Week, occurring

this year on Nov. 18-24, 2013. Providers

can get free educational materials at

www.cdc.gov/getsmart.

Maria Oliva-Hemker, M.D., professor of pediatrics and director of pediatric gastroenterology andnutrition at the Johns Hopkins Children’s Center


has one of the highest rates of CA-MRSA in the country. “About 60% ofthe University’s emergency departmentpatients with a culture that grows Staphaureus have MRSA,” he says.

“Not everyone gets skin abscessesfrom MRSA. Those who do likely havethe more virulent strains,” explains Dr.Gilliam. “We know there are differentstrains with different virulence factors.At the 2013 Interscience Conference onAntimicrobial Agents and Chemotherapy(ICAAC) this September, they found thathaving MRSA when admitted to the hospital was less of a problem thanacquiring it in the hospital, because asick person with multiple co-morbiditieswill do worse with a bad bug.”

“If a hospital can identify that thepatient has MRSA when they areadmitted, they can better control it,” Dr Gilliam concludes.

Rapid Testing Is KeyIn place of the standard test for MRSAthat involved sending a tissue sample or nasal swab to a lab and waiting 48hours for results, a number of new rapiddiagnostic tests are now available on the market, such as GeneXpert.

“However, these tests are expensive andnot yet widely used,” Dr. Gilliamobserves. “We have to figure out how to use them in a way that improves care.Getting people on a narrow-spectrumantibiotic as soon as possible, such as onethat treats gram-positive bacteria only andnot also gram negative. Current researchhas focused on how to identify peoplewith resistant infections versus thosewhose infections are not resistant.”

Continued Need for Education“Pediatricians and other physicians areslowly doing a better job of using theappropriate antibiotic only whenneeded, rather than giving patients whodemand an antibiotic one even when it’snot appropriate,” continues Dr. Gilliam.But even physicians don’t always draw alink between giving a patient an antibioticin the office today and the rise ofsuperbugs – they’re more focused abouthaving an individual patient do well.”

Infectious disease experts estimate that as much as half of the antibioticscurrently prescribed are unnecessary.“The overuse and misuse of antibiotics isa large part of the problem,” Dr. Gilliamagrees. “Dutch studies involvingchildren with otitis media found thatthey could reduce drug resistance if theyused antibiotics only when needed.”

Newer Weapons, Similar OutcomesHospitals have been pursuing new waysto prevent MRSA. A study of 75,000ICU patients published in the NEJM inMay 2013 found that using dailychlorhexidine wipes and antimicrobialnasal ointment on all ICU patientsreduced the presence of MRSA by 37%.This approach was more effective thanisolating MRSA patients and treatingthem differently.

Since treating MRSA is expensive –estimated to cost $10,000 or more percase – preventing it is a key componentof controlling healthcare costs as well as health.

“In today’s hospitals, one factor in ourfavor is also likely the increase in privaterooms,” Dr. Gilliam remarks. “However,most providers don’t identify or addressMRSA in the clinic situation or thephysician exam room. No one is lookingat this – instead, the focus is on hospitalsand long-term care facilities.”

He adds, “Several new drugs havebecome available in the past seven to 10 years, including linezolid,daptomycin and ceftaroline fosamil.They can replace vancomycin whenthere’s toxicity but they may not bebetter at treating Staph aureus.”

Dr. Gilliam concludes, “Unfortunately,we don’t have the silver bullets forMRSA that it appears we’ll soon havefor hepatitis C. We have lots of newerweapons, but not necessarily betteroutcomes. We need a medical systemthat recognizes that not getting the rightcare costs more. The Dutch were able todecrease antimicrobial resistance whenthey decreased usage of antibiotics. Weneed similar measures here in the U.S.”

Anurag Maheshwari, M.D., clinical assis-

tant professor of medicine, University

of Maryland School of Medicine, Institute

for Digestive Health and Liver Disease at

Mercy Medical Center.

Maria Oliva-Hemker, M.D., Stermer Family

Professor of pediatric inflammatory bowel

disease and professor of pediatrics, Johns

Hopkins University School of Medicine;

director of pediatric gastroenterology

and nutrition at the Johns Hopkins

Children’s Center.

Bruce Gilliam, M.D., associate professor of

medicine and medical director of the

Institute of Human Virology clinic at the

Midtown campus of the University of

Maryland Medical Center.


Healthcare IT

Whether or not they have an Accountable Care Organization (ACO), many providers, hospitals and health

systems are actively working toward accountable care.Maryland Physician looks at where ACOs

stand today, and why some providers choose to participate while others pass.

ACCOUNTABLE CARE

EXPANDS W ITH

OR W ITHOUT AN



CMS’s Pioneer ACO Pilot ResultsIn the summer of 2013, the first resultsfrom the 32 participants in the Centersfor Medicare and Medicaid Services(CMS) Pioneer Accountable CareOrganization pilot project becameavailable. All participants met theirquality improvement-reporting goals,but only about a third reduced costs.Medicare spending for patients in theseACOs as a whole grew by only 0.3%,compared to 0.8% for a comparablegroup of non-ACO patients. Seven ofthese participants shifted to a less riskyshared-savings program, while twoopted out completely.

One of the more successful pilotparticipants was Beth Israel DeaconnessCare Organization, based in Boston. Itwas able to provide care to about 30,000Medicare patients at 4.2% below budget,to garner $15 million in shared savings.It achieved these savings by targetinghigh-risk patients for additional services,such as home visits from nursepractitioners, and by emphasizing caremanagement with its physicians.

Private-Sector ACOsWhile, more than 250 Medicare ACOsare currently in operation, commercialACOs are also booming, with more than

300 estimated to be running as of mid-2013. Aetna reports that it has signedaccountable care deals with 27 hospitalsor health systems, including five systemsin Maine, and that it plans 200 moresuch deals.

Similarly, United HealthCare reportsthat it has accountable care agreementswith over 575 hospitals, including arecent agreement with Mount CarmelHealth Partners in Ohio, and that itplans to more than double itsaccountable care contract payments by2017. It claims that its accountable careprograms have reduced emergency visitsby 16% and inpatient days by 17%.

One potential advantage of private–sector ACOs is that they can design theirbenefits plans to provide financialincentives for plan members to useproviders within the network. Medicare-based ACOs cannot take this sameapproach.

Maryland’s ACOsIn January 2013, five new MarylandACOs were approved by CMS, bringingthe state total to 10. Of the new ACOs,three are overseen by a subsidiary ofUniversal American, a healthcare organiz-ation in New York, while Anne ArundelMedical Center (AAMC) and the

Maryland State Medical Society (MedChi)were approved for one ACO each.

Of the 10 ACOs, three are partneredwith MedChi. MedChi CEO GeneRansom comments, “Maryland has beena leader in ACO development. We have10 ACOs now, out of about 185 in thecountry, and three Advance PaymentACOs, out of about 30 in the nation. All four of the early ACOs wereapproved and able to report their data toMedicare. They will get their resultsback from CMS by the end of 2013.”

“I’ve attended some recent boardmeetings of the existing ACOs and havereally been impressed. It’s too early totell if they will be successful long-term,”Ransom adds, “but they appear to beworking. One of their benefits is thatthey are helping to make other changesin care. It’s a way to keep privatepractice viable.”

He continues, “In Western Maryland,hospitals and physicians are alignedthrough the Total Patient Revenuepayment model, so it’s easier. Therehave, of course, been challenges. We’veseen some tension between primary carephysicians and specialists, and betweenphysicians and hospitals, but on thewhole they’re succeeding in moving tomore coordinated care.”

Maryland is one of 16 states that arein the running for a Health CareInnovation Award grant,” Ransomnotes. “ACOs put us in a good positionto be a finalist. Physicians interested inconsidering an ACO are encouraged tocontact MedChi and ask for MedChiNetwork Services.”

AAMC ACOThe AAMC Collaborative Care Network (CCN) is one of the CMSShared Savings ACOs approved in 2013.Its decision to develop an ACO wasmade in the context of its strategic plan,Vision 2020, which, among other goals,seeks to build relationships withcommunity physicians.

A large employed group, Anne ArundelMedical Group, and two other physiciangroups partnered with the hospital toform the ACO, which was launched inJanuary 2013. It has approximately10,000 Medicare beneficiaries (5,000 isthe minimum) and was established with

Thomas Pianta, administrator of AAMC Collaborative Care Network


Healthcare IT

an upside-risk-only model. The ACO only recently started

receiving data on its attributed patients.Thomas Pianta, administrative directorof CCN, explains, “In August 2013 westarted getting data from Medicare, sowe have a better idea where to target ourinterventions. We are required to submitquality data to Medicare in the firstquarter of 2014 on a sample of patientsselected by CMS. Additionally we arenow receiving data from CRISP(Chesapeake Regional InformationSystem for our Patients).”

Combining different data fromdifferent sources, as always, has beenpart of the challenge. “We have differentEMRs that don’t all talk to each other,”Pianta comments.

Care management of vulnerablepatients is a new concept and animportant tool in managing ACOpopulations, although Medicare doesn’tspecifically pay for care managers.Luckily, changes in care delivery werealready underway at the ACO’sparticipating physician offices, all ofwhich were already PCMHs.

Pianta notes, “Our goal is to targethigh-care utilizers and those withsocioeconomic barriers to good health,such as problems with housing, food ortransportation. A priority of ours is tohelp manage the patient’s ability to accesscare and get their basic needs met.Healthcare is often the third or fourththing on the list of what a person needs.We’re trying to make connections with,and more efficient use of, services thatalready exist.”

He believes that “the primary reasonto join an ACO is to take advantage ofcombined resources that make it easierto know about and manage yourpatients. When you know which patientsare managing their diabetes, forexample, it makes you a better doctor.We are trying to help our physiciansthrough good data.”

GBMC Healthcare ACOToday, after launching in 2012, theGreater Baltimore Health Alliance(GBHA) ACO has slightly more than ayear of experience under its belt. It hasnearly 14,000 combined beneficiaries inthe Shared Savings Program establishedby Medicare and the Cigna

Collaborative Accountable CareProgram. There are 100 participatingprimary care providers, including nursepractitioners (NPs) and physicianassistants (PAs), plus some specialists.Some providers are employed and othersare aligned with the ACO. The entitycurrently has four care managers and is hiring two additional ones. It alsoemploys three care coordinators formanaging non-clinical issues.

Regardless of insurance type, all

patients cared for by GBHA providersreceive the same type of innovative,patient-centric care. For example,participating physician practices have introduced new approaches tocaring for urgent issues that includeextended office hours and leaving 30%of the daily schedule open for same-day appointments.

Data is key. Colin Ward, executivedirector of GBHA, says, “The ACO isphysician driven. We assimilate clinical

Eric Wagner, MedStar Health executive VP for external affairs and diversified operations


information and claims data from thephysicians, then give it back to them tofoster shared decision-making. The truevalue of the ACO lies in its ability to getreal-time and retrospective informationabout its patients so doctors canintervene quickly to prevent minor issuesfrom spiraling into major health crises.”

“Our ACO can give participatingphysicians data such as which of theirhypertensive patients are not under goodcontrol, or which of their patients haveA1C levels that are too high,” Wardcontinues. “We can provide the clinicaldata tied to specific patient names toshine a light on places where thephysician’s attention is needed.”

He adds, “As a pilot program withCRISP, which runs the state’s HealthInformation Exchange (HIE), theEncounter Notification Service (ENS)has been critical in helping coordinatepatient care. We get real-timenotification of hospitalizations andemergency visits, so that patientsdischarged from the hospital have the opportunity to be seen in thephysician’s office within 48 hours.

“It’s a mindset shift that, if done right, provides clear benefits to bothphysicians and their patients,” Wardreflects. “An ACO can return joy to thepractice of medicine, because physicianscan see meaningful changes in the careof their patients.”

Accountable Alternatives to ACOsFor over 16 years, MedStar Health hasprovided some 30,000 Marylanders withmanaged healthcare through MedStarFamily Choice, a provider-sponsoredManaged Care Organizationparticipating in the state’s HealthChoiceProgram and the Maryland Children'sHealth Program.

MedStar Health considered creatingan ACO when the CMS regulations werefirst published, but ultimately decidedthat the model didn’t make sense for its

health system. Eric Wagner, its executiveVP for external affairs and diversifiedoperations, notes, “CMS ACOs havemany restrictions and they have anattributed population, not an enrolledpopulation – so what you can do is morelimited. In an ACO, a doctor may notknow that a patient is attributed to them

until after the fact.”He adds, “However, MedStar Health

has long been involved in populationhealth management. We decided wecould pursue similar goals in a differentway. In our MedStar Family Choiceprogram, we have assumed full risk, notshared risk, for our members. Like anACO, we have to hit quality metrics andfinancial targets, and we have carecoordination, outreach and otherfeatures comparable to a PCMH. Incontrast to old-school managed care,we’re managing health, not resources.Financial and quality results follow froma focus on the patient.”

The MedStar Family Choice programhas roughly 2,500 participatingphysicians, of which about half areemployed by the health system. “It’s notclinic-based care,” Wagner stresses. “We have a full team to handle caremanagement, and outreach staff toconnect with patients. We know who isdiabetic and whether or not they’ve hadcare. If a patient is overdue for care, wecall them and can even schedule anappointment in a three-way call.”

For the Medical Assistance population,asthma and pregnancy have turned outto be some of the key conditions tomonitor, along with diabetes.

Wagner notes that getting real-timepharmacy data and daily feedback from the state is extremely valuable.“We tie disparate data together withtechnological tools, to, for example,notify care managers when a patient isadmitted to the hospital, do outreachand send a home health care nurse outupon discharge.”

More recently, MedStar has used itsexperience with Family Choice to pursueother opportunities. In January 2013,they became a participating MedicareAdvantage provider in D.C., and theyplan to expand to other areas over time. They’re also talking to commercialpayers about developing shared riskmodels within the next six to 12 months.Some 38,000 individuals are coveredunder their benefit plans.

Wagner believes ACOs have yet toprove themselves a viable model, stating,"The jury is out. Many are enthusiasticabout ACOs. I have some concerns aboutwhether they will get us where we need tobe. My advice to physicians is to thinkout of the box. Having non-physicians dooutreach can free physicians to practicemedicine. That can be very rewarding.”

Whether physicians decide toparticipate in an ACO or another model,it appears that most care models areheading toward greater accountability.Hopefully, patients and providers alikewill emerge as winners.

* * * * * * * * * * * * * * *

See the article entitled ACOs: Can TheyWork for Your Practice? in MarylandPhysician Magazine’s November/December 2012 issue for more information.(www.mdphysicianmag.com/2012/11/01/accountable-care-organizations-can-they-work-for-your-practice/)

The Advance Payment ACO Model isdesigned for physician-based and ruralproviders who have come togethervoluntarily to give coordinated, highquality care to the Medicare patientsthey serve. They receive upfront andmonthly payments, which they can useto make investments in their carecoordination infrastructure.

Eric Wagner, executive VP for external

affairs and diversified operations,

MedStar Health

Thomas Pianta, administrative director,

AAMC Collaborative Care Network

Colin Ward, executive director, Greater

Baltimore Health Alliance

Gene Ransom, CEO, the Maryland State

Medical Society (MedChi)

“Many are enthusiastic about ACOs. I havesome concerns about whether they willget us where we need to be.” – Eric Wagner


HEN THE MARYLANDGeneral Assembly passed HB 1101 in its 2013 legislative session, it madehistory by paving the way for the state’sfirst hospital-based medical marijuanaprogram. Physicians have been animportant impetus to bring this bill tofruition, as it was introduced by Del.Dan Morhaim, M.D., the only physicianin the General Assembly, and was basedon a proposal from the Secretary of theDepartment of Health and MentalHygiene (DHMH) Joshua Sharfstein, M.D.

Gov. Martin O’Malley’s administrationhad previously opposed medicalmarijuana legislation out of concerns that it could violate federal laws thatprosecute state employees involved in distributing medical marijuana.However, the experience of other stateswith similar programs has eased thoseconcerns, and the administration this year withdrew its opposition.

Medical cannabis, or marijuana, hasfew clinical studies documenting itseffectiveness in symptom control forcancer and other diseases, includingchronic pain. However, many cliniciansbelieve it can be useful for preventingnausea and vomiting, stimulating appetite,improving sleep and reducing pain.

The CommissionThe legislation created an independentcommission within the Department ofHealth and Mental Hygiene that ischarged with developing a request forproposals from academic medical centersto establish medical marijuana programsfor select patient groups, approvingapplications and monitoring and

overseeing the programs that areestablished.

Gov. Martin O’Malley appointed the 11 members of the new commissionthis September. Its chair is Paul W.Davies, M.D., a pain managementspecialist who is the founder and CEO of KURE Pain Management. Boardcertified in interventional painmanagement and fellowship-trained in pain management, Dr. Davies has over 10 years’ experience treatingpatients in pain.

The other commission members are: > Michael A. Horberg, M.D., MAS,

FACP, FIDSA, executive director of Research and Community Benefitfor the Mid-Atlantic Permanente Medical Group and director of theMid-Atlantic Permanente Research Institute

> Robert A. Lavin, M.D., attendingphysician on faculty at the Universityof Maryland, School of Medicine, andthe Kernan Hospital of Baltimore. He is also director of the Chronic Pain Management Program at the Baltimore Veterans

> Shawn McNamara, Ed.D., M.S.N.,R.N., assistant dean of the School ofHealth Professions and Nursing Programadministrator for the Community College of Baltimore County

> Kevin W. Chen, Ph.D., MPH, associate professor in the Center forIntegrative Medicine and Departmentof Psychiatry at the University ofMaryland, School of Medicine

> Dario Broccolino, J.D., state’s attorneyfor Howard County since 2008

> William C. Charles, Pharm.D., a clinical pharmacist specializing in discharge and readmission reduction at MedStar Franklin Square Medical Center

> Deborah R. Miran, president andfounder of Miran Consulting, Inc., who advised both brand and genericdrug makers on the FDA approvalprocess

> Colonel Harry Robshaw, III, chief ofpolice, Cheverly Police Department

> Nancy Rosen-Cohen, Ph.D., an executive management professionalexperienced in healthcare reform andcorporate development

> Eric E. Sterling, J.D., a lawyer withover 32 years of experience in medical marijuana issues

Outcomes-Oriented ProgramsDr. Davies comments, “The commissionis charged with developing policies, rules and regulations to implement thelegislation. We hope to acceptapplications starting in 2014 foracademic medical programs involved in investigating uses of medicalmarijuana. Such programs must haveresidency curriculums and be involved in human research.”

Each program applicant must describewhat medical conditions will be treated,treatment duration, proper dosage,where marijuana will be obtained,sources of funding, measurementmethods for data and outcomes.” Theywill have to provide DHMH with dailydata on participating patients andcaregivers that will be shared withappropriate law enforcement agencies.

Policy

Medical Marijuana Commission is Launched

WMaryland Becomes The 19th State to Legalize Medical Marijuana

Paul W. Davies, M.D., chairof Maryland's Medical Marijuana Commission


Some of the many issues the newcommission must grapple with includewhere the marijuana seeds will beobtained, who will grow the plants,what the security criteria will be andwho is allowed to dispense it. To overseeimplementation of the program, thecommission seeks to appoint a full-timeadministrator. Due to the complexities of implementation, medical marijuana is not expected to become available inMaryland until at least 2015.

Chronic Pain Patients Will Benefit“I’m optimistic that this legislation will benefit many patients with chronicpain,” Dr. Davies notes. “We’ll have toestablish which disorders will benefitfrom medical marijuana, but patients are likely to include those with cancer,HIV/AIDS, chronic pain and neuro-logical disorders. The committee willdefine specific diagnoses, which is veryimportant, because we should make surethat Maryland patients have access touseful interventions. Our state is uniquebecause we are studying outcomes datato make sure that we see symptomimprovement and potential benefits,without significant side effects.”

Dr. Davies adds, “We’ll be closelywatching developments in Washington,D.C., the closest area to approve medical marijuana. Surprisingly, afterthree months of operation, they haveonly enrolled 30 patients, where theyexpected a stampede. Physicians should closely follow the progress ofimplementing this program and supportit because it may be a new tool to helpfight pain.”

Physicians and Public Invited to Commission MeetingsThe commission held its first meeting onSept. 24, 2013. In 2014, it will generallymeet on the third Tuesday of eachmonth. All meetings are open to thepublic, and physicians are encouraged toattend. Over the course of the meetings,the commission will be taking testimonyfrom the public, physicians and experts.For more information, physicians shouldvisit http://dhmh.maryland.gov/SitePages/Medical%20Marijuana%20Commission.aspx.

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ESTLED WITHIN THErolling hills of Chester County,Pennsylvania, Brandywine Valley hasmade its mark on the map with itsunique combination of art, history,heritage and some of the most impressivedisplays of horticulture to be found inthe United States. Located just an hourwest of Philadelphia, “the Brandywine”is easy to get to and promises plenty toexplore for tourists who are simplypassing through for the day as well asthose who are looking for a unique placeto unwind for a night or two.

Highlighted are a few BrandywineValley area “hot spots” that you won’twant to miss, regardless of when you go.

Longwood GardensCharge those camera batteries, for therewill be plenty of scenery that you willwant to remember forever as you take in Longwood Gardens’ 1,077 acres ofbeauty. With an international reputationfor its exquisite garden design andpremier botanical gardens, visitors raveabout the more than 11,000 varieties oftrees, plants and flowers, imported fromaround the world, gracing LongwoodGardens. While weaving in and out of the20 outdoor and 20 indoor garden arenas,you will also be stunned by the designand variety of fountains that complementthe grounds, some of which shoot waterup to 130 feet in the air. LongwoodGardens is open year-round and is hometo more than 800 horticultural andperforming arts events annually.

Brandywine Battlefield State ParkTour the very fields where the Battle ofBrandywine took place; notably thelargest battle in terms of combatantsduring the War of Independence in thelate 1700s. With a goal to broaden thepublic’s understanding of the significanceof the Battle of Brandywine and its

impact on the American Revolution, thepark organizes tours, educationalprograms and reenactment events on its50 square miles that stretch across bothChester and Delaware Counties. Thearea was named a State Park in 1949and has been recognized as a NationalHistoric Landmark since 1961.

Winterthur Museum, Garden and LibraryThe former 175-room home of HenryFrancis du Pont, the WinterthurMuseum, Garden and Library houses acollection of more than 90,000 pieces ofhistorical and decorative artifacts,commemorating the development ofAmerican art from the late 1600sthrough the early 1800s. Guided toursare available to ensure that visitors don’toverlook some of the most notablepieces of American furniture known toexist as well as inspirational fine art,ceramic, glass and metal artifacts, andtextile and needlework exhibits. You willalso want to plan some time into yourday to explore the grounds’ 60-acregarden, including the “EnchantedWoods,” a fairy-tale garden that pleasesall ages, and in particular, Winterthur’syoungest visitors.

Brandywine Valley Wine TrailIn 2003, a group of small wineriesspanning Chester County joined forces tocreate the Brandywine Valley Wine Trail.Eight wineries within a 50-mile radius arepart of the tour, with no designated“start” and “stop” points. Each offerssomething special for wine lovers alongthe way, from vineyard tours and tastingrooms, to styles that range from light,fresh and fruity to rich, earthy, andeverything in between. The commonrecommendation is that tourists who wishto “see it all” visit no more than two tothree vineyards each day, to ensure the

complete experience can be fulfilled ateach venue. Participating wineriesinclude: Black Walnut Winery,Borderland Vineyard, ChaddsfordWinery, Kreutz Creek Vineyards,Paradocx Vineyard, Patone Cellars, PennsWoods Winery and Twin Brook Winery.

Brandywine River MuseumHoused in a 19th-century grist mill, theBrandywine River Museum features animpressive art collection includingAmerican illustrations, still-life paintingsand landscapes. The artistic talent ofAndrew, Jamie and N.C. Wyeth, as wellas more than 100 other famousAmerican artists and illustrators, isdisplayed here, earning the museum aninternational reputation and attractingart enthusiasts from around the globe.Additionally, the BrandywineConservancy’s Wildflower and NativePlant Gardens are located on themuseum’s grounds, showcasingnaturalized plants, wildflowers, trees andshrubs, and seasonal flowers and foliage.

Planning your visit to the BrandywineValley area is easy, with an abundance ofresources, tips and local guides availableonline. Visit www.thebrandywine.comand www.brandywinevalley.com to getstarted and learn a bit more about theattractions highlighted, as well as a few others that you may want to visit,while in town.

Living

Sites to See and Explore AcrossBrandywine Valley

By Tracy M. Fitzgerald

NLongwood Gardens



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Medical Mastermind.....................................................6www.medicalmastermind.com/EHR

PNC Bank ............................................................................7www.pnc.com/cashflowinsight

Coverys ................................................................................8www.coverys.com

Savvy Marketing ..........................................................14www.aSavvyMarketingSolution.com

The Doctors Company ...............................................15www.thedoctors.com

Papercamera...................................................................19www.papercamera.com

Hospice of the Chesapeake ....................................25www.hospicechesapeake.org

HRI .......................................................................................25www.hri-online.com

Upper Chesapeake Health ......................................27www.uchcancer.org

KURE Pain Management ..........................................28www.kurepain.com

Center for Vein Restoration ...................................31www.CenterforVein.com

Shady Grove Adventist Hospital .........................32www.YourCancerTeam.com

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Solutions

Five Ways the Taxpayer Relief Act Could Affect Your 2013 Taxes

By Karl J. Appel, CPA

OMING INTO 2013, THEfiscal cliff and impending doomassociated with it was a major news story.The simultaneous increase in tax ratesand decrease in government spendingthrough sequestration, were believed tohave potentially catastrophic impacts onour economy. Instead, the AmericanTaxpayer Relief Act of 2012 (ATRA) wassigned on January 2, 2013. This actlargely resolved the revenue side of thefiscal cliff by modifying, makingpermanent, or extending a number of thetax provisions from the “Bush Tax Cuts”that expired in 2012 and 2011. Thepassage of this historic legislation createda number of changes for taxpayers,especially those in higher income taxbrackets. Following are five key changesyou should consider when planning to fileyour 2013 tax return.

Medicare Surtax In 2013, there are two significantchanges to the Medicare tax. As in prioryears, in 2013 the employer andemployee will each pay a 1.45%Medicare tax on all wages. In 2013,taxpayers will pay an additional 0.9%Medicare tax on wages in excess of$200,000 ($250,000 married filingjointly). Also in 2013, there is aMedicare surtax of 3.8% on investment(unearned) income for taxpayers withmodified adjusted gross income (MAGI)over $200,000 ($250,00 married filingjointly).

New Top Tax Bracket In 2012, the highest marginal tax ratewas 35%. This rate was reserved fortaxpayers with over $388,350 of taxableincome. In 2013, single taxpayers withbetween $398,510 and $400,000(between $398,510 and $450,000married filing jointly) of taxable income

C continue to have a marginal tax rate of35%, but taxpayers with more than$400,000 ($450,000 married filingjointly) have a new higher marginal taxrate of 39.6%.

Personal Exemption and ItemizedDeduction Phase-outs In arriving at taxable income, taxpayerscan typically take a personal exemptionand itemized deductions to reduce theirincome. In 2013, the PersonalExemption and Itemized Deductions aresubject to a phase-out. Individualtaxpayers with less than $250,000 ofadjusted gross income (AGI) ($300,000married filing jointly) are able to takethe full personal exemption of $3,900(up from $3,800 in 2012). The personalexemption of $3,900 per person will bereduced by 2% for every $2,500 of AGIin excess of $250,000 ($300,000married filing jointly) and will phase outcompletely at $372,500 ($422,500married filing jointly). Itemizeddeductions will also be phased out forindividual taxpayers with AGI greaterthan $250,000 ($300,000 married filingjointly). Itemized deductions allowtaxpayers to reduce their taxable incomebased on certain expenses that theyincur, including mortgage interest, stateincome and sales tax and home officeexpense. The itemized deduction phase-out reduces the value of itemizeddeductions by 3% of the AGI above$250,000 ($300,000 married filingjointly) to a maximum reduction of 80% in value.

Increased AGI Limit for DeductibleMedical Expenses Another change that could reduce theamount of itemized deductions you cantake is the increase to the AGI limit fordeductible medical expenses. Taxpayers

can take an itemized deduction for theamount of certain medical expenses inexcess of the AGI Limit. In 2013, theAGI Limit rises from 7.5% to 10%unless you or your spouse is 65 or older.If you or your spouse is 65 or older, thenew AGI threshold will not take effectuntil 2017.

Long-Term Capital Gains and Dividends For most taxpayers, the tax rates onlong-term capital gains and dividendswill remain the same as 2012. Fortaxpayers in lower tax brackets (10%and 15%), the rate remains at 0%. For taxpayers in the middle tax brackets,the rate remains at 15%. For thosetaxpayers with AGI of more than$400,000 ($450,000 married filingjointly), the marginal tax rate for bothlong-term capital gains and dividendsincreases from 15% in 2012 to 20% in 2013. When you factor in theMedicare surtax of 3.8% on investmentincome mentioned above, the marginaltax rate for long-term capital gains and dividends will increase by 8.8% for those taxpayers with AGI of morethan $400,000 ($450,000 married filing jointly).

These are just a small sample of thetax changes you should prepare forwhen planning your 2013 tax return.You should consult with your taxadvisor for additional changes that mayaffect you. Karl J. Appel, CPA, is vice president of the

Gardiner & Appel Group, Inc. Mr. Appel can

be reached at [email protected].


Thinking (and Working) Outside of the Medicine Box

ANIEL BECKER, M.D.,always knew he wanted to pursue acareer in the medical field. What hedidn’t realize when he began his journeyas a neurologist was that he wouldeventually find himself treating patientsin places and spaces far from the confinesof a hospital or clinical exam room.

“The first time I found myself workingwith a patient who was in a beach chair,I really had to step back and take in themoment,” said Dr. Becker, whospecializes in treatment of spinal cordinjuries, rehabilitating adults andchildren who suffer from paralysisbrought on by multiple sclerosis,transverse myelitis or a traumatic injury.“I see a lot of patients struggle, and somuch of my work is about helpingpeople improve their quality of life.When you take them out of thetraditional rehabilitation setting, you canhelp them see that they can do thingsthey didn’t think they could.”

So, as much as possible, Dr. Becker doesjust that. In May 2011, 10 of his patientslearned that they were in fact very capable

of exploring the underwater world whenthey accompanied their doctor on a trip to the Grand Cayman to go scuba diving.More recently, in April 2013, five patientswent along with Dr. Becker to theAdaptive Sports Center in Colorado for atherapeutic skiing trip, proving that insome cases, even those who are paralyzedcan still enjoy hitting the slopes.

“A patient once told me that he wouldnever be able to do the things he wasable to do before he got injured, andnow he is skiing,” said Dr. Becker. “You

can see it in their faces and hear it intheir voices as the people who do theseactivities to feed off of each other’spositivity. It’s really important to focuson what the person can do rather than what they can’t.”

With data from two adventure tripsnow at his fingertips, Dr. Becker isgaining a deeper understanding of howand why unconventional therapiesimpact patients with spinal cord injuries.He is investigating and documentingwhat types of activities are ideal orbeneficial for patients with differentinjury types, and how those activitieshelp or support rehabilitation processesand long-term outcomes. Dr. Becker is planning a second trip out to theAdaptive Sports Center; this time to

provide kids with paralysis a chance to have some fun as their doctor’sresearch continues.

“I have spent a lot of time in mycareer in labs, doing research,” said Dr. Becker, who serves as an assistantprofessor of Neurology at JohnsHopkins Hospital, and is founder anddirector of the InternationalNeurorehabilitation Institute,headquartered in Lutherville. “This is anout-of-the-box way to do research andgives me a chance to be there for some ofthe great moments in my patients’ lives.The line between my professional andpersonal life starts to blur because I getto know them on a very personal leveland watch them experience and enjoylife. It’s rewarding. It motivates me. It’swhy I do what I do.”

Good Deeds

D

“This is an out of the box way to do research andgives me a chance to be there for some of thegreat moments in my patient’s lives.” – Daniel Becker, M.D.

By Tracy M. Fitzgerald

Committed to helping those with paralysis focus on what they can accomplish in life, Dr. Daniel Becker recently took a group of patients to the Adaptive Sports Center in Colorado for an experience on the ski slopes.

Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at [email protected].

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Documents

Maryland Physician Magazine Nov/Dec 2013 Issue