Maryland Physician Magazine November/December 2012 Issue

PhysicianYOUR PRACTICE. YOUR LIFE.

PALLIATIVE MEDICINE& HOSPICE CARE:A BETTER END OF LIFE

CAN ACCOUNTABLECARE WORK FORYOUR PRACTICE?

PHYSICIAN ANDCONGRESSMANANDY HARRIS

PALLIATIVE MEDICINE& HOSPICE CARE:A BETTER END OF LIFE

CAN ACCOUNTABLECARE WORK FORYOUR PRACTICE?

PHYSICIAN ANDCONGRESSMANANDY HARRIS

VOLUME 2: ISSUE 6 NOV/DEC 2012

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YOUR PRACTICE. YOUR LIFE.

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10 A Better End of LifePalliative medicine and hospice care the right choice for many

16 Preventing Falls and Medication Complications in SeniorsSimple measures in the office reduce risks

20 Accountable Care OrganizationsCan they work for your practice?

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 2: ISSUE 6 NOV/DEC 2012

1016 24

Cases | 7 | Supporting Patient Spirituality

Compliance | 9 |Healthcare Reform & Compliance with Department of Labor Mandates

Living | 24 | Deep Creek Lake: AWinterWeather Lover’s Dream ComeTrue

Policy | 26 | Physicians in the Political Process: Congressman Andy Harris, M.D.

Solutions | 29 | Essentials of an Accountable Care Organization

Heritage | 30 | Dr. Bob’s Place Brings Comfort and Care to Kids withTerminal Illnesses

On the Cover: Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake.

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE ROTH, PUBLISHER/EXECUTIVE [email protected]

LINDA HARDER, MANAGING [email protected]

CONTRIBUTING WRITERSTracy FitzgeraldJackie Kinsella

CONTRIBUTING PHOTOGRAPHYTracey Brown, Papercamera Photography

www.papercamera.comMark Molesky, Moleskey Photography

www.moleskyphotography.com

EXECUTIVE ASSISTANT/WEBMASTERJackie Kinsella

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KAREN COUSINS-BROWN, D.O.Maryland General Hospital

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

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IFIRSTBECAMEAWAREOFTHEPOWEROFFACINGDEATHANDGRIEFwhen my mother read Elisabeth Kubler-Ross’ book, On Death and Dying in the early‘70s. I don’t remember why she was reading it but knowing my mother, it was a mustread. My mother had tremendous intellectual curiosity and that time was a time ofspiritual awaking and awareness for many.

Kubler-Ross’ work revolutionized how providers took care of the terminally ill andour understanding of the grieving process. Her work continued to have a direct impacton my life years later when I grieved the loss of my mother and just a bit later, mysister. Because of the care delivered by incredibly caring hospice providers whopersonally touched my family with hospice care and grief counseling, I am foreverinspired to share with others what hospice entails: a better end of life and a betterunderstanding of the end of life. That now includes a newer concept of care for boththe terminally and chronically ill, palliative care. The decision to focus on hospice careand palliative medicine as this issue’s cover story, A Better End of Life (page 10), is partof my personal mission.

Hospice of the Chesapeake’s Chief Medical Officer Lou Lukas, M.D., says aboutpalliative and hospice care, “When you give patients control, they usually decide what’sbest for them and society.” The same applies to the goals of an Accountable CareOrganization (ACO). The ACO model was hotly debated as part of healthcare reform,but many hospitals and doctors have moved to the model to receive financialincentives, achieve quality gains and reduce healthcare spending – all obtainable byengaging and empowering patients in their care and wellness. Maryland PhysicianManaging Editor Linda Harder presents a thorough review of the birth of ACOs inMaryland and the impact they hope to have on patient care (page 20).

Medicine isn’t always about the most cutting-edge treatment or high techequipment – often, providing simple comfort, common sense and a respect forspirituality can improve outcomes. Simple measures both in your practice and yourpatients’ homes outlined in our feature on geriatric care can greatly reduce risk of fallsand medication complications for the senior members of your patient population. Theymay even prevent tragic consequences (page 16). Learning and understanding yourpatients’ most cherished beliefs will impact their care and perhaps even lead to a betterunderstanding of yourself (see Cases page 7).

With that message of spirituality and recognition of the holidays ahead, I wish youand yours a joyful and peaceful holiday season.

To life!

Jacquie RothPublisher/Executive [email protected]

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DISCUSSION In the recent past,concerns about spiritual matters rarelywere brought to a physician’s attention;such matters were thought to be moreproperly in the purview of the chaplainor clergyperson. Both the HealthInsurance Portability and AccountabilityAct (HIPAA) and the Joint Commissionon Accreditation of HealthcareOrganizations (JCAHO) include theneed to assess patients’ religious orspiritual resources and their need forspiritual/religious care. We might betempted to believe this is aresponsibility of an institution ratherthan an individual. Yet, becausephysicians typically lead the medicalteams that address these issues, they

should know what information is usefuland how to obtain it, even if anotherteam member actually collects theinformation. Further, many patientsprefer to discuss these matters with theirown physicians rather than with medical,nursing, or chaplaincy personnel whomthey do not know.

Religious beliefs can play a majorrole in how people live their lives andhow they approach illness, dying, anddeath. For example, one religion holdsthat a certain procedure must never bedone, while another holds that it can (orshould) be done. Even people espousingthe same religion might see its tenetsdifferently. In this case, Al and Lyn areof the same religion, but Al sees illnessas a punishment meted out by God,while Lyn sees medical personnel,procedures, and medications as God’sgifts which are to be used wheneverpossible. Although a physician’s religiousbeliefs might come into play if he or sheis being asked to do something contraryto one of these beliefs, it is generally thepatient’s beliefs that must be elucidatedand explored vis-à-vis his or hercondition and acceptable treatments.Because the patient is often in avulnerable state, weakened by illness ormental anguish, insisting on a therapythat is clearly against his or her beliefs isusually counterproductive in getting thebest outcome for the patient and family.

Several screening tools have beenused to sort out religious/spiritual beliefsthat are of primary importance to apatient, especially when such beliefshave an impact on what therapies will beaccepted. Although no screening tool isperfect, physicians should be aware ofthe most widely used tools.

The American College of Physiciansoffered the ACP Spiritual History:1

� Is faith (religion, spirituality) importantto you in this illness?

� Has faith been important to you atother times in your life?

� Do you have someone to talk to aboutspiritual matters?

� Would you like to explore religiousmatters with someone?

Puchalski et al developed the FICASpiritual History:2

� F (faith) - What is your faith tradition?� I (importance) - How important is your

faith to you?� C (community) - What is your

community of faith?� A (apply) - How do your religious and

spiritual beliefs apply to your health?� A (address) - How might we address

your spiritual needs?

The American Academy of FamilyPhysicians offered the HOPE SpiritualAssessment:3

� H: Sources of hope, meaning, comfort,strength, peace, love, and connection

� O: Organized religion� P: Personal spirituality and practices� E: Effects [of beliefs/practices] on

medical care and end-of-life issues

These questions can start importantconversations, even if the physician doesnot personally provide the spiritualcare. Learning about and respectingpatients’ most cherished beliefs often hasa transformative effect on members of themedical team, especially when patientsare better understood. In addition,learning about what gives meaning toanother person might bring some clarityas to what brings meaning to oneself.Pat Fosarelli, M.D., D.Min., is the associate

dean of The Ecumenical Institute of Theol-

ogy of St. Mary's Seminary & University in

Roland Park. The Ecumenical Institute offers

several master’s-level courses that explore the

intersection of medicine and religion, spiritual-

ity and health.

1Lo, Quill & Tulsky in Annals of Internal Medicine

130 (1999): 744-49. 2Puchalski & Romer in

Journal of Palliative Medicine 3 (2000): 129-373www.aafp.org/afp/2001/0101/p81.html

Cases

Supporting Patient Spirituality

CASE: Al, a 56-year-oldpatient you’ve treated foryears, has been diagnosedwith advanced lungcancer. He chooses to donothing about it because“It’s obviously God’s willthat I die now.” Lyn, hiswife, also your patient,believes that medicalpersonnel and treatmentsare gifts from God; shewants Al to avail himselfof all treatment optionsfor which he qualifies.You are in a quandary, asyour belief system doesnot correspond witheither of theirs.

Pat Fosarelli, M.D., D.Min.


S WE APPROACHTHE 2014 health insurance mandate,the principal element of healthcarereform (HCR), there continues to be morequestions than answers for the variousstakeholders involved. For practice leadersor employers, the next 15 months willprovide time to evaluate your healthinsurance options and define your futureliability. The evaluation process also willrequire paying attention to compliancewith the U.S. Department of Labor(DOL) mandates. Employer size doesmatter in the evaluation process ofdefining your liability for 2014 and indefining what DOLmandates need tobe addressed. Investing the time now toproperly evaluate your options will pay off.The Presidential election outcome maybring a repeal of HCR, but the need tocomply with DOLmandates will remain.

The LawIn March 2010, the HCR bill was passed;implementation began September 23rd ofthe same year. Regulators intend to hirethe equivalent of a military division ofnew IRS, Employee Benefits SecurityAdministration (EBSA) & DOL auditorsto ensure compliance with the newlegislation and the dated EmployeeRetirement Income Security Act(ERISA) laws. That increased capacity toaudit employers makes it essential tocomply with DOL mandates.

The following key compliance elementsrequire attention:

Section 125 plans - if an employer ispre-taxing an employee’s share of themedical insurance contributions, theyshould have a section 125 premium onlyplan (POP plan) document in place andthe plan should be subjected todiscrimination testing annually.Employers of any size are required to

have this document in place, yet most donot have a current document or completethe annual testing. Without a POP plan,the IRS could disallow all prior pretaxmedical insurance deductions taken.

COBRA (20+ employees) orMaryland Continuation of Benefits(under 20 employees) - employers thatsponsor health, dental and visioninsurance benefits are required to offerterminating employees and theirdependents the extension of coverageand may charge 102% of premium. Thereare strict notification rules and penaltiesfor not complying. Outsourcing thisrequirement is advised; the cost is notprohibitive.

As of September 23, 2012, employersare required to distribute a Summary ofBenefits and Coverage (SBC) for mostfully insured plans they sponsor to newenrollees and existing employees. TheHCR-related mandate is designed tosimplify communication materials foremployees. The related insurancecompany is responsible for creating theplan-specific SBC, which must bedistributed during the open enrollmentperiod that falls after September 23 forparticipants and beneficiaries and theeffective date of coverage for newenrollees. Employers must adhere to therules for information distribution.

Summary Plan Descriptions for allemployer-sponsored plans must beavailable for employees, for companies ofany size. Most insurance companiesprovide certificates of coverage orcontracts of coverage to employers fordistribution, but almost all lack theERISA required elements of informationto make them compliant. Providing acomplete summary plan description is theresponsibility of the employer. It is easyto have a third party create an ERISA“Wrap” document that contains the

missing ERISA information, whichsatisfies the Summary Plan Descriptioncompliance requirement for eachemployer sponsored benefit plan.

If an insurance plan change has beenmade since the plan has been in effect,the specific plan must have a writtenSummary of Material Modification(SMM) to document the change. Oncethe SMM is completed, it must bedistributed to plan participants andbeneficiaries.

Annual reporting 5500 Form Filing -for employers with over 100 full timeemployees, each employer sponsored planmust file a 5500. Filing a 5500 form isrequired for employer sponsored retirementplans irrespective of employee and planasset size. Failure to have filed theappropriate 5500 forms could result insignificant penalties from the IRS or DOL.

Family Medical Leave Act (FMLA) -an employer with more than 50 employeesis required to comply with FMLA.Integrating payroll with the multiple dataelements that require tracking underFMLA requirements has merit.

With 15 months remaining to theimplementation of healthcare reform andthe insurance mandate, it makes sense tomap your evaluation process. Take timenow to assess your level of compliancewith the DOL mandates. Given theincrease in government auditing capacity,it is even more critical to audit your ownpractice or company. With the self-imposed DOL audit completed, you willbe well positioned to focus on health plandesign, cost and liability in the secondhalf of 2013.Jack Weidner, CLTC, is managing member of

Chartwell Benefits Solutions, LLC, a consulting

firm specializing in the areas of group &

individual health insurance, Medicare supple-

ment, disability income, life & long term

care protection.

Compliance

By Jack Weidner, CLTC

AHealthcare Reform & Compliancewith Department of Labor Mandates

A BETTEREND OF LIFE


BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN

PALLIATIVE MEDICINE AND HOSPICEARETHE RIGHT CHOICE FOR MANY

Withmore than 5000hospice programs nationwidecovering about 1.6 millionpeople, perhaps healthprofessionals should bemore comfortable havingend-of-life conversationswith patients than they are.However, medical trainingis oriented to aggressiveinterventions to save patients,not ease their end of life,and these conversationsare difficult to initiate.Maryland Physicianinterviewed hospice andpalliativemedicinephysicians and other expertsfor some advice.

e’re not taught how to havethese conversations inmedical school; in fact, we’re

taught the opposite – to do everythingwe can,” laments Madai Chardon, M.D.,associate medical director, SeasonsHospice & Palliative Care of Maryland.

The number of people over age 85has doubled in the last decade,” says LouLukas, M.D., chief medical officer,Hospice of the Chesapeake. “If we treatthem like 60 year olds, we can do moreharm than good by over-treating them.”

What is Hospice?While awareness and understandingabout hospice have grown,misconceptions persist. Even physiciansmay not fully understand what hospiceentails – and many don’t understand thenewer concept of palliative care (alsocalled palliative medicine).

Dr. Chardon notes, “A lot ofphysicians still have misconceptionsabout hospice and feel that we’re givingup on the patient. We’re definitely not.Our goal is to shift to more aggressivepain management. Hospice is aphilosophical shift in the way we treatpeople. Frequent communication andunderstanding the person’s goals is key.”

According to Dr. Lukas, “Hospiceinvolves the entire family. We ask,‘How do we add quality of whatevertime this person has left? How do wemake this time worth living? What isimportant to the patient, what are theirgoals? Then, what treatments will helpreach those goals?’”

“We’re a team,” says SharleneRajapakse, M.D., associate medicaldirector, Seasons Hospice & PalliativeCare of Maryland. “We deal with thespiritual, emotional and physical issuespatients and their families have.”

A superb way to bridge the gap

between cure-based care and hospice ispalliative care (also called palliativemedicine.) Don Schumacher, CEO of theNational Hospice and Palliative CareOrganization (NHPCO), says, “In thelast 10 years, palliative care has becomemore popular. Physicians usually aremore comfortable making a referral tothis type of program and it can bea great bridge to hospice.”

What is Palliative Medicine?Palliative medicine is specializedmedical care for people with seriousillnesses, whatever the diagnosis, toprovide relief from symptoms, pain,and stress. In contrast to hospice care,it can be provided along with curativecare. Hospice of the Chesapeakelaunched Chesapeake PalliativeMedicine in 2012.


W

Lou Lukas, M.D., chief medical officer, Hospice of the Chesapeake

Sandra Anderson, communicationsdirector for Hospice of the Chesapeake,comments, “The choice used to bebetween care and cure. Palliative care isthe bridge between those two.”

“Both hospice and palliative care arereally about comfort,” contributes Dr.Rajapakse. “Everything we do is to makepeople feel better.”

When Should Palliative Medicine orHospice Be Considered?“Doctors are typically afraid of makingthe referral too early and then tend tooverestimate survival by as much as fivetimes, so it isn’t surprising that we tend toget patients very late in their illness whenwe have less time to be helpful. The bestguide to the need for palliative care iswhat we call the ‘surprise question’ –would I be surprised if this patient died inthe next year or two? If you wouldn’t besurprised, it is time to start theconversations!” Dr. Lukas exclaims.

Physicians can request a palliativecare consultation while the patient is inthe hospital, or directly from theirprimary care practice. “Anytime a patientneeds increasing management of theirpain and symptoms, it’s time to ask for apalliative care consult,” says Mr.Schumacher.

“It’s up to us as doctors, especially asprimary care physicians – we need to riseto the occasion and advocate for patients

to get new models of care, not newtreatments,” Dr. Lukas adds. “When yougive patients control, they usually decideon the treatment that’s best for them andfor society. Palliative and hospice care aregood for the patient and for the system.”

Starting the Conversation withYour Patient“Too often, it’s a ‘don’t ask, don’t tellgame’ between the doctor and patient,”Dr. Lukas says. “Research has foundrepeatedly that an honest conversationcreates a momentary anxiety but thenanxiety diminishes.”

Dr. Chardon concurs. “We physiciansoften don’t realize that the family wantsus to be honest with them – most of thetime, though, they’re waiting for us toinitiate the conversation.”

“An earlier conversation is far better,”contributes Mr. Schumacher. “Patientsoften ask why they weren’t referredearlier.”

Our experts recommend that doctorsask the patient and family about theirunderstanding of the patient’s illness. Dr.Lukas advises, “Ask them what theyunderstand about the prognosis. What aretheir goals? What feelings are theyhaving? Then discuss the options thatthey have.”

Physicians don’t need to fear thathospice means the end of theirrelationship with the patient. “We don’ttake patients from their doctors,” notesDr. Lukas. “In fact, we love to have theminvolved because they know the patientbetter than we do. They can choose toparticipate or not.”

NHPCO’s Caring Connections atwww.caringconnections.org offers free,downloadable brochures that can helpphysicians begin discussions with theirpatients and families.

Not Just for Cancer PatientsWhile most people think of cancerpatients when thinking of hospice, thereality is that only about half of patientsin hospice have a cancer diagnosis. Therange of other appropriate diagnoses isvast, spanning a number of chronicdiseases in their terminal stages,including cardiac and pulmonarydiagnoses such as COPD, and medicalfrailty with or without dementia.“Parkinson’s, Amyotrophic LateralSclerosis (ALS) or any chronic disease


“…physicians stillhave misconcep-tions about hos-pice and feel thatwe’re giving up onthe patient.We’redefinitely not.”

– Madai Chardon, M.D.

Sharlene Rajapakse, M.D. and Madai Chardon, M.D. associate medical directors, Seasons Hospice& Palliative Care.

Hospice of the Chesapeakeoriginated in 1977 from theefforts of a small group of

volunteers who saw the need to helpthose who were terminally ill. Afterhearing Dr. Elisabeth Kubler-Ross speakat Hopkins, the group was empoweredto seek to provide hospice care locally.The group met for about a year beforetheir labors paid off, and the first patientwas seen in 1979.

Martha O’Herlihy, a R.N., and herhusband, Hilary O’Herlihy, M.D., wereamong those founding pioneers. Ms.O’Herlihy recalls, “It was a massiveeducation task. Fran Grauch did all ofthe administrative work, and she, myhusband and I spent hours educatingphysicians. My husband was instrumentalin getting physicians to volunteer on ourpatient care team. Since doctors weretrained to cure, many got upset abouttheir patients dying. Oneof the wonderful things was that, asvolunteers, we were pioneers and could

spend as much time as we wanted withpatients and their families.”

Ms. O’Herlihy remembers one familywhere the nine children were fightingover who was spending more time withtheir dying mother. “Hospice of theChesapeake intervened to help the familyrealize that they needed to decrease thetension in the family and accept theirmother’s wish to die without moreinterventions. They finally came to accepther death,” she says.

Over the years, Hospice of theChesapeake grew into a majororganization with a host of residentialand outpatient services, including theTate House, Anne Arundel County's firstin-patient hospice facility, and theMandrin Inpatient Care Center. The LifeCenter (TLC) provides grief counseling,support groups and education forpatients and their families. It evenoperates two weekend camps forgrieving children and teens. “Today, wehave bereavement teams that include

social workers, volunteers and pastoralcare. Someone from the bereavementteam may visit before death upon requestof the social worker; at the time of deaththe nurse gives information about TLC,”says Ms. O’Herlihy.

The hospice has an even moreambitious future. “We’re at a pivotal pointin our history,” notes Sandra Anderson.“We’re launching a new vision thatincludes research and physicianeducation. We have a group of patientsat the end of their life that can help usexpand our knowledge of what worksbest. We can provide a classroom fordoctors who want to specialize in thisarea. We’re also seeking to build a newfacility with over 20 beds. It’s moreconducive to caring for those at end-of-life than a typical hospital unit.”

All of these programs and facilitiesremain focused on the organization’soriginal mission. As Ms. O’Herlihyconcludes, “Hospice is about living thebest life you can until death occurs.”

can be appropriate for hospice,” Dr.Chardon notes.

Dr. Rajapakse agrees. “We forget thatmany other patients besides those withcancer may benefit from hospice.”

Open Access – ControversialYet a third option for some patients isOpen Access, a concept that is stillcontroversial among those in the field.“Seasons Hospice started this in Chicagomore than a decade ago,” says Dr.Rajapakse. “It’s a bridge betweenaggressive treatment and hospice care. If ablood transfusion offers a better quality oflife, it might be performed. Open Accessmay help to get patients on hospicesooner; it’s tailored to each patient.”

ReimbursementPalliative medicine is reimbursedthrough Part B Medicare or private

insurance, comparable to billing for otherphysician services. By contrast, Medicarereimburses hospice agencies on a perdiem basis for all non-physician care.The per diem fee covers medications,chaplain and counseling services,nursing, home health aides and muchmore. Private insurance is more variable,but many insurers model their hospicecoverage after Medicare.

Selecting a HospiceMaryland is fortunate to have a wealth ofhospice programs to choose from, withmore than 20 programs across the state,many of which serve multiple counties.Dr. Chardon comments, “That increasesthe quality of care. Look for support,availability, and services offered. It’s asimilar process to choosing a physician.”

Hospice and palliative care play animportant role at the end of life, perhaps

most comparable to anticipatoryguidance provided for expectant mothersand newborns. Dr. Lukas concludes, “Ittakes as much planning to make the endof life go well as it does to make thebeginning of life go well.”


Lou Lukas, M.D., chief medical officer,

Hospice of the Chesapeake

Madai Chardon, M.D., and

Sharlene Rajapakse, M.D., associate

medical directors, Seasons Hospice

& Palliative Care

Don Schumacher, CEO, National Hospice

and Palliative Care Organization

Sandra Anderson, communications

director, Hospice of the Chesapeake

Martha O’Herlihy, retired R.N. and

founder, Hospice of the Chesapeake

Hospice of the Chesapeake

H35Years of Innovative End-of-Life Care


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PREVENTINGFALLS AND

MEDICATIONCOMPLICATIONS

IN SENIORSSimple measures in the office reduce risks

16 | WWW.MDPHYSICIANMAG.COMColleen Christmas, M.D., geriatrician and associate professor

of medicine at Johns Hopkins Bayview Medical Center,

MINIMIZE MEDICATION PROBLEMSSeniors face myriad health issues, butperhaps one of the worst is that theyare often sick from the very medicationsthat are prescribed to get them well.While seniors comprise about 12% of theU.S. population, they consume roughly35% of prescription drugs and anastonishing 50% of over-the-counter(OTC) products.

Given that the elderly are more likely tobe takingmultiple medications –frequently6 to 12 – some of which may combine tocreate adverse reactions, it’s not surprisingthat they are most prone to disaster.

Colleen Christmas, M.D., geriatricianand associate professor of medicine atJohns Hopkins Bayview Medical Center,notes that doctors could do more toaddress this issue. “Numerous studiesshow that physicians often neglect to askthe elderly what other medicationsthey’re taking. And lots of providers don’ttalk to each other.”

She continues, “As a geriatrician,I’ve improved the health of far more peopleby stopping pills than by starting them. Ahuge number of people are over-medicated.”Dr. Christmas advises the followingactions for primary care physicians to helpameliorate these problems:

> Communicate with other providers aboutwhat medications they have prescribed.Communication among providers helpsreduce adverse reactions.

> Empower patients and their families.They are the ones who are connectingwith all of the providers. “I always printout the full list of medications at the endof the visit and have the patient or familymember double check at home to makesure they don’t have other pills beyondthis list,” Dr. Christmas states.

> Have patients bring all of their pills, in-cluding OTC pills, to their visit and take

time to thoughtfully review them.“I review my patients’ pills everysingle visit,” notes Dr. Christmas. “Iunderstand the time pressure but wecan’t afford not to do it. It has to takepriority. It’s fine to use a nursepractitioner or other skilled staff forthis purpose, but it should be done.”

Patients often take large quantitiesof OTCs, assuming they’re safe becausethey don’t need a prescription for them.“Patients sometimes take fistfuls ofibuprofen and other NSAIDs,” Dr.Christmas laments.

> Make sure the patient’s chart is up to datewith the correct list of medications.

> Ensure that any new medication you pre-scribe does not interact negatively with thepatient’s other medications.Dr. Christmas notes, “Warfarin and otherblood thinners send many people to theER. Antibiotics are perhaps the mostfrequent class of drugs that adverselyinteract with these. A patient may startwith a cough, then suddenly their INR is8 and they have a nosebleed.”

> Generally avoid prescribing anymedication new to the market.“Newer medications are often notadequately tested, especially in elderlypopulations who have multiple diseases,”Dr. Christmas observes. “Some 10% of

new drugs are later withdrawn and theyare often tested in healthy people withonly one disease. New drugs in oldpeople are simply a bad idea.”

> Encourage patients to use onlyone pharmacy.“At times, I’ve been grateful when apharmacist called to double check aprescription I wrote,” recalls Dr.Christmas. “They are another set of eyesto review the medications prescribed.”

Mail order pharmaceuticals can makethat kind of oversight more challenging,but they offer convenience and costsavings for patients. “I’ve found thesecompanies may send notices but they’renot always on target, she adds.”

> Employ technology to promotemedication safety.Dr. Christmas comments, “Our EHRflags drug interactions. Most of the time,I was already aware of it, but in a smallpercentage of cases, it was helpful.”

> Exhaust all non-drug methods to im-prove health, and then start with the lowestpossible dose.

> Determine if any current medicationscan be discontinued.“I always ask myself if there’s a pill I canstop prescribing,” Dr. Christmas declares.

> Prescribe the simplest medicationregimen possible“Physicians have to be practical – wecan’t prescribe complex regimens,”advises Dr. Christmas. If the best time totake a medication is at night, but thepatient can better remember to take it inthe morning, determine if that couldwork. Using pillboxes, including newerones with alarms that go off ifmedications aren’t taken, can help. Andof course, the best resource of all isanother person.”


I’ve improvedthe health of farmore people bystopping pillsthan by startingthem. – Colleen Christmas, M.D.

BY LINDA HARDER



ASSESSING AND PREVENTING FALLSThe health statistics associated withseniors who fall are appalling. Each year,30 to 40% of those over 65 who are still inthe community fall, while about half ofthose in an institution fall. After elderlypeople have fallen, they have a 65% riskof falling again. Some 15% of falls lead tohip fractures, and 40% of those sufferingthese fractures will die within one year.

Once hospitalized with a broken hip,it’s difficult to get patients up and movingagain, prevent risks such as blood clots,confusion, pressure ulcers and infectiousdiseases, and overcome the fear of fallingagain. Finally, falls are also one of theleading causes of death from injury in thisage group.

Assessing and preventing falls,therefore, is key to keeping elderlypeople healthy. Yet the problem is multi-factorial; falls can be the result of adversemedication reactions, vision loss,musculoskeletal weakness or arthritis,balance loss or even environmentalfactors such as poor lighting or loosethrow rugs.

A large study published August 1,2012 in the Journal of the AmericanMedical Association found that those whohad cataract surgery during the study

period had 16% fewer fall-related hipfractures in the year following theirsurgery. However, this and other studiessuggest that the risk of hip fractures mayactually increase after one cataract isremoved, perhaps due to impaired depthperception or wearing an older glassesprescription.

Simple Fall Prevention Measuresin the OfficeEven within the limits of the primary careoffice visit, physicians can prevent manyfalls with a simple question and test,believes George Hennawi, M.D.,geriatrician and director of geriatrics atMedStar Good Samaritan Hospital.

“He states, “I recommend thateveryone over age 65 be asked at leastyearly, ‘Have you fallen in the past year?’If they fell, ask about the circumstancesof the fall, whether they tripped, and ifthey fell more than once.”

‘Get Up and Go’ TestDr. Hennawi also recommendsperforming a simple ‘Get Up and Go’test. “Using a stop watch, ask them to getup without using an armrest, walk 10 feetand come back. Evaluate their gait – ashuffling gait could indicate Parkinson’sDisease, limping could be indicative ofarthritis, listing to one side could suggesta neurological disease and so on. Lessthan 10 seconds is the norm; in the frailelderly, 11 to 20 seconds is more usual.Anything longer than 14 secondsindicates a heightened risk of falling. Ifthere is a major gait disturbance, or theyhave had more than one fall in the pastyear, they should be referred to a physicaltherapist (PT) or geriatrician.”

Vitamin D, PT Prevent FallsAccording to the U.S. Preventive ServicesTask Force, Vitamin D and PT are theonly two factors that have been proven toprevent falls. “This group tends to beconservative,” acknowledges Dr.Hennawi. PT can improve balance,endurance, strength and range of motionas needed to reduce the risk of a fall.

It has been shown that most fallshappen between patients’ beds and theirbathrooms. Modifying environmentalfactors, such as installing nightlights orother easy-to-access lights, limiting theneed to climb stairs, installing grab barsand removing throw rugs or anything thatcan be tripped on are common-senseways to reduce these falls.

The role of primary care physiciansin fall prevention may grow, as accessto a geriatrician is likely to get morelimited as the population ages. Dr.Hennawi says, “Some 16 to 17% of thepopulation is projected to be over age 65by 2020 – and there aren’t enoughgeriatric medical training programs tokeep up with the demand.

“When you realize how much damagea fall causes, you realize the issuewarrants more attention than it currentlygets,” Dr. Hennawi notes. “Even if thereis no fracture, patients are at increasedrisk for a decline in functional status anda possible institutionalization. Theybecome afraid of falling again so theybecome less mobile. It sets off a negativesequelae of events. Most at risk are thosewho have suffered ‘a long lie’ – thosewho fell down and were unable to getthemselves up without assistance. It’sa major predictor of decline.”

“I’m starting up a multi-disciplinaryfalls prevention program involving PTsat both MedStar Good Samaritan andMedStar Union Memorial,” heconcludes. “We still don’t know howmuch PT is necessary, who qualifies, andhow often, and for how long. That’swhere the future is.”

…everyone over age65 [should] be askedat least yearly, ‘Haveyou fallen in the pastyear? – George Hennawi, M.D.

George Hennawi, M.D.,geriatrician and directorof Geriatrics at MedStarGood Samaritan Hospital.

Colleen Christmas, M.D., associate

professor of medicine and program

director, Internal Medicine Residency

George Hennawi, M.D., director of

Geriatrics, MedStar Good Samaritan

Hospital; assistant clinical professor,

University of Maryland School of

Medicine; medical director, Geriatric

Unit, MedStar Union Memorial Hospital

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ACCOUNTABLE CARE ORGANIZATIONS

Healthcare IT

Can they work for your practice?


Maryland Physician interviewed physiciansand health administrators to understand howACOs are evolving in Maryland and what impact

they hope to have on patient care.

ACO�

BY LINDA HARDER



An Accountable Care Organization (ACO)is a major undertaking, on first blushappropriate only for those in large groupsor health systems in urban areas.However, physicians in small practicesand rural areas can also participate insome ACOs. Most ACOs are starting aspart of the Medicare Shared SavingsProgram created under the AffordableCare Act (ACA), yet future models willapply the ACO approach to privatelyinsured patient populations.

ACOs are designed to encouragephysicians and other healthcare providersto come together to coordinate patientcare with shared data and infrastructure,for a fixed cost. Requirements forMedicare ACOs include having aminimum of 5000 Medicare beneficiaries(existing Medicare patients do not optin or out of the program, but can opt outof sharing their historical data) andreporting on 23 of 33 total quality metrics(other metrics are provided by surveysand other data).

Maryland ACOsAs Maryland Physician went to press, outof 154 ACOs in 37 states, the MedicareShared Savings had approved fourMaryland ACOs:

� Greater Baltimore Health AlliancePhysicians LLC (GBHAP)

� Accountable Care Coalition ofMaryland LLC, in Southern Maryland(ACC of MD)

� Maryland Accountable CareOrganization of Eastern Shore LLC

� Maryland Accountable CareOrganization of Western MD LLC

At least five other Maryland ACOshave filed for approval in January 2013.

These ACOs are taking differentapproaches to their administration andfinancing. One is financed andadministered by an arm of its hospitalpartner, GBMC. Med Chi assisted theother three ACOs, two of which aresmaller, rural ACOs that were approvedunder the Advanced Payment Model; thethird (ACC of MD) partnered withCollaborative Health Systems, asubsidiary of Universal American.

Hospital-Affiliated Model: GBHAPGBMC is the first hospital in Maryland topartner with physicians to create an ACOthrough its affiliate, Greater BaltimoreHealth Alliance Physicians, LLC(GBHAP). Colin Ward, GBHAP’sexecutive director, says, “It has taken two

years to go from concept to fruition; oneyear was spent consulting with lawyersand other consultants to put the structurein place and file for approval.”

This ACO has about 10,000beneficiaries and 100 participatingproviders, including nurse practitioners(NPs) and some specialists, some ofwhich are employed and others of whichare aligned.

“An ACO has a similar concept toa Patient Centered Medical Home,(PCMH)” says Robin Motter, D.O., aparticipating family practitioner andmember of GBHAP’s board. “In March2012, we received Level 3 recognitionfrom NCQA. We participated in CarefirstBlue Cross Blue Shield’s PCMH, whichprovided a foundation for the ACObecause its metrics are very similar.”

The first wave of practice changeswas launched as part of the PCMH, withcare managers and enhanced IT tomonitor care. Diabetic care had alreadybecome more rigorous, with greateremphasis on patient education andmonitoring. Additional changes in thebrief months that the ACO has beenoperating include leaving 30% of theschedule open for same-dayappointments to take care of urgentissues. Mr. Ward also notes, “Transitionguides are now in place at GBMC tofollow congestive heart failure patientsand get them back to the physicians.”

“My referral patterns to specialistsalso may change once I see outcomesdata,” Dr. Motter adds.

Many practices in GBHAP useeClinicalWorks (EHR vendor), thoughit’s not required. The ACO is a designpartner for the vendor, which involveshelping the vendor select relevant clinicaldata for other ACOs as well as their own.They are also in a pilot program withCRISP to provide real-time notificationof hospitalization, so that patientsdischarged from the hospital have theopportunity to be seen in the physician’soffice within 48 hours.

GBHAP had to submit a list of taxIDs for all participating physicians. Thatlist will likely remain stable over thethree years of the pilot to avoid impactingbenchmark data. “We’re sending outletters that the practice and their doctors

Robin Motter, D.O., chairman, Family Practice (GBMC)/family practitioner (GBMC at Hunt Valley), memberof the GBHA Board of Directors

are participating in the Medicare ShareSavings program,” notes Mr. Ward. “Theaggregated claims data of patients ofparticipating physicians is automaticallyshared, except for any patients who optout of having their information reported.”

GBHAP chose Medicare’s single-sided payment model, which providesfee-for-service payments plus theopportunity to share in a percent of anysavings at the end of each year. Thismodel provides the group with lesspotential upside than the two-sidedmodel, but no downside risk.

Advance Payment Model for Small,Rural PracticesIn November 2011, the CMS Center forMedicare and Medicaid Innovation alsocreated a competitive Advance PaymentModel that will allow up to 50 rural ACOsto receive advanced compensationwithout any downsized risk. The risk-freeadvance ($250,000 plus $36 times thenumber of beneficiaries) is paid off from a

portion of any savings at the end of eachof three years. Physicians in this modelalso receive $8/month/beneficiary to helpoffset the costs of coordinating care andenhancing data.

These ACOs must meet criteria thatinclude having no health system/insurerinvolvement, having a sufficient numberof Medicaid beneficiaries and ruralproviders, and a quality spend plan. Assoon as MedChi saw the regulations, theyjumped at the opportunity to assistphysicians in this type of practice.

Two ACOS affiliated with MedChiNetwork Services – MarylandAccountable Care Organization ofEastern Shore LLC (15 physicians) andMaryland Accountable Care Organizationof Western MD LLC (23 physicians) –were approved in July, and two morehope to receive approval in January 2013.

Craig Behm, executive director ofMedChi Network Services, explains, “Weown the legal entity designated as eachACO and intend to work with theparticipating practices to enter into a

management agreement to provide carecoordination and other services. Servicesmust be tailored to each ACO due tocommunity differences; in GarrettCounty, most practices are close to thehospital, whereas in Easton, they aremore spread out. On the IT side, we’recurrently demoing a number of systemsthat can provide both the caremanagement system and the interfaceengine to gather and analyze data. Veryfew systems are good at both.

“Having PCMH experience helps; anACO is a logical extension of that,” hecontinues. “We’re using the ACO to pilotexciting new things such as telehealthand after-hours support that rotatesamong practices. Patients will receivepreventive health reminders andcoordination across care settings, amongother advantages. ACOs provide smartcare coordination with secure, real-timedata utilization.”

“ACOs differ from HMOs in severalkey ways,” adds Mr. Behm. “First, the

quality metrics are clearly defined.Second, they are physician-led andoriented towards patients. Third, there isno in-network requirement and fourth,there is increased health IT and datacapability.”

Accountable Care Coalition of MD –Partnering with a National FirmAccountable Care Coalition of MarylandLLC (ACC of MD) in Hollywood is apartnership between a national ACOadministrative company, CollaborativeHealth Systems (CHS) (operating 16ACOs in total as of July 2012), and areagroup practices that include 109physicians. It will serve more than 11,000Medicare beneficiaries in St. Mary’sCounty and Southern Maryland.

CHS and the physician group eachown half of the new entity, ACC of MD,that contracts with CMS and careproviders. It functions like a managementservices organization.

Nayan Shah, M.D., medical director,Shah Associates MD LLC, the large

multi-specialty practice providing muchof the ACO’s care, states, “The ACOmodel appealed to us immensely. Itmakes providers accountable to patients.Especially the elderly, who have multiplemedical problems and get fragmentedcare from multiple specialists.”

“An ACO requires good ITinfrastructure,” contributes Vicky Parikh,M.D. MPH, executive director, RelianceHealth, “plus good care managers whounderstand the patient’s social andeconomic needs. They make sure thepatient goes to their primary carephysician and specialists as needed andtakes their medications. Studies haveshown that if the patient is seen withintwo to three days after discharge, they domuch better.”

Dr. Shah concludes, “As participantsin both the state and Carefirst PCMHs,we already had care managementexperience, but we didn’t have good ITor financial resources. CHS has helped usachieve our goal.”

Jim Korry, senior VP of networkoperations at CHS, comments, “We have15 years of experience with Medicare andhave operated many Medicare Advantageplans where we were at risk, so we haveexperience with care coordination,infrastructure and compliance. However,there are major differences, too. We aresetting up full partnerships with doctors.Our mantra is that we’re the backbone –we provide the infrastructure, resourcesand information, so the doctors canprovide the best care possible.”

He continues, “We promote the useof EHRs for participating practices butit’s not required. Universal American hasa relationship with NextGen, whichpractices can take advantage of if theywish. We’re being approached by anumber of consultants and vendors thatwant to partner with us. In the future, aswe track our results, I expect we’ll be indialogue with specialists and hospitals.”

The challenges of launching an ACO,even with a partner, are tremendous.They typically require one to four milliondollars of capital investment, to pay fordeveloping a complex IT infrastructure,hiring and managing care managers, etc.However, the physicians participating inthe ACO have no financial risk to join.

“It takes 14 to 15 months to see anymoney from CMS,” says Dr. Shah. “Andif savings do not occur, you need to investyet more dollars in the second year.”


Healthcare IT

Our goal is to provide care we’d want for amem-ber of our own family. Better managing patientcare gives your job themeaning you sought whenyouwent tomedical school. – Robin Motter, M.D.


The Future: Taking the ACO Conceptto the Employer MarketBeyond Medicare, a future ACO modelalso awaits commercially insured patients.Stuart Sutley, chief strategy officer ofAllegeant, a mid-Atlantic companyfocusing on accountable care solutions foremployers, says, “Hospitals that haveemployed us to execute integrated healthmanagement programs for their ownorganization are now asking us to helpthem take the same concept to theemployer market by using ACOfundamentals to develop new revenueopportunities and manage health tobetter outcomes.”

Starting with the premise that morethan three quarters of chronic disease islifestyle-related, Allegeant has workedwith hospitals and other employers toimprove the health of employees anddependents and reduce healthcareutilization, using strong data analytics andinnovative wellness initiatives.

“We typically capture daily ormonthly claims and pharmacy feeds forself-insured employers. We can, overtime, develop a snapshot of the member’shealth and deliver it to their doctor if thatdoctor (or practice) is aligned with ourhospital client,” explains Mr. Sutley.“That frees up physicians to use thepatient visit for more in-depth healthdiscussions.”

Mr. Sutley adds, “We need to startlooking at how to treat patients that arestill working. We see doctors interested inaligning themselves with employers.Employers are incentivizing theiremployees to utilize providers thatmanage health and save costs. What

doctors like is that they’re getting anincentivized patient who is more likely tocomply with their advice.”

Patients are then at risk to incur morehealthcare insurance costs if they don’tfollow the doctor’s recommendation.

Allegeant has contracts with severalMaryland and out-of-state hospitals tobuild and launch hospital-brandedwellness programs aligned with primarycare physicians to take to the community

to build foot traffic and make hospitals adestination of choice versus a destinationof need.

Joining an ACOIt’s not too late for unaffiliated physiciansto sign up with an existing ACO, but afterJanuary 2013, they can only do so on anannual basis.

ACO requirements have become lessonerous as CMS responded to providerconcerns. “CMS made ACOs morephysician and provider friendly since theyfirst issued the regulations,” Dr. Shahsays. “Many physicians have a negativeidea of ACOs from the old regs, but it’s

worth looking at now. Structured properly,they will decrease the burden on theprimary care physician. “

Dr. Motter concludes, “Our goal is toprovide care we’d want for a member ofour own family. Better managing patientcare gives your job the meaning yousought when you went to medical school.The system we had was not right anddoes not work – we have to do somethingdifferent.”

Robin Motter, D.O., chairman, Family

Practice (GBMC)/family practitioner

(GBMC at Hunt Valley), member of the

GBHA Board of Directors

Colin Ward, executive director, Greater

Baltimore Health Alliance

Craig Behm, executive director, MedChi

Network Services

Nayan Shah, M.D., medical director,

Shah Associates MD LLC, and president,

Reliance Health

Vicky Parikh, M.D. MPH, executive

director, Reliance Health

Jim Korry, senior VP of network

operations at Collaborative Health

Systems (CHS), the ACO partner with

Shah Associates.

Stuart Sutley, chief strategy officer,

Allegeant, LLC

An ACO requires good IT infrastructure,plus good care managers who understand thepatient’s social and economic needs. – Vicky Parikh, M.D.

Stuart Sutley, chief strategyofficer of Allegeant, LLC

OME PEOPLE FIND THEM-selves booking trips to Alaska, Iceland orother frigid destination points around theglobe, in search of the most “serious”winter weather escapes and adventures.Each year, an estimated 1.1 million otherssimply go to Deep Creek Lake.

Nestled in Garrett County, Maryland,the four-season resort town has earnedits place on the map of “hot spots” thatare known to get quite cold. In fact,according to data from the U.S. Census

Bureau, daily temperatures in the area aretypically 10 to 15 degrees cooler thanwhat are recorded in the surroundingmetropolitan areas, and the averageannual snowfall of 120 inches is just aboutdouble that of what residents and visitorsof Fairbanks, Alaska see in a given year.

Bottom line: during the wintermonths, it’s COLD. And with that, comesa wealth of opportunities to see, do andexplore a one-of-a-kind winter wonderfulthat offers something for everyone of all


Living

Deep Creek Lake:AWinterWeather Lover’s Dream ComeTrue

By Tracy M. Fitzgerald

Wisp Resort is Maryland’s only ski resort, featuring 32 slopes and trails for skiing and snowboarding, as well as designated areas for iceskating, snow tubing, snowmobiling and more.

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ages and interests. Best of all, the whitefluffy stuff that slows or even closestowns elsewhere, is the very thing thatkeeps the Deep Creek Lake area aliveand thriving.

“Nothing stops here when it snows 18inches,” said Nicole Christian, presidentand CEO of the Garrett County Chamberof Commerce. “If people can’t drive, theyuse a snowmobile to get around. It’s oneof the few places where ‘winter blues’don’t happen!”

Let there be snow!Skiers and snowboarders need not lookany further for the best place to go thanWisp Resort, featuring 32 slopes and trailsacross 132 acres of skiable terrain, coveredwith snow naturally or through use of asnowmaking system that is recognized asone of the most efficient in the world.Those looking for a spot to lace up theirskates will find Garrett County’s only icerink at Wisp, and when it’s time to givethose legs a rest, resort visitors are oftenfound meandering toward Bear ClawSnow Tubing Park, featuring twoconveyor belts that lug snow lovers to thetop of a hill, for their next whirl backdown to the bottom of the mountain, inthe comfort of their tube. Snowmobiling isanother popular attraction at Wisp, withguided tours available on private trails foradults and children.

“Adventure enthusiasts who like tobe outside when it’s cold will find everyactivity they could possibly desire here,”said Christian.

No white stuff requiredNo snow? No problem. There areplenty of other activities available tokeep you busy and entertained during

Deep Creek’s winter months. Signup for Wisp’s Flying Squirrel CanopyTour, a challenging zip line course thatwill teach you how to break, steer andzip along tree-top cable lines. Hoponboard the resort’s famous Mountain

Coaster, with tracks that run overtopthe ski trails, giving riders a 1,300 footview of Deep Creek Lake in thedistance as their two-seater cart ascendsup Wisp Mountain. At the top of theresort, don’t miss the opportunity to visitAdventure Sports Center International,a “white water on demand” facility thatfeatures a re-circulating white watercourse with adjustable levels ofdifficulty, based on each person’sexperience and skill.

The less adventurous folks will notfeel disappointed at Deep Creek, either,with horse-drawn carriage rides offeredfor couples and families in search ofpeaceful and relaxing tours of town, anddogsled rides available for those cravinga faster-paced, one-in-a-lifetime kindof experience.

Staying in, staying activeLooking for a bit of indoor fitness andactivity? Check out Garrett County’s newCommunity Aquatic and RecreationCenter (CARC), open to the public andoffering competition and recreationalswimming pools, basketball courts, andscuba, kayaking and canoeing learningprograms. Families and especially thosewith little ones in tow will want to maketime for a visit to the Deep Creek LakeDiscovery Center, an interactive naturecenter with educational exhibits andactivities for all ages.

Historical sites to seeWhile most people visit Deep CreekLake with a vision to spend a goodportion of their time in the greatoutdoors, others come to tour the town’smuseums and historical sites, includingthe Oakland B&O Railroad Museum and

the Garrett County Historical SocietyTransportation Museum, both featuringvarious transportation artifacts anddisplays. Anyone wishing to dig deep intotheir family’s genealogical history shouldvisit the Friend Family Association’s

National Heritage Museum, known for itssecond-floor library that is packed withancestral data. The Grantsville Museum,housed in the town’s former library, is agood spot to stop for a peek at the workof renowned photographer Leo Beachy,as well a display of local historical artifactsfrom Garrett County.

Kick back and relaxDeep Creek Lake is known for its cozyaccommodations, with bed andbreakfasts, cottages, cabins and lodges,and luxury vacation home rentalsavailable to suit every budget and style.Fireplaces are common, making it easy tosnuggle up with a good book and cup ofhot cocoa after a long, but fun-filled dayout in the cold. Looking for someadditional pampering? Schedule amassage or spa service in one of thearea’s eight salons, go on a wine tastingor tour or just throw on some comfortableclothes and plan to catch a movie at thetown theater.

Plan your tripThe Garrett County Chamber ofCommerce makes planning a visitto Deep Creek Lake easy. Visitwww.visitdeepcreek.com for guidance andinformation on local accommodations,dining, activities and attractions, eventsand more.


“Nothing stops here when it snows 18 inches. Ifpeople can’t drive, they use a snowmobile to getaround. It’s one of the few places where ‘winterblues’ don’t happen!”

– Nicole Christian, President and CEO, Garrett County Chamber of Commerce

Skiing is a favorite activity for many visitors tothe Deep Creek Lake area, with downhill trailsavailable at Wisp Resort and cross country op-tions available through many of GarrettCounty’s 10 state parks and forests.


Q:When in your career did youdecide to become proactively involvedin politics?I’ve always been interested in politicsbecause my parents are both refugees.My father spent several years in theSoviet Gulag for being anticommunistand experienced a political system outof control, so they understood theimportance of being involved. In 1998,I was on the faculty at Hopkins andinvolved with my state anesthesiologyassociation and realized that anopportunity existed to get into electedoffice. I ran, and served for 12 years inthe Maryland State Senate.

Q:What are your priorities as aphysician in Congress?As government becomes more involved

in the process, we actually have a declinein quality and access to healthcare. AsMedicare policy becomes morecumbersome, access is decreasing…because the government’s response toa budget crisis is always to decreasepayments to providers. It’s what I callback-door rationing. You can see aphysician, but you have to wait in linelong enough. We know that Medicaidis in the same situation, that only 42%of specialists will see a Medicaid patient.That’s not a system we ought to promoteand progress to.

Q:What are your suggestions toget Maryland physicians to take amore active role?They just have to get involved. We don’tgo to medical school to learn how to

advocate in the legislature. But becausethe legislature has gotten so involved,part of taking care of patients now ismaking your views heard in thelegislature. Along with being involvedin specialty societies, take time off tomake your views known to the peoplewhose policies will have incredibleeffects on your practice.

Q:Have you seen an increase inactivism by physicians?Overall, nationally, more physicians are‘getting it’ – that you really do have to beinvolved. Medical schools now frequentlyinclude courses in advocacy. The systemis kind of stacked against patientsbecause they don’t have time to go andexpress their opinions to legislators.Insurers or legislators can’t be theiradvocates because balancing a budgetis almost diametrically opposed toguaranteeing access. When I was in thelegislature, every year when the budgetwas deficient, they would pick a providerclass and decrease payments to them.The end result is that, if you have aMedicaid card in Maryland, you almostcan’t go to the physician of your choiceand you’ll end up in a managed carepanel. We should do better.

Q:How do you stay in touch withphysicians and what they need?I’m still active in the nationalanesthesiology society and still maintainmy license. Ten days a year, I’m in ahospital with my colleagues. I’m alsoinvited to societies around the countryto address the issues, so I’m frequentlyin touch with physicians. Recently, I wasin Texas addressing and listening to theconcerns of their medical society. Theyhave huge drug shortages that are reallybeginning to impact care.

One of the causes of the shortagesis that the regulatory environment is so

Policy

Physicians in the Political Process:Maryland Congressman Andy Harris, M.D.

Maryland Physician Publisher/Executive Editor Jacquie RothandManaging Editor Linda Harder recently interviewedCongressmanAndy Harris, M.D., (R), a practicinganesthesiologist committed to healthcare issues.

Congressman Andy Harris, M.D.

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unfavorable for drug manufacturers.When the new FDA ratcheted up theregulatory warnings, and there were threeto four times as many warnings in its firstyear, companies decided to stopproduction. We effectively restrict whatcompanies can charge, through a varietyof schemes that include what the federalgovernment will pay.

When you make it economicallyunfavorable to make a drug, usuallygeneric drugs, companies stop makingthem. Take epinephrine, we haveshortages of this very inexpensive drugbecause companies don’t think they canmake enough money on it. As governmenthas gotten more involved, and not beingwilling to restrict tort, you have the logicalconclusion that the company decides tomake something else.

I think there’s a bright future forbiomedical research and pharmaceuticalinnovation. But we have to be mindful ofthe fact that when you place a 2% tax onmedical technology, you get less medicaltechnology. That’s one of things that theACA [Affordable Care Act] taxed. It’s aninteresting policy judgment.

Q:Maryland is actively involved instem cell research, with support fromthe 2006 Maryland Stem Cell ResearchAct. What’s your opinion of this?The moral question is whether we shoulddo stem cell research with your own cellsor with embryonic cells from someoneelse. Since, in the long run, the solutionis going to be using your own cells… arewe losing opportunities if we look at[using embryonic cells]?

Embryonic cells are totipotentbecause they can become any organ... Weneed to get other cells back to the stagewhere we can turn their genes on and off.I’m convinced we’ll be able to do that. Soto me, that’s where the focus should havebeen because there’s so much controversythe other way... We’re just not smartenough to figure it out how to do it yet.

Q:Are there any aspects of theACA that you support?I’ve long supported healthcare reform.There are two aspects of the ACA I dosupport, [though not on a federal level].One is coverage for people with pre-existing conditions – everyone has or willhave a pre-existing condition at somepoint. In Maryland, we’ve solved this. Ifyou have a pre-existing condition, you’re

guaranteed health insurance. You have togo to the Maryland InsuranceCommission site. I supported thatconcept when I was in the statelegislature, because insurance fails whensomeone is uninsurable. I think that 35states already have high-risk pools; wejust need to incentivize the other ones.

The other thing is, I think we shouldrequire all insurers to offer a policy forchildren up to age 25. However, I believe

that, in general, state solutions workbetter than a centrally imposed federalsolution… If a state is not doing a goodjob, the federal government canincentivize them to. We can do it throughthe states without a single, one-size-fits-allmandate. In Massachusetts, for example,they decided they want universalcoverage and that’s fine. But to imposetheir system on another state wherepeople don’t feel quite the same, that’snot the way the country should be set up.

Q:Do you support H.R. 5707(Medicare Physician PaymentInnovation Act of 2102) to repealthe SGR and reform Medicare?The problem is that, whenever you puthealthcare in the federal government andthey have a budget problem, they cutpayments to providers. This is whathappened with SGR. When they ran outof money, they decided to automaticallycut payments to providers and it’saccumulated over time…

It’s a real quandary. We will never cutthat reimbursement rate and weshouldn’t. Seniors understand what theresult of that will be – that their physicianwill no longer be able to afford to seethem. Congress did what it’s famous for –kick the can down the road and the cliffgets steeper and steeper.

The 10-year cost of fixing SGRis over $300 billion. We have manycompeting demands for that money.The best we’re going to get right nowis a solution one year at a time. H.R.5707 proposes to use the savings we getby not spending money in Iraq andAfghanistan… but it’s not real dollars,so this bill doesn’t get to the core of theproblem. As a society, we have to decidewhat level of care we’re going to provideto our seniors and how to make it solvent.

The current Medicare system is not goingto guarantee access for seniors. We havean aging population and we’re nottremendously expanding the number ofphysicians. 10 to 15 years from now, it’slikely that most primary care will bedelivered by mid-level providers.

If there’s a push to train more primarycare physicians, we’ll have a shortage ofspecialty physicians. As people age, theyrequire more specialty care, so we

shouldn’t pretend that that shortage is notgoing to exist. From the government’sview, that shortage controls costs – youend up waiting longer to see a physician.We should have a discussion – do we wantto control costs by controlling access?....

Q:What are your views ontort reform?I was an obstetric anesthesiologist whofinished my training in 1984. At that time,a solo practice obstetrician who wascovered every other weekend wastreating my wife. When it’s time for mydaughters to go to obstetricians, they willbe in large groups and if they’re lucky,they might see the same person twice.That’s because obstetricians are worriedabout getting sued and can’t afford theinsurance. The answer? You have to go tosystems. In the Maryland legislature, Iproposed a bill that took cerebral palsy offthe litigation table by forming a fund thatwould pay for care for that child withoutassigning blame. But until we canovercome advocacy by the trial bar, theproblem will continue.

These are bipartisan issues.Neurosurgeons face the same

problem. My first idea to solve this isto take litigation off the table forgovernment patients (Medicare orMedicaid). The other thing is we haveto put common-sense limits on non-economic damages. We should probablystart with ER, obstetrics and neuro-surgery. We have changed the wayhealthcare is delivered as a result of tortliability, and it’s not been for the good.Andy Harris, M.D., is an anesthesiologist and

the Congressman for the 1st Congressional

district of Maryland. He previously served as a

Maryland State Senator. He serves on the Trans-

portation and Infrastructure, Natural Resources

and Science, Space and Technology committees.

“I believe that, in general, state solutions workbetter than a centrally imposed federal solution.”


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Clinical FeaturesMaryland Physician focuses on the latest cancer

developments. We talk with top Maryland specialists to

get their take on the effectiveness of the latest treatments

for prostate, breast and blood cancers.

Healthcare ITIn every issue, Maryland Physician explores a different

facet of the race to implement EHRs to meet Meaningful

Use and other e-health government incentives. Don’t be

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In Every Issue and OnlineCases � Solutions � Compliance � Medical Beat � Policy

Jacquie Roth � Publisher/Executive Editor443-837-6948 � [email protected]

www.mdphysicianmag.com


Solutions

Essentials of an AccountableCare Organization

By Cindy Friend, RN, BSN, MSN, MBA/HCA

HE DIRE NEED FOR REFORM OFthe current healthcare system hasprompted one of the most unprecedentedhealthcare delivery transformation effortsin U.S. history. Healthcare leadersrecognize that a patient-centered medicalhome (PCMH) integrated, accountablecare organization (ACO) that utilizeshealth information technology (HIT) in ameaningful way and supports healthinformation exchange (HIE) can improvethe quality and safety of care, whileholding promise to reduce overall costs.

Many public and private payer-sponsored ACO shared-savings programsare emerging to incentivize healthcareproviders to establish ACOs. An ACO iscomposed of groups of healthcareproviders – including physicians,hospitals, and specialists – that establish ahealthcare delivery organization tocoordinate and facilitate high quality carefor the patients they serve. ACOs areevaluated on the effectiveness, efficiency,and quality of care provided and must beable to report on the performance ofclinical quality indicators.

Establishing or participating with anACO can be beneficial for physicianpractices. While a feasibility assessmentand gap analysis are critical first steps,below are a few additional elements toconsider when determining whether todevelop or join an ACO:

ACO Structure and OperationsAn ACO needs to establish a financiallysustainable organization with soundbusiness operations. The organizationshould be stakeholder inclusive andensure that clinical leadership is highlyinvolved with the ACO activities. Theorganization may take on a number ofshapes but should at least have thefollowing components:� Governance - a Board of Directors

comprised of all stakeholders toprovide oversight.

� Operations and BusinessManagement - an operationsmanagement team including anExecutive Director to provideleadership and oversee the day-to-daybusiness management. In addition,a Program Management team isneeded to provide program/projectmanagement support and implementthe recommendations from the Boardof Directors and Advisory Groups.

� Advisory Groups - engage subjectmatter experts to participate inadvisory groups to guide its businessdevelopment, policy, technical andclinical areas.

Clinical Practice and Care DeliveryAll healthcare providers participating withthe ACO need to work together to developa coordinated approach to managing thepatients they serve. This includescomponents such as access, populationmanagement, care management, careplanning, care transitions, care coordination,and optimal use of health IT. Below area few key aspects of a robust clinicaldelivery model:� Patient-Centered Care Model� Integrated Health IT� Clinical Staff Engagement and

Training Program� Patient Engagement and

Education Strategy� Continuous Quality and Performance

Improvement Program

Technology Infrastructure and ToolsTo provide effective and coordinatedcare, healthcare providers must have thetools to collect, manage, analyze, andshare health information. An ACOshould consider including the followingtechnology:� HIE - technology that enables

healthcare providers to share healthinformation with other providers thatare also caring for the patient.

� HIT - tools allow healthcare providersto collect, manage, and analyze healthinformation. Essential HIT toolsinclude:• Electronic Health Records (EHR)• Computerized Physician OrderEntry (CPOE)

• Electronic Prescribing (eRx)• Clinical Decision Support (CDS)• Standing Orders• Patient Portal• Data Analytics/Reporting• Care Coordination (CC)• Care Plan (CP)• Self-Care Management

While EHRs have come a longway over the past couple of years andmanufacturers have integrated morefunctionality, such as eRx, CPOE,CDS, standing orders, and patientportal; EHRs have a long way to goto adequately support clinical needssuch as care coordination, care planning,patient self-care management, andquality improvement tools. An ACOshould work closely with its technologypartners and explore the marketplaceto develop a strategy that meets itsorganization.

Performance Reporting andQuality MeasuresAn ACO will likely need to report itsperformance on quality measuresexternally if participating in a shared-savings program. It will need to programthe requirements and develop thereports for each of the various programs,a complex task since the reportingrequirements can vary from payer to payer.Cindy Friend, RN, BSN, MSN, MBA/HCA is the

owner and managing director of Trivantage

Solutions, LLC, a Maryland-based full service

healthcare consulting firm providing clinical,

technical, and business services to the health-

care industry and specializing in PCMH and

ACO transformation.

T


Dr. Bob’s Place Brings Comfortand Care to Kids withTerminal Illnesses

R. BOB’S PLACE IS ABaltimore-based program that providespalliative and hospice care for childrenwith life-limiting conditions, named inhonor of the late Robert Irwin, M.D. Itwas “Dr. Bob” who had the vision, yearsago, to open a hospice facility centeredaround the needs of young patients, inpartnership with Joseph Richey Hospice,where he served as a volunteer physician.

Ten years after his death, hisvision became a reality. Dr. Bob’s Placeopened in July 2011, as a project ofJoseph Richey Hospice. Dr. Irwin’smemory is preserved by the center thatdons his name, as well as the fact thathis son, pediatrician John Irwin, M.D.,serves as medical director today. Theprogram, offering care for kids fromage birth to 18, is recognized as thefirst in the country to feature aninpatient facility for children, as alicensed hospice provider.

The mission at Dr. Bob’s Place isfairly simple: maximize quality of life bymanaging pain and symptoms, and allowkids who are sick to stay at home, or ina “home-like” setting, for as long aspossible. Recognizing that children areunique human beings, with little bodiesthat require treatment that it is quitedifferent from what an adult wouldexperience, the center practices aninterdisciplinary clinical approach,combining medical care with emotional,psychosocial and spiritual support forpatients and their families.

“We can’t change the outcome, but wecan change the comfort level and giveparents an opportunity to hug and snuggle

with their kids,” said Charlotte Hawtin,executive director of Joseph RicheyHospice. “While we are caring for thepatient, we are also doing a lot of things tohelp strengthen the connection betweenthat child and his or her parent. What wedo is a God-send for many families.”

Upon entering Dr. Bob’s Place, itis immediately clear that the center isdesigned to comfort and sooth children.

Colorful murals, animal-themedfurnishings, playrooms and large familygathering areas help welcome patients andtheir parents, and provide a “home awayfrom home” for those requiring palliativeor end-of-life care. Accommodations allowfor one parent to live at Dr. Bob’s Placealongside their child.

“People have an amazing response tothe environment,” said Janet Will,

RNMS, and director of Dr. Bob’s Place.“It doesn’t feel like a hospital andeverything you see is child-friendly. It’svery welcoming. In fact, some peopledon’t want to leave.”

Raising the necessary funds to openand operate Dr. Bob’s Place, a three-story,20,800 square-foot facility, was no smallfeat. A $4.5 million fundraising endeavorprovided enough resources to open thefacility, stock it and see it through thestart-up phase. Fundraising effortscontinue today, with goals to purchasemore equipment, continuously recruitmore staff, add furnishings and open asensory room.

“Death is a natural part of life andis not something to be afraid of,” saidHawtin. “But we believe strongly thatcomfort is a right. Everything we do forour patients and their families is gearedtoward that.”

Pediatricians with patients requiringcurative and palliative care concurrentlycan refer patients to Dr. Bob’s Place bycalling 410-523-1414. More information isavailable at www.drbobsplace.org.

Heritage

D

“We can’t change the outcome, but we canchange the comfort level and give parents anopportunity to hug and snuggle with their kids.”

– Charlotte Hawtin, Executive Director of Joseph Richey Hospice

By Tracy M. Fitzgerald

PHOTO

SCOURTE

SYOFDR.B

OB’S

PLACE

Pediatrician John Irwin, M.D., leads a team ofclinicians and support providers who focus onmaking children with terminal health conditionsas comfortable as possible. Dr. Bob’s Place is afacility specializing in palliative and end-of-lifecare for patients from birth to age 18.

Good intentions or bad judgment?

There are times we do crazy, misguided things; feats that shouldn’t be possible,and sometimes aren’t. So when you push yourself past your limits, it’s nice toknow there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedureslike hip resurfacing – all combined with the latest rehabilitation services.

Nice work knees and hips – the dynamic duo – when we ask too much of you!www.lifebridgehealth.org

Good intentions or bad judgment?There are times we do crazy, misguided things; feats that shouldn’t be possible, and sometimes aren’t. So when you push yourself pastyour limits, it’s nice to know there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip andknee replacements and progressive procedures like hip resurfacing –all combined with the latest rehabilitation services.

Nice work, knees and hips – the dynamic duo – when we ask too much of you To find an orthopedic specialist near you, call410-601-WELL (9355).

www.lifebridgehealth.org/RIAO

Guillaume Marçais, 37, Montgomery County, Treated with Heart Ablation for Atrial-Fibrillation

Climbing withConfi dence

After Catheter Ablation

at

For priority transfer of your cardiac admissions,

call Cardiac One-Call 866-684-8460.

To refer a patient for a cardiac surgery consult,

call 301-891-6101.

Documents

Maryland Physician Magazine November/December 2012 Issue