Medical Journal Houston March 2013

INSIDE▼

The Leading Source for Healthcare Business NewsMarch 2013 • Volume 9, Issue 12 • $3.50

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INDEX▼

Legal Affairs......................3

Financial Perspectives.......4

Tecchnology......................6

Integrative Medicine.........8

THA................................10

Healthy Fare....................11

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Legal Affairs: Dermatologist will pay $26.1 million to settle FCA allegations, see page 3

Special Feature: Construction Report

Eat too much?Maybe it’s in the blood

see page 11

PRSRT STDUS POSTAGE

PAIDHOUSTON TX

PERMIT NO 13187

Hospice is not a place…..see page 8

BY DAVID MCLEMORE, AIA, ACHA, LEED AP, EVP and Healthcare Leader, Kirksey Architecture

The 2013 Construction Cost Update as recently assembled by Kirksey architecture was

prepared with statistical input from twenty-three General Contractors in the greater Houston marketplace. While the survey delved primarily into cost trending for “corporate” or “commercial” office buildings and their respective interiors, the survey did expand on a variety of shell building types, many of which can also provide useful cost insights into clinical and physician office building projects.

The rising trend in construction costs associated with building either the One-Story Flex building, the Low-Rise Office building or the Mid-Rise Office buildings as mentioned in the report, will correlate directly to a building of the same scale that finds itself housing a new outpatient clinic, diagnostic and imaging center, or physician office and clinical lease space. However, it

would not be surprising to see these upward cost pressures to be a little more pronounced in buildings constructed exclusively to house these medical functions in that they all tend to be a little more robust in their mechanical, electrical and plumbing (a.k.a.

their “MEP”) systems that support these uses, but… more on that later. While it’s true that basic MEP systems are almost always a critical factor when considering cost

The University of Texas Medical Branch at Bolstered by its success in the north county, the University of Texas Medical Branch will begin a $90 million building expansion project at its Victory Lakes facilities that will include an emergency department and beds to accommodate patients requiring overnight stays. Construction recently began at the Specialty Care Center at Victory Lakes in League City, followed by a groundbreaking ceremony.

The project will create 142,000 square feet of clinical space, allowing for the addition of 39 patient beds and inpatient stays of up to 72 hours in order to better serve its patients. In a related project, UTMB will build a central-plant facility to provide utilities to its 62-acre Victory Lakes campus. “UTMB Health is committed to providing the best patient care possible in its mission

to improve health for the people of Texas and around the world,” said Donna Sollenberger, executive vice president and CEO of UTMB’s Health System. “We are excited that this expansion allows us the opportunity to provide more services and convenience to our patients who live in the rapidly growing Bay Area in a completely

Breaking Ground: UTMB Victory Lakes $90 million expansion

Please see BREAKING GROUND page 14

Please see CONSTRUCTION page 12

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2013 Construction Cost Update

Medical Journal - HoustonPage 2 March 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Journal - Houston Page 3March 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BY MARY M. BEARDEn AnD ALLIsOn sHELtOn,BROwn & FORtunAtO, P.C.

On February 11, 2013, the United States Department of Justice (DOJ) announced that it agreed to settle claims against Steven J. Wasserman, M.D., for $26.1 million. This is one of the largest settlements in U.S. history of False Claims Act (FCA) allegations brought against an

individual. Wasserman is a dermatologist practicing in Florida. Under the settlement, he will have 180 days to pay the full amount. He is also excluded from all federal health care programs.

According to the government’s allegations, Wasserman violated the federal anti-kickback statute by entering into an illegal arrangement with Tampa Pathology Laboratory (TPL) and TPL’s owner, José SuarezHoyos, M.D. Specifically, the government alleged that since 1997, Wasserman sent skin biopsies to TPL for slide preparations and professional readings. TPL would then prepare for Wasserman’s signature a pathology report that included the professional diagnosis. In exchange for an increased number of referrals from Wasserman, TPL would allow Wasserman to bill Medicare for the professional component of TPL’s services while TPL billed the technical component. According to the government, the number of skin biopsies Wasserman performed in 1997 almost doubled from the amount he performed in each of the six previous years.

Any claims resulting from the alleged kickback arrangement and submitted to a federal health care program violated the FCA. In the original complaint, the government contended that from 2000 to 2005, Wasserman billed the professional component and TPL billed the technical component for more than 35,700 claims. As a result, Wasserman received $3.5 million and TPL received $3.9 million in Medicare reimbursement. For the entire duration of the alleged kickback arrangement, the government claimed that Wasserman received $6 million in Medicare payments for services actually performed by TPL.

The claims against Wasserman, TPL, and SuarezHoyos, originated from a lawsuit brought in 2004 by Alan Freedman, M.D., under the FCA’s whistleblower provisions. In the FCA, such whistleblowers are called qui tam relators. Freedman is a pathologist who was employed by TPL from 2000 to 2003. As a result of the qui tam provisions in

the FCA, Freedman will receive $4,046,000 from the settlement with Wasserman.

The government intervened in the suit brought by Freedman and filed a complaint in October of 2010. TPL, SuarezHoyos, and Wasserman sought to dismiss the government’s claims in 2011. On March 18, 2011, the U.S. District Court for the Middle District of Florida, Tampa Division, rejected

the defendants’ motion to dismiss. The court’s decision was based in part on the fact that the government’s allegations originated from first-hand knowledge obtained by Freedman during his employment with TPL. In 2012, SuzarezHoyos and TPL settled the government’s FCA allegations for $950,000.

The government’s allegations against Wasserman involved not only the kickback

arrangement with TPL but also up-coded claims and claims for unnecessary services that Wasserman submitted to Medicare. According to the government, Wasserman up-coded the type of evaluation and management (E/M) services he performed. In the original complaint, the government indicated that Wasserman received $1.9 million in Medicare payments for E/M

If Eleanor isn’t moving, she isn’t happy. There’sskiing, wakeboarding, rock climbing, and themore down to earth activities like biking to thestore. When she needed surgery on her ankle,she was worried.

She came to UTMB Health and benefited froma multidisciplinary team of surgeons, doctors,nurses, and physical therapists who knew thatEleanor needed aggressive treatment toreturn to her active lifestyle. They kept herinformed at every step.“I’m a Nurse Practitioner.I practice what I preach about staying activeand healthy. When it came time for rehab, thepeople here made sure I stayed with the plan.You get out of it what you put in.”

Today, Eleanor is back to her old tricks, whichalso happened to include kicking up her heelsand dancing at a friend’s wedding.

Whether it’s working in ortho, neuro, or anyaspect of the musculoskeletal system, UTMBhas gifted clinicians. These are the doctorsand surgeons who teach others their art, usingthe very latest equipment, technology andtechniques.

It’s about getting your life back.Your life.Whether that means gardening, hiking, fishing,playing guitar, typing on a keyboard, extremesports or just lifting your grandkids, our team isready to return you to the things you love to do.

If something isn’t right, do what Eleanor did.Take charge of your health and call us at800-917-8906, or go to utmbhealth.comto work wonders for you.

The University of Texas Medical BranchMember, Texas Medical Center

inkmuscles,joints andbones.It’s about gettingyour life back.

Left: Nikoletta Carayannopoulos, DOChief, Orthopaedic Trauma Surgery

Center Left: Joel Patterson, MD, FACS, FAANSChief, Division of Neurosurgery

Center Right: Vinod Panchbhavi, MD, FACSChief, Division of Foot and Ankle Surgery

Right: Gregory McGowen, PT, Cert MDTAIB Certified in Vestibular Rehabilitation, Rehabilitation Services

The four clinicians featured here are representative of the whole team of specialists spanningour musculoskeletal services.

MS-Houston Med Jrnl (Nov):7.5x9.312 Island 10/25/12 12:04 PM Page 1

LEGAL AFFAIRs

. . . . . . . . . . . . . . . Dermatologist will pay$26.1 million to settle FCA allegations

Please see LEGAL AFFAIRS page 13


27

Like us

BY REED tInsLEY, CPA, CVA, CFP, CHBC

In order to compete in a market that is moving towards ACOs, value-based purchasing, cost efficiency, and cost containment,

doctors must change old clinical habits. In other words, today and future mature markets will reward doctors based upon cost effectiveness, rather than utilization under the old fee for service system. Doctors not considered cost effective risk a continued reduction in third party reimbursement and also risk participation in provider networks. For example, I know of an ENT

physician who was recently deselected from a provider network simply because the plan felt he performed too many surgeries on new patients in comparison to the other ENT doctors in the network. A predicted challenge for many medical practices in the future will be to gather the information necessary to prove to a third party payer the practice is indeed cost effective. A practice must somehow gather utilization and outcomes data, usually by clinical episode or diagnosis code. This type of information will be critical when competing for contracts and can also be extremely valuable in the negotiation and renegotiation of managed care rates. Let us look at a simple example.

An Ob/Gyn group wants to negotiate rates with third party payer. It arms itself with the following limited practice data: (1) C-section rates, (2) VBAC rates, (3) Average length of stay in the hospital, (4) Rate of surgical complications, and (5) Length of stay and complication rates for

laparoscopic hysterectomies. At the same time, the group was able to obtain national utilization data for its specialty. It beat the national average in every category named above. Obviously this is an enviable situation for a medical practice since it can demonstrate with actual statistics that it is a cost effective provider. In this situation, the third party payer will probably at least listen to proposed changes to its reimbursement schedule for this particular group. Also, this data puts this group in a good position to deal with emerging affiliation models such as ACOs and the like.

The below charts are samples of provider utilization reportss by CPT code and by

diagnosis code.

As you have seen from the examples above, here are some of the most common quality indicators you should be looking at for your practice:

• Cost per patient for a particular series of diagnosis codes• Surgeries/Procedures performed as a percent of patient encounters• Usage of ancillary services• Lengths of stay in the hospital• Specialist referrals as a percent of patient encounters or by diagnosis codes (for primary care doctors)• Number of repeat visits due to surgical complications

These are just a few but I bet you can think of others for your own medical specialty. Just think what services you perform that drive healthcare costs for your medical specialty. Also keep in mind quality can

FInAnCIAL PERsPECtIVEs

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The importance and economicsof utilization and outcomes

Please see FINANCIAL PERSPECTIVES page 13

ICD9 Code # of Patients

Total Charges

Avg Chg Per Patient

# of Visits Avg. Chg Per Visit

386.02 30 2395.00 79.83 40 59.88 V76.1 11 1060.00 96.36 11 96.36 558.9 18 8019.84 445.55 19 422.10

CPT Code # of Patients

Total Charges

Avg Chg Per Patient

# of Visits Avg. Chg Per Visit

99212 5 280 56 11 25.45 99070 1 15 15 1 15.00 99214 6 330 55 4 82.50 Total 12 625 52.08 16 39.06

Provider utilization reportss by CPt code

Provider utilization reportss by diagnosis code


23510 Kingsland, Phase I of the development, is centrally located on the northwest corner of Kingsland Boulevard and Cobia Drive. The site was selected based on its close proximity to five major hospital systems, great accessibility to Grand Parkway and Interstate 10 as well as its position within a high growth suburban area.

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

TIM GREGORYSENIOR VICE PRESIDENT HEALTHCARE ADVISORY [email protected]

JEFF MICKLER PRESIDENT AND CEO JACOB WHITE [email protected]

• Excellent location across from future St. Luke’s hospital in Katy, Texas West of Grand Parkway

• Great accessibility to Grand Parkway, I-10 corridor, and Katy Mills Mall

• Close proximity to four major hospital systems (Memorial Hermann, Methodist, Texas Children’s, and Christus St. Catherine)

• LEED, high-performance, class “A” buildings designed for the highest standards of indoor air quality, and energy efficiency.

• 40% to 50% reduction in total OPEX cost

• State-of-the-art building management system

• Physician Ownership Available

Katy Medical Plaza February 7, 2013

150,000 SF MEDICAL/OFFICE DEVELOPMENT NEAR GRAND PARKWAY ON KINGSLAND BLVD.

PHASE I OF CONSTRUCTION

FOR LEASING INFORMATION:

* Current Construction Aeriel

FOR DEVELOPMENT INFORMATION:

*Rendering of Proposed Development Phase I, Phase II, and Phase III


texas Children’s Hospital improves quality of care, identifies inefficiencies with enterprise data warehouse from Health Catalyst Internationally renowned Texas Children’s Hospital reduced unnecessary chest X-rays in pediatric patients with asthma by 15 percent in just six weeks after rolling out an adaptive data warehouse platform and advanced analytics from Health Catalyst. This initial success has convinced the hospital to expand its deployment of the technology to include multiple medical and surgical programs and processes. The hospital launched an overall quality and safety strategy several years ago, including implementation of an electronic health record (EHR) to collect raw clinical and financial data. The objective was to transform the data into meaningful information the facility could use in guiding its clinical quality interventions and waste reduction efforts. Clinicians, however, still weren’t able to effectively leverage the data they needed to improve quality of care for individual patients and specific patient populations. To meet clinicians’ expectations, leaders of the hospital’s quality, clinical and IT departments knew they needed to develop an enterprise data warehouse (EDW). Implementation of the Health Catalyst Adaptive Data Warehouse was completed in a “phenomenally fast” three months, according to Margaret Holm, Ph.D., Director of Quality and Clinical Systems Integration at Texas Children’s Hospital. At the same time, Health Catalyst conducted a data-driven financial and clinical assessment across the enterprise, looking at variability of care and resource consumption. Armed with actionable dataAfter evaluating the results of the assessment, a multi-disciplinary team at the hospital decided to focus quality improvement efforts on asthma care. A cross-functional team was selected to assess and manage acute asthma in the hospital from the time of arrival in the emergency department (ED) to discharge. Within weeks, the team could identify a higher volume of chest X-rays being administered to asthma patients. The team also recognized that, according to the evidence, only 5 percent of chest X-rays were indicated. Physicians were skeptical of the number of unnecessary chest X-rays, instead surmising that the data might be incorrect. “Unlike

in the past, Health Catalyst enabled us to drill down into near real-time data to reveal patterns and convince [the physicians] they could help reduce the number of unnecessary chest X-rays,” said Charles Macias, MD, MPH, Director of Evidence-based Outcomes at the hospital. The asthma team addressed the issue by providing education and analytics dashboards for the clinical staff to monitor chest X-ray procedures. In six weeks, the team produced a 15 percent reduction in unnecessary chest X-rays. The technology makes it possible for the asthma team to analyze data on demand, rather than many months later. Armed with this near real-time data, the team is drilling down into specific interventions, such as the delay between the time a child arrives in the ED and the time he or she receives the appropriate medications. Expanding Use of the TechnologyHolm said the hospital is working with Catalyst Health to add chronic asthma, cardiology and pneumonia, as well as other conditions and diseases. “The culture is changing, and it’s all happening very fast,” Holm noted, adding that the hospital’s clinicians are now actively using the data to improve patient care by asking better questions about how care is delivered and uncovering the root causes of variation. In turn, rapid clinical feedback is reducing the development time required by technicians and analysts to build out the advanced analytics necessary to monitor and sustain improvements. The hospital’s goals for future quality improvement efforts include providing near real-time process and outcome metrics; standardizing the delivery of evidence-based care; enhancing gains in operational deficiencies and clinical effectiveness; increasing clinicians’ use of the tools; and improving strategic alignment toward managing populations. Robot-assisted walking therapy for Veterans

The Michael E. DeBakey VA Medical Center (MEDVAMC) provides robot-assisted walking therapy to help Veterans suffering from stroke, spinal cord injuries, as well as other neurologic conditions. The patient is suspended in a harness over a state-of-the-art treadmill device called a Lokomat®. The frame of the robot, attached by straps to the outside of the legs,

tECHnOLOGY

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Please see TECHNOLOGY page 12


The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with

patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical

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Donald J. Palmisano, MD, JD, FACSBoard of Governors, The Doctors CompanyFormer President, American Medical Association

We hate lawsuits. We loathe litigation. We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company.

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BY VICtOR s. sIERPInA, MD, ABFP, ABIHM, Distinguished teaching Professor, Family and Integrative Medicine, utMB Health

Hospice is a team of dedicated, trained professionals who assist patients and their families through the transition from chronic, end-stage disease and the process of dying. I gave a talk recently at UTMB to the Dame Cicely Saunders Society Hospice Training for hospice volunteers. Notably, this group was comprised of medical students, nursing students, and other health care professionals willing to donate their time to care for the dying. I was reminded of the vital role hospice plays in our lives, and in our deaths.

My father, at 91 years old, was on hospice care for an untreatable kidney tumor for the last 3 months of his life. All of his medical needs were cared for including costs of medications, special equipment, visits from nurses, doctors, physical therapists, social workers, a spiritual support team, and even someone to bathe him. The hospice nurse kept in close touch with us by phone and in person. This turned out to be crucial as my father’s decline was occurring at the same time Hurricane Ike had destroyed our home in Galveston. We were struggling to balance rebuilding our life here in Galveston while shuttling to Phoenix to spend as much time as we could with him before he made his transition. He did so peacefully, gracefully, and with dignity. He did so free of pain and surrounded by friends and family at his home about a month after Ike. If it hadn’t been for hospice, the process would have been much more challenging for him and all who loved him.

There are many misconceptions about hospice that prevent more effective use of this resource. Incredibly, about 30% of the Medicare budget is spent on those in the last year of life, often on procedures, hospitalizations, and care that ultimately do not alter patient outcomes or extend their longevity. If a patient has a terminal diagnosis, a short life expectancy, make a hospice referral. Just do it. Your support of this process as physician is incredibly powerful and gives the family and the patient validity and empowerment to make important choices at the end of life.

The patient’s primary care doctor, a nurse, social worker, or even the person’s family

can make a hospice referral. It can make a wonderful difference in the dignity and appropriateness of end of life care. Hospice care is primarily provided in the person’s own home though sometime brief stays in the hospital or nursing home are appropriate. The costs of hospice are covered by Medicare and other insurances and include the full spectrum of palliative care. Attempts to “cure” the patient are stopped. Instead, an emphasis is placed on improving quality of life, optimizing pain control, and providing psychosocial and spiritual support to the patient and their family.

Regrettably, hospice referrals are often too late and too little. Nationally, stays in hospice have average around 3-4 weeks or less before death. Three to six months are a more appropriate time for this level of care. Often, physicians delay this referral because of our own discomfort about raising the issue. Often, patients feel they are just not ready for “that hospice place.” Sometimes the delay in referral is because of the misunderstanding, so often stated to me by patients and families, that hospice referral means “giving up” and that no further care will be provided. This is far from the truth as hospice services provide more intense and medically appropriate levels of care, at a much lower cost and decreased emotional burden for the person and their family. House calls and home care are key to the effectiveness of most hospice care.

Planning for the dying process is best done long before patients reach the hospice level. The time to make “end-of-life” planning is not best done at the end of life. Signing an advanced directive and medical power of attorney are optimally done by the patient and their family members well in advance of a critical event such as a stay in the intensive care unit or the discovery that a cancer has recurred and is now incurable.

A common misconception is that hospice patients need to have cancer. While end-stage cancer is a common situation in hospice care, any person with a life expectancy of six months or less can enroll in hospice. Any end stage organ disease such as chronic lung disease, heart failure, kidney or liver failure is appropriate for referral. Furthermore, dementia, failure to thrive, and general decline in the elderly can qualify a person for hospice. Interestingly, the “hospice paradox” is that under hospice care, the six-month ticking clock to demise

IntEGRAtIVE MEDICInE

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Hospice is not a place…..

Please see INTEGRATIVE MEDICINE page 14

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survey: Majority of texans support Medicaid expansion

special to Medical Journal – Houston BY DAn stuLtz, M.D., FACP, FACHE, President/CEO, texas Hospital Association

A voter sur¬vey con¬ducted by the Texas Hos¬pi¬tal Asso¬ci¬a¬tion adds to the grow¬ing cho¬rus of statewide sup¬port for Texas to expand its Med¬ic¬aid pro¬gram. Accord¬ing to the poll, 54 per¬cent of vot¬ers said the State of Texas should par¬tic¬i¬pate in the expan¬sion of Med¬ic¬aid. After learn¬ing more about Med¬ic¬aid expan¬sion, 59 per¬cent responded favorably.

While reforms are needed to ensure access to physicians, Tex¬ans under¬stand that Med¬ic¬aid expan¬sion is a wise invest¬ment because it decreases stress on emergency departments and reduces costs to the local tax¬pay¬ers, who shoul¬der the bur¬den when the state and fed¬eral gov¬ern¬ments cut fund¬ing to hos¬pi¬tals.

Hos¬pi¬tals are required by law to pro¬vide health care regard¬less of a patient’s abil¬ity to pay, and in 2011 alone, Texas hos¬pi¬tals pro¬vided $5.4 bil¬lion in uncom¬pen¬sated care and char¬ity care. Unre¬im¬bursed Medicare costs total¬ing $9 bil¬lion fur¬ther strained the state’s hospitals.

Patients who can’t pay for their own health care ser¬vices cause higher insur¬ance pre¬mi¬ums and higher taxes, and that’s why it makes sense to pro¬vide health cov¬er¬age to more Tex¬ans. In Texas, the aver¬age person’s insur¬ance pre¬mium is $1,800 higher per year due to costs asso¬ci¬ated with uncom¬pen¬sated care, accord¬ing to the Cen¬ter for Amer¬i¬can Progress Action Fund.

A recent study released by Gallup adds to this growing concern. According to the study, conducted daily in 2012, Texas still leads the nation with the high¬est rate of unin¬sured at 28.8 percent, and the gap between the Lone Star State and the runner-up is widening.

Accord¬ing to THA’s poll, 74 per¬cent responded favor¬ably to Med¬ic¬aid expansion’s impact on increas¬ing access to pri¬mary care and get¬ting employ¬ees with¬out health insur¬ance back to work quickly. Vot¬ers also responded over¬whelm¬ingly (60 per¬cent) in favor

of Med¬ic¬aid expan¬sion after learn¬ing it would be fully funded for the first three years by the fed¬eral gov¬ern¬ment with an option for Texas to drop out of the pro¬gram if the fed¬eral gov¬ern¬ment exerted too much con¬trol on the funds.

Last fall, a study by the eco¬nom¬ics firm, The Per¬ry¬man Group, con¬cluded that the expan¬sion of Med¬ic¬aid would lead to sub¬stan¬tial eco¬nomic activ¬ity; an increase in fed¬eral funds flow¬ing into Texas; a reduc¬tion in costs for uncom¬pen¬sated care and insur¬ance; and, enhanced pro¬duc¬tiv¬ity from a health¬ier population.

Accord¬ing to the Per¬ry¬man study, Med¬ic¬aid would pay for itself by gen¬er¬at¬ing $256 bil¬lion in eco¬nomic activ¬ity over 10 years and cre¬ate about 300,000 jobs.

The Per¬ry¬man study find¬ings are con¬sis¬tent with a more recent analy¬sis from for¬mer deputy comp¬trol¬ler Billy Hamil¬ton, a tax pol¬icy con¬sul¬tant. Hamil¬ton deter¬mined the expan¬sion of Med¬ic¬aid would gen¬er¬ate more than 260,000 health care jobs by 2016 – in just two years after expan¬sion – while reliev¬ing city, county and hos¬pi¬tal dis¬trict tax bur¬dens borne by local taxpayers.

Vot¬ers, as well as an increas¬ing block of bipar¬ti¬san law¬mak¬ers and a grow¬ing num¬ber of non-partisan orga¬ni¬za¬tions, under¬stand the impor¬tance of a smart invest¬ment of state tax dol¬lars in a local community’s health care infra¬struc¬ture. By expand¬ing Med¬ic¬aid, we can improve access to pri¬mary health care, cre¬ate good-paying jobs along the way, and help keep insur¬ance pre¬mium costs from increas¬ing any faster.

Under the new fed¬eral health care law, more than a mil¬lion peo¬ple in Texas who are unin¬sured could get health care cov¬er¬age through Med¬ic¬aid if the state acts to expand the pro¬gram in 2014. While the state would be required to pro¬vide match¬ing gen¬eral rev¬enue dol¬lars after the first three years, Texas’ required share never increases above 10 percent.

Expand¬ing cov¬er¬age is the respon¬si¬ble move, and Texas should use the lever¬age it cur¬rently has with the fed¬eral gov¬ern¬ment to ask for the flex¬i¬bil¬ity to use these addi¬tional funds to cre¬ate a Med¬ic¬aid pro¬gram that works for Texas based on per¬sonal respon¬si¬bil¬ity, tai¬lored ben¬e¬fit design and provider pay¬ment reforms that pro¬mote qual¬ity and cost-effective health care. t

tHA


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Bone marrow cells that produce brain-derived eurotrophic factor (BDNF), known to affect regulation of food intake, travel to part of the hypothalamus in the brain where they “fine-tune” appetite, said researchers from Baylor College of Medicine and Shiga University of Medical Science in Otsu, Shiga, Japan, in a report that appears online in the journal Nature Communications.

“We knew that blood cells produced BDNF,” said Dr. Lawrence Chan, professor of molecular and cellular biology and professor and chief of the division of diabetes, endocrinology & metabolism in the department of medicine and director of the federally funded Diabetes Research Center all at BCM. The factor is produced in the brain and in nerve cells as well. “We didn’t know why it was produced in blood cells.”

Dr. Hiroshi Urabe and Dr. Hideto Kojima, current and former postdoctoral fellows in Chan’s laboratory respectively, looked for BDNF in the brains of mice who had not been fed for about 24 hours. The bone marrow-derived cells had been marked with a fluorescent protein that showed up on microscopy. To their surprise, they found cells producing BDNF in a part of the brain’s hypothalamus called the paraventricular nucleus.

“We knew that in embryonic development, some blood cells do go to the brain and become microglial cells,” said Chan. (Microglial cells form part of the supporting structure of the central nervous system. They are characterized by a nucleus from which “branches” expand in all directions.) “This is the first time we have shown that this happens in adulthood. Blood cells can go to one part of the brain and become physically changed to become microglial-like cells.”

However, these bone marrow cells produce a bone marrow-specific variant of BDNF, one that is different from that produced by the regular microglial cells already in the hypothalamus.

Only a few of these blood-derived cells actually reach the hypothalamus, said Chan.

“It’s not very impressive if you look casually under the microscope,” he said. However, a careful scrutiny showed that the branching nature of these cells allow them to come into contact with a whole host of brain cells.

“Their effects are amplified,” said Chan. Mice that are born lacking the ability

to produce blood cells that make BDNF overeat, become obese and develop insulin resistance (a lack of response to insulin that affects the ability to metabolize glucose). A bone marrow transplant that restores the gene for making the cells that produce BDNF can normalize appetite, said Chan. However, a transplant of bone marrow that does not contain this gene does not reverse

overeating, obesity or insulin resistance.

When normal bone marrow cells that produce BDNF are injected into the third ventricle (a fluid-filled cavity in the brain) of mice that lack BDNF, they no longer have the urge to overeat, said Chan.

All in all, the studies represent a new

mechanism by which these bone-marrow derived cells control feeding through BDNF and could provide a new avenue to attack obesity, said Chan.

He and his colleagues hypothesize that the bone marrow cells that produce BDNF fine

HEALtHYFARE

. . . . . . . . . . . . . . . Eat too much?Maybe it’s in the blood

Please see HEALTHY FARE page 14


moves the patient’s legs in a natural walking pattern. A computer monitors the speed and natural motion of the legs, creating a repetitive walking pattern that seems to help strengthen the muscles, improve circulation, and teach the brain to use and recognize walking motions. “Besides the obvious primary goal of improving ambulation, the weight-bearing nature of this device can also have an effect on range of motion, bone density, and spasticity,” said John Kertz, M.P.T., N.C.S., a physical therapist in the Spinal Cord Injury Care Line. The majority of patients treated with the Lokomat® have had their ability to walk impaired due to a stroke, spinal cord injury, or other neurologic condition. The therapy is accomplished during a minimum of 60-minute sessions once a day, three days per week, for four to eight weeks. The computer charts patient progress with measurements for strength, range of motion, and distance. “This device encourages the patient to walk with a more normal gait. This continuous repetition of movement promotes motor control and neuroplasticity,” said Angelica Rivera, M.P.T., a physical therapist in the Rehabilitation Care Line. An added benefit of this technology is that it helps to reduce physical strain on therapists while increasing consistent therapy for patients. The robotic device does most of the heavy work; therefore, the pattern and pace are consistent throughout the session. Therapists only have to make adjustments and help as needed; thus, pushing patients to their full potential.

“The overall goal is to transition patients from this type of therapy to more functional walking over-ground, whether that is with a walker, a cane, or no assistive device at all,” said Kertz. “This is another great piece of technology VA has to help Veterans regain or improve their ability to walk.” Memorial Hermann reports widespread success with HealthPost patient booking solution HealthPost Inc., a global search and booking platform that is reinventing access to healthcare across the broader ecosystem, recently announced that Memorial Hermann Health System, the largest not-

for-profit health system in southeast Texas, has successfully booked tens of thousands of online appointments in its first year using HealthPost’s enterprise search and booking platform. This marks an industry first - Memorial Hermann is the first hospital system in the country to provide real-time

online search and booking across the entire outpatient delivery network, including employed and affiliated physicians, urgent and emergency care, imaging, outpatient rehabilitation, preventive screening services and more. In addition, Memorial Hermann leverages HealthPost in its call center and post-discharge care coordination programs. Memorial Hermann selected HealthPost as its partner in transforming access to care in September 2011 after extensive evaluation of competing solutions, as part of a broader strategy designed to improve the patient experience, expand market share and create a care coordination platform for its ACO. David Bradshaw, Chief Information, Marketing & Planning Officer of Memorial Hermann, explained, “Implementation was

smooth and patients have readily adopted the platform. The system, which we have introduced under the name ScheduleNow, is easy to use and enables patients and referring providers to schedule appointments at their convenience. It enables Memorial Hermann to offer patients and referring

providers a single point of access to book into our vast outpatient delivery network.”

Memorial Hermann Memorial City Medical Center first in west Houston to offer robotic partial knee replacement

Memorial Hermann Memorial City Medical Center is now offering MAKOplasty® partial knee resurfacing, a minimally-invasive treatment option for adults living with early to mid-stage osteoarthritis (OA) that has not yet progressed to all three compartments of the knee. MAKOplasty is less invasive than traditional total knee surgery and is performed using RIO®, a highly advanced, surgeon controlled robotic arm system. Memorial Hermann Memorial City is the first and only hospital in west Houston to acquire this technology. “MAKOplasty allows us to treat patients with knee osteoarthritis at earlier stages and with greater precision,” said Stefan Kreuzer, M.D., an orthopedic surgeon affiliated with Memorial Hermann Memorial City. “Because it is less invasive and preserves more of the patient’s natural knee, the goal is for patients to have relief from their pain, gain back their knee motion, and return to their daily activities quickly.” MAKOplasty potentially offers the following benefits as compared to total knee surgery:• Reduced pain• Minimal hospitalization• More rapid recovery• Less implant wear and loosening• Smaller scar• Better motion and a more natural

feeling knee

estimates for buildings of this type, there are also other key factors that need to be looked at, which may or may not affect the current cost trending for medical uses, depending upon the intended long-term flexibility of a proposed shell, medical building.

For example, the onset of Electronic Medical Record (EMR) systems usage is driving more users to look at buildings that can readily support twenty-four hour cooling and emergency power to spaces that house ever growing amounts very expensive I.T. equipment. While this may not result in the initial addition of these systems to a base building, projects are being designed to more easily accommodate these tenant improvements in a cost effective manner, making these buildings more attractive to health care providers who are seeing reimbursement rates shrinking on multiple fronts. These accommodations, such as common space to house an emergency generator, will obviously drive up initial construction cost as added area equals added material cost. Still, the potential

return seems to be growing day by day as providers find more ways to capitalize on the implementation of EMR.

Likewise, if a medical building is to be flexible enough to house ambulatory surgical care, often referred to as “day surgery”, there are construction requirements such as a covered patient loading zone and fire separation elements that have to be provided for to meet state licensing requirements. These two elements alone can easily add two to three dollars to the total per square foot (p/s/f) cost of a 100,000 square foot shell building. Having said that, it’s worth noting that over the course of the past two years, we have repeatedly seen announcements from various local and national healthcare providers stressing the need to provide more patient care and more types of patient care such as expanded types of surgery, in the outpatient setting. So it would seem that moving forward, providing a shell building that is flexible enough to be easily licensed for ambulatory surgical care will be increasingly more important for many healthcare providers in their selection for a new location, as it could potentially have a direct impact on their cost analysis to deliver a space that meets their unique, changing needs.

Stepping outside of the building, it is not uncommon for more land to be used to accommodate separate staff and patient entrances for healthcare providers, along with vehicle access for generator fuel delivery, or medical waste storage and disposal, and also medical gas storage and access, all of which can drive up the initial site infrastructure and construction cost, thus the overall shell building cost analysis. Interestingly, in years past, it used to be viewed purely as an amenity to pay for and provide dedicated parking for physicians and key personnel, but in a brave new medical world striving to find every possible efficiency, the addition of readily available, dedicated parking, with easy in and out access can actually save clinicians valuable time and thus have a huge impact on the decision making process for new or expanded locations.

Circling back around to the topic of MEP equipment, it’s important to keep in mind that a typical “shell” building will provide only a limited amount of MEP infrastructure, to avoid wasteful or unnecessary spending upfront, with final component installation by the specific medical user group as tailored to their specific needs. This effectively defers

a significant portion of the overall upward trending cost, in a few ways. The first is that there is simply more of these material systems going into these specific building types. The second reason is due to simple supply and demand trending. During the past few years, during the depth of the recession, we saw manufacturers and suppliers reducing their inventories to all time lows, with many more material components being made as orders came in, as opposed to the previous trend of suppliers stocking up to be able to provide materials to the market as quickly as possible, to increase their competitiveness.

With inventories now trending low, and manufacturers unwilling to rapidly ramp up production or hire workers too quickly, there is simply less factory made product readily available to builders, which includes all the typical MEP components such as air handlers, pumps, compressors, etc., that will be needed to complete the building interior construction. With demand increasing and supplies not having caught up, prices are understandably rising, all of which has to be factored in when considering final construction cost. t

CONSTRUCTIONcontinued from page 1. . . . . . . . . . . . . . .

TECHNOLOGYcontinued from page 6. . . . . . . . . . . . . . .

Please see TECHNOLOGY page 15

Orthopedic surgeons pictured (left to right) with RIO® in an operating room at Memorial Hermann Memorial City Medical Center: Adam Freedhand, M.D., joint replacement and sports medicine; Robert neff, M.D., joint replacement; Donald stafford, M.D., general orthopedic surgery; stefan Kreuzer, M.D., joint replacement; and Alex schroeder, M.D., sports medicine.


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services provided in 37,467 patient visits from 2000 through 2008. According to the government, Wasserman up-coded these services and was, therefore, not entitled to 80% of the reimbursement he received. To justify this claim, the government contended that on several days, it would have taken Wasserman more than 24 hours to perform the E/M services he had billed. Further, the government alleged that the same improbability was evident in Wasserman’s claims for adjacent skin transfers submitted to Medicare.

Dermatologists perform adjacent skin transfers to close openings created when lesions are excised. Such procedures are time-consuming and complicated.

According to the government, Wasserman consistently billed for adjacent skin transfers for openings greater than 10.1 centimeters when the openings were in fact less than 10.1 centimeters. By misrepresenting the services, Wasserman could receive approximately $150 more per claim. In the original complaint, the government indicated that between 2000 and 2008, Medicare reimbursed Wasserman $4,186,341 for adjacent skin transfers which Wasserman misrepresented on his Medicare claims.

To settle the government’s FCA allegations arising from the alleged kickback arrangement and unnecessary services, Wasserman will pay one of the largest amounts ever paid by an individual in an FCA settlement. In the government’s announcement of the settlement, the DOJ quoted a few attorneys who worked on the case. Stuart F. Delery, Principal

Deputy Assistant Attorney General for the Civil Division of the DOJ, expressed that the DOJ “will not tolerate those who abuse the public health care programs to which we all contribute and on which we all depend.” Robert O’Neill, U.S. Attorney for the Middle District of Florida, reiterated the government’s concern for the integrity of publicly funded health care programs: “Schemes of this magnitude require extraordinary remedies, and we are proud to have reached such an outstanding resolution for the taxpayers and their health programs.”

The government’s action involved a joint investigation by agents from the Department of Health and Human Services (HHS), the Office of Inspector General, and the Federal Bureau of Investigation. Since May of 2009, these agencies have cooperated under the Health Care Fraud Prevention and Enforcement Action Team

to address financial fraud committed against federal health care programs. The FCA is the primary tool for the government to address health care fraud and abuse committed by hospitals, health systems, clinical laboratories, and other providers. Actions brought by qui tam relators are on the rise along with the amount recovered by the government.

Since January of 2009, the DOJ has recovered $14 billion under the FCA. HHS and the DOJ recently published the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2012. According to this report, in 2012, the DOJ and HHS deposited in federal accounts approximately $4.2 billion which derived from judgments and settlements of health care fraud claims. From the amount deposited, FCA qui tam relators will receive more than $284 million. t

LEGAL AFFAIRScontinued from page 3. . . . . . . . . . . . . . .

also be defined by clinical outcomes as well as by hard figures. One example is asthma and allergy: What are the number of days missed from work for those patients the practice is treating? For Glaucoma specialists: How well was eyesight restored after glaucoma surgeries or are there complications? For addiction specialists:

What are the relapse rates? For cardiologists: How soon do patients come off (and stay off) blood pressure medications?

The problem today is that most doctor office computer systems are incapable of providing this type of information. The reason is simple. Most medical billing/EMR systems were built for a traditional fee for service environment and not for a managed care/cost containment environment. However, I have found that you can “data mine” in to many systems to obtain this clinical/

utilization data. You can also obtain clinical information from you hospital’s information system and even from third party payers themselves. That is why I often suggest meeting regularly with managed care representatives to discuss utilization issues. It is important to keep abreast just how the plan perceives the practice as a driver of healthcare costs – efficient or non-efficient?

The point should be clear: Medical practices must start addressing utilization and outcomes issues now or risk losing out

in the future. Managed care rates can be negotiated or renegotiated with supportable utilization and outcomes information. To engage in and with future provider network models resulting from healthcare reform and the continued shifts in the commercial markets towards value-based purchasing, physician practices must pay strict attention to utilization and outcomes data. It cannot nor should not be ignored. t

FINANCIAL PERSPECTIVEScontinued from page 4. . . . . . . . . . . . . . .


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HEALTHY FAREcontinued from page 11. . . . . . . . . . . . . . . . . . .

INTEGRATIVE MEDICINEcontinued from page 8. . . . . . . . . . . . . . .

is often extended, sometimes to several years because of the quality care provided. Patients who were once considered terminal may end up living much longer with hospice care. An article in the Wall Street Journal reported on this phenomenon, describing patients who had enrolled in hospice with the expectation that they would be dead in six months. Some had survived as long as nine or ten years despite their grim prognosis, which they often attributed to the hospice care they had received. Hospice services can be renewed and recertified almost indefinitely if the patient continues to do better than expected.

Over the years, it has been my privilege to be present not only at births at the beginning life, but also with dear patients during their last breaths ending life. These are both profound bookends to the human experience. Both must to be handled with the utmost compassion, caring, competence, and love. As a physician, I have found the beginning and end of life to be some of my most incredibly intense, emotional, and

growing experiences. These moments are truly gifts we as physicians receive from our patients in recompense for our being present at these vulnerable, vital transitions.

Physicians have the option to continue to care for their patients during hospice care and to be reimbursed for this. You can also release your patient to the care of the hospice medical director or collaborate with him or her. I recommend that you consider staying involved at whatever level your relationship with your patient calls for. Regular house calls on hospice patients have been one of the most heartfelt and impactful aspects of my professional life. They have the renewing power of delivering a baby.

Here are some key points I hope you consider as your care for your patients:

• When your patient is facing the inevitable, imminent end of life, refer them sooner rather than later in hospice. A few months is better than a few weeks and you may even survive longer, with more dignity, independence, and in a healthier state.• Encourage patients to complete Advanced Directives and Medical Power of Attorney documents available well in advance of when you think they might need them. These can

always be amended if the situation changes.• Recommend that patients let their family know clearly, while their minds are clear and health reasonably good their wishes about end of life care. “Doing everything you can” is not always the best choice while “doing everything reasonable” might be a better option. Discuss this with all involved parties until it is clear what the patient’s intentions and wishes are and how they would like them carried out. • Palliative care under hospice ensures, as far as humanly possible, that needs for pain control, attention to suffering, and physical requirements are met in the most desirable, professional way, typically in the comforting surroundings of home and family.

References: Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers, http://jama.jamanetwork.com/article.aspx?articleid=193279

The Role of the Family Physician in the Referral and Management of Hospice Patients, http://www.aafp.org/afp/2008/0315/p807.html

Portions of this were previously published in the Galveston Daily News. t

tune the appetite response, although a host of different appetite-controlling hormones produced by the regular nerve cells in the hypothalamus do the lion’s share of the work.

“Bone marrow cells are so accessible,” said Chan. “If these cells play a regulatory role, we could draw some blood, modify something in it or add something that binds

to blood cells and give it back. We may even be able to deliver medication that goes to the brain,” crossing the blood-brain barrier. Even a few of these cells can have an effect because their geometry means that they have contact with many different neurons or nerve cells.

He credits Urabe and Kojima (now with Shiga University of Medical Science in Japan) with doing most of the experiments involved in the research.

Others who took part include: Tomoya Terashima, Nobuhiro Ogawa, Miwako Katagi, Kazuori Fujino, Asako Kumagai,

Hiromichi Kawai, Akhiro Asakawa, Akio Inui, Hitoshi Yasuda, Yutaka Eguchi, Kazuhiro Oka, Hiroshi Maegawa, Atsunori Kashiwagi and Hiroshi Kimura, all of Shiga University of Medical Science.

Funding for this work came from the Ministry of Education, Culture, Sports, Science and Technology, Japan, the President’s Discretionary Fund from Shiga University of Medical Science and the U.S. National Institutes of Health grant HL-51586 and the Diabetes Research Center (P30 DK79638). t

BREAKING GROUNDcontinued from page 1. . . . . . . . . . . . . . .

integrated system of care,” she said. The clinical space project is valued at $82 million and is scheduled for completion in February 2015. The contractor is McCarthy Building Cos. The designer is HKS Inc. The central-plant facility is valued at $8 million and is scheduled for completion in August 2014. It will generate electricity, emergency power, and hot and chilled water. The contractor is Tellepsen Builders. The designer is AEI Affiliated Engineers Inc. The Specialty Care Center’s ambulatory surgery and complex diagnostic services will expand to provide 39 inpatient beds for up to 72-hour stays, 17 emergency/urgent care treatment rooms, four operating rooms, endoscopy rooms and 25,000 square feet

of shell space for future development. In addition, the finished site will provide increased imaging capabilities including an X-ray fluoroscopy facility, ultrasound and CT unit. The utilities project will build a 5,000 square-foot plant to provide added thermal utilities, normal and emergency electrical power, and redundancy for each system at Victory Lakes. The system will be capable of independently providing electricity, hot water and chilled water for up to 72 hours. The design will provide for three 400-ton chillers and 6 million BTU of hot water. UTMB opened the Specialty Care Center, 2240 Gulf Freeway South, in 2010. It houses several clinics and currently covers 110,000 square feet. The University of Texas System Board of Regents approved the expansion at its meeting Nov. 14, 2012.

tIRR affiliated rehab clinic to open in the Heights

Memorial Hermann Northwest and TIRR Memorial Hermann Rehabilitation Network are proud to announce the opening of the general rehabilitation clinic at the Memorial Hermann Northwest Hospital. Board certified in rehabilitation medicine, Natasha Eaddy Rose, M.D., heads up the clinic. The new treatment center will offer general rehabilitation- consultation, evaluation and follow up, as well as spasticity management, diagnostic and treatment. Outpatient medical practice starts March 25, 2013, and is located at 1740 West 27th St., Suite 100, Houston, 77008. This is in conjunction with the TIRR Neurological Outpatient Rehabilitation Clinic that is located in the Northwest hospital and provides physical therapy, occupational therapy, speech and neuropsych service. t


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TECHNOLOGYcontinued from page 12. . . . . . . . . . . . . . .

Through its innovative use of technology, MAKOplasty takes partial knee resurfacing to a new level of precision. The RIO® system enables the surgeon to complete a patient specific pre-surgical plan that details the technique for bone preparation and customized implant positioning using a CT scan of the patient’s own knee. During the procedure, the system creates a three-dimensional, virtual view of the patient’s bone surface and correlates the image to the pre-programmed surgical plan. As the surgeon uses the robotic arm, its tactile, auditory and visual feedback limits the bone preparation to the diseased areas and provides for real-time adjustments and more optimal implant positioning and placement for each individual patient. “Precision is key in planning and performing partial knee surgeries,” said Adam Freedhand, M.D., an orthopedic surgeon also affiliated with Memorial Hermann Memorial City. “For a good outcome, you must align and position the implants just right. Precision in surgery, and in the pre-operative planning process, is what RIO can deliver for each individual patient.” The opportunity for early intervention is important as OA is the most common form of arthritis and a leading cause of disability worldwide, according to the American

Academy of Orthopaedic Surgeons.

The Michael E. DeBakey VA Medical Center (MEDVAMC) is one of the first VA hospitals to offer innovative robotic

catheter ablation technology for patients suffering from abnormal heart rhythm or arrhythmia. “This state-of-the-art technology allows us to steer the conventional ablation catheter

inside the heart chambers with much more ease and precision, and to access areas of the heart that were previously difficult to reach using traditional methods,” said Irakli Giorgberidze, M.D., Electrophysiology Laboratory director at the MEDVAMC and

assistant professor of Medicine at Baylor College of Medicine. Recently approved for commercial use by the U.S. Food and Drug Administration, the Sensei® X Robotic Catheter System, is

a very specialized and highly sophisticated tool used for catheter-based mapping within the chambers of a patient’s heart. Previously, two-dimensional technologies, such as fluoroscopy or ultrasound, were used by physicians to guide catheters inside the heart. As a result, achieving steady contact at every location within the heart necessary for a successful procedure was challenging. Now combining a robotic motion control with three-dimensional visualization of the cardiac chambers, this technology allows physicians more precise manipulation and stable catheter positioning during complex cardiac ablation procedures. “An added benefit of this new technology is that it allows the physician to remotely control the catheter resulting in a significant reduction in radiation exposure for both the patient and the interventional electrophysiology team,” said Hamid Afshar, M.D., staff cardiac electrophysiologist at the MEDVAMC and assistant professor of Medicine at Baylor College of Medicine. “This new technology increases accuracy and reduces procedure time, which means our patients have less tissue damage and less discomfort,” said Blase Carabello, M.D., Medical Care Line executive. “We are proud the Michael E. DeBakey VA Medical Center has some of the best doctors and nurses in the country and offers the latest, minimally invasive alternatives for our Veterans.” t

Cutline: Irakli Giorgberidze, M.D., Electrophysiology Laboratory director, (left) uses the sensei® X Robotic Catheter system, to treat a Veteran suffering from an abnormal heart rhythm.Photo: Lucy Lacy, Cath Lab Nurse Manager


WE HAVE THE BACKBONE.

We continually push the boundaries of neuroscience.At the Mischer Neuroscience Institute at Memorial Hermann–Texas Medical Center, we have a reputation for innovation. We were selected to participate in the nation’s first multi-center trial to study the use of hypothermia following head injury. We established one of the first dedicated stroke programs in the world. We orchestrate more clinical trials for new multiple sclerosis therapies than anyone in Texas. And we are leaders in performing complex spine surgeries and reconstructions. All of this is enabled by our groundbreaking affiliation with The University of Texas Health Science Center at Houston (UTHealth) Medical School. Together, we make more neuroscience breakthroughs every day. Learn more at neuro.memorialhermann.org.

NEUROSCIENCE BREAKTHROUGHS EVERY DAY

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Medical Journal Houston March 2013