maryland physician magazine july august 2014 issue

VOLUME 4: ISSUE 4 JULY/AUGUST 2014

Physic i anYOUR PRACTICE. YOUR LIFE.

mdphysicianmag.com

MARYLAND

ADVANCES IN LOWER EXTREMITY REPAIR

ENHANCING DIAGNOSTICACCURACY

PCMHS AND ACOS: ARE THEY WORKING?

10 Advances in Lower Extremity Care16 Enhancing Diagnostic Accuracy

F E AT U R E S

D E PA R T M E N T S

ContentsVOLUME 4: ISSUE 4 JULY/AUGUST 2014

2610 20

Cases | 6 | Minimally Invasive Spine Surgery: Fast Relief for Intractable Pain

Compliance | 9 | Avoiding Billing Pitfalls in the Age of Affordable Care

Heritage | 19 | Dr. Beans: The Forgotten Man in the Star-Spangled Banner Story

HIT | 20 | PCMHs and ACOs: Are They Working?

Solutions | 25 | KISS-IT: Keeping It Simple with Information Technology

Good Deeds | 26 | Rappel for Kidney Health

On the Cover: William Cook, MD, chair of orthopaedics at The University of Maryland Upper Chesapeake Health System

Almost across the board, technology is being applied to care delivery. Both patients and healthcare reformdemand it. Healthcare reform is driving value, new technology, engagement andintegration. Baby boomers, estimated to account for more than 40% of the country’spopulation by 2020, demand it. In this issue, we explore two significant clinical areaswhere this premise prevails: orthopaedics (Advances in Lower Extremity Care page 11)and diagnostic testing (Enhancing Diagnostic Accuracy page 16).

When this issue went to print, I was spending some treasured time with my 88-year-young dad, who now suffers from dementia. He was a practicing physician well into in his 70s, and for almost 30 years, he was director of pathology in themedical lab of a community-based hospital. During our visit, I told him that one of my colleagues referred to pathologists as the future rock stars of care delivery. I wish my dad had been able to fully grasp what that meant. He was always a man of outstanding integrity who recognized the critical role each member of his staffplayed in the diagnosis of innumerable patients.

According to data supplied by the World Bank, healthcare accounted for almost18% of the United States’ GDP in 2012. We’re all quite aware of claims of inefficienciesin delivery of care, and although we spend more than any other industrialized nation,metrics focused on quality of care rank very low. That will change.

With a population that both demands and requires more efficiency in care delivery,the metric of United States healthcare expenditure will most likely remain at the topof the industrialized nations, but the metric focused on quality will shift. It has to. Our article examining whether or not Patient Centered Medical Homes and/orAccountable Care Organizations (see Healthcare IT page 20) are impacting care findsthat cost savings may be elusive initially, but they are improving care delivery.

Genomics also are already playing a part, and I wish my dad was able to understandwhere the foundations of his training and practice are going. For me, I’m extremelyproud to have had it be a part of my heritage and most fortunate to be part of anindustry that is indeed shaping the future.

To life!

Jacquie Cohen RothPublisher/Executive Editor [email protected]

@mdphysicianmag

4 | MDPHYSICIANMAG.COM

JACQUIE COHEN ROTHPUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

JACKIE KINSELLA, MANAGEROPERATIONS,

SOCIAL & DIGITAL [email protected]

CONTRIBUTING WRITERTracy Fitzgerald

COPY EDITOREllen Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

Gary Marine Photography

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

Mojo Media, LLCPO Box 949Annapolis, MD 21404443.837.6948mojomedia.biz

Subscription information: Maryland Physician is mailedfree to Maryland licensed and practicing physicians and a selectaudience of Maryland healthcare executives and stakeholders.Subscriptions are available for the annual cost of $52. To beadded to the circulation list, call 443.837.6948.

Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email [email protected].

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

PATRICIA CZAPP, MDAnne Arundel Medical Center

HOLLY DAHLMAN, MDGreenspring Valley Internal Medicine, LLC

PAUL W. DAVIES, MD, FACSKURE Pain Management

MICHAEL EPSTEIN, MDDigestive Disorders Associates

STACY D. FISHER, MDUniversity of Maryland Medical Center

REGINA HAMPTON, MD, FACSSignature Breast Care

DANILO ESPINOLA, MDAdvanced Radiology

GENE RANSOM, JD, CEOMaryland Medical Society (MedChi)

CHRISTOPHER L. RUNZ, DOShore Health Comprehensive Urology

JAMES YORK, MD Chesapeake Orthopaedic & Sports Medicine Center

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

Printed on FSC certified, 100%PCW, chlorine-free paper

PLATINUM SPONSORS

AAMC Medical StaffWhat’s Up? Media

WRNR 103.1 FM

Aerotek, Inc.Annapolis Endodontics Annapolis PediatricsAnnapolis Primary Care Annapolis Radiology AssociatesAnne Arundel Community CollegeAuxiliary of AAMCBank of AmericaBoomershine Consulting Group, LLCBuck Distributing Capital Gazette CommunicationsCareFirst BlueCross BlueShield Carol Cowie Art Direction & Design Cassidy Turley Coldwell Banker Corporate Office Properties TrustC.R. Goodman Associates, LLCDoctors Emergency Service, P.A.Drs. Walzer, Sullivan, & Hlousek and Jones First Citizens BankFutureCare Health and Management CorporationGenesis Health CareG & G Outfitters, Inc. GilbaneGinger Cove Greenberg Gibbons CommercialHeim Lantz CPA’s and Advisors

Hospice of the ChesapeakeInsurance SolutionsIP DataSystems, Inc.James and Mary T. MyersJames and Therese Roberts Jerry and Christy South John and Cathy Belcher John and Cecilia Daltner Koch HomesKURE Pain ManagementLarry and Pam Batstone LECLAIR RYANMcNamee, Hosea, Jernigan, Kim, Greenan & Lynch P.A.Moran InsuranceMulrenin & Associates Murphy Commercial Real Estate Services, LLC

Oasis: The Center For Mental HealthPlastic Surgery SpecialistsPNCReliable Contracting Company, Inc.Ricoh RxNTSandy Spring BankThe Creston G. & Betty Jane Tate FoundationThe Mark & Lynne Powell FoundationThe Morrissette Family Foundation

DIAMOND SPONSOR

COMCAST

For more information about the AAMC Gala, contact Kendra Smith Houghton at the AAMC Foundation (443) 481-4739 or email [email protected].

SILVER SPONSORS Anesthesia Company, LLCBB&T Carol M. Jacobsohn FoundationDrs. Lee, Bonfiglio, Vesely & AssociatesHargrove, Inc.Hyatt & Weber, P.A.Jan Churchill and Randy KellSevern Savings BankThe Whiting-Turner Contracting Company

BRONZE SPONSORS Barry and Mary GossettMaryland Physician MagazineM&T Bank

COPPER SPONSORS

The 2014 Spring Gala celebrated Anne Arundel Medical Center and our “Care Beyond the Walls.” Every year, AAMC contributes tens of millions of dollars in care to the most vulnerable in

our community. Many of the citizens benefitting from our services are managing the debilitating deseases of physical and/or mental illness, or the disease of addiction. It is your philanthropic support

that makes this vital care possible.

ANNE ARUNDEL MEDICAL CENTER FOUNDATION

T O O U R G E N E R O U S S U P P O R T E R S

Thank You

DISCUSSION: Back pain, sciatica, herniated discs and spinal stenosis affect90 percent of all Americans at somepoint in their lives and represents thesecond most common reason a patientpresents to a physician. Fortunately, it’soften easy to treat these problems withconservative care. However, a subset of patients will not improve on conserva-tive therapies, and their quality of lifecan be severely altered.

These patients may benefit from spine surgery, depending on theirsymptoms, physical exam and imagingstudies. Many patients are terrified ofspine surgery after hearing anecdotalstories of large incisions, extendedconvalescence, prolonged pain and longabsences from work. Older patients are afraid that they will lose theirindependence, either having to go to a nursing home after surgery orneeding help from family members who may be busy or live out of town.

Minimally invasive surgery (MIS) of the spine is a modification of standard spine surgery whereby asmaller incision is made and the musclesof the spine are preserved. Small tubes or small retractors are used to create a narrow corridor to the spine. The useof microscopes, loupes, fluoroscopy and surgical navigation allow moreprecision in order for the surgeon towork through a smaller opening. MIScan be used for many types of spinesurgeries, including discectomies,laminectomies and spinal fusions.

With an MIS approach, the musclesare not stripped off the spine. Instead,the surgeon accesses the spine through a small opening between muscle fibers.Using this muscle-sparing approach,with smaller incisions, can provide anumber of advantages to the patient.Surgical blood loss and hospital length

of stay have been shown to decreasewith less-invasive surgery, particularlyMIS spinal fusion surgery. Return towork also has been shown to be fasterwith MIS of the spine, and a recent study from Yale University suggestedthat the infection risk may be lower.

Post-operative pain and use of opiates after spinal MIS also is less than standard surgery. Additionally, with the use of pre-emptive analgesia,including pre-operative doses of Lyrica,Celebrex, and acetaminophen (po or IV),post-operative narcotic use can besignificantly diminished. This has beendocumented in multiple studies in bothspine literature and anesthesia literature.Intra-operative use of ketamine andsteroids also have been shown todecrease post-op pain.

This particular patient decided hecould no longer tolerate the pain. He chose to have a minimally invasivelaminectomy and interbody fusion with pedicle screw instrumentation.Surgical time was only two hours andfive minutes, blood loss was 75 cc, and the patient was discharged from the hospital after one day.

He had been on prolonged narcoticsprior to surgery, but was able to stop all narcotics one week following hisprocedure. He began working fromhome immediately, started part-timework at one week, and returned back to full-time work at two weeks. He isnow six months post-op and hasachieved a solid fusion. He continues to work full time and has resumed allprevious activities, including sports.Philip Schneider, MD, is the medical directorof the Holy Cross Hospital Spine Center

and president of Montgomery Orthopaedics,

a division of The Centers for Advanced

Orthopaedics. He can be reached at

301.949.8100 or [email protected].

Cases

Minimally Invasive Spine Surgery:Fast Relief for Intractable Pain

CASE: A 54-year-old malepresents with a four-year history of severeback pain, sciatica anddifficulty walking. Hehas spinal stenosis andspondylolisthesis at L4-L5. The patient hasloss of sensation andweakness. He is nolonger able to work out or even enjoyrecreational activitieswith his wife due tointense pain and theneed for opiates. He has failed conservativetreatment, includingmedication, physicaltherapy and epiduralblocks. He has been told that this problem is correctable withsurgery. However, hehas avoided surgerybecause he works inoutside sales and has no income if he doesnot work. He has twochildren in college andcan’t afford to takemuch time off forsurgery.

Philip Schneider, MD


Revised Maryland Medical Marijuana LawWill Certify Physicians

FTER 2013 MARYLANDmedical marijuanalegislation failed to

produce any academic medical centersthat were willing to make the drugavailable for medical purposes, theMedical Marijuana Law Senate Bill 923and House Bill 881 were passed in thislegislative session. Signed by Gov. MartinO’Malley on April 14, 2014, the new law retains the Natalie M. LaPradeMedical Marijuana Commission that was established in 2013, and charges the Commission with promulgatingregulations to implement the changes by Sept. 15, 2014.

The new legislation will allow “certifieddoctors” to give recommendations (not aprescription, as these are prohibited byfederal law) for medical marijuana topatients that they believe would benefit.

Paul Davies, MD, chairman of theMedical Marijuana Commission, said,

“After our Commission proposes theregulations, they will be reviewed by the Maryland Department of Health and Mental Hygiene, the attorneygeneral’s office and a legislative oversightcommittee.”

Once final regulations have beenpromulgated, which is anticipated totake about four-six months, theCommission can begin taking applicationsfrom physicians and prospective growersand dispensers.

“Maryland will have one of the bestprograms in the country, thanks to thelessons learned from the many states that have already legalized medicalmarijuana,” Dr. Davies notes. “Anyphysician wishing to recommend medicalmarijuana for his or her patients willhave to undergo a training program andbe credentialed by the Commission.”

The Commission chairman estimatesthat it will take until early in 2016 to

establish the necessary network to make the drug available to qualifiedpatients. “We are already working on an implementation plan,” he said.

While initially, the number of potential licensed growers is limited to15, the Commission may choose toincrease the number of licensed growersin future years. Licensed growers must undergo a background check. Dr. Davies anticipates strong demandfrom growers, and is hopeful thatphysicians will exhibit equally stronginterest. “Studies have shown thatmarijuana can help ameliorate nauseaand vomiting, stimulate appetite, reduce pain and lower intraocular eyepressure.”

The new legislation increased from 11 to 14 the number of Commissionmembers, which include medical,pharmaceutical, law enforcement, and legal professionals.

A

JULY/AUGUST 2014 | 7


Is there a doctor in the house?

Physician’s Mortgage ProgramPurchase or Refinance

Primary or Second/Vacation Homes

High Loan-to-Value with No Mortgage Insurance

Great Rates

Loans Serviced Locally

Million Dollar+ Loans

Low Down Payment

*Applicant must be an existing or newly licensed doctor. Loans subject to program availability and credit approval. Terms and conditions may apply.

Call or visit410.260.2000

severnbank.com


Compliance

Avoiding Billing Pitfalls in theAge of Affordable Care

By Thomas C. Morrow

N THE SECOND DECADE OF THE21st century, many healthcare providersare struggling to decide whether or notto accept patients who have Medicaid. A key issue is the provider’s ability toensure compliance with its myriadreimbursement regulations.

Failure to maintain familiarity with the requirements can result in withheldreimbursement, civil lawsuits forrestitution of past payments, and evenfederal and state criminal prosecution. As the pool of Medicaid-enrolled patientsincreases, a growing number of providerswill need to navigate complex andconfusing reimbursement procedures.Thorough knowledge of proper billingprocedures is not optional. Failure toadhere to reimbursement regulations andrequirements can be disastrous toindividual and institutional providers.

The Patient Protection and AffordableCare Act (ACA) includes provisions thatMedicaid payments may be suspended as the result of an audit, even withoutproof of fraud. A credible allegation offraud is the sole requirement. Section6402(h) of the ACA requires a state tosuspend payments to an individual orentity providing medical services pendinginvestigation into such allegations. Astate may decline to withhold paymentsonly if it determines that there are goodreasons not to withhold such payments,and these are limited.

Potential Sources of Fraud Allegations Sources of allegations include theobvious, such as “whistle blowing” from a disgruntled employee or tips to afraud hotline. Sources also may includevirtually any allegations that mayultimately be deemed “credible.”Increasingly, such allegations originatefrom computer analyses of claims datathat produce atypical, and thereforesuspicious, patterns compared to

I similarly situated providers. An exampleis “up-coding,” where a provider uses a higher billing code than the normamong similar providers.

Another example involves consistentfailure to provide documentation thatthe auditing entity requires to justify the procedure associated with a specificcode. Obvious examples of fraud includebilling for services not provided ormultiple billings for single procedures.Outright false billing aside, allegationscan arise from errors made whenproviders delegate the coding/billingprocess to persons inadequately trainedin the complexities of the billing process.

Maryland LawIn Maryland, a provider may appeal a notice of suspension to the Office ofAdministrative Hearings (OAH). TheOAH does not conduct an independentreview to determine if the suspension isjustified, but limits its determination towhether or not the allegation of fraud is credible. This standard is far from the “preponderance of evidence” standardused in civil trials, and demands less proofthan the “probable cause” standardrequired to initiate a criminal charge.

The criteria to justify a suspension are probably most analogous to“reasonable belief,” which requires onlythat the specifics of the allegation itselfbe verified by a state entity and that thesource has the indicia of reliability. Thus, the appellate review of asuspension in the Maryland OAH istypically limited to an inquiry into thenature of the allegation and thereliability of its source.

Once the state has “verified” an

allegation of fraud, the ACA requires the allegation to be referred to theMedicaid Fraud Control Unit (MFCU),an investigation and prosecution unit of the Attorney General’s Office in moststates. CMS has published standards forevaluating fraud allegations.

Know When to Seek an AttorneyBecause suspension of reimbursement is usually based on a “credible allegationof fraud” that will inevitably beevaluated by MFCU, a provider notifiedof a pending suspension shouldimmediately contact an attorney.Aggressive intervention by counsel

familiar with reimbursement issues may have the suspension terminatedthrough negotiated settlements and help a provider establish that the codingwas justified.

Where coding practices are erroneous,an attorney can help establish that errors were not the result of intentionalfraud. This may lead to settlementoptions ranging from reimbursing theMedicaid program for overpayments,implementing corrective action plans andeducational programs, reorganizing andupgrading medical records and otherremediation options. Most importantly,early resolution of such investigationscan avoid the economic devastation ofdefending a complex false-claims suit orthe professionally catastrophic impact ofdefending criminal charges.Thomas C. Morrow, partner of Shaw & Morrow, P.A., represents healthcare

providers in professional discipline and

credentialing matters. For more information

go to shaw-morrow.com.

The criteria to justify a suspension are probablymost analogous to “reasonable belief.”


William Cook, MD, chair of orthopaedics at The Universityof Maryland Upper Chesapeake Health System

ROBOT-ASSISTED THAWith baby boomers increasingly seekinghip and knee replacements at a youngerage, and with longer-lasting componentmaterials, getting a good ‘fit’ isincreasingly critical. Hip replacementsare now expected to last for 20 years or more, both fueling and responding to this trend. Robot-assisted total hiparthroplasty (THA) is a newer option to increase the precision in componentorientation, now available in Maryland.

William Cook, MD, chair oforthopaedics at The University ofMaryland Upper Chesapeake HealthSystem, is among the first to employMAKOplasty® for THA in Maryland.


Living longer has its advantages. But our lower extremity joints weren’t necessarily built to withstand all of the stresses placed on them.

Our orthopaedics experts discuss the latest in repairing these critical joints when they suffer lifelong damage.

“MAKOplasty is a CT-guided navigationsystem that gives us a new level ofaccuracy,” he states. “It uses a softwareprogram based on a 3D model of thearea that enables us to plan our surgeryaccording to the patient’s unique anatomy.We optimally position our implantsahead of time based on the computermodel. Then, when we’re performing the procedure, the robot preventschanges and minimizes bone resection.”

Since the hospital system purchasedthe MAKOplasty component for hips in the fall of 2013, Dr. Cook and his colleagues have performedapproximately 20 procedures withrobotic assistance. “The exciting thing

LOWER EXTREMITY

CAREBY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

about MAKOplasty for hips is that itcan precisely align the acetabular cup inthe correct inclination and the correctversion, to create the most stable hippossible. We can precisely duplicate the anatomy, leading to a lower risk of dislocation and reduced leg lengthdiscrepancy. One of the main reasons for patient dissatisfaction following hipreplacement is leg length discrepancy.”

He adds, “We can duplicate apatient’s hip offset, which is the distancebetween the socket and the leg. If thesoft tissue is aligned properly, it restoresthe muscle tension and decreases painand recovery time.”

A good candidate for MAKOplasty

ADVANCES IN

is someone who is not overly obese or muscular and has bone that is notexcessively osteoporotic. Dr. Cookexplains, “I currently reserve thisprocedure for very active patients, suchas someone who is jogging or playingtennis. The difference is less critical for older, less active patients.”

After the patient decides to haveMAKOplasty, he or she typicallyundergoes a 3D CT scan one-two weeks in advance of the procedure. The data from the scan is fed into thecomputer program, then the surgeonselects the appropriate sized implant and the amount of bone to be removed.Patients typically have a one-night stayin the hospital, and then are dischargedto home with full weight bearing.

Depending on the patient, they mayreceive home or outpatient physicaltherapy. “Pain scores are consistentlylower,” says Dr. Cook. “Most patientscan recover in four-six weeks instead of three months, with the roboticapproach.”

Anterior ApproachDr. Cook performs the majority of THAs using an anterior approach, whichhe has employed on appropriatecandidates for the past 10 years (seeMaryland Physician July/August 2012,“Joint Tune Ups” for more on anterior

hip replacements). “An anteriorapproach prevents having to detach andreattach muscles, which can lead toatrophy and/or a limp,” he notes. “A posterior approach has a higherdislocation rate, and a lateral approachrequires muscle detachment. However,due to the positioning of the leg in theanterior approach, it’s not appropriatefor everyone, such as those withsignificant osteoporotic bone, which can fracture, or obese patients.”

Rethink Pain ManagementDr. Cook has seen a growing trendamong referring physicians to sendpatients who fail physical therapy and anti-inflammatories for painmanagement. “There is a tendency tosend patients for narcotics rather thanreferring them to an orthopaedicsurgeon. In my opinion, that’s not theideal management of these patients.While you don’t want a patient toundergo surgery unnecessarily,physicians may not be recognizing thatmany of these patients have issues thatwon’t be satisfactorily addressed bynarcotics. The infection risk in THA is less than 1% nationally, and thesatisfaction rate is greater than 95%.”

Trending YoungerDr. Cook comments, “In the 70s and80s, the mindset was to have patientswait until they were in their 60s or 70s to get a THA. That started to change in the early 2000s. Myphilosophy is that we can offer theseprocedures to younger patients nowbecause we can expect one implant tolast up to 30 years. The more precisely itmimics the patient’s anatomy, the betterthe outcome and longevity. One of thereasons I love being a joint surgeon isthat you give people back their lives.”

IS CEMENTLESS KNEEARTHROPLASTY SUPERIOR?The increase over the years in thenumber of hip replacements is linear, but knee replacements are increasing

exponentially, according to AntoniGoral, MD, medical director of the JointCenter at Holy Cross Hospital. “We’redoing about 800,000 knee replacementstoday, but by 2030, we expect that togrow to 3.5 million. Why? In partbecause we’ve been doing kneearthroscopy since the 1980s for meniscaltears and other problems, and people goback to high levels of activities. Werelieved people’s symptoms, but were wesetting many of them up for developingarthritis over time? For young and activepatients, wear and loosening contributeto the need for revision surgery of aprior knee replacement.”

If knees were simple hinge joints, itmight be easier to repair or replace them.But because they involve both rollbackand pivoting, they are complex to treat.As with hips, more people are choosingto have a knee replacement whileyounger and more active. That alsomakes it crucial for knee surgeons tocarefully assess and recommend theoptimal approach.

Dr. Goral explains, “Most of the loadon a hip joint is compressive, but withknees, many of the loads are shear. Thegoal of knee arthroplasty is to restore the normal kinematics of the knee.”

Evaluation and Non-Surgical Approaches“Some physicians still focus on usinganti-inflammatories even when there’s no inflammation,” complains Dr. Goral.“Analgesics, such as acetaminophenaround the clock, are better in thesecases. Some studies suggest thatchondroitin and glucosaminesupplements are protective of cartilage,but the American Academy ofOrthopaedic Surgeons has graded this approach a “C,” meaning that the evidence can’t presently support that claim.”

He adds, “If there are flare-ups,injecting cortisone or a biologicallubricant such as hyaluronics into thejoint may help. Injectable medications,unlike pills, have to get into the joint.

The exciting thingabout MAKOplasty for hips is that itcan precisely alignthe acetabular cupin the correct inclination and thecorrect version, tocreate the moststable hip possible.– William Cook, MD


FOUR KEYS TO SUCCESSFUL THA OUTCOMES1. Version 2. Inclination 3. Leg Length 4. Femoral Offset (muscle tension)


I tell people that you can’t put oil on the hood of a car, you have to put it inthe engine.”

History of CementlessCementless knee arthroplasty has beenavailable since the 1980s, whenloosening of a knee replacement overtime was believed to be due to ‘cementdisease’ – a reaction to the cement usedto adhere the replacement. Duringsurgery, the bone is slightly compacted,contributing to the problem.

“Today, we believe that a combinationof motion and minute particles that wearaway lead to inflammation and enzymesthat trigger osteoclasts. The osteoclaststhen gradually eat away the bone,” says Dr. Goral. “There are sharp changesin loading going from bone to implant,so manufacturers have tried to design an ‘ingrowth’ approach using moreporous implant surfaces into which bonecould grow. In the 1980s, the implantswould have layers of tiny beads or amesh to address this, but we found thatthey separated and left too much spaceover time.

“While the vast majority of kneereplacements today are still cemented,we’ve tried various cementlessapproaches over the years. Today, one approach uses a powdery plasmaspray that increases osteo integration.However, with a cementless approach,you need to provide additionalstabilization of the implant during early recovery.”

Comparable ResultsTo provide the necessary stabilizationafter a cementless approach, there arethree options for fixing the tibial side –pegs, screws or stems. Dr. Goralcomments, “There are advocates foreach approach, though I personallyprefer stems. All three hold the implantfirmly for the three-four months that the bone is potentially growing up to,and into the surface.”

According to Dr. Goral, cementlessand cemented knee arthroplasties haveroughly the same results. “Most studiesof implant longevity and patientsatisfaction have found that therestoration of a neutral knee alignment

…with knees, manyof the loads areshear. The goal ofknee arthroplasty isto restore the normalkinematics of theknee. – Antoni Goral, MD

Antoni Goral, MD, medical director of the Joint Center at Holy Cross Hospital

is most important, not the implanttechnology,” he notes. “Better, morecustomized instrumentation and roboticguidance improve outcomes. The idealoutcome is a ‘forgotten’ joint, one that has no clicks or pain and that feelsstable enough that the patient forgets it is there.”

On the HorizonIn the future, Dr. Goral believes thatplatelet-rich plasma, which containsgrowth factors, may be used to promotehealing. “It’s safe, but we’re not sure yet if it’s effective. Autologous, adipose-derived stem cells may also hold promise,though there’s insufficient evidence as ofnow, so it’s not reimbursed by insurers.”

HEALING COMPLEX ANKLEFRACTURESKnees and hips get much of the attentionin orthopaedics, but a strong, properlyfixated ankle is critical to staying mobile.According to Stuart Miller, MD,MedStar Orthopaedics foot and anklesurgeon, “When you go up a set ofstairs, you’re putting five times yourbody weight on your ankle. And anklefractures, surprisingly, are one of themost common fractures, occurringacross all age groups.”

Fortunately, a growth in dedicatedfoot and ankle specialists, bettertechnology, and more flexiblestabilization devices are revolutionizingcare of this key joint.

Growth in Foot and Ankle Specialists“There’s been an explosion in foot andankle specialists recently,” Dr. Millerclaims. “Some 10 years ago, there weresix in the greater Baltimore area; today,there are 12 specialists, and two moreare coming soon. When a fellowship-trained specialist performs a foot orankle procedure, it may be more precisebecause it’s all we do.”

Dr. Miller says, “I perform many totalankle joint replacements today. Morethan 80% of these patients have trauma-caused arthritis. One journal recentlyreported that it can take 21 years froman ankle fracture to the development of arthritis. It’s why we’re seeing somuch of it now. Over the years, we’velearned that even a small amount ofdisplacement creates a big problem over time.”

Anatomic Locking Fibular PlatesA substantial improvement in anklefracture stabilization is the number of new anatomically locking fibularplates that are available. Designed to fit on the lateral aspect of the distalfibula, these devices maximize bonefracture stabilization and minimize softtissue irritation.

“They are pre-contoured to fit thepatient’s anatomy, and use lockingscrews that function somewhat like a molly bolt, to work far better incomminuted osteoporotic fractures,”explains Dr. Miller.

Fixation of Syndesmosis & FractureSuture “Buttons” Offer Advantages Over ScrewsNewer approaches to stabilizing theligaments and bones following acomplex ankle fracture have eliminated


With the eliminationof casting, patientsno longer have tospend months gettingback range of motion, and they are much happier. – Stuart Miller, MD

Stuart Miller, MD, MedStar Orthopaedics foot and ankle surgeon

Clinical FeaturesMaryland Physician spotlights advances in the latest

in clinical developments each issue with updates in

leading-edge diagnosis and treatment options led by

Maryland’s specialists.

Healthcare ITMaryland Physician explores a different facet of the race

to implement EHRs to meet Meaningful Use and other

e-health government incentives. Don’t be left behind –

read what Maryland physicians and healthcare IT experts

have to say that eases the pain of transition to an

electronic world.

In Every Issue and OnlineCases xSolutions xCompliance xPolicy

Physicians Physical Therapists

yregrusrosgurdredisnocylesicreptahtsreudecorpstsiparehTlalcisyhPdnaruO.llatisyaaysemanehT

uoyreKuotyaaywtsebehtreovcsidyniapkcendnakcabruoyhtiwlaedyyteiravanidecneirepxeylhgihreasnaemhcaorppayranilpicsid-itlmur

.niapru oyreoffoeB.

l acigrus-nonfoysnaicisyhPruosn

Most Insur

epain.comkur

ances AcceptedMost Insur

epain.com

the need to use screws, which areremoved in a follow-up procedure.These approaches instead use a tinyincision to insert a suture between two ‘buttons.’

“We drill across the tibia and fibula,insert a tiny oblong rod or ‘button’that’s analogous to a rice kernel inshape,” Dr. Miller states. “We pull/twist it so that it can’t go back through the hole. Today, we’re alsousing this method to fix anklesyndesmotic injury and gain stability.Biomet Sports Medicine offers aZipTight™ Fixation System and Arthrex offers a Knotless TightRope®

System for syndesmosis repair. They are low-profile and knotless, to preventsoft-tissue irritation and allow moreprecise duplication of joint mechanicsduring movement.”

From Casts to ROM SplintsNewer approaches to immobilizingankles after a fracture are putting cast technicians out of business. “We got rid of our cast tech at UnionMemorial Hospital years ago,” Dr. Miller notes. “Our patients go into a splint after surgery and then to a Range of Motion (ROM) ‘boot’ at one week. We use it like a cast for the first four-six weeks post-op, thenstart gradually introducing weightbearing. This approach promotes fasterand better rehabilitation, the skin ishealthier, and patients can take the boot off to do gentle ROM and tobathe. If the fracture is stable, patientsmay even be able to take the boot off at night.”

The ROM boots can be non-inflated(appropriate for minor injuries), pre-inflated, or have an adjustablebladder that allows the ankle to befixed at a given point or permits range of movement within a set angle.Dr. Miller concludes, “With theelimination of casting, patients nolonger have to spend months gettingback range of motion, and they aremuch happier.”


William Cook, MD, chair of orthopaedicsat The University of Maryland Upper

Chesapeake Health System

Antoni Goral, MD, medical director ofthe Joint Center at Holy Cross Hospital

Stuart Miller, MD, MedStar Orthopaedics@mdphysicianmag

Jacquie Cohen Roth x Publisher/Executive Editor443.837.6948 x[email protected]

mdphysicianmag.com


DIAGNOSTIC ACCURACYAN EXPLOSION IN THE TYPES AND COMPLEXITY OF DIAGNOSTICTESTS MAKES IT CHALLENGING FOR PHYSICIANS TO ORDER ANDINTERPRET WITH CONFIDENCE. PLUS, REIMBURSEMENT CHANGESINCENTIVIZE PHYSICIANS TO ORDER ONLY WHAT IS ESSENTIAL.HERE’S A GUIDE FOR ENSURING MORE ACCURATE DIAGNOSES.

By Linda Harder

ENHANCING

WHERE IS THE GREATEST CAUSE of errors in diagnostic testing? It’s in thepre-analytical phase, when the specimenis drawn and transported, not in theanalytical phase in the lab, nor in thepost analytical phase, when physiciansget test results back. Surprised?Christopher Grove, MD, director ofpathology at Carroll Hospital Center,gets that reaction a lot.

“Most people, physicians included,are surprised to learn that very fewerrors occur when the test is beingrun,” he says. “Most testing is highlyautomated today and our techs run a number of safety checks along theway. For example, the system flags a specimen if there are clots.”

A new study published in theJournal of the American Board ofFamily Medicine’s March/April 2014issue found that primary carephysicians report experiencinguncertainty nearly 15% of the timewhen ordering tests and 8% of thetime when interpreting their results.That translates to millions of patientswhose results may be inappropriatelyordered and interpreted. Both thearticles’ authors and Dr. Groveattribute this problem in large part to an upsurge in the number andcomplexity of clinical laboratory tests.

VALUE OVER VOLUMEThere’s also a financial cost toordering lab tests. According to a2011 article in the American Journalof Clinical Pathology, physicianscontrol as much as 80% of healthcarecosts, and lab data influences over half of their decisions. However, moretest ordering has not correlated to ahigher quality of care.

Dr. Grove observes, “One of thebiggest changes in ancillary testing isthat we’re moving from fee-for-serviceto population-based reimbursement.We’ve had an inefficient system that has spent twice as much as any otherindustrialized nation on healthcare, yet we consistently rank near thebottom in several quality measures.Now, we’re looking more for value than for volume. But data suggests that

primary care physicians order tests on 30-40% of the patients they see. Too many take a shotgun approach by ordering a wide panel, when anarrower one would be appropriate.

“At Carroll Hospital Center, we’reworking on a solution to help primarycare physicians,” he adds. “We list the appropriate tests to order so wecan eliminate archaic tests, and we’redeveloping order sets for differentconditions to streamline testing. We’dlike to see decision support as part ofthat, so that a physician ordering testsfor a diabetic patient, for example,would have a pop-up screen at thetime of order entry that lists the mostappropriate tests for that condition.”

While the cost of lab testingrepresents only about 4% of overall

healthcare spending in the UnitedStates, it represents nearly $60 billion ayear of healthcare costs. That number islikely to climb, given that molecularand genetic testing is growing rapidly.

MOLECULAR TESTINGMolecular testing is now available for a burgeoning number of medicalproblems, including cancer, infectiousdiseases, dementia and geneticdisorders. New molecular panels add to the complexity of testingoptions and to the expense. WithMaryland hospitals facing globalbudgeting under the new Medicarewaiver, they are likely to be seekingways to reduce expensive tests unlessthose tests can cut other costs.

Such tests can present ethicaldilemmas as well. New researchindicating that 10 phospholipidsfound in the blood can predict with90% accuracy whether an individual

will develop Alzheimer’s diseasewithin the next two-three years may prove valuable as more effectivetreatments are uncovered. However,many physicians fear that they willcontribute to unnecessary worry, with limited options to take action.

Dr. Grove believes that, whilemolecular testing has its place, itshould not be used when a lessexpensive, high-quality option exists. In these situations, apathologist can be extremely helpful.He gives the example of Lyme PCR on cerebrospinal fluid for thediagnosis of Lyme-related meningitis.This molecular test is often usedinappropriately in place of the simpler,less expensive, and equally accurateenzyme-linked immunosorbent assay

(ELISA) or immunofluorescent assay(IFA) tests for Lyme disease.

“ELISA or IFA are screening teststhat cost about $45, compared to aPCR-based test that costs $200. Theytest for the presence of antibodies andhave a rapid turnaround time of one-two hours, compared to several daysfor a molecular send-out test. Theyalso have excellent sensitivity andspecificity for CNS involvement byLyme disease,” says Dr. Grove.

The Mayo Clinic website states that PCR testing should be ‘limited to patients with a positive, or at leastan equivocal, serologic test forantibody to Borrelia burgdorferi.’

Another example Dr. Grove cites is testing for patients with suspectedthyroid disease. “The best startingpanel includes a TSH and freeT4 test.A T3 resin uptake has no role indiagnosis today for the vast majorityof these patients.”


Pathologists are increasingly using evidence-based medicine in our decisions.We can play a key role in helping doctorschoose the right test. – Christopher Grove, MD

NEW SEPSIS BIOMARKERA newer assay on the horizon that maybe of great clinical utility to primarycare physicians is procalcitonin (PCT),a biomarker for sepsis that just recentlyreceived FDA approval. “Increasedlevels correlate with bacteremia inemergency department patients,” Dr.Grove explains. “We’re hoping to bringit in-house at our hospital over the nextfew months. It takes about an hour toget results, is relatively inexpensive and can be used together with CBC,lactate levels, and blood cultures in theevaluation of pediatric and adult sepsis.PCT levels offer another importantdata point to help us decide if a patientneeds to be admitted.”

COAGULATION TESTING“We’ve decreased or eliminated most, if not all, of the coagulation testsperformed on inpatients who presentwith deep vein thrombosis and/orpulmonary embolus,” Dr. Grove says.“In the past, clinicians ordered anexpensive panel of serologic andgenetic tests as part of a thrombophiliaworkup to see if there was a problemwith the coagulation cascade. But thepatient was often discharged before the results came back. Additionally,many of the tests are unreliable in thesetting of active thrombosis and anti-coagulation. Our utilization committeedecided to move testing to theoutpatient setting after the appropriateperiod of anti-coagulation and after thepatient’s episode of acute thrombosis.”

SELECTING A LABDr. Grove advises physicians to lookfor the following characteristics whenchoosing a lab provider:

‰ Is accredited by the College of American Pathology

‰ Is conveniently located for patients‰ Offers a courier service‰ Interfaces with your office

computer system ‰ Provides reports that offer

ready interpretation of the results‰ Offers good customer service,

including a representative who can answer your questions

‰ Is covered by the patient’s insurance

And he advises referring physiciansto take advantage of their pathologistsas resources, saying, “Pathologists are increasingly using evidence-basedmedicine in our decisions. We can play a key role in helping doctorschoose the right test.”

A SALIVA TEST FOR SCOLIOSISSaliva testing is gaining in popularity asa diagnostic technique that can identifymarkers for inflammatory, endocrine,immunologic, infectious and otherdiseases. Saliva can assay steroidhormones like cortisol, genetic materiallike RNA, enzymes and antibodies and natural metabolites. It can helpdiagnose cancer, HIV, Cushing’s disease,perinatal genetic disorders, and evenallergies and scoliosis.

Who knew that 53 genes play a role in developing scoliosis or that spitcould help predict its course? MichaelMurray, MD, a spine surgeon withMedStar Orthopaedics, says, “Thecause is multifactorial, involving both genetic and environmentalcomponents. It’s possible for only oneidentical twin to get the condition.”

The ScoliScore Test, which has been available for about five years buthas had limited use to date, tests for 53 genes that have been linked toAdolescent Idiopathic Scoliosis (AIS).Twenty-five of those genes areprotective, while the other 28 areprogressive. Dr. Murray notes,“Combining the results of this test withthe patient’s level of skeletal maturityand degree of curve on a x-ray helps uspredict the risk of scoliosis developingto the point where surgery is needed.”

He continues, “An algorithm ofthese factors creates a possible scoreranging from 1-200. A score of 50 orless is 99% accurate in predicting thatsurgery won’t be necessary. It alsomakes it less likely that the child willneed bracing.”

The ideal candidates for this test are9- to 13-year-olds who have a Cobbangle of 10-25 degrees of curvature of the spine. Each child provides asaliva sample that is analyzed atTransgenomic’s lab for DNA markers.Results take about six weeks. Dr.Murray explains that one reason the

test isn’t more widely performed has todo with insurance coverage. “However,Transgenomics tries to work withinsurance companies to get coverage.”

If the scoliosis progresses to an angleof 40 degrees or more, that is usuallyconsidered an indication for surgery. If it progresses to 25-35 degrees,physicians may consider bracing. A lowScoliScore indicates a lower likelihoodof needing bracing as well as surgery.

“The test is most useful for the low-risk group,” acknowledges Dr. Murray. “That can change theirmanagement. For the other groups, it may not change how their physiciansmanage their care.”

Presently, the ScoliScore test is onlyvalidated on Caucasians. “However,work is underway to test this on otherethnicities,” Dr. Murray comments.Primary care physicians should referpatients with greater than a 10-degreecurvature to a spine surgeon. Thosewith intermediate to high risk ofdeveloping significant curvature should receive routine x-rays everythree-six months during their growth spurt, when the scoliosisprogresses the fastest.

“Bracing, if necessary, is ideally used for 22-23 hours a day. It’s liketethering a bean stalk,” explains Dr.Murray. “The brace pushes the spine in a straight direction. The child shouldwear it until finished with their growthspurt, and until skeletal maturity hasbeen reached.”

He concludes, “The unique powerand chief utility of the scoliosis testlies in its ability to reassure patientsthat they are unlikely to develop apotentially disabling condition, notthat they are at increased risk ofdeveloping scoliosis. Genetic screeningis utilized in a growing number of teststoday, such as testing for BRCA1 and 2 or MLH1/MSH2 genes and theirassociation with developing breastcancer and colon cancer respectively.”


Christopher Grove, MD, director ofpathology at Carroll Hospital Center

Michael Murray, MD, Medstar

Orthopaedics


Heritage

Dr. Beanes: The Forgotten Man in the Star-Spangled Story

Meg Fairfax Fielding

HE MEDICAL & CHIRURGICALFaculty of Maryland (MedChi) wasfounded in 1799, just years after thebirth of our country. Many of MedChi’searly members fought in the AmericanRevolution, and were prepared to fightagain in the War of 1812 – and in theBattles of North Point and Baltimore,which took place in September of 1814.

It is one of MedChi’s foundingmembers, William Beanes, MD, ofPrince George’s County, who played apivotal, yet largely unknown, role in thehistory of the Star-Spangled Banner. If not for Dr. Beanes, Francis Scott Keywould not have been on a ship inBaltimore’s Harbor, and he would neverhave written the poem that became ourNational Anthem.

William Beanes was born at BrookeRidge in Prince George’s County onJanuary 24, 1749. There were nomedical schools when Dr. Beanes studiedmedicine, so he apprenticed with a localphysician. Professionally, his finereputation spread beyond the county,and in 1799 he became one of thefounding members of the Medical andChirurgical Faculty of Maryland, and a member of its first examining board.

During the summer of 1814, as theBritish prepared to invade Washington,General Ross selected Dr. Beanes’ homeas his headquarters, and Dr. Beanesagreed not to object to his presence orharm the troops. However, when theBritish Army returned to UpperMarlborough (now spelled Marlboro)after burning Washington, they werejubilant, drunk and marauding. Dr. Beanes and some of his neighborswere forced to arrest some of the mostbadly behaved of the group. Oneprisoner escaped and reported this to General Ross.

T

General Ross returned and arrestedDr. Beanes in the middle of the night. Dr. Beanes traveled with the BritishArmy down the Potomac River and up the Chesapeake Bay, where theBritish prepared to burn Baltimore asthey had done in Washington.

A lawyer named Francis Scott Keywas engaged to free Dr. Beanes from theBritish Army. Key traveled to Baltimorewith letters of support from PresidentJames Madison, as well as letters fromBritish prisoners whose injuries Dr.Beanes had treated only weeks earlier in Upper Marlborough.

Dr. Beanes was being held on a truceship just south of Baltimore, and Keysailed out to negotiate for his release.Key secured Beanes’ release, but as thebattle was beginning, the men were notallowed to leave.

For more than 25 hours the battleraged. Dr. Beanes and Key watched and waited all through the night.Toward morning, the cannon fire slowed and then stopped, followed by an ominous silence from across the

water. As the dawn broke, Key and Dr. Beanes were able to see that the flag was still there, flying above FortMcHenry. They knew that the Britishhad not captured Baltimore.

As the men sailed back to Baltimore,Francis Scott Key penned the nowfamous poem on the back of anenvelope. It was printed in a local paperand then set to the tune of an olddrinking song, To Anacreon in Heaven.

Dr. Beanes returned to his home,Academy Hill in Upper Marlborough,and continued to practice medicine. He died at age 80 in October of 1828.

Dr. Beanes is buried in a smallgraveyard in Upper Marlborough, and is remembered throughout PrinceGeorge’s County, where roads, schoolsand parks bear his name and continue to tell his story.

Dr. Beanes is the forgotten man in the Star-Spangled story.Meg Fairfax Fielding is director of development, Center for a Healthy Maryland,

The Foundation of MedChi. For more

information, visit healthymaryland.org.

Maryland native William Beanes, MD, played a pivotal yet largely unknown role in the history of the Star Bangled Banner, which celebrates its bicentennial September 2014.


Healthcare IT

The literature presents a mixed picture of the effectiveness of Patient Centered Medical Homes (PCMHs) and Accountable

Care Organizations (ACOs), which Maryland Physicianfirst explored in 2012. Maryland experts provide theirperspective, and discuss why the new Maryland Medicare

waiver may provide an impetus to both.

BY LINDA HARDER

AND

ARE THEY WORKING?

ACOs:PCMHs


ACOsIn 2014, some 343 Medicare ACOs are operational in the United States, with 15 of those in Maryland. Of the roughly 900,000 Medicare beneficiaries in the state, about 100,000 are now participating in an ACO.

“ACOs are pretty much aligned with other populationhealth initiatives,” says Craig Behm, executive director,MedChi Network Services. “I’m optimistic about ACOs andthe potential to work closely with hospitals because of thealigned goals. The ACO program certainly has flaws, such asthe timelines the Centers for Medicare and Medicaid Services(CMS) established, but for the most part, it’s pretty good. Thequality measures, for example, need some work but are anappropriate starting point.”

Mitch Gittelman, DO, is medical director of the LowerShore ACO, one of the Maryland ACOs established under the CMS Advance Payment Model and managed by MedChiNetwork Services. Based largely in Wicomico County, itencompasses 11 practices with 33 physicians and mid-levelproviders serving approximately 10,000 Medicare patients.

Quality MeasuresCMS measures the ACOs on 33 quality measures, 23 of whichthey have to report on themselves. “The measures includeitems such as: are patients with coronary artery disease takinga daily aspirin; have patients with congestive heart failure hadan echocardiogram in the past year; has a woman had amammogram; have patients received pneumococcal vaccines,etc. I personally like the measures that are part of this model,”says Dr. Gittelman. “There’s strong evidence and goodthought processes behind most of them.”

He further notes, “Going forward, we’ll need to be able to break out the data for individual practices so I can go backto an individual doctor about his or her results. The hope isthat by providing data, physicians will change their practices.Doctors will only change when given evidence-basedinformation and resources. It seeps into your consciousness.Building a web-based, protocol-driven platform that everyonein the ACO could use took most of our first year, but will bewell worth the time spent.”

ACO ResultsAn independent evaluator determined that the first “pioneer”group of ACOs as a whole improved the quality of patientcare and saved CMS nearly $150 million in their first year.However, results varied widely among the ACOs participatingin that pilot group. Evaluations of the next group of ACOsfound that more than 50 of the Medicare Shared SavingsProgram ACOs spent less than their budgets, but that only 29 of them qualified for shared savings, while 60 ACOs spentmore than their budgets.

CMS Advance Payment Model“Quality scores did increase year over year for the twoMaryland Advance Payments ACOs that have beenestablished for two years,” Behm notes. “Even if the ACO program doesn’t last beyond the initial three-yearcontract period with CMS, it still has value in that it providesconsistent care and greater communication. We’ve achievedthe philosophical goal. In terms of savings, it’s still early andwe didn’t expect significant cost reductions, but among theACOs created in 2012, one had modest savings and the other did not.”

The CMS Advance Payment Model provided up-frontfunding as well as some ongoing funding in the form of non-recourse loans. MedChi Network Services alsocontributed to the ACOs, including that which was put inthrough in-kind services. To build and operate the clinical and technological infrastructure to manage about 28,000beneficiaries, the ACOs received about $4 million. However,that amount is not sufficient to take on some of the care that the ACOs would like to have.

Behm notes, “There are lots of things we’d love to do but can’t afford, such as assigning nurse care managers tointensely manage high-risk patients for 90 days, offeringmultiple telehealth services, and even paying forG

ARY MARINE

Mitch Gittelman, DO, family practitioner and medical director

of the Lower Shore ACO


transportation programs. We have a central team of caremanagers who do telephone outreach, and who guidepractices in evidence-based medicine, but we can’t currentlyafford to do one-on-one care management.”

Demonstrating savings may not be easy within the fairlyshort three-year timeframe of the project. “You have toachieve a minimum savings rate to be eligible to share in the savings with CMS,” explains Behm. “The percentage of savings varies with the size of the ACO – with 10,000beneficiaries, you need to achieve a savings of 3.7%, whereas if you have 50,000 beneficiaries, you need 2%savings. If a small ACO saves CMS 3%, it does not receiveany savings back.”

ACOs Have Changed Medical Practice“Our ACO has changed my practice,” says Dr. Gittelman.“Before the ACO, I did many things well, but there weremany things that hadn’t been on my radar screen until I was involved with this ACO. Things can get left out because there’s so much to do on any given visit. The ACOemphasizes prevention as well as treatment. We’re not justchecking off boxes.”

He continues, “The new waiver plus the ACA represent a sea change, improving the quality of life for sickerpopulations by keeping them out of the hospital. Hospitals are appropriately scared about the changes, but my hope is that these changes provide an impetus to spend more on preventive care.”

The PCMH ControversyThe National Committee for Quality Assurance (NCQA) has granted NCQA medical home recognition status to about 6,000 practices representing nearly 30,000 providers.The Joint Commission and URAC have validated others.

Several recent articles have reviewed the success of thePCMH model. One of those, an article by Meredith Rosenthalet al., published in the Journal of the American MedicalAssociation in September 2013, may have unnecessarilymuddied the waters.

Niharika Khanna, MD, MBBS, director of the MarylandLearning Collaborative for the state’s Multi-Payer Program(MMPP) for PCMH, says, “This paper caused controversy,but it’s based on an advanced primary care program inPennsylvania that started in 2008 as a chronic disease modeland transitioned into a PCMH program. The program focused on efficient chronic disease management, but did not incentivize practices to achieve ‘the triple aim, as PCMHprograms do today.’”

She adds, “The majority of PCMH programs in the United States have demonstrated success in several areas,including reducing ED use and lowering length of hospitalstay and overall costs, but some PCMH programs have notdemonstrated overt success; hence the controversy. There is a need for PCMH programs to mature over time in order to truly assess the return on investment.”

Maryland: Two PCMH ModelsIn Maryland, two PCMH programs exist – the state’s MMPPand a PCMH available to physicians participating in CareFirstBlue Cross Blue Shield. Both are demonstrating results, withCareFirst touting savings of $98 million in 2012 and $38million in 2011.

The MMPP program has demonstrated success in a varietyof ways, including enhanced teamwork, embedded carecoordination, increased use of medical assistants to the top oftheir licenses, enhanced satisfaction for both patients andproviders and health information technology optimization.Outcomes in the first year are significant for a decrease inthe number of asthma admissions, an increase in the use of primary care, decreased use of specialty care and relativedecrease in costs of care.

CareFirst: Coordinated CareMore than one million CareFirst members are patients ofphysicians participating in the PCMH program, and about80% of eligible primary care physicians in the CareFirstnetwork participate.

CareFirst CEO Chet Burrell says, “We are now well into the fourth year of the PCMH program. In each of the first twoyears, more than 60% of participating primary care providersearned performance-based increased reimbursements – calledOutcome Incentive Awards – through PCMH, and costs forCareFirst members covered by the program were lower than expected. We are still finalizing year-three results, but we expect those positive trends to continue. Just asimportantly, we see trends on a number of quality measuresthat suggest the program is having a positive impact onCareFirst members.”

The program’s success spurred CareFirst to obtain anInnovation Challenge Grant from CMS to expand its PCMHmodel to Medicare patients, and is expected to launch in apilot program this summer. CareFirst received $24 million tomanage 25,000 beneficiaries through this program.

MMPP: A Better Way to PracticeData from MMPP is more difficult to obtain, but Dr. Khannasays, “Our program has consistently seen quality enhancementsand demonstrated improved teamwork. Emergency visits aredecreasing and patient satisfaction is high.”

Melvin Gerald, MD, whose Gerald Family Care practice inGlenarden, Bowie and Washington, D.C., has participatedwith MMPP since 2011, couldn’t agree more. “I was tired ofdoing things the same way. When the idea of the MarylandPCMH program came along, I was excited. We wentelectronic in February 2010, which helped.”

Dr. Gerald describes how PCMH changed their way ofpracticing medicine. “Before PCMH, I thoughtI was the superstar and the only one who could take care ofpatients, but I realized that when my staff worked up to theirlevel of certification, they did a better job than I did. Itallowed us to see more patients, distinguish ourselves fromother practices and enjoy our jobs more.”


Mitch Gittelman, DO, family practitioner and medical director of the Lower Shore ACO Craig Behm, executive director, MedChi Network ServicesNiharika Khanna, MD, MBBS, director of the Maryland LearningCollaborative and associate professor of Family and CommunityMedicine, University of Maryland School of MedicineMelvin Gerald, MD, family practitioner and founder of GeraldFamily Care

He adds, “I’m extremely happy. Patients are receiving better care, and electronic data allows us to act on issues more quickly. Since being recognized as an NCQA Level-3provider, some insurers are also sending more patients to us.”

Dr. Gerald observes that every patient who comes into theirpractice, not just their Medicare patients, are benefiting fromthe PCMH model. He says, “Before seeing any patients, wehuddle every morning to discuss patients who may haveproblems or needs. It’s a cultural change. I used to sign off onlab work, but now our mid-level providers do it. Our patientportal also helps patients be more aware of their health.

“My advice to other primary care physicians is that, if theywant to stay in practice and provide optimal care, they should

be involved in a program like MMPP,” Dr. Gerald continues.“I have more time to practice medicine thanks to this model.There is more time involved but patients get better care. I totally embrace it.”

The Waiver ImpactThe new Maryland Medicare waiver, which went into effect in early 2014, is expected to provide added impetus to ACOand PCMH-like models.

“We have to have hospitals and mental health caregiversinvolved in the care of patients who are chronically ill andneed treatment for end-stage diseases,” says Dr. Khanna.“Maryland hospitals are interested in the PCMH model. Ifthey can give us some resources, such as mental health andcommunity health workers, we can help them keep patientshealthier and out of the hospital. Many patients still haveneeds such as housing, transportation and equipment thatimpact their health. We’re in early discussions with theMaryland Hospital Association and the Health Services CostReview Commission to figure out the role of the PCMH in the waiver, which gives us a very big opportunity.”

Behm concurs. “I think that the waiver will furtherincentivize communities to work together to save costs. I’moptimistic about ACOs and hospitals working together.”

Community Integrated Medical HomeDr. Khanna closes by saying, “Today, primary care is truly atthe table and we hope that every new innovation in healthcarereform will consider the foundational role that advancedprimary care can play. I personally prefer the term ‘PatientCentered Care’ to PCMH, but reimbursement is challenging if you don’t call yourself a PCMH and obtain recognitionthrough NCQA, the Joint Commission or URAC.

“A new term is the Community Integrated Medical Home(CIMH),” she adds, “where an integrated platform for caredelivery is envisioned and public health joins with primary careand hospitals. Howard County is undertaking a pilot programto determine what a CIMH might look like, and the MarylandLearning Collaborative is providing technical assistance toinvolve primary care in the model and understand howcommunity-based care teams can integrate into the PCMH.Following recommendations from the legislature, a stateadvisory body is reviewing many of the issues around CIMHand expects to make a recommendation by December 2014.”See also “A New Era: Maryland’s Medicare Waiver,” in Maryland

Physician March/April 2014, and “Can Accountable Care Work for

Your Practice?” Maryland Physician, November/December 2012.

My advice to other primary care physicians is that,if they want to stay in practice and provide optimal care, they should be involved in a program like theMaryland Multi-PayerPCMH program. – Melvin Gerald, MD

Melvin Gerald, MD, familypractitioner and founderof Gerald Family Care


ADVERTISER INDEX

Center for Vein Restoration...............................................2CenterforVein.com

The Anne Arundel Medical Center Foundation.........5aahs.org

RS & F Joint Venture ..............................................................7bit.ly/rsfhallc

Severn Savings Bank .............................................................8severnbank.com

Hospice of the Chesapeake Golf Tournament .........8hospicechesapeake.org

Papercamera ..............................................................................8papercamera.com

KURE Pain Management ...................................................15kurepain.com

University of Maryland Upper Chesapeake MedicalCenter .........................................................................................24uchs.org/ortho

CMS ..............................................................................................27cms.gov/ICD10

Advanced Radiology ...........................................................28advancedradiology.com

Strategize and increase the power of your marketing to Maryland physicians, healthcare executives and stakeholders via mdphysicianmag.com and with Maryland Physician eNews blasts.

Maryland Physician eNews exceeds all leading industry digital performers.

Drive a higher volume of targeted traffic with Maryland Physician online.

Jacquie Cohen RothPublisher/Executive Editor

[email protected]

ONLINEmdphysicianmag.com

@mdphysicianmag


Solutions

KISS-IT: Keeping It Simple with Information Technology

By Elizabeth Diable

O HERE’S A NEWS FLASH,you are a medical professional, not an IT expert. However, you are required tomaintain compliance, adhere to allregulations, operate a prosperousbusiness with increased demand forservices on a smaller and smaller budgetdue to dwindling reimbursements,deliver superior quality of healthcare to your patients… let’s stop there. Theone requirement you have is to deliversuperior healthcare to your patients.

So how do we bridge the gap betweendoing what you love, keeping patientshealthy and making them healthy whenthey are ill, and keeping up with the IT mumbo jumbo required to stay inbusiness? We KISS-IT by keeping itsimple silly when it comes toinformation technology. Here is how:

Identify Problems and Needsz Hardware Infrastructure in place

is at the “end of life”z Not meeting compliance criteriaz Not meeting regulation requirementsz Disjointed systems, network and

applicationsz Limited or burned out IT resources

State Goals and Objectivesz Minimize capital expenditures (CapEx)z Comply with HIPAA rules and

guidelinesz Meet regulatory and data security

compliance requirementsz Centralize all systems, networks,

applications and communicationsz Initiate a help desk engagement that

optimizes the value of internal andexternal resources

Evaluate IT Healthcare-Specific Solutionsz Optimize your return-on-investment

(ROI) with upgrades to your

S hardware infrastructure, voice anddata network improvements andenhanced security of data, all whilesupporting initiatives to enhancepatient care and engagement.Evaluate MPLS networks, servervirtualization and cloud technologies.

z Reduce operating costs and CapEx to offset reductions in Medicare andMedicaid reimbursements withoutimpacting reliability and the deliveryquality of care. Consider cloudcomputing, disaster recovery andredundant data backup and storageto accelerate risk reduction and cost savings.

z Strengthen privacy and HIPAAcompliance with centrally managedsecurity, IP and voice communicationsservices. Look for network security,managed on-premise firewall, datacenter firewall and PCI compliancesolutions.

z Facilitate communication across your health network with scalablevoice and data services customizedfor each location with applicationservices of MS 365, HostedExchange, SharePoint and Lynccommunications. Facilitate patientcommunication through a secureWiFi network and remote employeecommunication with secure remoteaccess, end-point management andmobile device management.

z Reduce cost, stress and complexitiesof your in-house IT resources with afully managed outsourced help deskthat is customizable and scalable.

Implementation and Professional Servicesz The team of implementation

professionals should include a projectmanager, implementation specialist,technical engineer, relationship/

account manager and senior-levelexecutive for escalation needs.

z Professional services should includedata migration, integration, physicalhuman resources and support.

z Post-sale support and services shouldensure you have a service levelagreement (SLA) that meets thedemands of your medicalenvironment. Data reliability,integrity and security are paramount.Having redundant systems andnetworks in place, along with backupand disaster recovery plans ready foractivation, will also be necessary.

z Make certain there is access tohuman resources on a per diem ortemporary basis. Some projectsencompass a level of complexity thatexisting on-premise staff is not ableto accommodate due to their “lean”operations. In these cases, partnerwith a company who offers physicalhuman resources as a service. Thiswill eliminate the need to hire andtrain new personnel in-house to getyou through the implementation.

z Consider having a professionalassessment conducted that evaluatesyour entire operation, includingcontracts, facilities, assets, etc. This wayyou can save money, improve efficiencyand increase revenue and profits.

KISS-IT and optimize the operation of your medical practice by bridging the gap between delivering superiorhealthcare services and utilizingtechnology to support your patient careand engagement initiatives. Leverage ITexperts to build and maintain the bridge.Elizabeth Diable is a healthcare IT solutionconsultant with EarthLink Business. Ms. Diable

can be reached by phone at 410.981.0211, or

email at [email protected].


Rappel for Kidney Health

N JUNE 7, 2014, ABOUT 100 people made their way up to therooftop of the Baltimore MarriottWaterfront Hotel, suited up, and stepped to the edge of the 32-storybuilding. Demonstrating not only theiradventurous sides but most importantlytheir commitment to supporting programdevelopment and research efforts forkidney disease patients, each participantof “Rappel for Kidney Health” took thehandle of a rope and slowly rappelled 28 floors down, ultimately setting foot on the hotel’s pool deck.

Sponsored by the National KidneyFoundation of Maryland, Rappel forKidney Health gives physicians, nursesand other clinical providers, as well asthe community at large, an opportunityto do something unique and exciting, all while raising awareness about kidneydisease and how it can be prevented,detected early and treated. The event is chaired by David Lesser, MD, whoserves as chief of Kidney and PancreasTransplantation at the University ofMaryland Medical Center.

“My professional life surrounds thisissue, so I am happy to put time andenergy into this event to raise awarenessand funding for research,” said Dr.Lesser, who had planned to rappelhimself at this year’s event, but insteadwas called to the operating room toperform two emergency kidneytransplants cases. “And, when people can say ‘Wow, I rappelled off theMarriott Waterfront’ that’s pretty wild.”

Since Rappel for Kidney Health firstlaunched five years ago, approximately350 people have participated, eachcontributing a minimum of $1,000toward the collective total of $525,000that has been raised. Dollars generatedthrough this event have benefited theNational Kidney Foundation ofMaryland’s emergency patient assistanceprogram, patient education and screeningprograms, physician education events andongoing research efforts through theUniversity of Maryland Medical Center

and Johns Hopkins Hospital.“Some do this in honor or memory of

a kidney disease patient and others joingroups and see this is a good corporateteam-building exercise,” said KatieKessler, development coordinator for the National Kidney Foundation ofMaryland. “Each year, the event growsand allows us to do more for localpatients while also providing researchgrants that help advance our mission.”

Part of that mission emphasizes theimportance of prevention and earlydetection of kidney disease, and includesa series of resources to help educate andscreen local citizens. The NationalKidney Foundation of Maryland offersKEY (Kidneys: Evaluate Yours)screenings at locations throughout itsservice area in Maryland, all year long.

“Kidney disease is a silent disease that often goes undetected until theadvanced phases,” said Bernard Jaar,MD, chairman of the Medical AdvisoryBoard for the National KidneyFoundation of Maryland. “This is whyawareness and early detection are soimportant. We are very proud of howsuccessful the Rappel for Kidney Health event has become and how much it is helping us get out there in the community and make a difference.”

For more information on the NationalKidney Foundation of Maryland, visitkidneymd.org.

Good Deeds

O

“My professional life surrounds this issue, so I’mhappy to put time and energy into this event toraise awareness and funding for research.” – David Lesser

By Tracy M. Fitzgerald

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

The Eastern Shore Kidney Health team, the National Kidney Foundation of Maryland’s top fundraising team. Team Captain,Trish Rosenberry, is a transplant coordinator who works directlywith Dr. Lesser.

GET READYFOR

ICD-10

Official CMS Industry Resources for the ICD-10 Transitionwww.cms.gov/ICD10

The ICD-10 transition will affect every part of your practice, from software upgrades, to patient

registration and referrals, to clinical documentation and billing.

CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to:

• Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

• Train Your Staff—Find options and resources to help your staff get ready for the transition

• Update Your Processes—Review your policies, procedures, forms, and templates

• Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

• Test Your Systems and Processes—Test within your practice and with your vendors and payers

STAY ON THE ROAD TO 10STEPS TO HELP YOU TRANSITION

Now is the time to get ready.www.cms.gov/ICD10

888-972-9700 • www.advancedradiology.com

The Imaging Provider of the Baltimore Ravens

Is Advanced Radiologypart of your game plan?

• Digital Mammography• New! 3D Mammography • MRI• Digital X-Ray• CT• PET/CT• Nuclear Medicine• Ultrasound• DEXA• Fluoroscopy

The Imaging Provider of the Baltimore

vensRaThe Imaging Provider of the Baltimore

en

dIs At of ypar

The Imaging Provider of the Baltimore

anced Radiologyvour game plan?t of y

anced Radiology

our game plan?

gy

our game plan?• ital M Dig• ! Ne w!• MRI

yaphrammogital M

yaphrammog 3D M

When the altimorBy trust the tthe

As ylandarMadiology o�R

est data sharand the lat

t of ypar

ensvae Raltimor need fast, accuratts at Aeam of expery trust the t

ing premier imags pr’’s prylandts and imageseporers online r � �ers online r

ing solutions that kest data shar

our game plan?t of y

esultse r need fast, accuratadiologydvanced Rts at A

videroing pr dvanced , Aeg, EMR intts and images

our praceep ying solutions that k

our game plan?

, esults. adiology

dvanced ration eg

tice our prac

our game plan? ital X• DigT• C

T/C• PE• Nuclear M

asound• UltrA• DEX

ya-Rital X

Tedicine• Nuclear M

asound

in the game!

888-972-9700 • w

ing solutions that kin the game!

anc.advww888-972-9700 • w

our praceep y

om.cadiologyedranc

oscluor• F

om

yoposc

maryland physician magazine july august 2014 issue

Documents

lower extremity care

quality of care rank

care findsthat cost

healthcare reformdemand

diagnostic accuracyf

lower extremity care16

diagnostic accuracy

u r e sd e pa r t