maryland physician magazine september/october 2014 issue

VOLUME 4: ISSUE 5 SEPT/OCT 2014

Physic i anYOUR PRACTICE. YOUR LIFE.

mdphysicianmag.com

MARYLAND

IS PRIVATE PRACTICE DEAD?NOT YET.

CLINICAL TRIALS: CUSTOMIZING CANCER CARE

TOMOSYNTHESIS: A BETTER MAMMOGRAM

12 Clinical Trials Propel Cancer Breakthroughs

18 Tomosynthesis: Better Detection of Breast Cancer

F E AT U R E S

D E PA R T M E N T S

ContentsVOLUME 4: ISSUE 5 SEPT/OCT 2014

2612 20

Cases | 7 | Start Palliative Care Consult at Time of Cancer Diagnosis

Compliance | 9 | How to Stay on the “Right” Side of the Maryland Board of Physicians

HIT | 20 | Is Private Practice Dead?

Policy | 24 | Reflection and Forward Thinking: DHMH Secretary Joshua Sharfstein, MD

Living | 26 | Maryland Wine Country: A Blend of Scenery and Tastes

Solutions | 29 | What Medical Practitioners Can Learn From Retailers

Good Deeds | 30 | Creating Systems of Support for Young Adults with Cancer

On the Cover: Steven Rosenberg, MD, PhD, chief of the Surgery Branch of the National Cancer Institute

Borrowing a line from Secretaryof the Department of Health and MentalHygiene (DHMH) Joshua M. Sharfstein, MD,“Maryland is a state where people are copingwith their anxiety about the future ofhealthcare by putting in place structures thatwill actually work.” This issue is full ofadvances on both the clinical and practicemanagement sides of patient care in

Maryland. Our cover story features clinical trials that focus on advancing cancertreatment, including an interview with Steven Rosenberg, MD, PhD, chief of theSurgery Branch of the National Cancer Institute. He’s dedicated himself to usingadoptive cell therapy to treat refractory cancers.

I had tears in my eyes when I had the honor of meeting Dr. Rosenberg, as I lost mymom to AML in 1997. With the advances that he and others have made, my mommight be alive today (see Clinical Trials Propel Cancer Breakthroughs page 12). As could the sister I lost to breast cancer just a few years later (see Feature page 18).When I met Dr. Rosenberg at NIH and shared my mom’s story with him, I thankedhim for the countless lives his 40 years of research with fellows from around theworld have saved.

When Managing Editor Linda Harder and I had the pleasure of our most recentinterview with Dr. Sharfstein (see Policy page 24), we were literally putting Marylandhealthcare into action. Shortly after we exchanged greetings at the Marylandhealthcare exchange, he apologized for needing to conduct the interview on the run,literally (Federal health guidelines recommend 30 minutes of moderate exercise. Wegot that!). Along the way, we met a group of young people in full superhero costumesfor Otakon 2014 (a conference celebrating animation and Japanese culture). Dr.Sharfstein tossed Linda his phone for a quick picture and then, like a healthcaresuperhero, he was off, leaving him at the steps of Baltimore City Hall.

We regularly write about the best methods and newest alternatives for managing a medical practice, whatever the size. In our last issue, July/August 2014, weexamined whether or not Patient Centered Medical Homes and/or Accountable CareOrganizations were positively impacting healthcare costs and improving caredelivery (they are). In this issue, we explore alternatives. Don’t want to be employedby a hospital and fear that private practice is no long viable? We have solutions (see Healthcare IT page 20).

For each issue and throughout the year, both Linda and I work with the MarylandPhysician Advisory Board for editorial counsel, recommendation, submission andreview. I’m delighted to announce that Vinay Satwah, DO, FACOI, with the Centerfor Vascular Medicine (CVM), has joined our board. He is board certified in internal medicine, cardiology, nuclear medicine and adult echocardiography withsub-specialty training in interventional cardiology and endovascular medicine.Welcome, Dr. Satwah!

Maryland autumns are spectacular. Read about one way to make the most of this year’s autumn that was inspired by my visits along the Chesapeake Wine Trail(see Living page 26). As I say with every toast and close in my letter to you…

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

VINAY SATWAH, DO, FACOICenter for Vascular Medicine

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

SEPTEMBER/OCTOBER 2014 | 7

DISCUSSION: The workup of issuessuch as routine low back pain can sometimes yield unfortunate results.While abnormal imaging in an otherwisehealthy person with persistent findings is not common in back pain, it is frequently how advanced cancerspresent. Lung, ovarian, pancreatic andesophageal malignancies still commonlypresent at stage IV with no preliminaryfindings, and helping patients makesense of this devastating finding as theynegotiate the healthcare system is one of the most challenging, but potentiallyrewarding, tasks physicians face.

Although palliative medicine (PM) is often considered an alternative onlyafter attempts at curative treatment have proven ineffective, recent researchsuggests that starting palliative careconsultation at the time of diagnosis isan important tool to improve quality oflife and quite possibly increase survivaltime. Adding an extra layer of supportwith the palliative medicine team early in the course of treatment can helppatients make decisions with clarity and reduce their symptom burden.

During the course of diagnosis andtreatment, the oncologist and PMphysician work together to understand a patient’s values and, within the limitsof the disease prognosis, develop goalsand treatment plans that optimizeoutcomes without excessive risks. Thisthree-step model of prognosis, valuesand goals of treatment provides a solidbasis for making decisions that best serve the patient and lay the groundworkfor more difficult conversations.

Prior to a first visit, a PM socialworker assesses the patient’s supportsystems and preferences for receivinginformation and making decisions.Bringing a friend or loved one to theoncology appointment is recommendedto help patients digest a potentiallydifficult prognosis. Providing writtenmaterials and data can be helpful for

patients who express this preference. The oncologist can discuss severaltreatment options, but ideally would not recommend a specific plan until the patient meets with the PM physicianshortly thereafter. This short time lapse allows patients to recover from the initial impact of receiving a life-threatening diagnosis, which many people describe as like being hit by a wave, after which they can't hearanything else.

The PM physician visit can focus on the bigger picture of what is mostimportant to the patient and assess forphysical and psychological symptoms. In the case of our patient Cheryl, the PM physician learned that she wassingle, without children and an executiveat a local nonprofit that served fosterchildren. Cheryl wanted to make surethat her successor was well equipped to run the agency. She wanted treatmentto reduce symptoms and if possiblelengthen her life, but she didn't wanttreatment that would make her unable to work or to take a trip to visit friendsand family even if it could add moretime to her prognosis.

With this information, the oncologistand PM physician recommendedtreatment with gemcitabine anderlotinib, which offered the combinationof symptom reduction and modestsurvival benefit. In a patient as young as Cheryl, and with good performancestatus, a new four-agent regime thatoffered the potential to improve survivalby several months would have typicallybeen recommended, but its potential for severe side effects conflicted withCheryl’s desire to maintain her short-term quality of life. Both doctors assuredher that she could rely on them for therest of her journey, wherever it led. Lou Lukas, MD, is chief medical officer

of Hospice of the Chesapeake. She can be

reached at [email protected]

or 410.987.2003.

Start Palliative Care Consult atTime of Cancer Diagnosis

CASE: Cheryl is a 55-year-old woman in good healthwith no significant medicalhistory, who presented withlow back pain radiating toher legs that has failed six weeks of conservativetreatment with physicaltherapy and NSAIDS. She attributed a 20-poundweight loss over two monthsto increased exercise and a new dietary supplement.Because of the increasingseverity of the pain, an MRI was obtained thatrevealed a moderate discdisease at L1 and L2, butalso showed multipleenlarged retroperitoneallymph nodes. Labs showedthe following abnormalities:tbili 2.2, dbili 0.8, CA 19-9 of135 and CEA 2.5. Cheryl’slab studies suggested apossible cancer diagnosis,with a nodal biopsy andoncology visit for furtherwork up. Additional imagingrevealed a 3-cm pancreaticmass involving the celiacaxis, and the biopsy showedmetastatic adenocarcinoma,suggesting stage IVpancreatic cancer, with 75% one-year mortality.

Lou Lukas, MD

Cases


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Compliance

How to Stay on the “Right”Side of the Maryland Board of Physicians By Natalie McSherry

RACTICING PHYSICIANS SHOULDmake sure to avoid licensing issues and potential disciplinary actions fromthe Maryland Board of Physicians bytaking a few simple measures. Failure to follow these steps could result indrastic consequences for your practice.

The Board is composed of 22members, 14 of whom are practicinglicensed physicians (including at leastone osteopath) appointed by thegovernor; one physician assistantappointed by the governor; onerepresentative of the Department ofHealth and Mental Hygiene nominatedby the secretary; five consumer membersand one public member knowledgeablein risk management or quality assurance.

The Board’s duties range from initial licensure through regulation,declaratory rulings and education, to discipline of physicians and a vastarray of allied health providers.

These basic steps will help ensure thatyou are on the “right” side of the Board,and not the one stricken with panicwhen the Board calls.

z On all applications for licensure orrenewal of licensure, be scrupulouslyhonest about everything. Doublecheck your CME credits to be sure they are accurate. If in doubtabout whether you have to disclosesomething, either disclose it or getlegal counsel.

z Remember to keep the Boardinformed if you move or change yourprofessional address or affiliation.

z Don’t miss a renewal date and end up practicing without a license. Thisis your non-delegable professionalresponsibility, so don’t rely on staff to do this task.

z Check the Board’s website and readits newsletter diligently. It may not be

riveting reading, but it frequentlycontains information about majorchanges in laws or regulationsrelating to the practice of medicine.The website has a wealth ofinformation, but is not terribly user-friendly, so keep exploring!

z Keep up-to-date on the Board’s andyour professional association’sguidance on matters such as painmanagement and controlledsubstances. This is an area of greatconcern for the Board, and one wherethe guidance is constantly evolving.

z Sometimes, despite your best efforts,a complaint gets filed with the Boardby a patient, a patient’s familymember, another physician or ahospital where you have privileges.Additionally, the Board receivescopies of all malpractice claims filedwith the Maryland Health CareAlternative Dispute ResolutionOffice. If you are notified by theBoard of a complaint:

z Notify your carrier if you havecoverage for Board proceedings.These proceedings can be expensive,and if you have coverage, thatcoverage will pay some or all of your legal expenses.

z Whether you get counsel throughyour insurance carrier or on yourown, you should get legal advicebefore responding to the Board.Ideally, you will get advice fromsomeone familiar with the Board’sprocedures and processes.

z Although extensions may be grantedon occasion, for good cause, do notignore or fail to meet deadlines oncethey are set.

z The Board investigation can takemonths. During that time you likelywill be required to provide copies ororiginals of charts and records, and

be interviewed by a Boardinvestigator. When providing charts or records, be sure to copyeverything.

z After conducting its investigation, the Board will either notify you that it is satisfied and is closing theinvestigation, or will issue chargesalleging that you have committed oneor more of the offenses listed in theBoard's disciplinary statute. Md.Code Ann., Health Occ. §14-404(a).

z If you are charged, you will have anopportunity to negotiate a resolutionand, failing that, have a hearingbefore an administrative law judge,who will make recommendations to the Board. However, the Board isthe final decision-making body.

z The Board can impose sanctionsranging from a reprimand torevocation of a license, and caninclude a vast array of conditionssuch as education. It also can imposesubstantial fines.

You should also consider the potentialcollateral effects of a Board sanctionwhen negotiating a resolution of charges.Probation, and certainly suspension of a license, can affect credentialing athospitals and with third party payers. If you are facing Board charges andconsidering a consent order withanything other than a reprimand, youshould ensure you are fully informed of the effects of a Board sanction onother aspects of your professional life.Natalie McSherry is a principal at Kramon

& Graham, P.A. She can be reached at

[email protected] or 410.752.6030.

The information in this article is provided for generalinformational purposes only. None of the information in the article is offered, nor should it be construed, as legaladvice on any matter. You should not act or rely upon any information contained in this article without first specifically seeking professional legal advice.

P


While a vast array of mutations make it impossible to find one

treatment approach that suits all cancers, thanks to clinical trials, researchers’ painstaking efforts are improving our understanding and use of the genome

and immune system for more customized therapies.

BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

CLINICALTRIALSPROPELCANCERBREAK-

THROUGHS

ADOPTIVE CELL THERAPY: NEW HOPEFOR REFRACTORY CANCERCelebrating his 40th year as chief of the Surgery Branch of the NationalCancer Institute, Steven Rosenberg, MD,PhD, has not slowed in his relentlesssearch to harness patients’ own immunesystems to destroy cancer. He notes,“Immunotherapy is a new type oftherapy for cancer, providing a new toolto cure the nearly 50% of those withcancer who aren’t cured throughradiation, chemotherapy or surgery. This is significant, as more than half a million Americans died last year from cancer.”


Various approaches to immuno-therapy have been explored in the past decades. The Identification ofInterleukin-2 (IL-2), a T-cell growthfactor, in 1976, allowed researchers to grow T lymphocytes in vitro for thefirst time. In 1985, Dr. Rosenberg andcolleagues reported in the New EnglandJournal of Medicine the first effectiveimmunotherapy for the treatment ofhuman cancer using high-dose IL-2 Tremission in patients with metastaticmelanoma. They achieved cancerregression in 15% of patients, includingabout 7% with durable regressionslasting over 20 years.

Adoptive Cell Therapy (ACT)Many of the earlier limitations ofimmunotherapy have been addressed by developing an approach calledadoptive cell therapy (ACT). Thistechnique involves extracting autologouslymphocytes with anti-tumor propertiesfrom the stroma of resected tumors,growing them in vitro, and then infusingthem back into the host. The firstsuccessful cell transfers from a tumorwere reported in the New EnglandJournal of Medicine in 1998.

Even with ACT, however, early studies found that tumor reduction wastransient in most patients. Subsequent

Steven Rosenberg, MD, PhD, chief of the Surgery Branch of the National Cancer Institute

research found that giving patients anon-myeloablative lymphodepletingregimen before the ACT dramaticallyimproved results.

“What we learned since the early days of ACT is that the body has its own mechanism to reject or regulate the response to lymphocytes, so ‘wipingout’ the immune system usingchemotherapy and radiation prior toreintroducing them into the body is keyto improving outcomes,” Dr. Rosenbergexplains. “We live in this balance ofpositive and negative physiologicalinfluences in the body, which has its own mechanisms to regulate itself.”

As a result of such advances intechnique, clinical trials reported in 2011 found 40% of patients withmetastatic melanoma had completeresponses to ACT, and, according to Dr. Rosenberg, all of these patients are still ongoing responders today.

Expanding the Approach to Solid Cancers“ACT is a more targeted approach that isproducing clinically meaningful results,”Dr. Rosenberg notes. “Today, for the firsttime, immunotherapy can cure metastaticmelanoma and lymphomas, and manyother cancer types are under study. Totarget many common solid cancers itappears that we will have to target theunique mutations present in eachindividual cancer. The problem is thatmost mutations are not recognized andattacked by the immune system.”

Dr. Rosenberg and his colleagues setout to find additional ways to applyACT to solid tumors. He recalls, “Two-thousand-six was the first time we couldtake normal lymphocytes and geneticallyengineer them to fight cancer.”

In 2012, his team performed the firstsuccessful extraction of tumor-infiltratingT cells from a patient with advancedcholangiocarcinoma that hadmetastasized to her lungs. The patientinitially was treated with the standardapproach to ACT, and her tumors shrank.

However, her initial tumor regressionproved short-lived. Rosenberg and hiscolleagues then extracted T cells fromthe woman’s tumor that specificallyrecognized her own cancer mutations,and infused more than 120 billion ofthese T cells back into the patient. Thistime, her tumors shrank quickly andremained in remission so she couldresume her normal activities.

“The most important part of

immunotherapy is picking theappropriate target,” states Dr. Rosenberg.“TIL can recognize the mutations that are unique to that cancer and that arecreating uncontrolled growth. Targetingthe unique mutation for this womancreated a blueprint for treating cancers of many types. It was complex – we hadto perform complete exomic sequencing,finding every mutation in the DNA thatcodes for proteins. Then we had todetermine which mutations arerecognized by the immune system andguide the system to attack those. It’s nowa complicated technology that we areworking hard to simplify.”

Complete Remission?This year’s American Society of ClinicalOncology meeting included a small PhaseII study that showed that two of ninepatients with refractory metastatic cervicalcancer were able to achieve completeremission after a single treatment withHPV-targeted T cells harvested from theirtumors and re-infused.

This approach is not without hazards.As the T cells multiply in the body,patients can experience an acute toxicityphase that can cause severe reactions andeven death.

“Adoptive cell transfer therapy isready for prime time today,” exclaims Dr. Rosenberg. “Four companies – KitePharma, Lion Biotechnologies, Novartisand Celgene, are working on gettingtherapies ready for FDA approval.”However, commercial availability of ACTlikely will not occur until 2016 or later.

He acknowledges, “Addressing aspecific mutation is a whole other levelof complexity. Since 90% of people diefrom solid cancers, we have more workto do. It’s not an approach usually takenby big pharma, as we essentially have to create a new drug for every patient.”

ADVANCING THE TREATMENT OF ACUTE LEUKEMIASIvana Gojo, MD, associate professor of oncology in the HematologicMalignancies and Bone MarrowTransplantation Program at JohnsHopkins Medicine, directs the leukemiadrug development program. She is chieflyfocused on finding new approaches totreating acute leukemias, which fall intotwo major groups – acute myeloidleukemia (AML), more prevalent inadults, and acute lymphocytic leukemia(ALL), more common in children.

“The median age of patients is with

AML is 67 years,” Dr. Gojo states. “For 40 years, the standard therapyentailing cytarabine and anthracyline has achieved a 30-40% long-termsurvival rate in those under age 60, butless than 10% in older patients.”

Relapse Tied to Leukemia ClonesToday, newer laboratory techniques,including whole genome sequencing,have identified novel and recurringmutations in AML. Researchers nowknow that some of these mutations mayoccur early on (‘driver’ mutations) orlater (‘passenger’ mutations), theknowledge of which helps them developtargeted therapies uniquely designed forpatients with individual mutation.

These studies also demonstrated thatleukemia relapse, the major problem inAML therapy, occurs because initialleukemia clones were not eradicatedwith chemotherapy. Dr. Gojo explains,“These clones evolve over time, which is why it’s much harder to put relapsedAML in remission. Our goal is toeradicate leukemia at the time of initialtherapy to avoid relapse. Thus, it isimportant to monitor and treat minimalresidual disease.”

Minimal Residual Disease (MRD)Newer tests can assess the level ofresidual disease after inductionchemotherapy, to help determine whetheror not the patient should be treated moreaggressively. Dr. Gojo notes, “Previously,we used only prognostic markers such askaryotype and molecular mutations atdiagnosis, but having MRD is alsoassociated with relapse. At Hopkins, wehave developed flow cytometry assay todetect leukemia stem cells using specificmarkers, and have a clinical study wherewe use this test to decide whether or notpatients with favorable or intermediateprognosis AML should go to transplantin first remission.”

Novel Targeted TherapiesClinical trials are testing targetedtherapies for several mutations,including IDH 1/2 and MLL. Dr. Gojosays, “Hopkins has been at the forefrontof developing inhibitors targeting FLT3mutation, which can be found in some30% of leukemias. After treatment with FLT3 inhibitors, some patients can be cured using allogeneic stem celltransplant. We’re also exploring the useof sorafenib, an FLT3 inhibitor, aftertransplant to improve outcomes.”



… PHYSICIANS SHOULDPURSUE TREATMENTOPTIONS FOR PATIENTS WITH AML.MUCH HAS CHANGED,AND THERE IS FARMORE WE CAN DO TO TREAT THESE PATIENTS TODAY THANIN THE PAST.” – Ivana Gojo, MD

Ongoing AML TrialsCurrent AML clinical studies fall intoroughly five categories:

z Kinase inhibitors such as FLT3inhibitors.

z Modulation of the immune system todetect and control leukemia cells.Trials are testing anti-CTLA4antibody, approved in melanoma, andpomalidomide, to remove suppressiveT cells after induction chemotherapyin newly diagnosed AML patients andenhance the immune system’s anti-leukemia activity.

z DNA repair. Because AML cells havedifficulty repairing DNA damage,trials are testing different agents(PARP and CHk1 inhibitors) thataffect cell cycle and DNA damageresponse, to improve the effectivenessof chemotherapy.

z Novel agents targeting leukemia stemcells, such as hedgehog (Hh)inhibitors and antibodies. AberrantHh functioning is believed to causecell proliferation and tumors.

z Less intensive chemotherapies, usedto treat elderly patients who cannottolerate aggressive therapy.

Extending Bone Marrow Transplants Notes Dr. Gojo, “We also havedeveloped less intensive strategies, suchas nonmyeloablative transplant, thatallows us to transplant patients up to age 75 without a problem. And we areone of the leaders in haploidenticaltransplants, which allow us to easily use half-matched related donors – father, mother, siblings, children – fortransplant, so that these days almosteveryone can have a suitable donor.”

She concludes on a hopeful note, “A key message is that physicians shouldpursue treatment options for patientswith AML. Much has changed, andthere is far more we can do to treat thesepatients today than in the past.”

RADIATION ONCOLOGY CLINICAL TRIALSEnrolling in a clinical trial once entailednumerous trips to a major medicalcenter. Today, many communityhospitals offer the same clinical trials as academic institutions. Illustrating that point is Randi Cohen, MD, MS,associate director of clinical research,Community Practice Program, Universityof Maryland Baltimore Washington

Ivana Gojo, MD, associate professor of oncology in theHematologic Malignancies and Bone Marrow Transplantation Program at Johns Hopkins Medicine

Medical Center (BWMC). She notes, “We’ve been selective

about which trials go to the community.It’s a long process to get each center tohave a protocol, which varies dependingon their Internal Review Board (IRB)process. We have many breast andprostate cancer trials in the BWMCcommunity because that’s what iscommon. And since most radiationtherapy is provided daily Mondaythrough Friday, we want to make it asconvenient for patients as possible, andcoordinate their radiation therapy visitswith care from their other providers.”

She adds, “Clinical trials can beoverwhelming for patients becausethere’s so much complex information,coupled with anxiety. I try to talk aboutappropriate treatment options first, and then provide verbal and writteninformation on the trial as appropriate.”

Dr. Cohen noted that Dr. HongchaoPan’s retrospective study of 80,000women, presented at this year’sAmerican Society of Clinical Oncologymeeting, found that obese women underage 50 with estrogen receptor-positivebreast cancer have a 34% greater risk of

death than those who were not obese.Overweight women were also at higherrisk than those of normal weight.However, the risk in menopausal womendid not increase with increased weight.

“The message for physicians is thatthis is one more reason to encouragetheir patients to be proactive about diet and exercise. However, Phase IIIrandomized trials are the goldstandard,” Dr. Cohen reminds clinicians.

Metastatic Breast Cancer TrialDr. Cohen is the University of Marylandinstitutional principal investigator forE2108, a randomized Phase III Trial ofthe Value of Early Local Therapy for theIntact Primary Tumor in Patients WithMetastatic Breast Cancer. The goal ofthis prospective, randomized trial of 368women is to determine if early, localizedtherapy to the breast can improvequality of life and/or prolong survival forpatients with Stage IV breast cancer.

One group will receive the currentstandard of care, consisting ofchemotherapy, hormone therapy or other medications. The second groupwill receive the standard treatment plus


CLINICAL TRIALSHAVE HELPED US OPTIMIZE RADIATION DOSE LEVELS AND HONEOUR THERAPEUTICAPPROACHES. – Randi Cohen, MD, MS

Randi Cohen, MD, MS, associate director of clinical research, CommunityPractice Program, Universityof Maryland Baltimore Washington Medical Center(BWMC)

Health Information Exchanges allow clinical information to move electronically among disparate health information systems. The goal of HIE is to deliver the right health information to the right place at the right time-providing safer, more timely, e�cient, e�ective, equitable, patient-centered care.

MARYLAND’S STATE DESIGNATED HEALTH INFORMATION EXCHANGE AND MEANINGFUL USE RESOURCE CENTERServing Maryland and the District of Columbia

7160 Columbia Gateway Drive, Suite 230 | Columbia, Maryland 21046 | T/ 877-952-7477 | F/ 443-817-9587 | [email protected]

www.crisphealth.org

Please visit our website www.crisphealth.org

or call us at 877-952-7477 to take advantage of these services.

The Chesapeake Regional Information System for Our Patients (CRISP) provides a number of health information exchange services (HIE) that can assist you in reducing some of the time consuming administrative tasks within your practice. The CRISP Query Portal allows physicians and support sta� to query health information about patients you treat. The HIE contains clinical information from all 46 acute care hospitals in Maryland and six hospitals in DC. Information available includes lab reports, radiology reports, discharge summaries, history and physicals, medications, and more. The Encounter Noti�cation Service (ENS) allows you to receive real-time noti�cation when any of your patients have a hospital encounter in Maryland, Delaware, and six DC hospitals. These noti�cations can enhance your care coordination and possibly prevent a patient from being re-admitted to the hospital. ENS can also assist your practice in receiving Medicare reimbursements for patient follow up. CRISP o�ers the above HIE services free of charge to providers.

CRISP is also excited to serve as Maryland’s Meaningful Use Resource Center. We understand that achieving Meaningful Use can be a confusing and challenging endeavor for providers and their sta�. CRISP created the Meaningful Use Resource Center to provide a single, comprehensive, informational tool for Eligible Professionals and their sta� as they work towards meeting the Meaningful Use requirements. Visit https://meaningfuluse.crisphealth.org to learn more about the Medicaid and Medicare EHR incentive programs. The Meaningful Use Resource Center provides guidance on the steps required to reach Meaningful Use as well as an incentive wizard to calculate incentive payments.

surgery (either lumpectomy ormastectomy) and possibly also radiationtherapy to the breast.

Dr. Cohen explains, “Some cliniciansthink that primary breast tumortreatment is not important once thecancer has metastasized, but others thinktreatment of the breast will improvepatient outcomes. All patients in thisstudy will get systemic chemotherapy orhormone therapy up front, then thosewho do well will be randomly assignedto one of the groups.

“Good retrospective data suggeststhere is benefit to treating the breast inselect women with metastatic breastcancer,” she continues, “and my guess is that for women with minimalcomorbidities who can perform theirnormal activities, treating the primarycancer site will help them. But womenhave to deal with so much emotionalduress and costs that we don’t want toadd to their burden unnecessarily.”

Prostate Cancer Clinical TrialsDr. Cohen is also involved in tworandomized Phase III clinical trials forprostate cancer. The first is RTOG 0815,a Phase III Prospective Randomized Trial


Steven Rosenberg, MD, PhD, chief, Surgery Branch, National

Cancer Institute

Ivana Gojo, MD, director, Leukemia

Drug Development Program, Sidney

Kimmel Comprehensive Cancer Center,

and associate professor of Oncology

in the Hematologic Malignancies and

Bone Marrow Transplantation Program,

Johns Hopkins Medicine

Randi Cohen, MD, MS, assistantprofessor, University of Maryland and

associate director of Clinical Research,

Community Practice Program,

University of Maryland Baltimore

Washington Medical Center

of Dose-Escalated Radiotherapy with or without Short-Term AndrogenDeprivation Therapy for Patients withIntermediate-Risk Prostate Cancer. Thegoal of this trial is to determine if thosewith intermediate risk, clinically localizedprostate adenocarcinoma (Gleason Scoreof 7 and/or PSA between 10 and 20)benefit from adding six months ofandrogen deprivation therapy (ADT) to their radiation therapy regimen.

The second prostate trial, RTOG0924, evaluates whether ADT combinedwith whole-pelvic radiation therapyimproves survival in patients withunfavorable intermediate-risk orfavorable high-risk prostate cancer betterthan ADT plus radiation therapy to onlythe prostate and seminal vesicles.

“Thanks to clinical trials, there havebeen significant improvements inradiation therapy techniques, deliveryand planning in the past 10 years,” Dr. Cohen reflects. “There have alsobeen many technological advances inradiation oncology, allowing us to bemore precise with radiation treatments.Today, for example, we can do a 4D CTscan of the lung to account for breathingand movement of the tumor. That allows

us to more precisely administer radiationand reduce dose to normal surroundingtissue. And in the prostate, we can useCalypso™ 4D Localization System,which is like having GPS for this organ.It helps us track prostate motion in realtime, which equals smaller margins andlower doses to neighboring organs.Clinical trials have helped us optimizeradiation dose levels and hone ourtherapeutic approaches.”


TOMOSYNTHESIS:BETTER DETECTION OF BREAST CANCERBy Linda Harder

Thanks to tomosynthesis, we’ve already detected additional cancers in the same breast that we would nototherwise have found. – Judy Destouet, MD, FACR

A recent article in theJournal of the American MedicalAssociation (JAMA) confirmed whatmany radiologists already believed andwhat single-institution studies hadindicated – that tomosynthesis, thenewer 3D approach to mammography,detects more crucial breast cancers while reducing callbacks.

The study, published on June 25,2014, evaluated over 450,000mammograms, nearly half of whichincluded tomosynthesis. It foundsignificantly greater invasive cancerdetection rates for mammography plus tomosynthesis (4.1 per 1,000screens) than for digital mammographyalone (2.9 per 1,000). At the same time,recall rates dropped from 107 to 91 per 1,000 when tomosynthesis wasadded to a conventional mammogram.

Daina Pack, MD, chief of breastimaging at Anne Arundel Diagnostics,says, “This study was well constructedand it found a demonstrable difference.Tomosynthesis is an important stepforward, though it’s not perfect. We keep trying to make mammography a better test.”

Judy Destouet, MD, FACR, whorecently stepped down from her long-held position as chief of breast imagingfor Advanced Radiology to work part-time, concurs. “Three-dimensionalmammography is not just finding morebreast cancer, it is also finding moreinvasive cancers which are the mostclinically significant.”

SINGLE MILLIMETER SLICESBreast tomosynthesis produces a three-dimensional view of the breast tissue in one-millimeter thick slices that helpmammographers detect breast lesions by minimizing the superimposed tissueseen on traditional 2D mammograms.

However, the new technology imposesadditional burdens on breast imagers.“Tomosynthesis provides thinnersections of the breast, allowing us to seefindings that previously were obscuredby overlapping breast tissue,” explainsDr. Pack. “It’s a completely different way of looking at the breast. However, it takes far more time, especially withlarger breasts, since we are looking atapproximately 300-400 images, insteadof the traditional four images. For eachtraditional image obtained, that image isnow reconstructed into one-millimeterslices for the entire the thickness of thebreast.”

She notes that new software reducesthe radiation dose. “Until recently, twoset of images had to be obtained. Thisincluded the traditional 2D views andthen the 3D additional images. Now,with newer software, the 2D imagingcan be reconstructed from the 3D dataset. This allows us to keep the radiationdose essentially the same as for a routinemammogram.

“You want to get an overall, globalpicture, then hone in on a microscopicarea,” Dr. Pack continues. “First, wecompare the 2D images with prior 2D mammograms, then we review theone-millimeter-thick images to determineif anything is hidden within the layers.It’s like seeing the individual pages of a book. Tomosynthesis has been shownto be of benefit for patients of all breastdensities, but will be most helpful inthose with moderate or dense breasttissue. Finding lesions in dense breastscan be like, as the saying goes, trying to find a polar bear in a snowstorm.”

ALREADY YIELDING BENEFITS IN PRACTICEDr. Destouet, a major proponent of tomosynthesis, notes that the exam hasalready benefited patients in their practice. “Several hundred women atAdvanced Radiology have had tomosyn-thesis, but the out-of-pocket cost isdampening demand,” she observes.“Thanks to tomosynthesis, we’ve already detected additional cancers inthe same breast that were not seen on2D mammography, though some of thelesions were seen on sonography andMRI. We’re currently using it almost as a diagnostic tool – if we see somethingsuspicious on a 2D exam, we bring thepatient in for tomography. It would be wonderful if we could use it as ascreening tool, especially on women with dense breasts.”

She continues, “Clearly, dense breasts benefit the most from 3D, which allows us to section and look atdifferent slices in the breast. Thesewomen usually have no risk factorsother than dense breast tissue – nofamily history or age-related factors.”

Dr. Destouet notes that tomography is not a replacement for breast MRI.“While 3D mammography may changeour patient management, such asindicating that the patient shouldundergo mastectomy rather thanlumpectomy, we still use MRI forwomen because it examines the

vascularity, and some cancers simplydon’t show up on mammography. MRIallows us to see if anything enhances.”

COMPARABLE PATIENT EXPERIENCEIn addition to producing exceptionallysharp images, the technology also offersan advanced ergonomic design to improve patient comfort. Appropriatefor all screening and diagnostic mam-mography patients, it can be especiallyvaluable for those who have dense breast tissue and/or women with a per-sonal history of breast cancer.

“From the patient experiencestandpoint, there’s not much differencebetween a conventional mammogramand mammogram plus tomography,” Dr. Pack notes. “The screening stillinvolves compression and we still don’twant any motion.

TIPS FOR ORDERING TOMOSYNTHESISPhysicians may wonder how they canorder tomosynthesis for their patients.“No special referral is needed,” notes Dr. Pack, “but because it’s available in a limited number of centers, be sure toask the scheduler which office offers it,and get on the schedule for that particular machine.”

Dr. Pack also advises that physicians“inform patients that it’s critical,regardless of whether the exam is 2D or 3D, to bring in prior mammograms if they had them taken at a differentfacility previously. Each mammogram is almost like a fingerprint for eachperson – they’re very unique, and priorstudies prevent us from doing unnecessaryimaging of stable, benign findings.”

While tomosynthesis is FDA-approved, many insurers do notreimburse for its additional cost. Typical out-of-pocket charges forpatients getting 3D mammography are$50 to $100. Dr. Destouet laments, “The American College of Radiologypresented information to the governmentfor coverage, but private insurers stillconsider 3D experimental. Hopefully,that will change.”


Daina Pack, MD, chief of breast imaging at Anne Arundel Diagnostics

Judy Destouet, MD, FACR, breast imaging specialist and former chief of

breast imaging at Advanced Radiology


Healthcare IT

Don’t want to be employed by a hospital but fear that private practice is no longer a viablemodel? Learn howsome physicians are discovering new alternatives.

IS PRIVATE

PRACTICEDEAD?

BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

WITH MORE THAN HALF OFtoday’s physicians employed by ahospital or health system, and newphysicians increasingly seekingemployment over private practice, is the autonomous physician practice on its deathbed? Will all physicianseventually become employees of thegovernment or a health system?

A 2014 survey of practice executivesby Medical Group ManagementAssociation (MGMA) found that 40%of over 500 respondents planned toengage in looser affiliations – such asjoining an ACO, a PHO, an IPA orclinically integrating with a healthsystem. Another 27% planned moreformal integration, such as mergers

with other practices or selling theirpractices to a health system.

However, Merritt Hawkins andAssociates, a physician search andconsulting firm, expects three-quarters of new physicians to be hired byhospitals this year, and Accenture found that only 39% of physicians today own their practice, compared with 57% in 2000.

While solo practice is likely to vanish as providers grapple with a move from fee-for-service to value- and population-based reimbursementapproaches, physicians may bepleasantly surprised to learn that newoptions for retaining autonomy areemerging. Among them is a newer

type of single- or multi-specialty ‘mega’ group that allows physicians to remainin their existing offices and maintainmore say over their practice than theywould as hospital employees.

Single-Specialty Mega GroupsIn Maryland, large groups have longincluded single-specialty groups likeAdvanced Radiology and ChesapeakeUrology Associates, and multi-specialtygroups like Clinical Associates. Newerentrants include Capital Digestive Care, a group of gastroenterologistsestablished in 2009 with 57 physicians in 16 offices, and The Centers forAdvanced Orthopaedics (The Centers),launched in early 2014 with the mergerof over 130 orthopedists in 46 locations(including 35 in Maryland).

Nicholas Grosso, MD, president

of The Centers, describes how the group formed. “It started with mygroup, Orthopaedic Associates ofCentral Maryland, and RobinwoodOrthopaedics from Hagerstown. After considering other practice models,we eventually hired Joseph P. MelvinCompany, a CPA group fromPhiladelphia. We were attracted to their proven model, and their experienceallowed us to anticipate where theroadblocks would be. At one point wehad about 35 interested groups. We dida vetting process of all the practices, and kept the ones we felt practiced great medicine. We also lost a fewphysicians to hospital employment.”

The Right TimingThe group took three years to finalize.“Each practice provided funding,”

Dr. Grosso notes. “Similar models havebeen tried before, but they often failedwhen implementing the details anddealing with members’ egos. I attributepart of our success to timing – mostsmart doctors can see the writing on thewall. I also give credit to the model thatwe chose, which allows each practice toremain a division that retains a lot oftheir autonomy.”

The Centers is keeping its additionaloverhead expenses low. In addition toDr. Grosso, who continues to practiceorthopaedics full time, the group hasonly a chief administrator and anassistant, and they soon will seek aquality and compliance officer.

Employing about 1,200 staff, thegroup offers a single benefits package,tax ID and billing system. They areundertaking a strategic planning process


Nicholas Grosso, MD, president of The Centers for Advanced Orthopaedics


now and researching EHR systems so they can transition the practices’separate systems to a single one. “If wehad told the practices they had to use asingle EHR to join,” laughs Dr. Grosso,“it never would have happened.”

As the group coalesces, it is under-taking a gradual branding process andcreating a physician portal to betteridentify appropriate super specialists inthe group and find the right provider for their patients.

Savings Coupled with Better RatesThe savings are already mounting. Thegroup estimates that they have alreadysaved as much as 30% on malpracticerates and injectibles, and they expectfuture savings from joint durable medicalequipment purchases. They also believethey have gained the attention of insurersin a way that would not have beenpossible as a collection of smaller groups.

“Suddenly, they are taking our calls,”notes Dr. Grosso. “We’ve alreadynegotiated somewhat on insurance rates,and in the future we’ll be able to considerbundled payment plans and the like.”

Preparing for the FutureDr. Grosso advises physicians seeking tobuild a large group to “have the rightconsultants and the right partners. It’s a small community so it’s pretty easy tofind the good consultants. Many groupshave expressed interest in joining ussince our launch, including practices inNew Jersey and beyond. For now, we’llstay in the D.C., Maryland and Virginiaarea, and then we may eventuallyexpand further.”

“None of us knows what the futurelooks like,” he comments, “but we are in a much better position to face it as alarge group. We know it’s a marathon,not a sprint.”

Privia: An AutonomousApproach to Population HealthLaunched in February 2014 with 143participating physicians in the greaterWashington, D.C., area, Privia MedicalGroup is a different model from mostmulti-specialty groups. For one thing, it is focused on transitioning physiciansto population health-based care. Foranother, while physicians are partnersand co-owners of the medical groupunder a single tax ID, doctor members

have autonomy over their staff andpractices. Providers maintain andmanage their own PC. Additionally, a board of governors comprised ofphysicians leads the group.

Andrew Aronson, MD, an emergencymedicine physician, is the new chiefmedical officer of Privia. He explains,“About 65% of our group are primarycare physicians and 35% are specialists.

Physicians are compensated based on the revenue they generate when theyjoin, and they keep additional revenuesthey generate. We partner with payers to help physicians increase their revenueby getting rewarded for quality care.Their expenses usually decrease as aresult of our ability to negotiate bettermalpractice rates; centralize billing,electronic medical records and ITsupport; and achieve economies of scale through group purchasing.”

Connecting the Data DotsPrivia selected open-source Athena as their common EMR, to which allphysicians in the group have elected toswitch before they ‘go live.’ “With abidirectional patient portal, dataaggregating warehouse, and a populationhealth software package, we’re seeking to connect the ‘data dots,’” states Dr.Aronson. “Physicians can do outboundcalling campaigns, such as urgingpatients to get flu shots during flu season,and patients can complete an onlinehealth risk assessment.”

The company also offers diseaseregistries, analytics, predictive riskstratification, and private healthinformation exchange (HIE)/connectivity.To better coordinate care, Priviaprovides remote health teams thatinclude nurse care managers, dietitians,fitness trainers, and soon pharmacists,mental health professionals, social

workers and nurse triage. Aronson notes that it takes about five

to six months from the time the practicesigns up until they can ‘go live’ with Privia.“The day that they go live is the day themanagement fee kicks in,” he notes.

Privia also offers physicians a secondpractice option – the opportunity toparticipate solely in Privia QualityNetwork, its Accountable Care

Organization (ACO). Currently, the ACO has over 240 participatingproviders, including the 200-plusproviders in the medical group, andabout 40 physicians that have signed up for the ACO only.

Future PlansHaving grown quickly in the first sixmonths, Privia Medical Group initially is targeting small- to medium-sizedpractices in the Maryland, Virginia andD.C. area, but is considering futureexpansion into non-contiguous markets.

“Our goal is to become verticallyintegrated by partnering with hospitals,sub-acute facilities and home careagencies so that we can provide health-care at all points where patients needcare, which is in line with federal healthreform goals,” notes Dr. Aronson. “Ourmodel follows what the payers want,which is local, primary care and multi-specialty care. This model is right for anyforward-thinking physician who wants to be rewarded for high-quality care. We want high-quality physicians whounderstand that healthcare is changing.”

Maryland’s Unique ChallengesNancy Smit, MBA, is a partner at RS&FHealthcare Advisors, a recent jointventure between RS&F, a major regionalaccounting and consulting firm, andSHR Associates, a healthcare consultingfirm. The new firm was launched in

I believe that nearly every practice willbe audited in the next 24 months by atleast one entity. – Nancy Smit, MBA


Nicholas Grosso, MD, president of theCenters for Advanced Orthopaedics

Andrew Aronson, MD, chief medical

officer of Privia Medical Group

Nancy Smit, MBA, partner at RS&FHealthcare Advisors

mid-2013 to help doctors and hospitalssuccessfully navigate healthcare changes.“RS&F’s culture was a good fit with ourfirm,” she comments. “They have high-level professionals who can address thefinancial and strategic work, while wefocus on internal operations and billing.As physician organizations grow incomplexity and size, they need thatrobust level of advisory support.”

Smit notes that physicians practicing in Maryland face some unique challenges.“Physicians in New Hampshire and manyother states are reimbursed about 40%above Medicare, whereas in Maryland,the private insurers’ reimbursements arebelow Medicare. Physicians also havehigh malpractice rates here, and themajor health systems – University ofMaryland, Hopkins and MedStar – are another key factor pressuring thephysician market in Maryland.”

Advice: Shop Wisely, BeEfficient, Prepare for AuditsSmit warns that physicians need to be savvy in their dealings with healthsystems. “My advice is to talk to anyone and learn what you can,including your competitors and yourreferring physicians. Hospitals may tryto play competitors against each other,so be careful not to believe that yourcompetitor is joining them withoutindependent verification.

“The best thing any physician can do today is to make his or her practice as efficient and patient-centered aspossible,” she continues. “Most practiceshave a 30-40% level of inefficiency that can be addressed by embracingtechnology, retaining high-quality staffand maximizing billing and collectionprocedures.”

Smit adds, “Predictions are that nearly

every practice will be audited in the next 24 months by at least one entity.Our company is helping practicesconduct those audits proactively to see if they need to make changes in theirdocumentation, coding or other practices to avoid having to pay backmoney or incur penalties.”

Predicting the Future “The days of the cottage industry formedical practice are over,” believesSmit. “Small practices need to buy the same software and systems as thelarger groups. The sheer pressures from administrative and overheadburdens are driving many small andsolo practices to merge or seekemployment. Five to 10 years ago, you didn’t need IT support, but todayyou can’t do without it. When thatkind of cost can be spread over morephysicians, it saves money.”

What will healthcare look like 10years from now? “From the physicianperspective, bigger will be better andthere will likely be much moreconsolidation and downsizing ofhospitals,” Smit predicts. “Urgent care is a growing trend, with more convenientlabs and X-rays. And I think hospitalswill continue seeking to employ primarycare physicians in an effort to controlwhere the patients ultimately go for their total healthcare needs.

“I also think the patient-centeredmedical home (PCMH) model, which I love, will continue growing,” sheconcludes. “The medical home offersopportunities for greater satisfaction for the physicians, patients and staff, and it encourages physicians not to dowhat the staff can do more cost-effectively. Interestingly, even the Fedsare embracing this model; we’re nowworking with community health centersand federal community health centers to credential them as medical homesthrough NCQA.”

Nancy Smit, MBA, partner at RS&F Healthcare Advisors


Q: At the end of this year, you’llleave public office to become theassociate dean for Public HealthPractice and Training at JohnsHopkins’ Bloomberg School of PublicHealth. You’ll also hold a facultyposition in the department of HealthPolicy & Management. What will beyour role at Hopkins?

For half of my time, I’ll supervise thepreventive medicine residency programand student training in public healthpractice. For the other half, I will be onthe faculty of the department of HealthPolicy & Management. I’ll be a linkbetween school and public health inMaryland, and will help to train futureleaders in public health.

Q: You’ve served as BaltimoreCity’s health commissioner, as deputycommissioner of the FDA, as the top minority staffer on the HouseGovernment Reform Committee, and now as DHMH secretary. As cityhealth commissioner, you expandedtreatment for addicts and vaccinatedhealthcare workers against influenza.Looking back on your many years ofpublic service, what have been yourgreatest challenges and successes?It is very satisfying to show that it ispossible to tackle stubborn challenges.

Many people think that substance- use disorders, infant mortality, access to healthcare, or even a particular IT problem, whatever it is, can’t ever be fixed. That demoralizes people and keeps them from trying to improvethings. Half the battle is overcoming that mindset. The challenge is to showpeople that there’s something they can do and that problems are amenable to intervention.

When I started as city healthcommissioner, the idea that there wouldbe drug treatment available on demandwas like a pipe dream for the city, butnow it largely exists. People thought that infant mortality in the city was verydifficult to improve, and they couldn’timagine we’d make significant progress,but we’ve seen it.I’ve been involved in everything

from getting unsafe caffeinated alcoholicbeverages and cough-and-coldmedications for infants off the market to restructuring hospital payment in

Policy

Reflection and Forward ThinkingDHMH Secretary Joshua Sharfstein, MD

Shortly aer Joshua M. Sharfstein, MD, announced that he wouldbe leaving his current position as secretary ofthe Department of Healthand Mental Hygiene(DHMH) to accept a position with Johns Hopkins BloombergSchool of Public Healthbeginning January 2015,Maryland Physician satdown with him to reflecton his challenges and accomplishments andlearn where his next position will take him.Maryland Physicianfirst interviewed Dr.Sharfstein in its July/August 2012 issue.


Maryland. It’s been an incredibleprivilege to serve in these positions. I’vebeen lucky to have such support from thepolitical leaders in the city and the state,and they played a critical role in gettingpeople to think that things can get better.

Q: When Maryland Physicianinterviewed John Colmers, he notedthat in Maryland we all have the same idea that government is goodand we have the same mindset.In Maryland, there’s an expectation that our job as public officials is to solveproblems. To that extent, peoplesometimes get upset that problems aren’tsolved quickly enough. I don’t thinkthat’s a bad thing. There are places in the country where they don’t considerproblems to be solvable. We’ve seen a lot of collaboration with the private sectorover the past few years, private-publichealth coalitions across the state, and the Chesapeake Regional InformationSystem for our Patients (CRISP) is a great example of that.We just published a white paper

called “A Prescription for Innovation:

Maryland’s Data-Driven Approach toContaining Costs and Advancing Health”– August 2014, which describes some of the recent accomplishments.

It’s beyond just government. Marylandis a state where people are coping withtheir anxiety about the future ofhealthcare by putting in place structuresthat will actually work. Everyone isanxious that there’s not enough moneyfor healthcare, but here we have astructure – through the waiver – theability for the state to control its owndestiny. Doctors and hospitals are lookingfor ways to share the savings. It doesn’tguarantee it will be successful, but there’s so much effort to get that moving

in the right direction, and peopleelsewhere just feel that they’re beingtossed on the seas of change.

Q: There are some metrics fromCMS that show things are moving in a positive direction nationally,though with some questions aboutwhether that’s due to healthcarereform or other economic factors.Nationally, particularly with respect tocosts, there is some uncertainty. Here in Maryland, by contrast, people arefocused. The budgets are set. Hospitalsare collaborating more, doctors areengaged, and long-term care facilities andcommunity health providers are lookingto collaborate. It’s an incredible moment.

Q: What would you advise Marylandphysicians to do moving forward?I would advise them to become involvedin the dialogue about what’s happening in Maryland.

MedChi is working closely with theHealth Services Cost Review Commission(HSCRC) to support a request to CMS to permit different types of sharingbetween doctors and hospitals undercertain circumstances. But this is just the tip of the iceberg of physicianinvolvement in the change underway.For example, the PCMH model is

very exciting, and we’re looking tostrengthen it.

Q: The Maryland health exchange,Maryland Health Connection, is being rebuilt using the software ofthe Connecticut exchange. There’sbeen some controversy surroundingboth states’ site construction. Your comments? The Connecticut exchange has beendoing very well. Consumers really lovethe system. The exchange opens upNovember 15 – it will be a different openenrollment season this year than last.

It’s been an incredible recovery story.Obviously, things did not go the way wewanted last year, but you can look at it as,when we faced that kind of challenge,what happened. It was an incredibleeffort by all to exceed our enrollmentgoals despite the IT problems. We wereable to aggressively pivot to a much

better system. Maryland’s Secretary of the Department of InformationTechnology Isabel FitzGerald and her staff have done a great job, and the Connecticut team has also been very helpful.

Q: Why did you selectConnecticut’s exchange system andnot the federal health exchange?We picked the Connecticut systembecause it is simple and elegant, and ithas a proven track record. The federalsystem doesn’t fulfill our requirements on the Medicaid side, and it was muchmore expensive, and to some extent risky,because of our very old Medicaid system.

It was very difficult to go through thesignup last fall, but I can’t say enoughabout how people rolled up their sleevesand did an enormous amount manually to help people get health insurance.There were people who said we shouldgive up, but we pushed through.Now we’re poised to see a much

improved website this year.

Q: Would more time have helpedprevent some of the rollout issues?I think the fundamental issue was thetechnology. Once we were committed tothe use of a platform that really could nothandle the job, we were in trouble.

Q: What do you expect the impactof the new Medicare waiver to be onphysician practice in the state? I think it will bring the healthcare systemtogether. Under the old system, hospitalssucceeded if they did their job, but nowhospitals will only succeed if the health-care system does its job. That pushes thehospitals to engage with physicians. I think that the HSCRC has helped

every hospital move to global paymentsin year one – achieving our five-year goal in one year. The hospitals were very interested in moving out of fee-for-service, so that’s created an urgencyfor collaboration, which we’re seeing inall sorts of different ways. I know thereare physicians who are nervous, but manyare very excited about it. The ones whoare more engaged are more excited. Iurge physicians to get more engaged inthe process.

The challenge is toshow people thatthere’s something they can do and thatproblems are amenable to intervention. – Joshua M. Sharfstein, MD


’VE CALLED MARYLAND HOMEfor over 30 years, and in that time I’vebeen regularly amazed at the history,natural beauty and destinations thisgreat state keeps showing me. Mostrecently, I wanted to develop my winepalette and wine knowledge. I alsoneeded some easy, outdoor-focused day trips. Visits and tours of some ofMaryland's highly regarded wineriesaligned perfectly with these goals. I was introduced to Maryland’s winerytours via social media, and shoppingsites like LivingSocial and GroupOn, and was hooked by their offers of special bundled tours. After one “specialoffer” purchase and several lovelyweekends spent day tripping, I found a healthy and vibrant industry growinggrapes, making wine and offeringdestination sites for tourists, weddingparties and even corporate events.

The Maryland Wineries Associationhas comprehensive information aboutour wineries, even grouping them intocurated “trails,” like the AntietamHighlands, Piedmont, Carroll, andFrederick Wine Trails. I decided on theChesapeake and Patuxent Wine Trailsbecause those wineries are a reasonabledrive from my front door. While Iappreciate good wine and am very happy to call out a bad one, I’m by nomeans a wine snob. My expeditionsstarted with the simple goals of learningsomething about a growing Marylandindustry, and picking up a little generalwine knowledge along the trail. Oh, and I purchased a few bottles.

First, I was drawn across the BayBridge to St. Michael’s Annual Wine

Living

Maryland Wine Country

I

A Blend of Scenery and Tastes

Festival and made a visit to St. Michael’sWinery, the largest winery on the EasternShore. Located in the Old Mill Complexon South Talbot Street, at the southernedge of town, this business is in a smallcomplex that also includes artists’ andfloral shops. I enjoyed this winery largelybecause a visit to St. Michaels is alwaysa pleasure, and their tasting room staffwas ready to help. This winery, however,is not the place to bring the kids, unlessyou stop off at Justine’s Ice CreamParlour first (also on Talbott Street), and at the day’s end, the retail storeSimpatico’s, Italy’s Finest for a taste of almost all things Italian.

On another early spring weekend weheaded off with a picnic basket and dog,and were welcomed with open arms anda dog water bowl to the rolling fields ofRunning Hare Vineyard, a sizeablevineyard in Prince Frederick, CarrollCounty. Their wines, specifically thePinot Grigio, Sangiovese, Chardonnay,Malbec , Shiraz, and Chambourcin

Dessert Wine, have won an impressivenumber of awards in the past five yearsin many national and internationalcompetitions. Their tasting room andevents facilities pay homage to Tuscanfarmhouse design, and there are justenough poplar trees dotting the rises that if you squint, you might mistake anout building for a Roman fortification.Maybe. Here’s a nice touch many ofthese wineries are adding: music andevents. Throughout the spring andsummer, Running Hare offers live musicon the weekends, so bring the family,and a picnic, purchase some wine, andprepare to enjoy the fresh air.

Just to show off some newly acquiredwine knowledge: not every winery is anestate winery; in other words, not everywinery grows its own grapes. Some will contract independent grape growersto supply them, or will purchase bulkgrapes from out of state. In a briefdiscussion with Kevin Atticks, executivedirector of the Maryland Wineries

JACQUIE COHEN

ROTH

Maryland wine country is a perfect destination for weekend day trips, weddings and even corporate events.

By Jacquie Cohen Roth


Association, I learned there are sixwineries that use exclusively fruit theygrow themselves. “About 50 winerieshave on-site vineyards, and otherspurchase local fruit, when available.There are over 90 varieties of grapesgrown in Maryland, but about 40varieties are grown to commercialscale,” says Attick. Black Ankle Wineryin Mount Airy was the state’s first estatewinery, and Knob Hall Winery nearHagerstown, and Sugarloaf MountainVineyards in Montgomery County, arefollowing suit. Add to that knowledgethat there are now 67 licensed statewineries, up from 14 just 10 years ago,and I say, get the word out: Marylandfarmers need to look into this crop.Vines can be planted close together tomaximize acreage use, they need fewpesticides, and this is a growing industrywith a clear need. Our new motto?“Maryland, the old vine state.”

It’s tough to pick a favorite, but in the running is Slack Winery, near themouth of the Potomac River, below the Patuxent River Naval Base. Slackcombines its property with the lovely18th-Century Woodlawn Inn for anunmatched historic Maryland experience.

UPCOMING FALL WINE FESTIVALSOctober 18 & 19

Wicomico County Autumn Wine Festival

5561 Plantation Ln.

Salisbury, MD 21801

October 25

Harvest at Swan Harbor Farm

401 Oakington Rd.

Havre de Grace, MD 21078

The beautiful views of the river arevirtually unchanged from the colonialtime of Governor Calvert. The openfarmland and welcoming atmosphere area breath of fresh air after a week of citytraffic and deadlines. The adjacentJubilee Farm is part of the operation,and has activities for children, dogs, andeven adults looking to be not-so-adult-like for a while. They too offer weekendmusic, events and celebrations throughthe summer and into the fall. Call aheadto arrange a tour of the vineyards andfarm, enjoy a flight of award winningwhites or reds in the tasting room, andconsider staying the night. I suggesttaking a trip to Slack in late fall.Tastings, hot cider, Adirondack chairsand a roaring fire pit- with dogs and kidsaround- make for a truly delightful wayto spend a Saturday during the earlyholiday season. There are many “crashcourses” in Maryland wines, or as we liketo call them, wine festivals, and they’reterrific opportunities to support the “buylocal” movement. They really are funevents for comparing the different resultsfrom different wineries. Atticks told me,“We have seven major festivals in the fall.Our last event of the season is October 25

at the bayside Swan Harbor Farm inHavre de Grace.” The Maryland Winewebsite can update you on the nextfestival dates. Different grapes, soils, andweather systems combine to createdifferent tastes, even from the same grape,and a wine festival can help you comparewinery to winery. The dry, rocky, steepslopes of Mount Airy, home to heraldedBlack Ankle, produce different resultsthan the flat, clay and sandy soil of theEastern Shore. I have so much more tolearn, and I think I’m up to it.

For more information visit Marylandwine.com. Next up? DiscoveringMaryland’s craft beer industry.

Physicians Physical Therapists

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Solutions

What Medical PractitionersCan Learn From Retailers

By Laura Westervelt and Matt Felton

HEN RETAILERSlike Starbucks or Walmart open a newlocation, they have already spent timeresearching areas where their modelworks best. In addition to under-standing their clientele’s demographics,spending patterns and habits, they willhave identified their competitors’locations, accessibility of the proposedsite and any planned residential andcommercial development that will impact their business.

Among the many ways it is reshapingthe healthcare industry, The AffordableCare Act is causing many medical groupsto consolidate in order to survive. Tomake a profit in the new normal of lowerMedicare and insurance reimbursements,doctors are sharpening their business plan models to increase patient volumes.Being strategic about their location allowsthem to maximize success by providingvisibility, accessibility and conveniencefor patients.

Medical practitioners, includingphysician practices, hospitals and urgentcare centers, have begun to act more likeretailers as they assess the viability ofexpanding into new locations. In ourincreasingly fast-paced world, patients are looking for the same convenienceand accessibility in medical services that they’ve come to expect from retailshopping. Business consultants who usemaps and technology to help businessesmake good location decisions are seeingmore and more healthcare companies use the ”location analytics” traditionallyrequested by retailers. This map-basedapproach to strategic planning givespractice managers and executives a newperspective on the market, and helpsthem clarify how and where to grow their practice.

W Harness the Power of GIS Making data-driven decisions hasbecome essential for the survival of most medical practices. Understandingthe “where” in this data provides auniquely competitive edge. Companieslike Datastory Consulting are helpinghealthcare organizations capture thisadvantage by offering location analyticsthrough the power of geographicinformation systems (GIS).

One of the most common places tostart is mapping the location of patientsand practices to learn more about theirlocation relative to one another. Bytransforming a patient list to a map,patterns emerge that show clusters ofpatients and underserved markets. The map is then layered with data about consumer habits (e.g., medicalexpenditures or number of visits to anallergist) and existing medical practices to create a supply-demand map thatreveals areas of highest opportunity.

These maps can also describe thedominant lifestyles in a given area to help practitioners know which servicesare best suited for each location. Areresidents “Laptops and Lattes,”“Prosperous Empty Nesters” or “Up and Coming Families?” This marketsegmentation moves beyond simpledemographics to align services with thelocal community and ensure long-termstability for the practice.

Trends: Backfill Big Box Stores and Partner with RetailersMedical practitioners also are beingdrawn to practice in retail locations. It is not uncommon for retail centers to fill their in-line storefronts with medicalusers and for former “Big Box” stores tobackfill with medical users. For example,

Saint Agnes Hospital recently backfilled a former 40,000-square-foot Room Storein Ellicott City, Carroll Hospital Centerplans to turn a former 56,000-square-footSuper Fresh in Mt. Airy into a healthcarecenter, and Anne Arundel MedicalCenter (AAMC) opened a new 45,000-square-foot facility in Pasadena next to a Walmart. Another emerging trend is the formation of partnerships betweenretailers and healthcare providers. CVSstores now have walk-in clinics, and Giant Food has teamed up with AAMC to establish clinics in several of theirlocations.

Real estate brokers that representmedical clients have, by necessity,become experts in both medical officeand retail lease transactions. The trend is driving retail leases to begin includingtenant improvements, but physiciansmust be aware that their plumbing andHVAC needs may incur an additionalexpense. Fortunately most retail locations already are designed toaccommodate the parking requirementsof medical users, and exterior and pylonsignage opportunities in key retail spacesare appealing to healthcare companiesseeking to attract new patients.

The lesson for physicians is to borrowsophisticated mapping tools from retailersto make sure their practice thrives.Laura Westervelt is vice president ofMacKenzie Commercial Real Estate Services,

a commercial real estate company in

Baltimore. She can be reached at 443.573.3207

or [email protected].

Matt Felton is president of Datastory

Consulting, a company that combines data,

maps and technology to help businesses

make good location decisions. He can be

reached at 410.583.8877 or matt@datastory

consulting.com.


Creating Systems of Support for Young Adults with Cancer

HEN A YOUNG PERSONis diagnosed with cancer, their list ofquestions, wonders and worries canseem never-ending. What are my chancesof beating this? How sick will I get? AmI going to lose my hair? What about mywork; how will I pay my bills? How willmy family cope? This list goes on. Butone question a young cancer patientdoesn’t have to ask is “Will I be alone?”The answer, by the way, is no, and thereason is that the Ulman Cancer Fundfor Young Adults works diligently toprovide patients with resources andsupport as they battle their disease.

It all started in 1997, when DougUlman was diagnosed with cancer at theage of 19. Immediately understandinghow important it is to have access toinformation and a network of otheryoung adults who had similar questionsand challenges, Doug and his familylaunched the Ulman Cancer Fund forYoung Adults. Their goal was to create a community of support for patients and their loved ones as they fight cancerand embrace survivorship. Today, theorganization is delivering exactly what it initially set out to do, with anabundance of events, programs, supportgroups and educational forums offeredto help cancer patients forge newconnections, create new friendships and never, ever, feel alone.

“The doctor’s job is focused ondiagnosis and treatment; we fill the gapfor everything else that surrounds theclinical part, so a young person withcancer feels supported and has theopportunity to connect with others whoare going through the same thing,” saidBrock Yetso, president and CEO of theUlman Cancer Fund for Young Adults.

Those on a mission to “get back toliving” following their diagnosis and

treatment might opt to participate in the organization’s “Cancer to 5K”program, which brings a group togetherto train and ultimately cross a differentkind of finish line, as a team. Then thereare programs like “Help Others Fight,”which unites cancer survivors, theirfamily members and the community at large to lend helping hands witheveryday tasks that may suddenly seemdaunting when you are fighting cancer.

“We organize groups of volunteers to come together to do yard work,prepare meals, put up holiday lights, orwhatever else the person that is beingtreated for cancer, needs,” said Yetso.“These are passionate people who, inmany cases, understand what it’s like to be going through cancer treatment,and they want to help.”

Yetso and his team are interested inmaking new connections with localphysicians who care for cancer patients,

in building awareness about the services offered by Ulman, and findingout how local patients can takeadvantage of them.

“We want doctors to know moreabout what we do, so they can refer theirpatients to us for support,” said Yetso.“We also want to learn more about whatour local doctors’ needs are, and whattheir patients’ needs are, as we continueto grow and build new programs.”

Physicians interested in learning moreabout the Ulman Cancer Fund for YoungAdults are encouraged to schedule alunch and learn session by sending anemail to [email protected].

Good Deeds

WBy Tracy M. Fitzgerald

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

A group of “Helping Others Fight” volunteers recently came together to do yard work for a patient undergoing treatment for cancer. This program is one of many organized by the Ulman Cancer Fund for Young Adults, to create a system of support and unity for young people diagnosed with the disease.

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