July/August Med Beat

MARYLAND HOSPITALS PLEDGE TO SERVE LOCAL FOOD AS PART OF STATE-WIDE BUY
LOCAL INITIATIVE

Thirteen Maryland hospitals have committed, so far, to buying and serving foods from local farmers in their
menus during the Maryland 2014 Buy Local Challenge. The annual Buy Local Challenge (BLC), an initiative
created by the Southern Maryland Agricultural Development Commission, is a personal commitment to support
farms by eating local. Maryland residents are asked to pledge to eat at least one thing from a local source every
day during Buy Local Week, July 19-27th.

The BLC has partnered again this year with the Chesapeake Food Leadership Council, an initiative of Maryland
Hospitals for a Healthy Environment (MD H2E), to invite hospitals and other large-volume purchasing
institutions to participate in the Buy Local Challenge by serving at least one local food each day during Buy Local
Week. Those that sign up to participate will be recognized on the BLC website.

The Maryland hospitals participating are: Carroll Hospital Center, Frederick Memorial Hospital, Johns Hopkins
Bayview Medical Center, Johns Hopkins Hospital, Laurel Regional Hospital, MedStar Montgomery Medical
Center, Meritus Medical Center, University of Maryland Harford Memorial Hospital, University of Maryland
Medical Center, University of Maryland Upper Chesapeake Medical Center, Union Hospital, Washington
Adventist Hospital and Western Maryland Health System. These hospitals are also encouraged to serve local,
sustainable meat and poultry produced without routine antibiotic use, as well as local certified organic foods.

Hospitals are also encouraging their employees, including their executives and surrounding community, to take
the pledge to eat local foods. “Health care providers understand the importance of providing the freshest produce
to their patients and employees while supporting local farmers, and growing our regional food system and local
economy,” said Louise Mitchell, sustainable foods program manager for MD H2E. Last year, fifty-six hospitals
and nursing homes in the Mid-Atlantic region served over $53,500 in locally produced vegetables, fruit, beef,
pork and poultry.

Jointly promoted with the Maryland Department of Agriculture, the statewide BLC initiative highlights the
environmental, health and economic benefits of buying local food. This campaign to engage health care has
catalyzed a movement towards healthier food choices at hospitals, increased support for local farmers and the
local economy, and healthier communities—not only during Buy Local Week, but throughout the year.
Any institution, organization or business participating in the BLC is encouraged to download free resource
materials including official BLC logos, fliers, press releases, and to use #buylocalchallenge to tweet the latest
BLC happenings around the state. For details and to sign up, visit the sustainable foods page at the MD H2E
website.

About MD H2E: Established in 2005, MD H2E’s vision is to advance a culture of environmental health and sustainability in Maryland’s health care community by engaging Maryland hospitals and health care providers though networking, education, technical assistance and recognition. MD H2E has established itself as the go-to organization for sustainability in healthcare in Maryland; no other program serves this role in this region.

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Revised Maryland Medical Marijuana Law Will Certify Physicians

After 2013 Maryland medical marijuana legislation failed to produce any academic medical centers that were willing to make the drug available for medical purposes, the Medical Marijuana Law Senate Bill 923 and House Bill 881 were passed in this legislative session. Signed by Gov. Martin O’Malley on April 14, 2014, the new law retains the Natalie M. LaPrade Medical Marijuana Commission that was established in 2013, and charges the Commission with promulgating regulations to implement the changes by Sept. 15, 2014.

The new legislation will allow “certified doctors” to give recommendations (not a prescription, as these are prohibited by federal law) for medical marijuana to patients that they believe would benefit.

Paul Davies, MD, chairman of the Medical Marijuana Commission, said, “After our Commission proposes the regulations, they will be reviewed by the Maryland Department of Health and Mental Hygiene, the attorney general’s office and a legislative oversight committee.”

Once final regulations have been promulgated, which is anticipated to take about four-six months, the Commission can begin taking applications from physicians and prospective growers and dispensers.

“Maryland will have one of the best programs in the country, thanks to the lessons learned from the many states
that have already legalized medical marijuana,” Dr. Davies notes. “Any physician wishing to recommend medical marijuana for his or her patients will have to undergo a training program and be credentialed by the Commission.”

The Commission chairman estimates that it will take until early in 2016 to establish the necessary network to make the drug available to qualified patients. “We are already working on an implementation plan,” he said.

While initially, the number of potential licensed growers is limited to 15, the Commission may choose to increase the number of licensed growers in future years. Licensed growers must undergo a background check. Dr. Davies anticipates strong demand from growers, and is hopeful that physicians will exhibit equally strong interest. “Studies have shown that marijuana can help ameliorate nausea and vomiting, stimulate appetite, reduce pain and lower intraocular eye pressure.”

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

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Minimally Invasive Spine Surgery: Fast Relief for Intractable Pain

BY PHILIP SCHNEIDER, MD  Dr_Schneider[1] (2)

Case: 

A 54-year-old male presents with a four-year history of severe back pain, sciatica and difficulty walking. He has spinal stenosis and spondylolisthesis at L4-L5. The patient has loss of sensation and weakness. He is no longer able to work out or even enjoy recreational activities with his wife due to intense pain and the need for opiates. He has failed conservative treatment, including medication, physical therapy and epidural blocks. He has been told that this problem is correctable with surgery. However, he has avoided surgery because he works in outside sales and has no income if he does not work. He has two children in college and can’t afford to take much time off for surgery.

Discussion:

Back pain, sciatica, herniated discs and spinal stenosis affect 90 percent of all Americans at some point in their lives and represents the second most common reason a patient presents to a physician. Fortunately, it’s often easy to treat these problems with conservative care. However, a subset of patients will not improve on conservative therapies, and their quality of life can be severely altered.

These patients may benefit from spine surgery, depending on their symptoms, physical exam and imaging studies. Many patients are terrified of spine surgery after hearing anecdotal stories of large incisions, extended convalescence, prolonged pain and long absences from work. Older patients are afraid that they will lose their independence, either having to go to a nursing home after surgery or needing 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 a smaller incision is made and the muscles of the spine are preserved. Small tubes or small retractors are used to create a narrow corridor to the spine. The use of microscopes, loupes, fluoroscopy and surgical navigation allow more precision in order for the surgeon to work through a smaller opening. MIS can be used for many types of spine surgeries, including discectomies, laminectomies and spinal fusions.

With an MIS approach, the muscles are 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 a number of advantages to the patient. Surgical blood loss and hospital length of stay have been shown to decrease with less-invasive surgery, particularly MIS spinal fusion surgery. Return to work also has been shown to be faster with MIS of the spine, and a recent study from Yale University suggested that 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 be significantly diminished. This has been documented in multiple studies in both spine literature and anesthesia literature. Intra-operative use of ketamine and steroids also have been shown to decrease post-op pain.

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

He had been on prolonged narcotics prior to surgery, but was able to stop all narcotics one week following his procedure. He began working from home immediately, started part-time work at one week, and returned back to full-time work at two weeks. He is now six months post-op and has achieved a solid fusion. He continues to work full time and has resumed all previous activities, including sports.

Philip Schneider, MD, is the medical director of 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 PhilSchneiderMD@gmail.com

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Rappel for Kidney Health

BY TRACY M. FITZGERALD

IMG_2719

On June 7,  2014, approximately 100 people made their way up to the rooftop of the Baltimore Marriott Waterfront Hotel, suited up, and stepped to the edge of the 32-story building. Demonstrating not only their adventurous sides but most importantly their commitment to supporting program development and research efforts for kidney disease patients, each participant of “Rappel for Kidney Health” took the handle of a rope and slowly rappelled 28 floors down, ultimately setting foot on the hotel’s pool deck.

Sponsored by the National Kidney Foundation of Maryland, Rappel for Kidney Health gives physicians, nurses and other clinical providers, as well as the community at large, an opportunity to do something unique and exciting, all while raising awareness about kidney disease and how it can be prevented, detected early and treated. The event is chaired by David Lesser, MD, who serves as chief of Kidney and Pancreas Transplantation at the University of Maryland Medical Center.

“My professional life surrounds this issue, so I am happy to put time and energy into this event to raise awareness and funding for research,” said Dr. Lesser, who had planned to rappel himself at this year’s event, but instead was called to the operating room to perform two emergency kidney transplant cases. “And, when people can say ‘Wow, I rappelled off the Marriott Waterfront’ that’s pretty wild.”

Since Rappel for Kidney Health first launched five years ago, approximately 350 people have participated, each contributing a minimum of $1,000 toward the collective total of $525,000 that has been raised. Dollars generated through this event have benefited the National Kidney Foundation of Maryland’s emergency patient assistance program, patient education and screening programs, physician education events and ongoing research efforts though the University of Maryland Medical Center and Johns Hopkins Hospital.

“Some do this in honor or memory of a kidney disease patient and others join groups and see this is a good corporate team-building exercise,” said Katie Kessler, development coordinator for the National Kidney Foundation of Maryland. “Each year, the event grows and allows us to do more for local patients while also providing research grants that help advance our mission.”

Part of that mission emphasizes the importance of prevention and early detection of kidney disease, and includes a series of resources to help educate and screen local citizens. The National Kidney Foundation of Maryland offers KEY (Kidneys: Evaluate Yours) screenings at locations throughout its service area in Maryland, all year long.

“Kidney disease is a silent disease that often goes undetected until the advanced phases,” said Bernard Jaar, MD, chairman of the Medical Advisory Board  for the National Kidney Foundation of Maryland. “This is why awareness and early detection are so important. We are very proud of how successful 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 National Kidney Foundation of Maryland, visit kidneymd.org.

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21st Century Healthcare: Value, Technology, Engagement & Integration

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

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 and the medical 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 staff played in the diagnosis of innumerable patients.

According to data supplied by the World Bank, healthcare accounted for almost 18% of the United States’ GDP in 2012. We’re all quite aware of claims of inefficiencies in 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 top of 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/or Accountable Care Organizations (Healthcare IT) are impacting care finds that 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 understand where the foundations of his training and practice are going. For me, I’m extremely proud to have had it be a part of my heritage and most fortunate to be part of an industry that is indeed shaping the future.

- Jacquie Cohen Roth

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Advances in Lower Extremity Repair

BY LINDA HARDER | PHOTOGRAPHY BY TRACEY BROWN

Living longer has its advantages. But our lower extremity joints weren’t necessarily built to withstand all of the stresses placed on them. Our orthopedic  experts discuss the latest in repairing these critical joints when they suffer lifelong damage.

Robot-Assisted THA

With baby boomers increasingly seeking hip and knee replacements at a younger age, and with longer-lasting component materials, getting a good ‘fit’ is increasingly critical. Hip replacements are now expected to last for 20 years or more, both fueling and responding to this trend. Robot-assisted total hip arthroplasty (THA) is a newer option to increase the precision in component orientation, now available in Maryland.

Orthopedics, cover July/August 2014

William Cook, MD, chair of orthopedics at The University of Maryland Upper Chesapeake Health System, is among the first to employ MAKOplasty® for THA in Maryland. “MAKOplasty is a CT-guided navigation system that gives us a new level of accuracy,” he states. “It uses a software program based on a 3D model of the area that enables us to plan our surgery based on the patient’s unique anatomy. We optimally position our implants ahead of time based on the computer model. Then, when we’re performing the procedure, the robot prevents changes and minimizes bone resection.”

Since the hospital system purchased the MAKOplasty component for hips in the fall of 2013, Dr. Cook and his colleagues have performed approximately 20 procedures with robotic assistance. “The exciting thing about MAKOplasty for hips is that it can precisely align the acetabular cup in the correct inclination and the correct version, to create the most stable hip possible. We can precisely duplicate the anatomy, leading to a lower risk of dislocation and reduced leg length discrepancy. One of the main reasons for patient dissatisfaction following hip replacement is leg length discrepancy.”

He adds, “We can duplicate a patient’s hip offset, which is the distance between the socket and the leg. If the soft tissue is aligned properly, it restores the muscle tension and decreases pain and recovery time.“

A good candidate for MAKOplasty is someone who is not overly obese or muscular and has bone that is not excessively osteoporotic. Dr. Cook explains, “I currently reserve this procedure for very active patients, such as someone who is jogging or playing tennis. The difference is less critical for older, less active patients.”

After the patient decides to have MAKOplasty, he or she typically undergoes a 3D CT scan one to two weeks in advance of the procedure. The data from the scan is fed into the computer program, then the surgeon selects the appropriate sized implant and the amount of bone to be removed. Patients typically have a one-night stay in the hospital, and then are discharged to home with full weight bearing.

Depending on the patient, they may receive home or outpatient physical therapy. “Pain scores are consistently lower,” says Dr. Cook. “Most patients can recover in four to six weeks instead of three months with the robotic approach.”

Anterior Approach

Dr. Cook performs the majority of THAs using an anterior approach, which he has employed on appropriate candidates for the past 10 years (see Maryland Physician July/August 2012, “Joint Tune Ups” for more on anterior hip replacements). “An anterior approach prevents having to detach and reattach muscles, which can lead to atrophy and/or a limp,” he notes. “A posterior approach has a higher dislocation rate, and a lateral approach requires muscle detachment. However, due to the positioning of the leg in the anterior approach, it’s not appropriate for everyone, such as those with significant osteoporotic bone, which can fracture, or obese patients.”

Rethink Pain Management

Dr. Cook has seen a growing trend among referring physicians to send patients who fail physical therapy and anti-inflammatories for pain management. “There is a tendency to send patients for narcotics rather than referring them to an orthopedic surgeon. In my opinion, that’s not the ideal management of these patients. While you don’t want a patient to undergo surgery unnecessarily, physicians may not be recognizing that many of these patients have issues that won’t be satisfactorily addressed by narcotics. The infection risk in THA is less than 1% nationally, and the satisfaction rate is greater than 95%.”

Trending Younger

Dr. Cook comments, “In the 70s and 80s, the mindset was to have patients wait until they were in their 60s or 70s to get a THA. That started to change in the early 2000s. My philosophy is that we can offer these procedures to younger patients now because we can expect one implant to last up to 30 years. The more precisely it mimics the patient’s anatomy, the better the outcome and longevity. One of the reasons I love being a joint surgeon is that you give people back their lives.”

Is Cementless Knee Arthroplasty Superior?

Cover article, July/August 2014The increase over the years in the number of hip replacements is linear, but knee replacements are increasing exponentially, according to Antoni Goral, MD, medical director of the Joint Center at Holy Cross Hospital. “We’re doing about 800,000 knee replacements today, but by 2030, we expect that to grow to 3.5 million. Why? In part because we’ve been doing knee arthroscopy since the 1980s for meniscal tears and other problems, and people go back to high levels of activities. We relieved people’s symptoms, but were we setting many of them up for developing arthritis over time? For young and active patients, wear and loosening contribute to the need for revision surgery of a prior knee replacement.”

If knees were simple hinge joints, it might be easier to repair or replace them. But because they involve both rollback and pivoting, they are complex to treat. As with hips, more people are choosing to have a knee replacement while younger and more active. That also makes it crucial for knee surgeons to carefully assess and recommend the optimal approach.

Dr. Goral explains, “Most of the load on a hip joint is compressive, but with knees, many of the loads are shear. The goal of knee arthroplasty is to restore the normal kinematics of the knee.”

Evaluation and Non-Surgical Approaches

“Some physicians still focus on using anti-inflammatories even when there’s no inflammation,” complains Dr. Goral. “Analgesics, such as acetaminophen around the clock, are better in these cases. Some studies suggest that chondroitin and glucosamine supplements are protective of cartilage, but the American Academy of Orthopaedic 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 biological lubricant such as hyaluronics into the joint may help. Injectable medications, unlike pills, have to get into the joint. I tell people that you can’t put oil on the hood of a car, you have to put it in the engine.”

History of Cementless

Cementless knee arthroplasty has been available since the 1980s, when loosening of a knee replacement over time was believed to be due to ‘cement disease’ – a reaction to the cement used to adhere the replacement. During surgery, the bone is slightly compacted, contributing to the problem.

“Today, we believe that a combination of motion and minute particles that wear away lead to inflammation and enzymes that trigger osteoclasts. The osteoclasts then gradually eat away the bone,” says Dr. Goral. “There are sharp changes in loading going from bone to implant, so manufacturers have tried to design an ‘ingrowth’ approach using more porous implant surfaces into which bone could grow. In the 1980s, the implants would have layers of tiny beads or a mesh to address this, but we found that they separated and left too much space over time.

“While the vast majority of knee replacements today are still cemented, we’ve tried various cementless approaches over the years. Today, one approach uses a powdery plasma spray that increases osteo integration. However, with a cementless approach, you need to provide additional stabilization of the implant during early recovery.”

Comparable Results

To provide the necessary stabilization after a cementless approach, there are three options for fixing the tibial side – pegs, screws or stems. Dr. Goral comments, “There are advocates for each approach, though I personally prefer stems. All three hold the implant firmly for the three to four months that the bone is potentially growing up to, and into the surface.”

According to Dr. Goral, cementless and cemented knee arthroplasties have roughly the same results. “Most studies of implant longevity and patient satisfaction have found that the restoration of a neutral knee alignment is most important, not the implant technology,” he notes. “Better, more customized instrumentation and robotic guidance improve outcomes. The ideal outcome is a ‘forgotten’ joint, one that has no clicks or pain and that feels stable enough that the patient forgets it is there.”

On the Horizon

In the future, Dr. Goral believes that platelet-rich plasma, which contains growth factors, may be used to promote healing. “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 of now, so it’s not reimbursed by insurers.”

Healing Complex Ankle Fractures

Knees and hips get much of the attention in orthopaedics, but a strong, properly fixated ankle is critical to staying mobile. AccordingCover article, July/August 2014 to Stuart Miller, MD, MedStar Orthopaedics foot and ankle surgeon, “When you go up a set of stairs, you’re putting five times your body weight on your ankle. And ankle fractures, surprisingly, are one of the most common fractures, occurring across all age groups.”

Fortunately, a growth in dedicated foot and ankle specialists, better technology, and more flexible stabilization devices are revolutionizing care of this key joint.

Growth in Foot and Ankle Specialists

“There’s been an explosion in foot and ankle specialists recently,” Dr. Miller claims. “Some 10 years ago, there were six in the greater Baltimore area; today, there are 12 specialists, and two more are coming soon. When a fellowship-trained specialist performs a foot or ankle procedure, it may be more precise because it’s all we do.”

Dr. Miller says, “I perform many total ankle joint replacements today. More than 80% of these patients have trauma-caused arthritis. One journal recently reported that it can take 21 years from an ankle fracture to the development of arthritis. It’s why we’re seeing so much of it now. Over the years, we’ve learned that even a small amount of displacement creates a big problem over time.”

Anatomic Locking Fibular Plates

A substantial improvement in ankle fracture stabilization is the number of new anatomically locking fibular plates that are available. Designed to fit on the lateral aspect of the distal fibula, these devices maximize bone fracture stabilization and minimize soft tissue irritation.

“They are pre-contoured to fit the patient’s anatomy, and use locking screws that function somewhat like a molly bolt, to work far better in comminuted osteoporotic fractures,” explains Dr. Miller.

Fixation of Syndesmosis & Fracture Suture “Buttons” Offer Advantages Over Screws

Newer approaches to stabilizing the ligaments and bones following a complex ankle fracture have eliminated the need to use screws, which are removed in a follow-up procedure. These approaches instead use a tiny incision 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 in shape,” Dr. Miller states. “We pull/twist it so that it can’t go back through the hole. Today, we’re also using this method to fix ankle syndesmotic injury and gain stability. Biomet Sports Medicine offers a ZipTight™ Fixation System and Arthrex offers a Knotless TightRope® System for syndesmosis repair. They are low-profile and knotless, to prevent soft-tissue irritation and allow more precise duplication of joint mechanics during movement.”

From Casts to ROM Splints

Newer approaches to immobilizing ankles after a fracture are putting cast technicians out of business. “We got rid of our cast tech at Union Memorial 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 to six weeks post-op, then start gradually introducing weight bearing. This approach promotes faster and better rehabilitation, the skin is healthier, and patients can take the boot off to do gentle ROM and to bathe. If the fracture is stable, patients may 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 adjustable bladder that allows the ankle to be fixed at a given point or permits range of movement within a set angle. Dr. Miller concludes, “With the elimination of casting, patients no longer have to spend months getting back range of motion, and they are much happier.”

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

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

Stuart Miller, MD, MedStar Orthopaedics foot and ankle surgeon

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

BY MEG FAIRFAX FIELDING Key Battle of Baltimore (1)

The Medical & Chirurgical Faculty of Maryland (MedChi) was founded in 1799, just years after the birth of our country. Many of MedChi’s early members fought in the American Revolution, and were prepared to fight again in the War of 1812 – and in the Battles of North Point and Baltimore, which took place in September of 1814.

It is one of MedChi’s founding members, William Beanes, MD, of Prince George’s County, who played a pivotal, yet largely unknown, role in the history of The Star-Spangled Banner. If not for Dr. Beanes, Francis Scott Key would not have been on a ship in Baltimore’s Harbor, and he would never have written the poem which became our National Anthem.

William Beanes was born at Brooke Ridge, in Prince George’s County on January 24, 1749. There were no medical schools when Dr. Beanes studied medicine, so he apprenticed with a local physician. Professionally, his fine reputation spread beyond the county, and in 1799 he became one of the founding members of the Medical and Chirurgical Faculty of Maryland, and a member of its first examining board.

During the summer of 1814, as the British prepared to invade Washington, General Ross selected Dr. Beanes’ home as his headquarters, and Dr. Beanes agreed not to object to his presence or harm the troops. However, when the British Army returned to Upper Marlborough (now spelled Marlboro) after burning Washington, they were jubilant, drunk and marauding. Dr. Beanes and some of his neighbors were forced to arrest some of the most badly behaved of the group. One prisoner escaped and reported this to General Ross.

General Ross returned and arrested Dr. Beanes in the middle of the night. Dr. Beanes traveled with the British Army down the Potomac River and up the Chesapeake Bay, as the British prepared to burn Baltimore as they had done in Washington.

A lawyer named Francis Scott Key was engaged to free Dr. Beanes from the British Army. Key traveled to Baltimore with letters of support from President James Madison, as well as letters from British prisoners whose injuries Dr. Beanes had treated only weeks earlier in Upper Marlborough.

Dr. Beanes was being held on a truce ship just south of Baltimore, and Key sailed out to negotiate for his release. Key secured Beanes’ release, but the as battle was beginning, the men were not allowed to leave.

For more than 25 hours the battle raged. Dr. Beanes and Key watched and waited all through the night. Toward the 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 Fort McHenry. They knew that the British had not captured Baltimore.

As the men sailed back to Baltimore, Francis Scott Key penned the now famous poem on the back of an envelope. It was printed in a local paper and then set to the tune of an old drinking 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 small graveyard in Upper Marlborough, and is remembered throughout Prince George’s County, where roads, schools and 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.

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KISS-IT: Keeping It Simple with Information Technology

BY ELIZABETH DIABLE Professional-Profile-Pic

So here’s a news flash, you are a medical professional, not an IT expert. However, you are required to maintain compliance, adhere to all regulations, operate a prosperous business with increased demand for services on a smaller and smaller budget due to dwindling reimbursements, deliver superior quality of healthcare to your patients… let’s stop there. The one requirement you have, that you made a lifelong decision about, was to go to school and become a medical professional. Why? To deliver superior quality healthcare to your patients.

So how do we bridge the gap between doing what you love, keeping patients healthy and making them healthy when they are ill, and keeping up with the IT mumbo jumbo required to stay in business? We KISS-IT by keeping it simple silly when it comes to information technology. Here is how:

  • Identify Problems and Needs
  1. Hardware Infrastructure in place is at the “end of life”
  2. Not meeting compliance criteria
  3. Not meeting regulation requirements
  4. Disjointed systems, network and applications
  5. Limited or burned out IT resources
  • State Goals and Objectives
  1. Minimize capital expenditure (CapEx)
  2. Comply with HIPAA rules and guidelines
  3. Meet regulatory and data security compliance requirements
  4. Centralize all systems, networks, applications and communications
  5. Initiate a help desk engagement that optimizes the value of internal and external resources
  • Evaluate IT Healthcare-Specific Solutions
  1. Optimize your return-on-investment (ROI) with upgrades to your hardware infrastructure, voice and data network improvements and enhanced security of data, all while supporting initiatives to enhance patient care and engagement. Evaluate MPLS networks, server virtualization and cloud technologies.
  2. Reduce operating costs and CapEx to offset reductions in Medicare and Medicaid reimbursements without impacting reliability and the delivery quality of care. Consider cloud computing, disaster recovery and redundant data backup and storage to accelerate risk reduction and cost savings.
  3. Strengthen privacy and HIPAA compliance with centrally managed security, IP and voice communications services. Look for network security, managed on-premise firewall, data center firewall and PCI compliance solutions.
  4. Facilitate communication across your health network with scalable voice and data services customized for each location with application services of MS 365, Hosted Exchange, SharePoint and Lync communications. Facilitate communication and engagement with your patients through a secure WiFi network. Facilitate communication with remote employees and locations with secure remote access, end-point management and mobile device management.
  5. Reduce cost, stress and complexities of your in-house IT resources with a fully managed outsourced help desk that is customizable and scalable.
  • Implementation and Professional Services
  1. The team of implementation professionals should include a project manager, implementation specialist, technical engineer, relationship/account manager and senior-level executive for escalation needs.
  2. Professional services should include data migration, integration, physical human resources and support.
  3. Post-sale support and services should ensure you have a service level agreement (SLA) that meets the demands of your medical environment. Data reliability, integrity and security are paramount. Having redundant systems and networks in place, along with backup and disaster recovery plans ready for activation, will also be necessary.
  4. Make certain there is access to human resources on a per diem or temporary basis. Some projects encompass a level of complexity that existing on-premise staff is not able to accommodate due to their “lean” operations. In these cases, partner with a company who offers physical human resources as a service. This will eliminate the need to hire and train new personnel in-house to get you through the implementation.
  5. Consider having a professional assessment conducted that evaluates your entire operation, including contracts, facilities, assets, etc. This way you can save money, improve efficiency and increase revenue and profits. Knowledge is power and power drives innovation.

KISS IT and optimize the operation of your medical practice by bridging the gap between delivering superior healthcare services and utilizing technology to support your patient care and engagement initiatives. You are a medical professional, not an IT expert; leverage IT experts and partners to build and maintain the bridge.

Elizabeth Diable is a healthcare IT solution consultant with EarthLink Business. Ms. Diable can be reached by phone at 410.981.0211, 202.812.1127 or by email at Elizabeth.diable@corp.earthlink.com.

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Avoiding Billing Pitfalls in the Age of the ACA

Tom-MorrowBY THOMAS C. MORROW

In the second decade of the 21st century, many healthcare providers are struggling to decide whether or not to accept patients who have Medicaid. A key issue is the provider’s ability to ensure compliance with its myriad reimbursement regulations.

Failure to maintain familiarity with the requirements can result in withheld reimbursement, civil lawsuits for restitution of past payments, and even federal and state criminal prosecution. As the pool of Medicaid-enrolled patients increases, a growing number of providers will need to navigate complex and confusing reimbursement procedures. Thorough knowledge of proper billing procedures is not optional. Failure to adhere to reimbursement regulations and requirements can be disastrous to individual and institutional providers.

The Patient Protection and Affordable Care Act (ACA) include provisions that Medicaid payments may be suspended as the result of an audit, even without proof of fraud. A credible allegation of fraud is the sole requirement. Section 6402(h) of the ACA requires a state to suspend payments to an individual or entity providing medical services pending investigation into such allegations. A state may decline to withhold payments only if it determines that there are good reasons not to withhold such payments, and these are limited.

Potential Sources of Fraud Allegations

Sources of allegations include the obvious, such as “whistle blowing” from a disgruntled employee or tips to a fraud hotline. Sources also may include virtually any allegations that may ultimately be deemed “credible.” Increasingly, such allegations originate from computer analyses of claims data that produce atypical, and therefore suspicious, patterns compared to similarly situated providers. An example is “up-coding,” where a provider uses a higher billing code than the norm among similar providers.

Another example involves consistent failure to provide documentation that the auditing entity requires to justify the procedure associated with a specific code. Obvious examples of fraud include billing for services not provided or multiple billings for single procedures. Outright false billing aside, allegations can arise from errors made when providers delegate the coding/billing process to persons inadequately trained in the complexities of the billing process.

Maryland Law

In Maryland, a provider may appeal a notice of suspension to the Office of Administrative Hearings (OAH). The OAH does not conduct an independent review to determine if the suspension is justified, but limits its determination to whether or not the allegation of fraud is credible. This standard is far from the “preponderance of evidence” standard used in civil trials, and demands less proof than the “probable cause” standard required to initiate a criminal charge.

The criteria to justify a suspension are probably most analogous to “reasonable belief,” which requires only that the specifics of the allegation itself be verified by a state entity and that the source has the indicia of reliability. Thus, the appellate review of a suspension in the Maryland OAH is typically limited to an inquiry into the nature of the allegation and the reliability of its source.

Once the state has “verified” an allegation of fraud, the ACA requires the allegation to be referred to the Medicaid Fraud Control Unit (MFCU), an investigation and prosecution unit of the Attorney General’s Office in most states. CMS has published standards for evaluating fraud allegations.

Know When to Seek an Attorney

Because suspension of reimbursement is usually based on a “credible allegation of fraud” that will inevitably be evaluated by MFCU, a provider notified of a pending suspension should immediately contact an attorney. Aggressive intervention by counsel familiar with reimbursement issues may have the suspension terminated through negotiated settlements and help a provider establish that the coding was justified.

Where coding practices are erroneous, an attorney can help establish that errors were not the result of intentional fraud. This may lead to settlement options ranging from reimbursing the Medicaid program for overpayments, implementing corrective action plans and educational programs, reorganizing and upgrading medical records and other remediation options. Most importantly, early resolution of such investigations can avoid the economic devastation of defending a complex false-claims suit or the professionally catastrophic impact of defending 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.

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PCMHs and ACOs: Are They Working?

BY LINDA HARDER | PHOTOGRAPHY BY TRACEY BROWN AND GARY MARINE

The literature presents a mixed picture of the effectiveness of Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs), which Maryland Physician first explored in 2012. Maryland experts provide their perspective, and discuss why the new Maryland Medicare waiver may provide an impetus to both.

ACOs

In 2014, some 343 Medicare ACOs are operational in the US, 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 population health initiatives,” says Craig Behm, executive director, MedChi Network Services. “I’m optimistic about ACOs and the potential to work closely with hospitals because of the aligned goals. The ACO program certainly has flaws, such as the timelines the Centers for Medicare and Medicaid Services (CMS) established, but for the most part, it’s pretty good. The quality measures, for example, need some work but are an appropriate starting point.”

MPM JulyAug 2014Mitch Gittelman, DO, is medical director of the Lower Shore ACO, one of the Maryland ACOs established under the CMS Advance Payment Model and managed by MedChi Network Services. Based largely in Wicomico County, it encompasses 11 practices with 33 physicians and mid-level providers serving approximately 10,000 Medicare patients.

Quality Measures

CMS measures the ACOs on 33 quality measures, 23 of which they have to report on themselves. “The measures include items such as: Are patients with coronary artery disease taking a daily aspirin; Have patients with congestive heart failure had an echocardiogram in the past year; Has a woman had a mammogram; 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 good thought 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 back to an individual doctor about his or her results. The hope is that by providing data, physicians will change their practices. Doctors will only change when given evidence-based information and resources. It seeps into your consciousness. Building a web-based, protocol-driven platform that everyone in the ACO could use took most of our first year, but will be well worth the time spent.”

ACO Results

An independent evaluator determined that the first “Pioneer” group of ACOs as a whole improved the quality of patient care and saved CMS nearly $150 million in their first year. However, results varied widely among the ACOs participating in that pilot group. Evaluations of the next group of ACOs found that more than 50 of the Medicare Shared Savings Program ACOs spent less than their budgets, but that only 29 of them qualified for shared savings, while 60 ACOs spent more than their budgets.

CMS Advance Payment Model

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

The CMS Advance Payment Model provided up-front funding as well as some ongoing funding in the form of non-recourse loans. MedChi Network Services also contributed to the ACOs, including that which was put in through in-kind services. To build and operate the clinical and technological infrastructure to manage about 28,000 beneficiaries, 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 to intensely manage high-risk patients for 90 days, offering multiple telehealth services, and even paying for transportation programs. We have a central team of care managers who do telephone outreach, and who guide practices in evidence-based medicine, but we can’t currently afford to do one-on-one care management.”

Demonstrating savings may not be easy within the fairly short three-year timeframe of the project. “You have to achieve 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 10,000 beneficiaries, 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 receive any 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 were many 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 ACO emphasizes prevention as well as treatment. We’re not just checking off boxes.”

He continues, “The new waiver plus the ACA represent a sea change, improving the quality of life for sicker populations 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 Controversy

The 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 the PCMH model. One of those, an article by Meredith Rosenthal et al., published in the Journal of the American Medical Association in September 2013, may have unnecessarily muddied the waters.

Niharika Khanna, MD, MBBS, director of the Maryland Learning 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 in Pennsylvania that started in 2008 as a chronic disease model and transitioned into a PCMH program. The program focused on efficient chronic disease management, but did not incentivize practices to achieve the triple aim, as PCMH programs do today.”

She adds, “The majority of PCMH programs in the US have demonstrated success in several areas, including reducing ED use and lowering length of hospital stay and overall costs, but some PCMH programs have not demonstrated 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 Models

In Maryland, two PCMH programs exist – the state’s MMPP and a PCMH available to physicians participating in CareFirst Blue Cross Blue Shield. Both are demonstrating results, with CareFirst touting savings of $98 million in 2012 and $38 million in 2011.

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

CareFirst: Coordinated Care

More than one million CareFirst members are patients of physicians participating in the PCMH program, and about 80% of eligible primary care physicians in the CareFirst network participate.

CareFirst CEO Chet Burrell says, “We are now well into the fourth year of the PCMH program. In each of the first two years, more than 60% of participating primary care providers earned performance-based increased reimbursements – called Outcome Incentive Awards – through PCMH, and costs for CareFirst 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 as importantly, we see trends on a number of quality measures that suggest the program is having a positive impact on CareFirst members.”

The program’s success spurred CareFirst to obtain an Innovation Challenge Grant from CMS to expand its PCMH model to Medicare patients, and is expected to launch in a pilot program this summer. CareFirst received $24 million to manage 25,000 beneficiaries through this program.

MMPP: A Better Way to Practice

Data from MMPP is more difficult to obtain, but Dr. Khanna says, “Our program has consistently seen qua

MPM JulyAug 20144

lity enhancements and demonstrated improved teamwork. Emergency visits are decreasing and patient satisfaction is high.”

Melvin Gerald, MD, whose Gerald Family Care practice in Glenarden, Bowie and Washington, DC, has participated with MMPP since 2011, couldn’t agree more. “I was tired of doing things the same way. When the idea of the Maryland PCMH program came along, I was excited. We went electronic in February 2010, which helped.”

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

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-3 provider, some insurers are also sending more patients to us.”

Dr. Gerald observes that every patient who comes into their practice, not just their Medicare patients, are benefiting from the PCMH model. He says, “Before seeing any patients, we huddle every morning to discuss patients who may have problems or needs. It’s a cultural change. I used to sign off on lab work, but now our mid-level providers do it. Our patient portal also helps patients be more aware of their health.

“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 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 Impact

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

“We have to have hospitals and mental health caregivers involved in the care of patients who are chronically ill and need treatment for end stage diseases,” says Dr. Khanna. “Maryland hospitals are interested in the PCMH model. If they can give us some resources, such as mental health and community health workers, we can help them keep patients healthier and out of the hospital. Many patients still have needs such as housing, transportation and equipment that impact their health. We’re in early discussions with the Maryland Hospital Association and the Health Services Cost Review 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 further incentivize communities to work together to save costs. I’m optimistic about ACOs and hospitals working together.”

Community Integrated Medical Home

Dr. Khanna closes by saying, “Today, primary care is truly at the table and we hope that every new innovation in healthcare reform will consider the foundational role that advanced primary care can play. I personally prefer the term ‘Patient Centered Care’ to PCMH, but reimbursement is challenging if you don’t call yourself a PCMH and obtain recognition through NCQA, the Joint Commission or URAC.

“A new term is the Community Integrated Medical Home (CIMH),” she adds, “where an integrated platform for care delivery is envisioned and public health joins with primary care and hospitals. Howard County is undertaking a pilot program to determine what a CIMH might look like, and the Maryland Learning Collaborative is providing technical assistance to involve primary care in the model and understand how community-based care teams can integrate into the PCMH. Following recommendations from the legislature, a state advisory body, is reviewing many of the issues around CIMH and expects to make a recommendation by December 2014.”

 

Mitch Gittelman, DO, family practitioner and medical director of the Lower Shore ACO

Craig Behm, executive director, MedChi Network Services

Niharika Khanna, MD, MBBS, director of the Maryland Learning Collaborative and associate professor of Family and Community Medicine, University of Maryland School of Medicine

Melvin Gerald, MD, family practitioner and founder of Gerald Family Care

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