I’ve Listened & We’re Expanding!

I launched Maryland Physician Magazine – Your practice. Your life with the inaugural issue May/June 2011. I recognized that there was a void and a need in the Maryland healthcare marketplace for a print and online public connection between Maryland-based physicians and healthcare stakeholders and with each other, spotlighting leading-edge healthcare diagnostic and treatment protocols as well as all aspects of practicing medicine. An online reader poll delivered a message, there’s a regional need for making that connection and I’ve listened. Our content scope is expanding to include the District of Columbia and Northern Virginia

In February 2011, my goal was to grow a multi-media platform for healthcare providers and healthcare stakeholders to connect via my founding mission: a physician and healthcare stakeholder network with a commitment to achieving the highest standards of quality and efficient patient care. That led to the print and online launch in May 2011. Maryland Physician‘s dedicated Advisory Board and print and online readership base responded positively to a proposed re-branding as Chesapeake Physician – Your practice. Your life.  Leading into our 4th year in the healthcare marketplace, we’re moving forward with the rebranding and growth effective with our January/February 2015 issue.

Over the last three-plus years, the multi-media platform has grown to become a well regarded brand, delivering news and connecting our readership via print, online, social media and events. That mission is being realized and our network is growing.  The inaugural issue went live with 480+ online readers; now, we’re trending for 20,000 and growing every single day. This explosive growth gives my team and I access to healthcare providers, healthcare policy makers and healthcare policy influencers with a shared and most honorable dedication to providing the highest level of quality patient care with greatest efficiencies of care.   We’ll be doing the same beginning in 2015 with an even an even greater scope, the Chesapeake region. – JCR

 

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Care Coordination: Improvements to the Effectiveness, Safety and Efficiency in Healthcare Delivery

Each issue of Maryland Physician is planned early in the respective year with a clinical theme linking our cover story and feature(s). Throughout the production process, each issue develops its unique life, with blog post is the last piece. My goal with each post is to introduce you to and to weave together our content. When it was “my turn” for this issue’s letter, a clear theme presented itself: care coordination, which is part of just about every piece in the following pages.

Care coordination, as identified by the Institute of Medicine, has the potential to improve the effectiveness, safety and efficiency of our healthcare system. Delivered to targeted vulnerable populations and enabled through the meaningful use of healthcare information technology, care coordination can improve outcomes for all: providers, payers and most importantly, the patients.

Underscoring the role of physicians as drivers of care coordination, we doubled up our usual Healthcare IT department to make it this issue’s cover story (Primary Care in the Driver’s Seat). There’s powerful evidence that emphasizing preventive care and population health management, sometimes with the inclusion of high-tech approaches, is a win-win. Here in Maryland, policy makers are working with providers to ensure that patients are gaining access to better care and the right care (Policy).

Maryland’s Prescription Drug Monitoring Program (PDMP – Managing Pain, Avoiding Addiction) highlights the critical role of healthcare IT in care coordination. Providers that participate in PDMP know what their patients are taking and what other providers are prescribing, which preserves care quality and legitimate patient access to pharmaceutical-assisted care. Clearly, PDMP is of paramount interest to our readers. Since we first featured it in the November/December 2011 issue of Maryland Physician, “PDMP” has remained the #1 search engine key word that leads online readers to mdphysicianmag.com. In this same pain care feature, one of our experts raises the need to distinguish between possible mental health and physical care needs.

In every issue, we also take you away from your clinical demands. We have delivered two such pieces in this issue. Our Living section focuses on Maryland’s burgeoning craft beer industry and Good Deeds features a piece that is certain to transport you to the holiday season upon us.

Wishing you and yours a joyful and peaceful holiday season….

To life!

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Walking with the Spirits

THU TRAN, MD, FACOG

A Journey through a South Dakota Sun Dance Ceremony

This past summer, I joined my son on a community service project in South Dakota to help the Lakota Native Americans prepare for their sun dance ceremony, an event that has occurred regularly for several years. Our destination was a track of land within the Pine Ridge reservation, outside of Rapid City.

Sun dance ceremonies, the most sacred in the Lakota culture, were previously outlawed, but as a result of the “The Wounded Knee Incident” in 1973, they have experienced a revival. Participants dance, gazing at the sun, stepping in rhythm to drums and eagle-bone whistles. The purpose of their dance is to pray for the world, their families and their community. To be a sun dancer is to “sacrifice” oneself for the good of others, with each step carrying spiritual meaning.

Dancers follow many purification rituals before the actual sun dance. Sweating in the “inipi” (a sweat lodge) is one of the most important pre-dance sacred ceremonies. Inipis, which are shaped like a turtle, or the “womb of Mother Earth,” is the spiritual place for prayers. It was our job to build two new inipis using willow branches.

We gathered sage, one of the four sacred medicines used for ritual cleaning in Native American cultures. It symbolizes strength, wisdom and clarification of negative energy. The other three are tobacco, cedar and sweetgrass. The dancers hold sage fans braided with red strings, and wear sage crowns on their heads.

The day before the dance, we awoke early to make wishes for a new “tree of life.” Our wishes wereThe Sage Pickers (1) made of colorful fabric with tobacco inside, carefully tied into a bundle. Tobacco is believed to be our connection to the spirit world, with the smoke thought to be the method of carrying prayers to God.

The day of the dance the dancers wore traditional ceremonial dress and had their wrists and ankles wrapped with sage and red ribbons or strings. Holding sage fans, wearing sage crowns and gazing at the sun, they blew eagle-bone whistles while stepping in rhythm with the drumbeat and ancient songs. Around the arbor, fellow supporters and I watched, mesmerized, and some of us joined in.

With the tree of life’s colorA Pow Wow Gathering (2)ful wishes standing against a blue sky, the scent of burned cedar, the instruments and singing, dancers with their silent gazes to the sun, and a community of supporters all praying for peace and good will, you can imagine the magic of the event. It’s those moments that help us realize what’s truly essential in our lives.

I found I had much in common with our new Native American friends. We care about our families, the world, the environment and our health. We might not worship the same God, but our level of spirituality is not different. We all have the same goal in life: being joyful and peaceful. My time with the Lakota taught me how simply I could live, how rich my life is, and how wonderful it is being part of a close-knit community where everyone is focused on building the common good.

I wish you Peace, or in Lakota, “WoLakota!”

Thu Tran, MD, FACOG, is an OB/GYN with Capital Women’s Care in Rockville; a founding member of ladydocscornercafe.com, and a member of Maryland Physician Magazine’s Advisory Board. The full blog post of “Walking with the Spirits” can be found here

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New Insights Into Autism

LINDA HARDER 

According to recent data from the CDC, about 1% of the world population has autism spectrum disorder (ASD). Prevalence in the U.S. is about 1 in 68 births and is growing at an alarming rate – some 6-15% per annum. Boys are almost five times as likely as girls to have ASD.

Why has the rate of ASD increased? Desmond Kaplan, MD, service chief, Child and Adolescent Inpatient Neuropsychiatric Unit at Sheppard Pratt Health System and clinical assistant professor at the University of Maryland, admits, “We don’t fully know. We suspect it’s a combination of more cases being diagnosed, increased awareness, changing criteria, genetics and environmental factors. Autism is not a simple Mendelian inheritance – there are likely hundreds of genetic variants that interact with each other. There is high concordance among identical twins and the incidence is related to increased parental age, especially increased paternal age. We know that the DNA in sperm is less stable with increasing age. Depakote, a seizure medication, may also be implicated.”

DSM-5 Revised Definition

The new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a revised definition of ASD that identifies three levels of severity based on the amount of support required. It defines ASD as consisting of 1) persistent deficits in social communication and social interaction across multiple contexts and 2) restricted, repetitive patterns of behavior, interests or activities. These symptoms must be present in early development and cause clinically significant impairment.

Signs of ASD

The National Institute of Child Health and Human Development considers the following five behaviors to warrant further evaluation by a multi-disciplinary team:

  1. Absence of babbling or cooing by 12 months
  2. Lack of pointing, waving or grasping by 12 months
  3. Not using single words by 16 months
  4. Not using two-word phrases on his or her own by 24 months
  5. Any loss of language or social skill at any age

“Younger children with autism typically lack ‘shared attention,’ for example, when the mother points to an object, the child looks at the object, or vice versa,” says Dr. Kaplan. “Eye contact and interest in faces is typically diminished. Older children may exhibit repetitive behaviors such as lining up blocks and becoming upset if their arrangement is changed. Or, they may become obsessed with spinning fans or flushing toilets. Autistic children don’t pick up social interactions instinctively. A minority of them have what’s called a ‘splinter function’ where they have superior abilities such as exceptional visuo-spatial abilities.”

He adds, “About two-thirds of children with ASD have intellectual impairment, while the remaining third do not. Children with ASD might also have comorbid behavioral problems or disorders such as, ADHD, anxiety, agitation, aggression, or self-injury.”

Early Screening is Critical

Research suggests that early developmental screening during well-baby or well-child visits is important. The American Academy of Pediatrics recommends that all children be screened at 18 and 24 months. One of their recommended tools is the Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R™), a validated tool that screens children 16 and 30 months of age for ASD risk.

Dr. Kaplan comments, “The M-CHAT screening interview can be used by pediatricians and family practitioners in their offices.”

“The Autism Diagnostic Observation Schedule (ADOS) is the gold standard for the diagnosis of ASD,” he continues. “This instrument involves trained examiners engaging the child in a series of structured play activities to make the diagnosis. We have a behavioral specialist on our unit who has been trained to administer the ADOS. It generates a lot of false positives but few false negatives. We refer children with possible autistic or other developmental disorders for outpatient services.”

The Autism Diagnostic Interview-Revised (ADI-R), a companion instrument, is a structured interview conducted with parents that covers the child’s full developmental history.

Exciting New Research

Both Dr. Kaplan and Deepa Menon, MBBS, assistant medical director, the Center for Autism and Related Disorders (CARD) at Kennedy Krieger Institute, are excited about several recent research papers on autism. The first, a small study by Sally Rogers and Sally Ozonoff at the UC Davis MIND Institute was published online in the Journal of Autism and Developmental Disorders. “This study suggests that early intervention, under one year of age, can change the developmental trajectory for children with severe autism symptoms,” says Dr. Menon.

Treatment involved six months of parental intervention based on the Early Start Denver Model (ESDM) that Rogers and colleagues developed. Dr. Menon observes, “Parents were trained to work on eye contact and play skills in babies aged 6 to 15 months who exhibited marked autism symptoms, such as decreased eye contact, social interest or engagement, and a lack of intentional communication. Six of seven children were able to bring their learning language skills up to normal by age two or three. It gives us hope that early intervention makes a difference. Of course, these findings need to be replicated in larger scale studies.”

A second study, published in the September 3, 2014 issue of Neuronexamined tissue from the brains of children and adolescents who had died by age 20. It found that those with autism had an excess of synapses in some areas of their brains. Dr. Kaplan comments, “That would suggest a deficit in the pruning of synapses in those with ASD. In other words, those with ASD have brains that don’t prune out excess connections in adolescence, which may cause chaotic signaling.

Dr. Menon concurs. “Animal trials indicate that dysfunction at the synaptic level tweaks the function of the genes and disrupts neuronal migration during early development. We think that multiple mutations are linked to autism. Certain genes need to get turned early in development. Cells may not be moving to the right place.”

Dr. Kaplan adds, “We know that autism is not caused by vaccines. It’s strongly genetic. Immunologic and other factors seem to be important as well. I think that we also need to look at adverse events during pregnancy, such as bleeding and exposure to toxins.”

Dr. Kaplan’s unit, at Sheppard Pratt, is one of six premier, national inpatient units dedicated to studying the management of patients with ASD in crisis. “The national research consortium was awarded a $1.2 million grant over two years to create this consortium to address the fact that severe autism has had very limited research involving bigger sample sizes. We started about a year ago to study severe ASD, which until now has been inadequately studied.”

Complementary and Alternative Therapies

A November 2009 article in the Annals of Clinical Psychiatry reviewed emerging therapies for autism and concluded that melatonin, acetylcholinesterase inhibitors, naltrexone and music therapy were “Grade A” interventions.

The authors of a review of complementary and alternative therapies for autism published in 2012 recommend only melatonin and an RDA/RDI multivitamin/mineral supplement for those with diet issues. They note that a third intervention that was published after their review, N Acetylcystein (NAC), showed promise in a random double-blind trial of 33 autistic children.

Notes Dr. Menon, “A third of the children with ASD have loss of developmental milestones (regression). Dr. Richard Kelley found that children with autism and regression could have a mitochondrial dysfunction that caused the regression and that, in these children, providing a formula containing vitamins, Q10 and Carnitine stopped the regression. We hope to get this research into a clinical trial.”

Advice for Physicians: Early Referral

“Parents today are more aware of autism,” comments Dr. Menon. “I find that they really do know their babies. The best advice I can give primary care physicians is to pay attention to any concerns the parents may have, especially if they’ve also had developmentally normal children. It’s better to have too many false positives than to ignore a child who could benefit from intervention. Looking for these deficits and referring to specialty centers is preferable to waiting to see how the child develops.”

She adds, “Regrettably, I still see a few eight- or nine-year-olds who were recently diagnosed, but there’s a clear history of ASD. It’s far better to send children early to be assessed than to wait.”

Treatment for ASD

Treatment chiefly involves behavioral therapy, supplemented by medications when children have concomitant issues with ADHD, depression and the like. Dr. Menon states, “Based on the theory that behavior is learned and shaped by one’s environment, Applied Behavior Analysis (ABA) breaks desired skills down into smaller parts to help children learn. Drs. Robert and Lynn Koegel developed Pivotal Response Therapy® based on ABA. It targets pivotal developmental areas such as social initiations and motivation instead of targeting individual behaviors to create widespread improvement.”

“We get the child to interact and play in smaller, one-to-one settings so they can learn and practice skills under guidance,” advises Dr. Menon. “Communication is often the biggest deficit, so we can teach sign language, use pictures or a tablet to help them communicate. Teaching them to communicate their needs decreases maladaptive behaviors.”

Many families have tried gluten-free and/or casein-free diets. “The research hasn’t demonstrated the value of this approach,” says Dr. Menon, “so the evidence at this time is anecdotal. I refer to a gastroenterologist for an allergy panel if there’s a history of constipation, diarrhea or other gastric issues. The problem with a diet, however, is that most kids with ASD are picky eaters and may only eat a few things. You have to do one thing at a time. I tell parents to be thorough about their interventions – try eliminating one food for four to six weeks and then try reintroducing that food again.”

ASD Resources

Maryland is fortunate to have several major autism centers. Kennedy Krieger offers research, clinical services, a therapeutic day program, day schools in Baltimore and Washington, D.C., partnerships with public schools, and training programs. Sheppard Pratt’s special education schools provide services to more than 300 students with ASD. They also offer a Child & Adolescent Neuropsychiatric Inpatient Unit that cares for children and adolescents with co-occurring developmental and psychiatric disorders, including ASD. Sheppard Pratt’s autism resource guide is visible online at autisminfoatsp.org. Mt. Washington Pediatric offers consults, diagnostic evaluations, social skills and individual and family treatment.

“Both Kennedy Krieger and Mount Washington Pediatric Hospital perform autism evaluations, and University of Maryland Medical Center conducts educational batteries,” says Dr. Kaplan.

In theory at least, the state offers autism services under the Autism Waiver Services Registry, including in-home, respite, residential and other services. Contact them at 1-866-417-3480. “However,” cautions Dr. Kaplan, “The waiting list is years long, and families can become exhausted and isolated while waiting.”

Dr. Kaplan is also the medical director of the Sheppard Pratt Behavioral Telepsychiatry Program, which was launched in 2005. Telemedicine units at both Sheppard Pratt and Kennedy Krieger are helping families in rural areas get developmental screening for their children without traveling for hours. “We have a telemedicine pilot that started in December 2013 with Atlantic General Hospital,” notes Dr. Menon. “We’ve had two clinics per month and have seen about 50 children, and we’re now expanding. Children with suspected ASD can then be evaluated in depth at one of our facilities.”

Sarah Wayland, PhD, who has two sons with Asperger’s Syndrome, offers parents Relationship Development Intervention® (RDI), a family-based, behavioral treatment designed to improve the ability to think flexibly for individuals with autism. She supports parents through a website (guidingexceptionalparents.com) and parenting classes.

Autism Speaks offers an Autism Treatment Network (ATN), a collaboration of medical centers dedicated to providing families with state-of-the-art, multidisciplinary care. The ATN was established to provide a place for families to go for high-quality, coordinated medical care for children and adolescents with autism and associated conditions.

Desmond Kaplan, MD,  service chief, Child and Adolescent Inpatient Neuropsychiatric Unit at Sheppard Pratt Health System

Deepa Menon, MBBS, assistant medical director, Center for Autism Related Disorders (CARD) at Kennedy Krieger Institute

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Managing Pain, Avoiding Addiction

LINDA HARDER | PHOTOGRAPHY TRACEY BROWN

How do you manage patients in pain without risking them becoming addicts? Maryland’s Prescription Drug Monitoring Program and these tips can help.

Opiates are powerful and useful pain relievers, but they too often are abused. More Americans have died from opiate overdoses in recent years than from heroin and cocaine overdoses combined. The CDC reports that moNovember/December 2014re than half of the 41,340 drug overdose deaths in the country in 2011 were related to pharmaceuticals, and that drug overdose death rates increased 118% between 1999 and 2011. Prescription drugs are often a gateway to heroin, with some 80% of heroin addicts first addicted to a prescription drug.

Prescription Drug Monitoring Program

One way Maryland physicians can now reduce abuse is with the new Maryland’s Prescription Drug Monitoring Program (PDMP), which went live December 2013. Doris Cope, MD, a pain specialist at Kure Pain Management, is thrilled with this resource. She notes, “Physicians can go online, put in a patient’s name, and track all of the controlled substances, as well as the pharmacy at which their prescriptions were filled. Maryland was one of the last states to implement such a program, but with the state experiencing increasing death rates from overdoses, this is a highly needed tool.”

Laura HerrNovember/December 2014era, MD, MPH, deputy secretary for Public Health Services, explains why Maryland was later than many states in implementing this program. “Beginning in 2006, several legislative attempts failed. A bill authorizing PDMP was signed into law by the O’Malley administration in 2011. It took about two years to develop the PDMP system that is integrated into our state health information exchange (HIE).”

“Over 40% of the deaths from overdose in Maryland since 2007 are connected to prescription pain pills, according to the CDC,” Dr. Cope observes. “Based on the experience from other states, having the monitoring program in place should significantly reduce the number of prescriptions and ‘doctor shopping.’”

PDMP Provider Access

As of September 2014, roughly 4,500 PDMP accounts had been established by pharmacies and prescribing providers, with over 12,000 visits per week. However, the program is still far short of its goal to credential all appropriate providers.

To access the PDMP, providers must register, watch an educational video, and sign a participation agreement.

Some hospital-based providers have single sign-on to the CRISP (Chesapeake Regional Information System for our Patients) portal, in which case their EHR log-in credentials are automatically relayed to the CRISP HIE. Patient information is also relayed to prevent having to re-enter patient search criteria and to access data with a single click. Interested providers can contact alert.hie@crisphealth.org or call 1.877.95-CRISP.

While PDMP is an excellent tool for prescribing physicians, there is a lag time of up to three days from the time data is entered until it is available to other providers.

“The program is just one aspect of our overdose prevention program,” says Dr. Herrera. “The PDMP allows participating providers to know what their patients are taking and how many other providers are prescribing. Our goal is to promote balanced use of prescription data that preserves the professional practice of healthcare providers and legitimate patient access to optimal pharmaceutical-assisted care. About 100 providers are signing on each week, and anyone who has a Controlled Drug Substance (CDS) and DEA number should participate.”

If patients are abusing or diverting drugs, Dr. Herrera encourages physicians, “Bring them in to discuss what the signs of abuse are, and provide referral to treatment. Our website contains links to resources for providers and patients. If a physician is not sure what to do, we’ll be happy to advise them.”

Providers should note that law enforcement can access the PDMP only if an investigation is underway.

The Medicine Abuse Project for Teens

Another resource for Maryland providers, aimed at helping to prevent drug abuse in teens, is the Medicine Abuse Project. It includes a locator for area abuse and mental health services and a standardized Drug Abuse Screening Test (DAST) that contains a 10-item and 20-item format physicians can use in their practices.

Creating an Opioid Agreement with Patients

To help monitor opiate use and educate patients about their potential risks, doctors can ask patients to sign “pain contracts” or “opioid treatment agreements” that outline a set of conditions patients must follow to stay in the practice. The goal is to discourage opiate abuse that could include excessive medication usage or selling medications. The American Academy of Pain Medicine, the American Pain Society and the Federation of State Medical Boards all recommend the use of opioid agreements in certain circumstances.

The agreements may require patients to consent to some or all of the following:

  • Submit to random blood or urine drug tests
  • Fill their prescriptions at a single pharmacy
  • Refuse to accept pain medication from any other doctor
  • Keep the medication out of other people’s reach
  • Keep the medication in a locked container
  • Not request early refills
  • Refuse to share their medication

Providers can also include a requirement that patients have their pills counted to make sure they’re the only ones taking them.

Avoid Narcotics Without a Specific Diagnosis

Dr. Cope acknowledges, “Primary care physicians are under a lot of pressure to see a high volume of patients, and the easiest thing to do is write a prescription for a patient. But when someone has a non-specific diagnosis, especially if they’re young, you don’t want to go down the path of prescribing narcotics. It’s important to take the time at the beginning and consider the long-term impact of opioids.”

She notes that diagnosing pain can be challenging. “An MRI is like a photo of someone in a particular position. It doesn’t show the body when it’s moving so it’s not totally diagnostic. Pain experienced due to body mechanics may not show up in an MRI. Physicians need to keep in mind what the goal is – to decrease pain and increase function. If a patient is sitting on a couch, life is not better. The treatment could be worse than the disease. You can’t cure ‘sadness’ with opiates.”

Dr. Cope continues, “Opiates are a useful tool when other options don’t work; however, you need to have a clear diagnosis first. If a patient has cancer or major back surgery, for example, they aren’t going to get better. The key is how well they function and how bad the side effects from the opiates are for that patient.”

Managing Manipulative Patients

Dr. Cope cautions physicians, “If you feel like a patient is manipulating you, they probably are. As doctors, we have to do the right thing, not the popular thing. The hardest patient is one who has been using opioids for years and still has severe pain and untoward side effects. We suddenly tell them they should consider tapering their opioids. If we had started earlier giving them healthier options such as weight-loss guidance, injections, acupuncture, or body-core strengthening exercises, it would have been far better for the patients. They do best if they feel in control of their bodies. If they are passive in managing their own health, it’s a poor prognostic sign.”

Some patients fixate on their body as a way of avoiding mental health issues. Dr. Cope explains, “They insist that they are depressed because they have pain, and blame the pain for their dysfunction. I recommend that, rather than directly confronting the patient, physicians say something like, ‘the pain is causing you stress, so you’re not able to enjoy your family. After a while, your friends and family may get tired of hearing about your pain, but a counselor can take the time to listen to you.’ “

Dr. Cope recalls that one of her most challenging patients was an anesthesiologist who had charted her pain every hour for years. “She was an example of a patient who needed to change her focus from pain to something more positive. I ask patients what they really want to be able to do again. You also have to modify some patients’ expectations. If they no longer have a 20-year-old body, they have to be realistic. We are likely not able to completely cure all of their pain or difficult life problems.”

Issues with Medical Marijuana

Medical marijuana has the potential to alleviate pain for many patients with cancer, chronic pain and nausea. One study indicated that whole-plant extract of cannabis that contained specific amounts of cannabinoids, sprayed under the tongue, relieved pain and improved sleep for patients with advanced cancer.

Yet prescribing the substance presents a number of thorny issues. A Journal of the American Medical Association article on June 18, 2014, discussed the pros and cons of the medicalization of marijuana. One drawback is that most users ingest marijuana by smoking.

“THC, which is believed to be the chief psychoactive component of marijuana, is available in pill form, but does not provide the euphoria that marijuana provides,” states Dr. Cope. “Further, marijuana is not standardized, as are all other FDA-approved drugs. Also, there are potential legal issues. There’s no defined optimal dose and we know there’s withdrawal. Furthermore, marijuana contains more than 100 active products. It likely has utility, but it’s like bootleg liquor in its variability. The concept is good, but it needs to be refined, subjected to scientific randomized prospective studies and approved by the FDA for a specific dose, application and protocol.”

In Maryland, the 2014 state legislature passed a revised marijuana bill after the prior law, which was focused on limiting distribution to teaching hospitals, failed to sign up any hospitals. The Natalie M. LaPrade Maryland Marijuana Commission was charged with filling in the details of the new law’s general framework for up to 15 approved growers, regulating distributors and creating/issuing ID cards for qualified patients. Wrestling with a number of details and facing criticism at a public hearing for their first draft, they had to delay the September 15, 2014, deadline for delivering their final draft regulations. Their goal is to provide marijuana to qualifying patients by early 2016.

Early Treatment, Newer Approaches Deter Abuse

Dr. Cope notes, “Treating pain early is one way to deter later abuse and help patients avoid the path to chronic pain. Another approach to control pain is the growing use of transdermal patches, which provide a steady dose of long-acting compounds. Tamper-proof opioids that are not crushable, agonist-antagonist medications, adjunct medicines, and implantable spinal cord stimulators and intrathecal pumps are additional alternatives.”

In July 2014, the U.S. Food and Drug Administration approved Targiniq ER, a new form of OxyContin that was designed to deter abuse by combining a long-acting form of oxycodone with naloxone. “If the pills are crushed, naloxone blocks the euphoric effects of oxycodone,” says Dr. Cope. However, some experts warned the drug could wind up with unintended consequences, as the naloxone doesn’t take effect when the pills are swallowed intact.

Ganglion Impar Nerve Blocks

A newer treatment for pelvic and perineal pain is a sympathetic nerve block to the ganglion impar (also called ganglion of Walther), a collection of nerve cells near the coccyx that relay pain signals to the brain. It can sometimes be used diagnostically to pinpoint pain in the perineal area, which can be difficult due to the variety of anatomic structures that share common nerve pathways. “For patients with a history of sexual abuse, counseling plus these injections can give them hope and keep them on a positive track,” notes Dr. Cope. “They can learn to function better in their activities of daily life.”

Relief for Fibromyalgia

Fibromyalgia is diffuse myofascial pain that leads to chronic fatigue and depression and that often shifts from place to place. Dr. Cope comments, “When they get a fibromyalgia diagnosis, about half of the patients are happy to find that they aren’t ‘crazy,’ while the other half will give up. With this disorder, stress leads to muscle tension and pain and increases insulin and body fat. The best treatment is physical exercise several times a week to get increased blood flow to the muscles, as the areas where muscles connect to bone have become ischemic. That can be combined, where appropriate, with a mild antidepressant. Increasing the heart rate increases blood flow, and exercise stimulates the brain chemistry.”

Pulsed RF for Disc Pain

Patients with disc pain may benefit from a newer approach – using pulsed radio frequency at the dorsal root ganglion, branches that carry pain signals into the spinal cord and central nervous system. Dr. Cope notes, “We have been using pulsed radiofrequency in these patients with good results. Studies in the Netherlands have demonstrated the efficacy of this approach.” Newer studies in the U.S. and Canada are underway.”

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS), formerly known as Reflexive Sympathetic Dystrophy, typically occurs after an injury or surgery to a limb. It typically is characterized by extreme pain, swelling, and/or changes in skin color and temperature. Symptoms can differ widely among patients, but most experience prolonged pain experienced as ‘pins and needles’ or a burning sensation, and light touch can be painful. The pain can spread along the extremity or even to the opposite extremity.

“Treat this condition early to avoid chronic pain,” recommends Dr. Cope. Sympathetic nerve blockage, physical therapy and adjunctive medications are the first line of treatment. In refractory cases Implantable spinal cord stimulation can help patients who don’t experience relief through more conservative measures, including pain medications and physical and psychotherapy. Interestingly, one of my patients with CRPS had a mild stroke that eliminated her pain.”

Inpatient Pain Programs

In addition to existing inpatient programs at The Johns Hopkins Blaustein Pain Treatment Center and Kennedy Krieger Institute’s Pain Rehab Program, a new inpatient pain program is now available at Father Martin’s Ashley in Havre de Grace. This non-profit inpatient treatment center provides care for drug and alcohol dependency, chronic pain and other co-occurring disorders.

When to Refer to a Specialist

Referral to a pain specialist is appropriate when:

  • The pain is not improving
  • Function is not increasing
  • The patient is manipulative or you are concerned that they may be
  • When you want to know if the patient is diverting

We can do drug screens and often determine if the patient is diverting their medications,” comments Dr. Cope. “Physicians can also refer to pain specialists just for a consult, to make sure they didn’t miss anything, if they suspect that opiates are being misused or if they just want confirmation that their opioid therapy is indeed appropriate.”

Laura Herrera, MD, is a family physician and deputy secretary for Public Health Services.

Doris K. Cope, MD, a physician at Kure Pain Management is double-boarded in Anesthesiology and Pain Medicine. She has served as an examiner in both specialties, and previously was professor and vice chair of the Department of Anesthesiology and Pain Medicine at the University of Pittsburgh Medical Center and director of the largest pain fellowship in the U.S.

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Don’t Be a HIPAA-CRIT: Are You Unintentionally Exposing Your Practice?

JAMIE LYNN MEIER, ESQ. J_Meier_2._Griffin-Ames

Most physicians are technologically savvy and provide quality healthcare in today’s cutting-edge, fast-paced practice of medicine. While you are likely taking precautions to protect your practice from the threat of a privacy breach, there are privacy risks that may not be so apparent. Protecting your practice from a breach requires planning, preparation and thinking outside of the box. Believing that you are protected from a breach because you have implemented privacy and security policies, while remaining unaware of everyday practice situations and circumstances that violate HIPAA, could make you a HIPAA-CRIT. The following scenarios will illustrate some of these hidden threats in order to help you avoid a HIPAA violation.

Check Responses to Web-Based Health Review Posts

With websites like Healthgrades and Yelp receiving millions of unique visitors a month, it’s understandable that a negative review would be a source of stress for physicians. It might even be tempting to respond to such a post if for no other reason than to explain an alternative theory for an unfavorable review. Before you try to set the record straight, however, you should consider the potential unintended consequences.

While patients are free to publicly discuss whatever they wish about their own healthcare experiences, physicians are limited – by the law and a patient’s express authorization – from disclosing protected health information (PHI). Responding to comments, even those that are blatantly false, can compound a physician’s troubles by setting the stage for a privacy complaint.

This is not to suggest that a physician has no recourse, but rather to encourage a path to resolution that does not involve public response. For example, you could request that either the site or the patient agree to voluntarily remove the post.

Control Office Chatter

On a typical day, your office staff probably answers the phone within earshot of patients sitting in the waiting room. Disclosures of PHI in this environment are generally considered incidental; however, if voices are raised above a conversational level, or staff are having an unnecessary side conversation and disclose PHI, this would not be considered incidental, and could subject you to a HIPAA breach.

When evaluating privacy protection and security, consider:

  • Avoiding the use of patients’ names in public areas such as hallways, elevators, etc.
  • Ensuring that voice levels are appropriate for the office setting. Where do your patient calls and staff conversations take place? The more compact your office and waiting room space, the quieter you will want to be if you need to have a discussion that involves PHI.
  • Communicating with your patients about how they want you to deal with their PHI. You need to do what is necessary to reasonably accommodate their requests.
  • Posting signs in the office to remind staff members to remain vigilant in their responsibility to protect patient confidentiality.

Encrypt Emails

Healthcare providers are increasingly using email to communicate with patients about their medical conditions. HIPAA does not expressly prohibit the use of email for sending electronic PHI in the Security Rule. However, it includes standards for access control, integrity and transmission security that require practices to implement policies and procedures to restrict access to, protect the integrity of, and guard against unauthorized access to PHI. It is critical to understand that many health and medical professional liability insurance carriers may require software encryption as a prerequisite to receiving coverage.

Regardless of how a breach occurs, compliance in its aftermath can be time-consuming and costly – not to mention the damaging effect a breach can have on your practice’s reputation. In addition to understanding your potential vulnerabilities, you can further mitigate your risk by purchasing a Privacy Breach policy in conjunction with your Medical Professional Liability policy. These steps will help you combat the hidden threats to the security of your practice.

Jamie Lynn Meier, Esq., is an associate in the legal department of the Medical Mutual Liability Insurance Society of Maryland. She can be reached at jmeier@weinsuredocs.com.

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Primary Care in the Driver’s Seat

LINDA HARDER | PHOTOGRAPHY TRACEY BROWN

Physician Leadership of New Care Models Benefits All

Physicians often have been the recipients, not the initiators, of healthcare changes. However, two new Maryland-based companies – Aledade and Evergreen Health Co-operative – are demonstrating that, when physicians are at the helm, care innovation can follow.

Physician-Led ACOs

The Centers for Medicare and Medicaid Services (CMS) has launched three different ACO models: Pioneer, Shared Savings and Advanced Payment models (designed for physician-based and rural providers). Participants in the Pioneer ACO group, which is subject to greater risk than the Shared Savings group, are dwindling from the initial 32 to 19 participants, with Sharp HealthCare, The Franciscan Alliance, Genesys PHO and Renaissance Health Network the latest ACOs to drop out.

But some of the Pioneer members are migrating to the Shared Savings model. Participants in the latter have grown from the first cohort of 27 ACOs to about 340, with more expected to join in January 2015. One will be a Maryland-centered ACO run in partnership with a new company, Aledade.

Recent CMS data on the performance of 220 of these ACOs showed that, as a whole, they had higher scores on most comparable quality measures than other providers, and that 53 of them shared $300 million in bonuses. However, the National Association of ACOs points out that the more than $1 billion invested by ACOs has generated only $372 million in returns, and that 167 ACOs will get no returns this year.

Initially, due to the high capital required to start an ACO, pundits expected the model to be led chiefly by hospitals. However, physicians are emerging as the primary leaders in ACOs, regardless of the model, and they were somewhat more successful in holding down costs than their hospital-led counterparts. And a January 13, 2014, Businessweek article noted that over half of the country’s 367 ACOs were led by physicians and did not include hospitals.

This should not be surprising, given that physicians are oriented to less expensive outpatient care, while hospitals have been oriented to filling their beds and emergency departments. Clinicians also have direct patient relationships and are better positioned to understand what it takes to meet patients’ healthcare needs.November/December 2014

Demand Destruction

Farzad Mostashari, MD, MSc, Aledade CEO and former national coordinator for health information technology at the Department of Health and Human Services (HHS), observes, “For most hospitals, population health is ‘demand destruction,’ where keeping patients healthy has a negative impact on their bottom line.”

Believing that more physician-led ACOs were needed, Dr. Mostashari launched Aledade in June 2014 with a $4.5-million investment led by venture capital group Venrock. The Bethesda-based company initially is signing up independent primary care physicians in Maryland, Delaware, Arkansas and the New York-metro area. On July 31, 2014, Aledade submitted an ACO application with a total of 25,000 attributed Medicare patients in these states.

Electronic Record Challenges

Dr. Mostashari recalls the enormous challenge HHS faced when it first sought to digitize the healthcare industry. “When we started, only 17% of doctors and 9% of hospitals were using electronic records to care for patients. We’re in the throes of rapid, jarring transformation, but a few short years later, it’s the norm to capture data electronically. The continuing challenge is how to change workflows and processes to make healthcare productive and decrease the burden on providers. That can take years.”

ACOs are not exempt from that challenge. A 2014 survey of 60 ACOs by Premier, Inc., and the eHealth Initiative found that they are struggling with sending and integrating data they receive, and under pressure to integrate their analytics into their workflow, with high investment costs and little to show for those investments to date.

Rather than require that physicians change to a single EHR, Aledade will work with practices to bring them up to the higher 2014 Edition Standards and Certification Criteria established by the Office of the National Coordinator of Health IT (ONC), which fosters better data exchange. Dr. Mostashari comments, “Today, EHR systems can talk to each other, though not well. We can get medication, immunization and procedure data. It’s painful but possible. We can even do predictive modeling from disparate systems.”

Flipping the Incentives

Dr. Mostashari explains why EHRs were slow to be adopted. “When I was the assistant commissioner for the Primary Care Information Project at the New York City Department of Health and Mental Hygiene, the major challenge for digitizing healthcare was that there wasn’t a business case for it under fee-for-service reimbursement. Doctors didn’t want to be slowed down if there was no incentive to use an EHR.”

Dr. Mostashari cites the impressive outcomes of a group of 18 primary care physicians in McAllen, Texas, who formed the Rio Grande Valley ACO Health Providers in 2012. In 2009, the area had some of the highest healthcare costs in the nation, yet the population was less healthy than nearby El Paso. By emphasizing preventive care and population health, the ACO saved over $20 million in the next year and a half while improving patient health.

He exclaims, “That ACO demonstrated that, with physician organization and leadership, we can achieve magic. When you flip the incentives, the care changes. This is an important pocket of sanity in the healthcare system. It’s very exciting now that doctors can make money with population health. It’s good for patients, doctors and society at large.

“The problem is,” Dr. Mostashari adds, “that there are too few physician-led ACOs. Doctors can’t do it on their own, but Aledade can help them do it. We create the vessel that makes it easy for physicians to come in and participate.

“You can’t save money by seeing patients for shorter and shorter times during an office visit,” he continues. “However, if you prevent one hospitalization, you can save $10,000. We want to create a concierge experience for patients to save money, not see them less. The trust relationship between a physician and patient is powerful and we’re facilitating that. We want to be like the “Easy Button” for doctors by helping them make the shift to value-based care.”

A Model Aligned with Primary Care

“Aledade’s business model is totally aligned with the primary care physician,” Dr. Mostashari explains. “We’re not paid on a consulting basis, where the interests aren’t always aligned.”

Physicians pay a small fee up front to ensure that they are serious about participating, but Aledade’s main revenue source won’t come until early 2016, when they will be reimbursed if they saved CMS money. Physicians will receive 60% of those savings, and Aledade will get the remaining 40%.

Aledade staff will meet monthly with physicians in the ACO to review best practices and figure out what’s not working. To help manage population risk, Aledade works with physicians to provide predictive modeling and integrated claims and clinical data.

Notes Dr. Mostashari, “We learned that we can’t achieve change without going to the physicians’ offices and being there week after week. There are advantages if the practices are tightly clustered geographically, but a lot of it is about the patient and physician relationship, not the location.”

He adds, “It’s not just about taking care of the patients who were in the office recently, but about the 99% of those who weren’t. We identify the top ones needing the physician’s attention and work to improve their care.”

Dr. Mostashari describes the advantage of moving from his position at HHS to head of Aledade. “The successes and failures are clearer. We’ll save money for doctors and save patient lives, or we won’t.”

He predicts that the ACO model will spread to the commercial population and younger patients. And in Maryland, where a new Medicare waiver took effect at the beginning of 2014, Dr. Mostashari sees an even broader opportunity to flip the incentives. He says, “The waiver changes the rules of the game so that each player’s enlightened self-interest benefits society too.”

November/December 2014Physician-Led Co-op

Peter Beilenson, MD, is chairman of the board of Evergreen Health Care and founder and CEO of its affiliated insurance company, Evergreen Health Co-operative. In 2013, his plans to launch the co-op were stymied by the difficulties with the state’s online health insurance marketplace, Maryland Health Connection. The exchange enrolled only about 72,000 members in 2013 ­­– half of the number it had planned to enroll in private plans like Evergreen or CareFirst. CareFirst offered the lowest premiums in 2013, and ended up with the vast majority of enrollees.

Beilenson expects this year to be different, as CareFirst premiums will increase while Evergreen’s will go down. “In April 2014, only 450 members were enrolled in our co-op, and today we have 5,000 enrollees. Our goal for the end of 2015 is to break even with 20,000 enrollees, which we expect to come from 12,000 small group members and 8,000 individuals.”

He adds, “We did poorly last year because of the exchange failure and because CareFirst underpriced its premiums. I’m very bullish about 2014. Our rates are very competitive and considerably less than CareFirst’s cheapest plan.”

The co-op’s physicians come from two key sources:

  1. Four Evergreen Health Centers, located in Columbia, Greenbelt, White Marsh and Baltimore City
  2. About 20,000 leased providers that are enrolled in MultiPlan (PHCS). Founded in 1980, MultiPlan is one of only a handful of large leased networks in the country, with almost 900,000 healthcare providers under contract.

The Evergreen Health model was based on Healthy Howard Health Plan, which was launched in 2008 when Dr. Beilenson was the county health officer. Healthy Howard, which delivers healthcare to uninsured residents of Howard County, also provides health coaching and care coordination with primary care.

Health Centers Employ PCMH

Evergreen’s health centers employ a Patient Centered Medical Home (PCMH) model of care, which includes wellness services that vary depending on the community’s interests. “One may offer acupuncture and Zumba, while another offers nutrition and therapeutic massage,” Dr. Beilenson notes. “All of them have healthcare coaches that develop wellness programs for patients. Each center is staffed by a primary care physician, nurse practitioner, nurse and licensed social worker.”

Dr. Beilenson describes the benefits of working in Evergreen’s centers. “We pay physicians employed in these centers a salary of $180,000 to $200,000, with outcome-based incentives. Physicians see 12 to 13 patients a day, not 30. They spend quality time with their patients. It’s primary care the way it should be.

“Co-op enrollees are encouraged, but not required, to use the health centers,” he states. “Network primary care physicians are paid fee-for-service, and we work with preferred specialists who are open to innovative financial approaches, including carve-outs and bundled payments.”

High-Tech Telehealth

Evergreen is employing some high-tech approaches to care, including telehealth services. “We started with telepsychiatry in September 2014, then we’ll expand to cardiac telehealth in January 2015, and later to dermatology.

“We have developed relationships with certain specialists so that, for example, a patient with non-urgent chest pain presenting at our health center can be seen within 30 minutes via teleconference by the cardiologist on call,” Dr. Beilenson explains. “For cardiology, we’ll use a Bluetooth stethoscope to transmit the patient’s heartsound to the specialist, and for dermatology, we’ll use a special camera so the specialist can clearly view skin conditions.”

Old Fashioned Service

Another feature that differentiates Evergreen from its competitors is a throwback to the old days when a human being actually answered a telephone, in contrast to the typically lengthy on-hold times for most major insurers. “We offer personalized member services,” promises Dr. Beilenson. “We pledge that a real person will talk to you within 30 seconds.

“I came to this model from a public health background with a patient-centered philosophy, not a business approach,” he reflects. “I want to know how the average person will be affected. I don’t assume they understand what a PCMH or a copay is. Having a physician at the helm creates credibility.”

Farzad Mostashari, MD, MSc, CEO of Aledade and former national coordinator for health information technology at the Department of Health and Human Services

Peter Beilenson, MD, chairman of the board of Evergreen Health Care and founder and CEO of Evergreen Health Co-operative

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Maryland’s Beer Industry Tradition, Science & Craft

 JACQUIE COHEN ROTHIMG_4482 (1)

After my adventures exploring the state of Maryland’s wineries (Maryland Physician September/October 2014 Living) I started to think about our craft beer industry. Is it as robust as the wineries I visited? How do our local beers stack up against other states’ products? After attending a couple of Octoberfests and renowned beer-lovers’ bars, I found that in the great state of Maryland, our selection of local ales, lagers, stouts, and hybrids may well knock your lederhosen right off. My next great investigative mission was born, and it underscores Ben Franklin’s observation, “Beer is proof that God loves us and wants us to be happy.”

Beer recipes have been found in the temples and tombs of pharaohs, so obviously fermented malt-style beverages have been around for a while. In Maryland the first known brewer was Ben Fordham, who, as early as 1707, had a respected establishment in downtown Annapolis. His efforts are memorialized by Fordham Brewing, which, unfortunately, is now in Delaware. Even our venerable National Bohemian, is no longer brewed in Maryland. But no worries, Hon, some very fine Maryland craft beers have stepped up to fill those ale and lager voids.

The two classic “beer” categories are ales (warm fermented beverages), and lagers, (cold fermented beverages), with a side of hybrids, specialties and session beers to bridge the gap. Ales and lagers break down further into all those esoteric groupings the waiter at the brew pub will throw around to impress you. Ales include “name your favorite UK style” (English, Irish, Scottish), India Pale Ales (IPA), Porters, Stouts, Belgian and French. Lagers include Pilsners, Light, European Ambers, Dark and Bocks.

Breweries are another piece of beer-knowledge to integrate. No longer are they only the giant operations from far-away places like St. Louis, or Golden, Colorado. The trade journal Beer Advocate segments them into nano-breweries (very, very small operations, three barrels or less, just a step up from home brewers), brew pubs (small operations, and they sell 25% or more of their product on the premises), micro-breweries (small operations, generally 15,000 barrels or less) and regional breweries (over 15,000, and up to 6 million barrels).

I needed some guidance at this point, because there are a lot of beers out there, and more seasonal brews are being introduced every day. Hello (and good bye) pumpkin beers. I turned to the experts. Annually the Baltimore Sun ranks the best of Maryland’s beers. First of all, hats off to the hardworking, lucky staff at the Sun who committed themselves and their resources to this kind of in-depth investigation. I was pleased to see that representing was the Eastern Shore’s Evolution Craft Brewing Company and Public House (201 E. Vine Street, Salisbury). This little establishment has been making some big Chesapeake Bay waves in brewing and with their eatery. They have a fine farm-to-table restaurant that’s well worth the visit to the Eastern Shore. And the Baltimore Sun will back me up since Evolution’s Lucky 7 Porter was ranked #18, and their Lot No. 3 IPA ranked #7 on their best-of list. Not bad for two brothers who started their brewery with just high hops.

For a little geographic variety, and a lot of beer variety, head to Baltimore for The Brewer’s Art (1106 North Charles Street), and try #4 on the Sun’s list, Resurrection. This abbey brown ale has become the signature Brewer’s Art beverage, and it’s quickly becoming the Baltimore draft. Still, leave room for their Beazly Ale, named after Mark Barcus- a bartender of the Mount Vernon bar for nearly 17 years- #1 in the eyes of the Sun’s intrepid reporters. It’s a golden-colored, Belgian-style, strong pale ale that will put that extra conviction in your cheers for the home teams on a blustery day. Also in Baltimore is well respected brewer Hugh Sisson and his Heavy Seas Brewery (4615 Hollins Ferry Road, Halethorpe). Sisson is a popular advocate of local brewing, and was a founding member of the Brewer’s Association of Maryland. His brewery’s production quality, number and variety dominate many a discussion about good, local craft beers. As proof, in the 2014 Maryland Comptroller’s Cup Competition they dominated with Best of Show – Best Overall Maryland Beer category, earning the gold for their Plank III, and bronze for their Gold.

Frederick has proudly nurtured several breweries, including 1994 Colorado transplant Flying Dog Brewery. With about 80,000 barrels of beer produced annually, Flying Dog has ranked as high as No. 28 on the Brewers Association’s Top 50 Craft Brewing Companies based on sales. But don’t let that overshadow a hometown favorite like Monocacy Brewing Co. and their restaurant Brewer’s Alley, also in Frederick (1781 N. Market St.).

Looking a little more broadly, the 2014 Great American Beer Festival, self-identified as “The largest commercial beer competition in the world!” awarded several medals to Maryland’s craft beers. The one’s to keep an eye out for are: Gold Medal winners “Gold” (again), from Heavy Seas Beer, in the Golden or Blonde Ale category, and “Rauchbeir” from Gordon Biersch Brewery Restaurant in Annapolis, in the smoke beer category. Silver Medals went to Gordon Biersch Brewery Restaurant in Rockville, for their “Belgian IPA” and Union Craft Brewing in Baltimore for their “Old Pro Gose” in the German Style Sour Ale.

One of the most consistent messages I got from the representatives at the breweries and the associations is that these small breweries encourage creative instincts. Using local resources and local inspiration, brewers are producing wonderfully creative beers. This trickles down even to the homebrew category. There are stores, clubs and associations that can launch the creative homebrewer such as Homebrewers Association and The Free state Homebrew Guild. It wasn’t too long ago that at my local farmers market I was beat out of boxes and boxes of blackberries by a home brewer intending to ferment a blackberry stout hybrid; I asked him for an invitation to his tasting. This could be interesting.

For more information on Maryland’s craft beers, visit marylandbeer.org. 

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Creating More Coordinated Care

An interview with Donna Kinzer, executive director, HSCRC November/December 2014

In mid-2013, then-consultant Donna Kinzer set out to help find a new executive director for the Health Services Cost Review Commission (HSCRC) and ended up being asked to serve in the role herself. A little over a year later, she talks about how the sea change in Maryland healthcare is impacting providers.

Q:  You previously worked as a healthcare analyst at Berkeley Research Group and were appointed acting executive director in June 2013 after Patrick Redmon departed. Was this move unexpected, and how did you prepare for your new role?

Yes, it was a surprise. I started as the acting executive director the day of the June Commission meeting. I had worked as a consultant my whole career. When Patrick left, the Commission was left with no director in the midst of negotiating a new waiver. I tried to help recruit someone but there weren’t any takers. Then I told (HSCRC Chair) John Colmers that I could do this job. I saw this as my opportunity for public service.

Q:  You have been credited with jumping in quickly to help forge the new waiver. To what do you attribute your success?

There are some very dedicated people here. We put our heads down and negotiated hard. I have a lot of respect for Joshua Sharstein, MD, (secretary of the Department of Health and Mental Hygiene) and John Colmers (HSCRC chair), who are very dedicated to Maryland healthcare and are skilled, experienced policy leaders. And I’ve trained to support payment transformation my whole life – with lots of rate-setting, payment and delivery reform, as well as other related experience, for the last two decades.

Q:  How do you see hospitals adapting in the next few years under the waiver?

We expect hospitals to focus on better care to drive needed change under the new waiver. The goal is to reduce utilization that can be avoided with better care, and to provide better care outside the hospital, while holding hospitals responsible for providing needed services. We won’t stand by and let hospitals benefit from not providing needed care.

We’re being very analytical and data driven. We started focusing on readmissions a few years ago, which is a great example of our ability to decrease costs by improving care. If someone is readmitted because they didn’t take their medications correctly, or because they got an infection after a surgical procedure, that’s bad for the patient and also bad for the hospital under the new waiver.

Q:  What do you think will be the biggest challenges for hospitals and providers under the new waiver? Can such massive change be accomplished in just five short years? If so, discuss what you see unfolding.

Hospitals will be doing even more work in the community to keep people with chronic conditions healthier and out of the ER. The goal is to focus on community resources to help people maintain better health. We have some great examples from the TPR (Total Patient Revenue) hospitals, all of which now have case managers in their ERs.

These case managers help people get a primary care physician and set up office visits where necessary, assist with medications and transportation, and the like. Hospitals were doing some of this work already, but the waiver has accelerated that. Better quality care can decrease costs because we currently don’t have good care coordination. Increasing that is one of the main goals of the waiver.

We have three main strategies. A first strategy is working with primary care and other community-based physicians to avoid hospitalizations in the first place, especially for those with chronic conditions. Medical home models are also focused on this objective. The second strategy is better care coordination. Commercial patients actually have better care coordination through their insurers than Medicare patients – the people who need it the most – do .

Third, we’ll need to work with long-term care providers. Medication reconciliation is a huge issue. Several hospitals are sending nurses to nursing facilities to reconcile patients’ medications. Doctors and nurse practitioners are beginning to follow patients across settings from the hospital through the nursing facility for specialized care such as pulmonary and cardiology. We’re focusing on re-using the dollars that hospitals save by decreasing utilization for care coordination and care improvement.

The new waiver locks revenue growth for the state. The HSCRC worked with the hospitals to establish global budgets to fix the revenue growth at the hospital level and also to allow hospitals to change and improve care delivery without experiencing revenue losses. Hospitals can adjust their rates up and down as volumes change, but they have to stay within a 5% rate ‘corridor’ or request an exception if volumes fall more than 5%.

Q:  How will the waiver impact physicians?  

Hospitals won’t be successful under the waiver unless they work with physicians. Hospitals will want to make sure there are primary care physicians in the right geographic locations and that care is being coordinated among primary care, specialists, hospitals and specialized programs, especially for individuals with chronic conditions. For example, several hospitals analyzed where most of their low-intensity ER patients and avoidable conditions came from, and worked to place care providers in those areas to provide more outpatient care and also to reduce hospital utilization. Nationally, ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) are driving primary care acquisition, so those models will mean that hospitals are still focused on practice acquisition.

Q:  What advice do you have for physicians in practice to help them thrive under the waiver?

Physicians and hospitals need to work together to provide better primary and follow-up care and help patients navigate the healthcare system. The Chesapeake Regional Information System for our Patients (CRISP), the state’s health information exchange and some other tools are helping physicians with this, but we need more.

Care coordinators and case managers have been added under the medical home models. Hospitals are adding care coordinators. Web-based tools and EHRs will facilitate creating care plans and having the right people access the patient’s information.

Q:  In June 2014, the HSCRC also updated its uncompensated care policy, cutting payments to hospitals from slightly over $1 billion in FY 2014 to $958 million in FY 2015. Discuss why uncompensated care is decreasing and whether you think this trend will hold in coming years.

Uncompensated care is clearly decreasing with the expansion of Medicaid. We had our first rate adjustment as a result in June 2014. There’s a lot of evidence that uncompensated care rates will continue to decrease, since many of the new Medicaid enrollees have mental illness, asthma, and other chronic conditions that created uncompensated care in hospitals. We’re bullish on thinking that expanded Medicaid coverage will decrease hospitalizations, as newly insured patients gain access to better community-based care. The expansion on the commercial side has been important too.

Q:  Discuss the work to date of the HSCRC Work Groups and how you expect their work might impact physicians going forward.

Physicians have been involved in all of our Work Groups. They recommended improving care-coordination resources and focusing on alignment models. We started the planning process with the Work Groups to explore what those models should be and what common tools we could employ.

On the alignment front, we are focusing on care coordination and infrastructure as well as pay-for-performance and shared-savings approaches. We are hoping to accomplish this in an organized, physician-friendly way, so that we can align efforts and incentives around care coordination and care improvement. At the HSCRC, we really want to hear from physicians. We’re serious about acting on their complaints and suggestions.

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Are Your Medical Records Safe?

Medical record protection is an important part of today’s medical practice. Although the switch to electronic record keeping has many advantages, it also entails many new risks. Read about the reasons why so many medical records are at risk.

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