Maryland Physician Magazine September/October 2013 Issue

VOLUME 3: ISSUE 5 SEPT/OCT 2013

NEW HOPE FOR BREAST, PROSTATE AND LUNG CANCER

USING 3T MRI AND PET/CT TO FIGHT CANCER

HEALTH INFORMATION EXCHANGES BEGIN TO BRIDGE THE GAP

Physic i anYOUR PRACTICE. YOUR LIFE.

www.mdphysicianmag.com

MARYLAND

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F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 5 SEPT/OCT 2013

2612 24

Cases | 7 | Lung Cancer Screening Benefits High-Risk Patients

Compliance | 9 | ACA Impact on Small Private Medical Practices

Policy | 24 | Maryland Health Connection: A New Insurance Marketplace

Living | 30 | Rock Hall: Capturing the Treasures of the Chesapeake Bay

Solutions | 33 | Four Tips to Tax-Efficient Investing

Good Deeds | 34 | NAMI: Educating, Supporting a nd Advocating for Local Patients with Mental Health Needs

On the Cover: Christopher Runz, D.O., University of Maryland Shore Regional Health’s Comprehensive Urology office

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE COHEN ROTHPUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA

Jackie [email protected]

CONTRIBUTING WRITERTracy Fitzgerald

PROOFREADEREllen Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

Melissa Grimes-Guy, Location Photography, Inc.Kevin J. Parks, Mercy Medical Center

Randy Sager, Randy Sager Photography, Inc.

BUSINESS DEVELOPMENTEileen Nonemaker

[email protected]

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

Mojo Media, LLCPO Box 949Annapolis, MD 21404443-837-6948www.mojomedia.biz

Subscription information: Maryland Physician Magazineis mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948.

Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email [email protected].

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

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

HOLLY DAHLMAN, M.D.Greenspring Valley Internal Medicine, LLC

PAUL W. DAVIES, M.D., FACSKURE Pain Management

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

STACY D. FISHER, M.D.University of Maryland Medical Center

REGINA HAMPTON, M.D., FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

CHRISTOPHER L. RUNZ, D.O.Shore Health Comprehensive Urology

JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center

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

Social and digital media havebecome an integral part of our culture, havingboth a positive and negative impact on our dailylives. They’ve changed the speed of informationexchange, powerfully affecting our everydayexistence and touching nearly every feature anddepartment in this issue of Maryland Physician.

Social media affords you the opportunity toconnect with your patients for health andwellness education, disease management andhealthcare delivery. Social media raises

awareness of risks for and treatments of disease. The news of Angelina Jolie’spreventative double mastectomy (a treatment option in response to a rare geneticmutation for breast cancer) was instantaneously communicated via social media. In ourcover story (page 10), we’ve consulted with Maryland experts on treating the three topcancers, so that you’re better informed when your patients ask about aggressivetreatments such as the one elected by Ms. Jolie, or developments in radiation therapyfor lung cancer or screening for and treating prostate cancer.

Digital media delivers real-time data and information that has a positive impact oncare delivery and reporting, yielding quality data such as such as readmission rates orER returns. Maryland is ahead of many states in connecting electronic information fromone provider to another; while interoperability presents its challenges, the benefits areclear – see Healthcare IT (page 26).

In Policy (page 14), we interviewed Rebecca Pearce, executive director of theMaryland Health Benefit Exchange. Our conversation with Ms. Pearce spotlights theMaryland Health Connection, the health insurance marketplace for Marylanders wherepatients and small businesses can digitally compare insurance plans and costs. Wediscuss the impact this marketplace may have on those of you running your ownpractices, including the potential influx of patients – some of who may be new to theconcept of having a primary care physician.

Health insurance companies target patients that are less expensive to carry – theyoung, healthy and those most savvy in managing their chronic diseases – to offset thosewho are more expensive to insure. These younger and savvier patients are the same oneswho have immediate access to information on your reputation as a provider as well asdisease and treatment options. Research demonstrates that patients are more likely totrust online information about you than information gathered anywhere else.

Do you know what your online reputation is, and how to manage it? In October,Maryland Physician Events launch with “Reputation Management & Social MediaEvolution for Medical Practices: Reactive, Proactive and Legal Implications.” Join usto learn how you can best engage with your patients and manage your online reputation,while understanding the legal implications. See page 6 for speakers, dates and locations.

Managing a practice may be more stressful than ever. Take a break from it; turn off yoursmart phone, shut down your computer and head outside this fall. Living (page 30)showcases one of the most beautiful spots on the East Coast found right here in Maryland –Rock Hall. The word is that the waterfront beauty found there is like no other.

To life!

Jacquie Cohen RothPublisher/Executive Editor [email protected]

@mdphysicianmag#mdphysicianmagEvents

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FEATURED SPEAKERS:

EVENT

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Reputation Management & Social Media Evolution for Medical Practices:REACTIVE, PROACTIVE AND LEGAL IMPLICATIONS

Educate and empower Maryland physicians to promote health education, health literacy and healthcare delivery AND to protect their online reputation

Director of Web & Communica-tions Technology at the Univer-sity of Maryland Medical System and is responsible for all aspects of their web programs. Mr. Bennett led the UMMS online initiatives designed to educate and attract new patients. He’s pioneered search engines opti-mization techniques that are now standard for hospital websites. Mr. Bennett sits on the external advisory board of the Mayo Clinic Center for Social Media.

Principal in the Maryland law fi rm of Pecore & Doherty, LLC, representing health systems and individual, group and institutional healthcare provid-ers and suppliers. Mr. Doherty maintains faculty appointments at the Johns Hopkins Bloomberg School of Public Health and the University of Maryland Francis King Carey School of Law.

President and Founder of Savvy Marketing Solution, LLC. With a combination of a clinical background with healthcare leadership roles, Ms. Brouillette delivers an astute understand-ing and expertise in healthcare social media. Savvy provides physician practice and health-care entities with strategic marketing and business devel-opment services.

(Anne Arundel County Event Only): Associate Director of the Center for the study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of Health Services. Dr. Flynn spe-cializes in how stress alters cogni-tive processes and offers clinical interventions to support patients and their families by adapting communication strategies for high stress situations instanta-neously communicated via social and digital media.

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SEPTEMBER/OCTOBER 2013 | 7

DISCUSSION: Until recently, efforts atscreening for lung cancer, includingsputum analysis and chest X-ray, havefailed to demonstrate a survival benefit,even for higher-risk patients. However,in the summer of 2011, the NewEngland Journal of Medicine publishedthe results of the NCI-funded NationalLung Screening Trial (NLST), whichdemonstrated a mortality benefit ofscreening high-risk persons for lungcancer by yearly low-dose CT scan.

Since these landmark results were made public, numerous medicalsocieties, including the American CancerSociety, the American College of ChestPhysicians and the American Society ofClinical Oncology, have providedrecommendations for annual screeningthat closely parallel the criteria utilizedby the NLST.

Following review of the NLST resultsand other ongoing related trials, the U.S. Preventive Services Task Force(USPSTF) recently proposed annual lungcancer screening of long-time smokers by low-dose CT scan. Those eligible forscreening are:

z 55-79 years of agez Current smokers or those who have

quit in the past 15 yearsz Those who have smoked a minimum

of 30-pack years

This draft recommendation from theUSPSTF is currently available for publiccomment, and is expected to be formallyadopted in the next few months.

The USPSTF recommendation hastremendous implications. Despitegenerally declining rates of cigarette

consumption, lung cancer remains theleading cause of cancer deaths in theUnited States, claiming the lives ofapproximately 160,000 Americansannually. In Maryland residents, theyearly incidence of lung cancer isapproximately 3,700, accounting forabout 2,800 deaths annually.

Unfortunately, in its early stages, lung cancer is rarely symptomatic. As a result, it can go unnoticed for monthsor years. Most people are diagnosed

with advanced-stage disease, with nearly 90% ultimately dying from their cancer.

Our patient was fortunate to have achest X-ray prior to shoulder surgerythat led to the incidental discovery of her early-stage lung cancer. Clearly, shewould have greatly benefitted fromscreening, as she fits the criteriaproposed for lung cancer screening.Once the USPSTF issues a finalrecommendation, it will be imperativethat all practitioners, and ultimatelypatients, are educated about the role and value of lung cancer screening.

Smoking cessation remains the mostimportant means of preventing lungcancer, but we finally have an evidence-based screening method to identifypeople at the highest risk. This proposedrecommendation should greatly reduceor eliminate the need for incidentaldiscovery of early lung cancers, asoccurred in this patient, and willultimately provide an increased chancefor earlier detection, treatment and curefor this devastating disease.Stephen Cattaneo, M.D., is Anne Arundel

Medical Center’s medical director, Thoracic

Oncology Division, and director, Surgical

Oncology.

Cases

Lung Cancer Screening Benefits High-Risk Patients

CASE: In 2012, a 65-year-oldfemale, current smoker with a58-pack year smoking history(the equivalent of one pack perday for 58 years) underwent achest X-ray as part of her pre-operative workup prior to leftshoulder arthroscopic surgery.Her radiograph identified anincidental left lung lesion.Subsequent diagnostic chest CTscan revealed a 2-cm, spiculatedlesion in the lateral basilarsegment of the left lower lobeapproximating the major fissure.PET/CT demonstratedsignificant hypermetabolicactivity within the left lower lobelesion, but without abnormaluptake in her hilar or mediastinallymph nodes or other distantsites. Since she had excellentperformance status and adequatepulmonary function, she electedto undergo surgical managementof her lesion that consisted of a thoracoscopic (VATS)therapeutic wedge excision of the nodule followed bycompletion lower lobectomy and lymphadenectomy. Finalpathology confirmed an invasiveadenocarcinoma extending tothe visceral pleural surface withall lymph nodes negative. Shehas been undergoing routineoncologic surveillance for herstage 1B lung cancer for the past18 months with no signs ofrecurrence.

By Stephen Cattaneo, M.D.

In Maryland residents, the yearly incidence oflung cancer is approximately 3,700, accountingfor about 2,800 deaths annually.

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N MARCH 23, 2010,President Obama signed into law thePatient Protection and Affordable CareAct (ACA), which aims to eliminateinefficiencies in our current healthcaresystem and extend coverage by providingaffordable care to uninsured Americans.Small private medical practices (less than50 employees) are planning ahead forthe effects these changes will have ontheir practices. Since federal agencies arecontinuing to develop new rules andguidance, practices should consult withlegal counsel for a comprehensiveexplanation of the ACA and howvarious regulations will apply to them.

As the owner of a small privatemedical practice, you should know whichprovisions taking effect January 1, 2014,may affect the health insurance plancurrently offered to your staff, including:

Employer MandateSmall private medical practices (1–49employees) are NOT subject to theemployer mandate or financial penalties.

Essential Health BenefitsAny plans sold or renewed in the smallgroup market (except grandfatheredplans that are renewed by December 1,2013) will include new benefitrequirements known as Essential HealthBenefits (EHBs). Many existing medicalplans currently include these benefits,but annual and lifetime dollar limitshave been removed. The EHBs are:

- Emergency services- Hospitalization- Laboratory services- Maternity and newborn care- Mental and behavioral health and substance use disorder services

- Prescription drug coverage- Rehabilitative and habilitative services and devices

- Pediatric dental and vision coverage

- Prevention, wellness, and chronic disease management services

- Outpatient or ambulatory care

ACA Premium Rating Methodology Small private medical practice rates inMaryland are currently based on theaverage age of the employees enrolled inthe plan. Going forward, group rates willbe the sum of individual rates for eachenrolled individual based on their age.

Rating will no longer be based onenrollment tiers of Employee, Employee+ Spouse, Employee and Child, andFamily. ACA-compliant plan premiumswill be calculated based on the age of the employee, his/her spouse and eachdependent (when applicable). For familyplans, rates will include the employee,his/her spouse, the oldest three childrenunder age 21 and all adult children ages21 to 26.

Premium IncreasesThe ACA also introduced new fees, taxesand assessments that may add to the costof health insurance plans, including:

z Federally Facilitated or StateExchange User Fees – in Maryland,state funding will cover this fee in2014.

z Transitional Reinsurance Program –All plans in Maryland will be chargeda $5.25 PMPM (per member permonth) fee.

z Patient-Centered Outcomes ResearchInstitute Fee – Commercial healthinsurers and employer-sponsoredhealth plans will be assessed anannual fee to fund patient-centeredoutcomes research. This fee, whichwill be imposed for a limited numberof years, is:

z $1 per covered life for the plan andpolicy years ending after September30, 2012, and before October 1, 2014

z $2 per covered life for the plan and

policy years ending after September30, 2013 and before October 1, 2014

z Risk Adjustment Fee – All non-grandfathered small group plans willbe charged this fee, estimated at $1for each covered life per year.

Additional fees will be applied, but theamounts have not yet been determinedby the federal government:

z Health Insurer Fee – All plans inMaryland will be charged this fee,estimated at 2% to 3% of thepremium.

z QHP Certification Fees for SmallBusiness Health Option Program(SHOP) – All plans in Maryland willbe charged this fee if purchasing aplan on the SHOP Exchange.

Medicare Payroll Tax for Higher-Compensated StaffCurrently, all employees pay a 2.9%Medicare tax. According to the IRS:

z An employer must withhold anadditional Medicare hospitalinsurance tax (0.9%) from wages itpays to an individual in excess of$200,000 in a calendar year withoutregard to the individual’s filing statusor wages paid by another employer.

z An individual is liable for additionalMedicare taxes if the wages,compensation or self-employmentincome exceed the threshold amountfor the individual’s filing status:- Married filing jointly threshold — $250,000

- Single threshold — $200,000

Take action now to ensure that youare prepared for the health insurancechanges coming in January 2014.Christopher M. Rutzebeck is the benefits

manager at Human Resources inc. He can be

reached at [email protected].

Compliance

By Chris Rutzebeck

OACA Impact on Small Private Medical Practices


What is an ACO?An ACO is an organizing entity thatallows providers to work in concert toprovide more coordinated patient care.Ward provides an interesting analogy:“We consider patients to be a movie, nota snapshot,” he says. “The ACO canlook at the gaps in patient care and reachout, actively engaging patients who havemultiple chronic conditions betweenvisits. The ACO itself is physician driven.We assimilate clinical information andclaims data from the physicians, thengive it back to them to foster shareddecision-making.”

ACO BenefitsThe true value of the ACO lies in itsability to get real-time and retrospective

information about itspatients so thatdoctors can intervenequickly to preventminor issues fromspiraling into majorhealth crises.

Ward observes,“It’s a mindset shiftthat, if done right,provides clear benefitsto both physiciansand their patients. An ACO can returnjoy to the practice of medicine because physicians can see meaningful changes in the care oftheir patients.

“Our ACO can give participatingphysicians data revealing suchinformation as which of theirhypertensive patients are not under goodcontrol, or which of their patients haveA1C levels that are too high,” Wardcontinues. “We can provide the clinicaldata tied to specific patient names toshine a light on places where thephysician’s attention is needed.”

GBHA ACOToday, the GBHA ACO has slightly morethan a year of experience under its belt. Ithas nearly 14,000 combined beneficiariesin the Shared Savings Programestablished by Medicare and the CignaCollaborative Accountable CareProgram. There are 100 participatingprimary care providers, including nursepractitioners (NPs) and physicianassistants (PAs), plus some specialists.Some providers are employed and othersare aligned with the ACO. The entity hasfour care managers and is hiring twoadditional ones. It also employs threecare coordinators for managing non-clinical issues.

Participating physicians use electronichealth record systems to share clinicalinformation among providers. The ACOprovides technical assistance to optimizethe system, or assist practices inimplementing a system from scratch.

To participate in the Medicare ACOprogram, GBHA had to submit a list of tax IDs for all participatingphysicians to determine the population ofpatients attributed to GBHA. As part ofthe program, CMS shares claims files thathelp the ACO understand patient needs,and close gaps in care. Notes Ward,“Both Medicare and Cigna are providingus with information that is vital toproperly engaging patients and caring forthem in a more proactive manner.”

GBHA chose Medicare’s single-sidedpayment model, which provides fee-for-service payments, plus the opportunity toshare in a percentage of any savings at theend of each year. This model provides thegroup with less potential upside than thetwo-sided model, but no downside risk.

Building on the PCMH ModelThe GBHA ACO builds upon the PatientCentered Medical Home (PCMH)concept. Robin Motter-Mast, D.O., aparticipating family practitioner in HuntValley, and member of GBHA’s board,recalls, “In March 2012, our practice

Profile SPONSORED CONTENT

ACOs: Returning Joy to the Practice of Medicine

Colin Ward, GBHA’s executive director

GBMC HealthCare wasthe first Maryland hospitalto partner with physiciansto create an AccountableCare Organization (ACO)through its affiliate,Greater Baltimore HealthAlliance (GBHA). Aftertwo years of planning andinitial setup, the ACO waslaunched in 2012. ColinWard, GBHA’s executivedirector, says, “We werevery deliberate in ourdevelopmental years,creating a physician-ledboard of directors andaligning with like-mindedproviders.”

received Level 3 recognition fromNCQA. We participated in CareFirstBlueCross BlueShield’s PCMH, whichprovided a foundation for the ACObecause its metrics are similar.” TheACO now has four NCQA-recognizedPCMH practices, and another threeunder consideration.

As a PCMH, the Hunt Valley practicehad already hired care managers andenhanced its IT capabilities to bettermonitor patient care. The approachesthey were beginning to use as a PCMH,such as greater education and monito-ring of diabetic patients, provided anexcellent basis for the ACO. When theytransitioned to the ACO, they also addednew services, such as leaving 30% of the daily schedule open for same-dayappointments to take care of urgent issuesand ensuring extended office hours.Virtually all of these open slots are filled each day.

The ACO entails changes on thehospital side as well. Ward notes, “Forexample, transition guides are now inplace at GBMC to follow congestive heartfailure patients and get them back to theprimary care physicians after discharge.”

From Reactive to Proactive Data“As a pilot program with CRISP, whichruns the state’s Health InformationExchange, the Encounter NotificationService (ENS) has been critical to help usbetter coordinate patient care,” Wardremarks. “We get real-time notificationof hospitalizations and ED visits, so thatpatients discharged from the hospitalhave the opportunity to be seen in thephysician’s office within 48 hours.

“Thanks to the statewide database, wecan see if a patient has visited severalEDs in the state, for example, and canintervene to address their medicalproblem and often prevent future visitsor hospitalizations. Or, we can tell that,while on vacation at the beach, one ofour patients had chest pain and went tothe ED in that area.”

“We’re movingfrom reactive toconcurrent andeventually proactivedata,” commentsWard. “That’smeaningful to patientsand doctors alike. Wecan do something toprevent an emergencyvisit if we see thatpatients aren’tcontrolling theirdiabetes or otherchronic conditionswell. Our care managers can contact apatient who was seen in the ED and askif they need help with prescriptions orhome health. Or, they can arrange for in-home PIC line placement after a patientis discharged, instead of having that donein the ED or hospital.”

Ward notes that the data also helps to shift patient thinking and behavior.“With the ENS, we can view the patient’schief complaint. When we contact thepatient and tell them that we could havehandled their problem in the physician’soffice, not in the ED, they are oftenpleasantly surprised. It’s an opportunityto educate them.”

Specialists can participate in multipleACOs and are not formally named asparticipants with GBHA. ACO referralguidelines set milestones for specialtycare, so that both the referring andreceiving physician agree on the plan of care. Once the agreed-upon clinicalmilestone is achieved, patients can bereturned back to the primary care office.“It frees up a specialist’s schedule so thatnew patients needing initial consultationscan be seen more quickly,” Ward notes.“One of the biggest challenges we hearfrom patients and providers is the delayin scheduling an appointment to see aspecialist, and this can alleviate that.”

As reimbursement becomes increasinglytied to outcomes, Ward advises,“Physicians will have pay-for-performance

contracts that require them to know howtheir patients are doing and to intervenequickly if necessary. Being aligned with anACO allows them to do that.”

He concludes, “The key is that we help reorganize and re-engineer withsmall, smart and focused changes thatgive physicians more joy and that keeppatients healthier. Physicians are nolonger going it alone. They get peer-to-peer interaction and learning, plusinformation about their practice that they can compare to other practices.They can handle activities that needphysician intervention while the ACOhandles non-provider tasks.”

Physicians interested in learning moreabout GBHA can contact Garret Morrisby calling 443.849.4242 or by [email protected]. Informationabout the Medicare Shared SavingsProgram is available atwww.cms.gov/sharedsavingsprogram.

*www.innovation.cms.gov/initiatives/ACO/


Is an ACO Right for You?Providers should have or be willing to get

the following to participate in an ACO

z Implement and use an EHR

z Share clinical data for quality

reporting

z Use evidence-based practices where

appropriate

z Offer some extended hours

(evenings, early mornings, weekend

coverage)

z Leave 20–30% of schedule open for

same-day appointments

z Interact with care managers for

patients needing additional support

CMS Description of an ACO ACOs are groups of doctors, hospitals and other healthcare providers, who come to-

gether voluntarily to give coordinated, high-quality care to the Medicare patients they

serve. Coordinated care helps ensure that patients, especially the chronically ill, get the

right care at the right time, with the goal of avoiding unnecessary duplication of services

and preventing medical errors. *

Robin Motter-Mast, DO, GBHA participating family practitioner.

FOR THE

TOP 3 CANCERSBREAST, LUNG AND PROSTATE


LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

PROPHYLACTIC MASTECTOMIES AND GENETIC MUTATIONSGiven that one in eight women are now at riskfor breast cancer in their lifetime, Dr. KristenFernandez, breast surgeon and director of theBreast Center at MedStar Franklin SquareMedical Center, says, “I often tell my newpatients that the two big risk factors for getting breast cancer are being a woman andgetting older.”

Media coverage of Angelina Jolie’sprophylactic bilateral mastectomy at age 37heightened awareness of the role of geneticmutations in breast cancer and raised questionsabout the best course of action in these cases.Jolie, who carries a mutation of the BRCA1 geneand whose mother died of breast cancer at age56, has stated that her physicians determined herrisk of breast cancer was 87% and her risk ofovarian cancer was 50%.

Genetic mutations greatly increase the risk ofincurring breast cancer. However, Dr. Fernandezcorrects some of the misconceptions about

genetic variants, noting, “Only 5 to 10% ofbreast cancers can currently be tracked to genemutation. People come to my office worriedabout their family history, but we look at whetherthere’s really a clear pattern and we look at boththe maternal and paternal family history. Evenmany physicians don’t realize that the father’sside of the family is equally important in assessing genetic risk.”

Determining Genetic Testing AppropriatenessDr. Fernandez continues, “The best person torefer for BRCA testing is a living relative who’salready had pre-menopausal or bilateral breastcancer, or breast and ovarian cancer, not theunaffected woman who may or may not be atrisk. If the relative with cancer tests negative for a mutation, there’s no need to test the patientwho’s worried about their risk.

“BRCA testing is easy to perform and typically covered by insurance, but it’s often not appropriate,” she adds. “If the patient is

Maryland Physician recently consulted with experts in breast, lung and prostate cancer to learn the latest about appropriate

screening and treatment for these common cancers.

NEW HOPE


negative for BRCA1 or 2 gene mutationsbut has a significant family history, youdon’t know what that means. We suspectthat about half of all genetically-relatedbreast cancers are caused by BRCA1 and2, but there are likely hundreds of geneticmutations that we haven’t yet identified,and those could put the patient at risk.”

Dr. Fernandez advises that womenwith the following personal or familyhistories should be counseled about theirincreased risk:

z Breast and ovarian cancer historywithin the same side of the family

z Multiple cases of premenopausalbreast cancer in the same side of the family

z Male breast cancerz Bilateral breast cancerz Those of Ashkenazi (Eastern

European) Jewish descent with breast or ovary cancer

“The BRCA1 and BRCA2 mutationsincrease the risk of ovarian as well asbreast cancer, and the former is farharder to detect at an earlier stage,” shenotes. “The lifetime risk for breast cancerthrough age 70 with BRCA1 and 2 is 50

to 87%, compared to about 12% for the average woman, and breast canceroccurs at a younger age in these womencompared to sporadic breast cancers in the general population. Anoophorectomy decreases breast cancerrisk by about half.”

When advising women at high riskabout the best course of action to take, Dr. Fernandez listens to what isimportant to them. “I try not to makeassumptions about what they will want.Prophylactic oophorectomy may be agood first surgery from a clinicalstandpoint, but if the woman is not readyto go through early menopause, but doeswant a mastectomy, that may change ourtreatment plan. Similarly, the decisionabout using autologous tissue from bellyfat in breast reconstruction is a personalone – it involves a second incision andmore pain, but it gives the woman a‘tummy tuck’ at the same time.”

She continues, “And for many women, surgery is not the best choice.Prophylactic mastectomy andoophorectomy are the best risk reductiontools that we have for women with aBRCA gene mutation, but that does notmean that every woman with a genemutation has to have surgery. Thedecision to have surgery such as this is a very personal one and should not bemade without a detailed discussion ofrisks, alternatives and expectations. I use our genetic counselor extensively inthese cases. And often my patients willgo with their siblings or parents so thatseveral family members can have theopportunity to hear the explanations andask questions of the genetic counselor.”

Breast Cancer Detection and PreventionDr. Fernandez stresses that monthlybreast self-exam is still a criticalcomponent of breast health. “Everymonth, I see several women who found a lump despite a negative mammogram.Women with genetic mutations shouldget a yearly breast MRI and a baselinemammography, followed by amammogram every two to three yearsuntil age 40, to minimize ionizingradiation. Breast ultrasound is best when there is a palpable lump or theMRI and mammogram results disagree.”

The U.S. Preventive Services TaskForce (USPSTF) and other medicalgroups now recommend chemo-prevention with tamoxifen andraloxifene for many women at highest

Dr. Kristen Fernandez, breast surgeonand director of the Breast Center at MedStar Franklin Square Medical Center


risk for breast cancer – those 40 to 70years of age with a family history ofbreast cancer, without signs or symptomsof breast cancer, and never diagnosedwith breast cancer or ductal carcinomain situ. Women with a history of bloodclots, including deep vein thrombosis,pulmonary emboli, strokes or transientischemic attacks, should not beprescribed these agents.

RADIATION THERAPY ADVANCES IN LUNG CANCERThe top risk factor for lung cancercontinues to be smoking; smokers are ata twenty-fold greater risk of incurringlung cancer than non-smokers, and thosewho quit after having smoked can halvetheir risk. “Counseling on smokingcessation remains critical because lungcancer is still the primary cause of cancer mortality for both men andwomen,” says Amar Rewari, M.D.,MBA, radiation oncologist at ShadyGrove Adventist.

Dr. Rewari is excited about two newerdevelopments in radiation therapy fortreating non-operable, early stage lungcancer: low-dose rate brachytherapy with mesh implant and stereotactic bodyradiation therapy (SBRT).

Mesh BrachytherapyWhile the gold standard for treating lung cancer is a full lobectomy, manypatients aren’t good candidates forsurgery. Until lately, a wedge resectionhad an 18% risk of recurrence – threetimes that of a lobectomy. External beamradiation therapy suffers from thedifficulty in limiting radiation to just thesuture line, where recurrences are mostlikely to develop.

However, using low-dose ratebrachytherapy during a wedge resectionfor patients with Stage I non-small celllung cancer greatly reduces that risk ofrecurrence. Dr. Rewari explains, “In thisprocedure, after the tumor is removed,the radiation oncologist gives the surgeona mesh sheet containing iodine or cesiumto place in the chest cavity. The sheet,

which is laid down directly on the sutureline, contains seeds with a half-life ofseveral days to several weeks, deliveringhigh dose radiation to a focused areawhile sparing normal lung tissue.”

He continues, “Studies have shown thisbrachytherapy procedure, which has beenused in academic centers but was notavailable in community hospitals untilrecently, to be very safe, without long-termcomplications. It makes the results morecomparable to a lobectomy for patientswho can’t tolerate major surgery.”

SBRTThe second development is StereotacticBody Radiation Therapy (SBRT). Thisapproach, appropriate for patients withinoperable early stage cancer, involvesimmobilizing the body and using image-guided radiation therapy. SBRT can beused only on Stage 1 lung cancer withtumors up to 5 cm in diameter.

Dr. Rewari describes this procedure.“Stereotactic radiation therapy wasoriginally created for the brain, wherephysicians used a coordinate system togive high doses of radiation withmillimeter level accuracy. The challengein the lungs was finding a way toprecisely focus the radiation on a movingtarget. The patient is set up with full

body immobilization and an abdominalcompression device to make each breathmore consistent, while a 4D CT takes CTscans over 10 phases of the breathingcycle to assess for tumor motion. For theimage guided radiation therapy we take amini CT scan of the lungs to pinpoint thetumor prior to each treatment.”

He adds, “If the tumor is not close tocritical structures, we can achieve an 85to 95% prevention of recurrence withjust three treatments, typically givenabout twice a week. Tumors close tocritical structures such as the heart andvessels may require five treatments with a smaller daily dose.”

Concurrent Therapy for Advanced CancerFor advanced stage lung cancers,radiation therapy is combined withchemotherapy. “If patients are goodsurgical candidates then chemotherapyand radiation is given before surgery,”says Dr. Rewari. “With radiation alone,the median survival is 10 months; withchemotherapy and radiation givensequentially, median survival ratesincrease to 14 months, and withconcurrent therapy, to 17 months. Recentstudies show that adding surgery couldreduce the chance of the cancerrecurring, may prevent having to treatlymph nodes that were previously treatedelectively, and reduce radiation doses,resulting in less toxicity.”

PSAS AND ACTIVE SURVEILLANCE: JUDGMENT IS KEY Excluding non-melanoma skin cancers,prostate cancer is the most common male

Amar Rewari, M.D., MBA, radiationoncologist at Shady Grove Adventist

Prophylactic mastectomy and oophorectomy arethe best risk reduction tools that we have forwomen with a BRCA gene mutation, but thatdoes not mean that every woman with a genemutation has to have surgery. – Kristen Fernandez, M.D.

cancer and the second highest cause ofmale cancer deaths. About 240,000 menwere newly diagnosed with prostatecancer in 2012, and about 28,000 died of the disease that year. While death ratesfell significantly in the early 1990s, theyhave leveled off in recent years. AfricanAmerican men and those with a familyhistory of prostate cancer includingfathers, brothers, sons, uncles andgrandfathers, are at higher risk forprostate cancer.

Screening for prostate cancer has comeunder intense scrutiny in the past fewyears. Christopher Runz, D.O., aurologist at University of MarylandShore Regional Health’s ComprehensiveUrology office, comments, “Until a fewmonths ago, the standard was to performa yearly digital rectal exam (DRE) and

prostate specific antigen (PSA) test onmen from age 50 to 75 or 80, dependingon their overall health and lifeexpectancy. Last year, the U.S. PreventiveServices Task Force (USPSTF)recommended that PSAs shouldn’t beperformed as community or employer-based screenings, but one size doesn’t

fit all and that’s where medical judgmentcomes in.”

Dr. Runz continues, “At this year’sAmerican Urological Association (AUA)annual meeting, new prostate cancerscreening guidelines were announced thatcall for a more individualized approach.Physicians need to talk to their patientsabout the benefits and risks of thesescreening tests and give them options.Generally speaking, we have tended toover-treat prostate cancer in the UnitedStates, especially in men over age 70, assome of these men have slow growingindolent prostate cancer. However, we donot want to miss a higher-grade prostatecancer in a man with a 15 to 20+ yearlife expectancy. The AUA recommendsthat all men age 50 to 69 talk with theirdoctor to determine if prostate cancer

screening is right for them.”General screening guidelines

recommended by Dr. Runz include:

z Men aged 40 to 54 years old shouldnot get routine PSA screenings, butthose who are having urinary changesor other concerns should talk with

their healthcare provider to determineappropriate steps.

z Men aged 55 to 69 have the greatestbenefit of routine screening. Theyshould talk to their healthcareprovider about the risks and benefitsof prostate cancer screening todetermine what is best for them.

z In men who wish to be screened forprostate cancer, the AUA nowrecommends a PSA and DRE everytwo years.

“Asymptomatic men aged 55 to 69and worried or at-risk men under 55derive the greatest benefit from beingscreened,” advises Dr. Runz. “Irecommend that primary care physiciansdiscuss the benefits and risks with theirpatients, understanding that these testsmay detect prostate cancer earlier, helpthem live longer and avoid problemsfrom the cancer. However, testing alsocan involve false negatives and positives,or diagnose a slow growing indolentcancer that may never cause a problemfor the patient yet whose treatment could entail side effects.”

Active Surveillance GuidelinesNew studies support active surveillanceas an appropriate approach for a selectpopulation. Dr. Runz notes, “A patientwith a normal digital rectal exam (DRE)plus a Gleason Score of 6 or less istypically appropriate for this approach. I also consider the patient’s lifeexpectancy and comorbid conditions.The first conversation we have is whether we need to treat the prostatecancer. I tell many of these patients withlow-grade, low-volume prostate cancerthat it’s not a short-term threat and maynot be a long-term threat to them. I’vefound that providing articles, books andonline videos also helps to educate mypatients about low-risk prostate cancerand make thoughtful, shared decisions.”

A Johns Hopkins study publishedonline in the Journal of ClinicalOncology on June 17, 2013, found thatAfrican American men were at higherrisk of upgraded cancer than white menwhen undergoing surgery after activesurveillance, suggesting that activesurveillance could be riskier for thispopulation.

Guidelines for active surveillance call for PSA/DRE exams every threemonths for the first year, followed by asecond biopsy. At the end of that first


Christopher Runz, D.O., University of Maryland Shore Regional Health’s Comprehensive Urology office

Studies have shown this brachytherapy proce-dure… to be very safe, without long-term com-plications. It makes the results more comparableto a lobectomy for patients who can’t toleratemajor surgery. – Amar Rewari, M.D., MBA


year of surveillance until about age 80,exams should be performed as needed,with follow-up biopsies every three tofive years.

“About 25% of our active surveillance

patients eventually go on to havetreatment if their repeat biopsy shows a change in their prostate cancer,” Dr. Runz says. “We readdress curativetreatment options with them if they havea grade or stage migration after a repeatbiopsy and they’re appropriatecandidates. This may mean continuingactive surveillance or surgery or radiationtherapy. It is important to ensure thatthis is a shared decision-making processwith the patient and family so they fullyunderstand the risks and benefits of eachoption, including understanding thenatural history of their particularprostate cancer.”

In May 2013, the FDA approved

Oncotype DX Genomic Prostate Score(GPS) as a new genetic test. “It’s a goodoption for men on active surveillance,”remarks Dr. Runz. “We send a specimenfrom the biopsy to a specialized lab.

GPS is a measure of the activity of 17genes within the tumor and can help to predict the aggressiveness of thepatient’s prostate cancer. This test is onlymeant for low to intermediate gradeprostate cancers, so it’s a good option for men who are on or considering activesurveillance. This test can help thosepatients without high-grade-diseasepersonalize their treatment based on theircancer genetics.”

New Treatment for AdvancedProstate CancerMen under age 65 with metastatic,castration-resistant prostate cancer who have failed radiation therapy or

surgery often are referred for androgendeprivation therapy (ADT). Thishormonal therapy typically halts thecancer progression for 18 to 24 months,but is not a cure. Until recently, the only other therapeutic option wasdocetaxel based chemotherapy. However,two new drugs – Xtandi (enzalutamide)and Zytiga (abiraterone) can blocktestosterone receptors and stoptestosterone production earlier in thecascade, providing promise for men with prostate cancer resistant tohormonal therapy.

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Clinical FeaturesMaryland Physician spotlights the latest innovations in

clinical care and treatment delivered by your Maryland

peers and colleagues as well as advances in medical train-

ing which facilitate achieving the highest standards of

quality care and practice management solutions.

Healthcare ITIn every issue, Maryland Physician explores a different

facet of the race to implement EHRs to meet Meaningful

Use and other e-health government incentives. Don’t be

left behind – read what Maryland physicians and health-

care IT experts have to say that eases the pain of transition

to an electronic world.

In Every Issue and OnlineCases x Solutions x Compliance x Medical Beat x Policy

Jacquie Cohen Roth x Publisher/Executive Editor443-837-6948 x [email protected]

www.mdphysicianmag.com

Amar Rewari, M.D., MBA, radiation

oncologist at Shady Grove Adventist

Radiation Oncology Center

Kristen Fernandez, M.D., breast

surgeon and director of the Breast

Center, MedStar Franklin Square

Medical Center

Christopher Runz, D.O., urologist at

University of Maryland Shore Regional

Health, Comprehensive Urology

Asymptomatic men aged 55 to 69 and worried orat-risk men under 55 derive the greatest benefit from being screened. – Christopher Runz, D.O.

ADVERTISMENT


NOPR DEMONSTRATES VALUE OF ONCOLOGIC PET/CTThe value of PET with F-18fluorodeoxyglucose (FDG-PET) inoncologic diagnosis and treatmentplanning was demonstrated resoundinglyin the National Oncologic PET Registry(NOPR), which began in 2006.

After the initial NOPR data wasanalyzed, in 2009 the Centers forMedicare and Medicaid Services (CMS)expanded coverage for FDG-PETscanning for Medicare beneficiariesdiagnosed with cancer. The NOPRcontinued to collect data for manyremaining cancer indications. The 2009CMS ruling provided reimbursement forPET scans used in the initial evaluationof patients with most types of solidtumors, and allowed for PET insubsequent evaluations for an expandednumber of cancer types.

Ethan Spiegler, M.D., chief of NuclearMedicine at Advanced Radiology andchair of Nuclear Medicine at Saint Agnes

Hospital, notes, “Since 2006, almost allsolid tumors have been approved forinitial diagnosis with PET.”

In 2011, based on a February 2010National Coverage Decision, the NOPRbegan collecting data on Medicarepatients undergoing PET with sodiumfluoride-18 (NaF-PET) to evaluate bonymetastatic disease. Dr. Spieglercomments, “While FDG-PET has provento be an excellent tool for soft tissueinformation, the registry is still used tocompare sodium fluoride bone scans toNaF-PET. I think the results are likely to show that PET is useful for bonemetastasis, common in prostate cancer.”

Beginning in early 2013, CMS allowedphysicians to order up to three FDG-PETscans after the completion of initialtherapy without having to submit datato NOPR. Local Medicare contractorsmust determine whether subsequentscans will be covered. The CMS decisionwas applauded by PET advocates,including the Society of Nuclear

Medicine and Molecular Imaging andthe Medical Imaging & TechnologyAlliance (MITA).

Dr. Spiegler notes, “Referringphysicians no longer need to completeNOPR paperwork to refer patients forPET/CT. While not perfect, NOPR isconsidered a successful model that islikely to be replicated in the future. Itgathered evidence from more than100,000 scans to show that PETpositively affects patient management. In the scheme of things, even thoughit’s an expensive technology, it wasfound to save dollars and lives.”

CMS also added prostate cancer as a clinical indication for PET this year.Dr. Spiegler cautions, however, “Inprostate exams, PET/CT is notappropriate for the initial diagnosis,although it has a strong role to play inguiding the management of advancedprostate cancer.”

He adds, “Myeloma also just gotcoverage approval this year. And we are

Imaging modalities play an important role in the earlydetection and monitoring of cancer. Maryland radiologists

describe how advances in 3T MRI and PET/CT areimproving oncologic imaging. By Linda Harder

Harnessing the

POWERof Imaging to Fight Cancer

now researching whether using FDG and NaF during the same PET/CT scancan be used in place of a bone scan plusother modalities. The only added cost of this approach would be the secondisotope.”

NEWER RADIOISOTOPES SHOW PROMISEIn September 2012, the FDA approvedthe production and use of C-11 cholinein PET as a result of its effectiveness in detecting recurrent prostate cancer. It is appropriate for patients previouslytreated for prostate cancer who haveelevated prostate-specific antigen (PSA) levels.

New isotopes for determining whetheror not prostate cancer is confined to the gland are also in the research anddevelopment stage. According to Dr.Spiegler, “No modality does that wellyet. It’s not clinically available today, but studies look promising.”

A Johns Hopkins study publishedrecently in the Journal of NuclearMedicine gives preliminary hope that a new small molecule radiotracer (18F-DCFBC) can be used in PET scans tovisualize metastatic prostate tumors.

Rather than using an analogue ofglucose labeled with 18F-fluorine, the study attached 18F-fluorine toDCFBC, the small-molecule compoundthey manufactured that can target theprostate-specific membrane antigen(PSMA) found in prostate cancer, andvasculature found in other types of solid tumors.

Because 18F-DCFBC targets PSMA asit protrudes from the cellular membraneof the tumor, it highlights cancerous softtissue, such as that in lymph nodes. Andits ability to directly target the tumor siteappears to enable it to pick up lesionsnot seen on conventional bone or CTscans because they haven’t yet resulted in local bone destruction.

ONCOLOGIC 3T MRI“A very important contribution 3T MRIhas had in oncologic imaging is theenhancement of MR spectroscopy,” saysElias Melhem, M.D., John Dennischairman of the Department of DiagnosticRadiology and Nuclear Medicine at theUniversity of Maryland Medical System.“The enhanced signal-to-noise ratio of 3Thelps because it can detect metabolitesdespite their low concentration. 3T alsoprovides better spectral resolution that

allows us to tease out the metabolites thatare significant in cancer.”

3T spectroscopy not only distinguishescancer cells from benign tissue, but it canalso determine how aggressive the tumorwill be.

Another advantage of 3T in oncologicimaging entails Susceptibility WeightedImaging (SWI). SWI has developed into a powerful clinical tool used to visualizevenous structures and blood products inthe brain and to study a range ofpathologic conditions. It providescomplementary information to thatoffered by spin density, T1 and T2. Dr. Melhem explains, “SWI isimplemented much better at 3T. We candetect metastatic breast cancer at a muchearlier stage, for example.”

3T MRI FOR PROSTATE CANCER3T MRI is used in conjunction withultrasound in staging prostate cancer, todetermine if the cancer has extendedbeyond the capsule. It can also be usedin computer-assisted 3D MRI/UltrasoundFusion Biopsy to create a more targetedbiopsy in men who have had a negativebiopsy but a rising Prostate-SpecificAntigen (PSA), or men diagnosed withprostate cancer who are undergoingactive surveillance. Radiologists andurologists combine efforts to fuse an

MRI image onto a live 3D ultrasoundimage to create a Doppler ‘map’ thatpinpoints the location of potentialtumors and replaces the current randomtemplate biopsy.

The near future of 3T MRI holds evenmore excitement. “The future is in MRImaging with Carbon 13 labeled 3-pyruvate, and UMMC will be one of thefirst to get it,” enthuses Dr. Melhem.“We will be part of a multi-center trialled by University of California SanFrancisco that will observe metabolicactivity in prostate cancer to determinewho is appropriate for watchful waitingand who is not. The challenge has beenhow to accurately classify patients.”

The new approach may be limited toacademic centers with deep pockets, as

it requires that a smaller 5T magnet beavailable in a room adjacent to the 3Tmagnet. “The C-13 is cooled to nearlyzero degrees Kelvin,” Dr. Melhem notes.“The 5T magnet is used polarize thecontrast agent. As soon as it’s polarized,it is brought into the room with the 3Tmagnet and the patient, and theninjected. When using C-13 in humans, it must be sterile, which makes thetechnique expensive.”

TREATING BRAIN TUMORS WITH 3T3T MRI is also starting to be used inconjunction with focused ultrasound totreat brain tumors. “We will be the firstin Maryland to use MRI-guided focusedultrasound to detect changes in braintissue temperature,” states Dr. Melhem.“We will use MRI to localize the tumor,then use the ultrasound to heat anddestroy cancerous tissue. It’s useful withprimary tumors or metastastic disease, aswell as epilepsy. We will be involved inPhase III trials of essential tremors. Wewould heat up an affected area, watchthat the tremors improved, and knowthat we had targeted the right tissues.”

Dr. Melhem predicts that in the nextyear or two, 3T MRI will be able totarget tissue in the breast and prostateusing much the same approach. He

concludes, “PET/CT and 3T MRI playcomplementary roles in detectingmetastatic disease. MRI is most useful inpeering into the brain to find evidence ofmetabolites, while PET/CT is excellentthroughout the body. Together, theyprovide nearly complete surveillance.”


…NOPR is considered a successful model that islikely to be replicated in the future. It gatheredevidence from more than 100,000 scans to showthat PET positively affects patient management.

– Ethan Spiegler, M.D.

Elias Melhem, M.D., the John Dennischairman of the Department ofDiagnostic Radiology and NuclearMedicine, University of MarylandMedical SystemEthan Spiegler, M.D., chief of NuclearMedicine, Advanced Radiology andchair of Nuclear Medicine, SaintAgnes Hospital

HY IS AN EHRpurchase or upgrade so often painful –and for so long after its initial purchase?And does it have to be? James Milligan,CEO of Medical Mastermind, who hasseen many physicians that are stillputting in long hours, long after theirEHR implementation, believes it shouldnot be so painful.

He says, “We’ve seen some doctorsthat were still carrying both paper andelectronic charts around for months.They were disenchanted because theEHR had not delivered on the paradigmit had promised – that it would be easierand better than paper and that theycould see more patients. It was true thatstaff no longer hunted for records andthat pharmacy orders could be delivered electronically, but otherwise it was more, not less, painful.”

While it’s also painful to abandon the many hundreds of hours andthousands of dollars invested in anexisting EHR, the failure to deliver onpromised efficiencies is one of thereasons that many physicians are nowlooking to change their EHR system.

“Some of the newer systems aredelivering on their promises,” Milligansays. “They are focusing on work flow,ease of use, being intuitive, decreasing

the number of clicks and being availableon mobile devices such as an iPad. These products are finally delivering on the paradigm that was promised.”

Suggested questions to ask whenevaluating a new EHR purchase or an upgrade follow.

Is It Designed With Physician Input?The desire to have an integrated systembased on the way physicians actuallypractice motivated Software UnlimitedInc. to merge with Integrated HealthCare Solutions (IHCS) in early 2013and rename the company MedicalMastermind. Milligan explains whyIHCS was selected out of 200 practicemanagement companies they hadconsidered. “IHCS was launched when a group of EHR designers gottogether with five dissatisfied physiciansand several programmers to create oneof the few EHR systems that meet

physician needs. They worked togetherto create a system that was easy to use, facilitated physician workflow and reflected the way each of thedoctors actually practiced medicine.”

“Of course, any EHR represents a big change and involves changemanagement,” Milligan acknowledges.“But it should not make things moredifficult, and after the start-up period, it should greatly reduce the timephysicians spend charting so that seeingmore patients is a natural consequence of using their EHR.”

The company, which is headquarteredin Pikesville, MD, has more than 1,500customers in the U.S. and about 250 of those are using the new EHR – we’rethe fastest growing EHR vendor in theU.S.,” Milligan comments. “We do all of our implementation on site and ourlocal staff provide service throughoutMaryland.”


Lessening the Pain of an EHR Upgrade or Purchase

Profile SPONSORED CONTENT

WJames Milligan, CEO of Medical Mastermind

Does the EHR Specialize in Your Specialty?One of the questions to ask an EHRvendor is whether their system canaccommodate the needs of your medicalspecialty.

“Medical Mastermind can be used by all specialties, but we have seven thatwe do exceptionally well, includingprimary care, pediatrics, orthopaedics,otolaryngology, podiatry, urgent care and chiropractic,” Milligan states.

Does the EHR Accommodate Variations in Practice Style?One of the greatest challenges EHRs faceis accommodating variations in the wayphysicians practice – even within thesame group. Jody Harbour, MedicalMastermind’s chief designer and VP ofProduct Development, recalls, “One ofour practices has seven surgeons; whilethey’re all in the same location, theypractice medicine in seven different ways.Our system was the only one they foundthat allowed them to keep practicingindividually. For example, one physicianwanted a templated (a pre-defined tool tocapture and organize clinical data withinthe system) approach, while anotherpreferred the narrative approach. Wefound a way to incorporate the narrativeapproach while still maintainingcompliance. We spent a long timelearning from the physicians and thenapplying what we learned to our system.”

Mark Brown, M.D., FACS, wasinitially the most reluctant physician inhis ENT practice to convert to an EHR.However, after rejecting a number ofEHR systems, he found he was impressedby Medical Mastermind’s willingness tolearn from him. “My attraction to thesystem was that they said, ‘we’re going tomake this work the way you practicenow,’ not, ‘you have to practice the waywe’re going to make this work.’’’ Afterbecoming one of the system’s biggestadvocates, Dr. Brown retired and wenton to become the medical director forMedical Mastermind.

The Medical Mastermind EHR systemis easy to adapt to the needs of a givenphysician because it has a series of‘switches’ that can be turned on and off.That makes it flexible without requiringan expensive or labor-intensive customsolution. Mastermind EHR arrives fullyintegrated with PM and Billing, and usesa permissions-based system to allow

access to various functions depending on the user. For example, to enable the complete Practice Management suite, settings are changed by MedicalMastermind once the licenses arepurchased, eliminating the need foradditional software installation orintegration.

Does the EHR Offer Integrated Practice Management?Another reason to replace an EHRincludes needing a system with integratedpractice management (PM), rather thanone that was retrofitted, or two separatesoftware programs attempting to sharedata. According to Milligan, “Manyvendor companies focused solely on theirEHRs, but that created inefficiencieswhen they tried to integrate the systemwith practice management. Without asingle, integrated database, you loseinformation on scheduling, patient data,billing and so on.”

Peter Whitehead, M.D., a pediatricianwhose group uses Medical Mastermind,notes, “They have helped us, from aphysician practice standpoint and anoperational standpoint, to manage ourmonies going in and out, manage ourvisits in, manage our patients to optimizehealthcare and to optimize revenue forthe practice.”

Can You Choose Between Client Serverand Cloud-Based Systems?As discussed in the Nov/Dec 2011 issueof Maryland Physician (Should You StoreEHR Data Onsite or Offsite?), physicianshave to determine whether a server-basedor cloud-based EHR approach makes themost sense for their practice. Milligannotes, “A big part of our acquisition ofIHCS was that it enabled us to offerphysicians the choice of either approach.Also, if the doctor wants us to handle hisor her billing, we can offer that as part ofour services.”

Mastermind EHR and Mastermind

PM are appropriate for the solopractitioner, but easily scalable to apractice with 50 practitioners or more inmultiple locations. “We have experiencewith both solo physicians and largergroups, whereas legacy products usuallybecome too complicated when you try toscale them down,” Milligan notes.

Does the EHR Offer a Robust Patient Portal?Meaningful Use Stage 2 will make patientaccess to their data and communicationbetween providers and patients morecritical. Patient portals have proven to bean effective way of achieving some of theStage 2 milestones as well as a time-saverfor physicians and patients.

Satisfied user Darmesh Bhakta, DPM,comments, “The patient portal is a hugebenefit for us. It saves time, especially ifpatients can fill out their medications anddosages at home. We get a morecomplete picture of the entire patient that

way. The patient portal helps us to bemore complete. Now we feel like wehave triple-checked their data. Thepatient checks it, our medical assistantand I check it, and we have an entirehistory – and it’s correct.”


….any EHR represents a big change... But itshould not make things more difficult, and afterthe start-up period, it should greatly reduce thetime physicians spend charting so that seeingmore patients is a natural consequence of usingtheir EHR. – James Milligan, CEO

Medical Mastermind, established in

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Q: What is Maryland HealthConnection? The Health Connection is a new health insurance marketplacedesigned to make it easier forMarylanders to shop for, compare andpurchase quality health coverage. We’renot federal health insurance; we’re theconduit – the “store” – for carriers toput their products on our shelves. Asingle, streamlined applicationdetermines eligibility for Medicaid orprivate insurance. Consumer assistancewill also be available through our callcenter or in person throughout the statein local health departments, departmentsof social services and a network ofconsumer assistance organizationsknown as “Connector Entities.”

Q: What was one of your greatestchallenges? Even though Marylandstarted early compared to many states,we had lots of policy decisions to make.And, we had to set up an entireorganizational structure – we startedwith just me. Today, our state agency has grown to more than 50 people.

Q: Who do you expect willpurchase insurance in the HealthConnection? The first year, we expectabout 250,000 newly eligible people toenroll, which includes about 100,000people who will be newly eligible forMedicaid when it expands from 116%to 138% of the federal poverty level.Maryland Health Connection willdetermine if a person qualifies forMedicaid or commercial insurance. At the end of 2015, we expect that all of the 1.2 million people on medicalassistance will use the marketplace.

In Phase 2, our long-term goal is to have the non income-based Medicaidpopulation go through it as well – thatis, long-term care, disability and alsosocial services.

We’ve done 12 focus groups aroundthe state. There’s a misnomer that peopledon’t want health insurance. We foundthat people want to have healthinsurance and want to know that theycan see a physician when needed. Whenwe presented them with a price and thevalue of the insurance they would getthrough Maryland Health Connection,and what the federal subsidies might be,they were willing to give up amenitieslike their cable television to get healthinsurance.

Q: Which insurers are participatingin Maryland Health Connection?Currently, we are working withCareFirst BlueCross BlueShield, Kaiser

Policy

Maryland Health Connection: A New Insurance Marketplace

As this issue went toprint, the date tolaunch enrollment forfamilies and individualsin Maryland HealthConnection waslooming for ExecutiveDirector RebeccaPearce and her staff.Ms. Pearce talks abouthow this new servicewill change healthcarecoverage for many, aswell as its potentialimpact on physicians.

TRACEY

BROW

N

An Interview with Rebecca Pearce, Executive Director, Maryland Health Benefit Exchange


Permanente, United HealthCare andEvergreen Health Cooperative. The 2011legislation requires that insurers makinga certain dollar level outside of theexchange must participate in MarylandHealth Connection. We’re also hoping tosee MCOs [Medicaid Managed CareOrganizations] starting in 2015; they’llneed to obtain a license first.

Q: Discuss the rates that will becharged under the Health Connection.Maryland’s rates are among the lowestof the 12 states with approved orproposed rates – on a dollar-to-dollarbasis, they’re lower than all but one planin New Mexico. New York, for example,decreased their rates 50% but they arestill higher than ours. And three out offour Marylanders are expected to qualifyfor federal tax credits.

You can’t do an apples-to-applescomparison to rates in the past yearbecause this is the first year that we will be offering essential health benefitsunder the new marketplace due to theACA. Because of self-selection, theindividual market has historically had alean set of benefits. It’s like comparingbuying a hatchback to buying a sedan.

Everyone is hoping the marketplacewill attract younger people. They areoften overlooked as the people who willget subsidies through the marketplace,but because many of them are notmaking large salaries, they will benefit.The federal subsidies apply toindividuals making up to $44,000 a year. Someone making the federalpoverty level of about $22,000 will paya maximum of 6.5% of their income, or about $114 per month, out of pocket for insurance because the federalgovernment is giving subsidies.

We don’t control the fee schedules thatcarriers pay providers, but they shouldbe similar to other fee schedules.

Q: For physicians who run smallbusinesses, what are the options andrequirements? The Small BusinessHealth Options Program (SHOP) willopen in January 2014 and provide smallbusinesses a choice of quality insuranceplans and carriers. Companies with upto 50 employees are eligible, but notrequired, to purchase insurance through

Maryland Health Connection. There isno penalty for employers of this size.And the federal government just saidthat there is no penalty for any sizeemployer in year one.

Employers can only access federal tax credits if they purchase coveragethrough SHOP beginning in 2014. Our website includes a Small BusinessTax Credit Calculator to help themdetermine if they qualify for a taxcredit for providing insurance foremployees.

Q: Will those using MarylandHealth Connection be able to see theirdoctor? In fact, we created the ability tosearch online for a list of participatinghealth plans by doctor. You can bring upall of the plans that include your doctor.We’re the only place you can do that.

Q: How will providers be affected?We would love to partner with thephysician community; we recognize thatthey’re going to be touching the peoplewe’re bringing in. We want to understandfrom them what they are seeing. Theymay see an influx of people who may notbe used to using primary care. So theremay need to be some education on theirpart – for example, they may see a 40-year-old who has used ERs, not a

primary care physician, to date. We are working directly with FQHCs

[Federally Qualified Health Centers] and community providers, and especiallythe mental health providers to let themknow that, as people get insured, theyneed to contract with the carriers inMaryland Health Connection, and here’swhat you need to do to change yourbusiness model. And we’re talking to thecarriers as well. We’ve been trying tobridge that gap between those two setsof providers. And the governor’s office isworking to address provider shortages.

Q: How will you educate and enrollthe 180,000 people that you anticipate?We have multiple ways to enroll people.The first way is through insurancebrokers. About 1,500 insurance brokers in the state have providednotice of their intent to use our Health Connection. They have to belicensed by the Maryland InsuranceAdministration to participate, andauthorized by us to sell throughMaryland Health Connection. Withabout 180,000 newly insured people,it’s a growth opportunity for brokers.We’ve been partnering with them since2011 – we want to supplement them,not replace them.

We also are establishing a customersupport center with a toll-free number,and we awarded grants to six consumerassistance organizations (ConnectorEntities) statewide to provide individualenrollment assistance. They will reachthe underserved and hard-to-reachpopulations, including those withdisabilities.

We’re hiring a total of 300 people toprovide in-person assistance; 150 ofwhom are navigators who provideeducation and outreach, as well asenrollment in both Medicaid andqualified health plans. The remaining150 people are known as assisters; theseindividuals also conduct education and

outreach. They can also enroll people in Medicaid, but not private insurance.

We are also working with theDepartment of Health and MentalHygiene and Department of HumanResources to train the caseworkers andeligibility workers in the local healthdepartments and departments of socialservices statewide. These 2,500 people,who currently enroll people in Medicaid, will receive in-depth trainingon the use of Maryland HealthConnection and enrollment. (continued on page 29)

The Small Business Health Options Program(SHOP) will open in January 2014 and providesmall businesses a choice of quality insuranceplans and carriers. – Rebecca Pearce


Healthcare IT

THE HEALTH INFORMATIONTechnology for Economic and ClinicalHealth (HITECH) Act made electronichealth records (EHRs) nearlyubiquitous. According to a 2012 surveyby the Centers for Disease Control andPrevention, the percent of physiciansusing an advanced EHR system climbedfrom 17% in 2008 to more than 50%by 2012, and over half had received anincentive payment for meeting Stage 1of Meaningful Use.

Similarly, the survey found thathospital adoption of EHRs grew from9% in 2008 to 80% by 2012. But asMeaningful Use Stage 2 looms on the

horizon starting in 2014, providers needto begin contemplating the next major hurdle – connecting electronicinformation among disparate EHRs and hospital systems to begin bettercoordinating care.

CRISP: Maryland’s HIETo encourage electronic sharing ofpatient information, the State HIECooperative Agreement Program hashelped fund state and regional efforts.With funds from this national program,as well as state funding, Marylandformed a statewide HIE called theChesapeake Regional Information

EHR adoption has skyrocketed, but can disparate systems talk to each other?Health information exchanges (HIEs) are beginning to bridge the gap;

Maryland is ahead of many states and stands to weather the loss of HITECH Act funds beyond 2013 better than most programs.

H e a lt H i n f o r m at i o n e xc H a n g e s :

THE NEXTHURDLE

LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN


System for our Patients (CRISP), a not-for-profit membership organization thatbecame operational in September 2010.

CRISP is in a better financial positionthan many HIEs, with a combination ofstate, federal and hospital funding. “Wehave less than one year left of federalfunding,” David Horrocks, CRISP CEO,comments. “But they are only about15% of our HIE budget. I’m confidentthat we have a revenue model that willallow us to continue our work.”

A 2013 status report from the RobertWood Johnson Foundation, HealthInformation Technology in the UnitedStates, found that, in contrast toMaryland, where all acute care hospitalsparticipate in CRISP, nationally only30% of community hospitalsparticipated in HIE during 2012. Andonly 10% of operational HIEs supportedsix Stage 1 Meaningful Use measures forinformation exchange. Not surprisingly,the use of HIE by physician practiceswas much lower, with 10% reportingparticipation in 2012 compared with 3% in 2010.

Adam Weinstein, M.D., nephrologistand medical director of the EasternShore ACO, says, “In Maryland, theinformation is centrally controlled,which gives us better control andstandards than in states such as Utah,which has an Intermountain Health HIE that is not statewide. The goal ofsharing data is the Holy Grail.”

Now that all hospitals and a numberof key radiology and laboratoryproviders have had ample time tocontribute data, the next step in thearduous process of achievinginteroperability is to provide moreelectronic information about hospitaladmissions, discharges and emergencyvisits to physicians, so that they canfollow up with outpatient care asappropriate.

Horrocks says, “We have threeservices – Query Portal, EncounterNotification Service (ENS), andReporting for Quality Initiatives. We’rehappy to help physicians start on aprocess to use the ENS or Query Portal.”

Query Portal ServiceComments Horrocks, “The Query

Portal currently receives about 15,000queries a month and that number isdoubling roughly every six months. Thetypical user is an ER physician or otherphysician in the hospital setting, butphysicians in ambulatory settings canalso take advantage of this service oncethey are credentialed.”

The portal allows clinicians to enter a patient name and view priormedical records (chiefly from priorhospitalizations) and also a growingamount of lab and imaging data. “In the last month, we’ve added several newfeeds from hospitals, such as new labresults. Our goal is to have more than90% of all possible feeds by this fall,”Horrocks notes.

Craig Behm, executive director,MedChi Network Services, explains,“The doctor can query the hospitalwhere his patient was discharged for lab values and other data, as available.It’s a work in progress, though Maryland

is at or near the top of connectivitycompared to other states.”

“The Query Portal is used primarilywhen the doctor is in a treatmentencounter, to help him or her make the best decision,” says Horrocks. “And we’re now partnering with theDepartment of Health and MentalHygiene to get pharmacy data on prior

opiod use data into physicians’ hands, to support the Prescription DrugMonitoring Program.”

CRISP is seeking to deploy single-sign-on between hospitals and practice EHRs and the Query Portal, so thatcredentialed doctors can quickly accesspatient information. Today, the patient’sname and address must be enteredmanually, taking up valuable time, andadding the risk of human error.

Encounter Notification ServiceA newer CRISP service that went live in August 2012 is the EncounterNotification Service (ENS), whichprovides messages to participatingphysicians when their patient visits theemergency department (ED), or isadmitted or discharged to a hospital.Physicians can select the services forwhich they want to receive notification.

Behm observes, “Any physicianpractice can participate in ENS. The

physician panel sends a list of patients to CRISP, and CRISP assigns thosepatients to a doctor. That doctor canselect what data he or she wants to get.It involves an open source, securemessage platform through a web portal.All of the data is free.”

“About 700 physicians have signedon, mostly primary care physicians,”

David Horrocks, CRISP CEO


Healthcare IT

says Horrocks. In large practices, thenotification may go to the carecoordinator, who channels informationto the appropriate physician. The datacan also be downloaded in a spread-sheet, so that information can be sorted.Practices can choose to receive onesummary email early each morning to provide information on all patientsthat can be incorporated into their daily routine.

“It’s a good fit for physicians in aPatient Centered Medical Home orAccountable Care Organization (ACO),”Horrocks adds. “And Medicare has newCPT codes that reimburse physicians fortimely follow-up care, so this servicepotentially enhances a physician’srevenue stream.”

Quality Initiative ReportingQuality initiative reporting is the newestaspect of CRISP’s data, operational sinceJanuary 2013. It provides inter-hospitalreadmission reporting, so that a patientdischarged from one hospital andreadmitted elsewhere within 30 days canbe tracked. The ER Bounce-Back report is being rolled out this fall, so thathospitals can track when dischargedpatients return to the ER within 72 hours.

Secure Messaging to Connect ProvidersCRISP also offers DIRECT Messaging, asecure and encrypted email service thatsupports electronic communicationbetween physicians, nurse practitioners,physician assistants and other healthcare providers. This servicecontinues the goal of securely sharing a patient's clinical information amongtheir treating providers in Maryland.Currently, DIRECT Messaging is free for the first year.

However, secure messaging is not yetwidely used. Dr. Weinstein notes thatelectronic communication betweenprimary care physicians and specialistshas a long way to go. “The challenge isto make the data HIPAA compliant. It’s far from the panacea envisioned, so most doctors are still faxinginformation. The staff has to print outthe faxed data; I manually sign it andsend it back.”

Getting Data to the ‘Last Mile’ As a provider trying to take the dataavailable from CRISP and put it to work for an ACO comprised of manyindividual practices, Dr. Weinstein has a unique perspective. “At the moment,we’re simply reporting the data, but ourACO is about to get CRISP data. We’ll

know that one of our patients was justdischarged and focus on care transitionsas points of potential intervention.”

He is focused on getting the data,whether electronic or not, to ‘the lastmile.’ He explains, “We’re trying toaddress the ‘last mile’ of connectivity –the provider. CRISP sends the data to usand we get it to each doctor, whether ithas to be via fax or whatever otherprocess the doctor can use. Each practicehas its own IT system, so we have to beflexible. Starting this summer, we’reputting the technology pieces in place.You need an extra staff person to handlethe data.”

He adds, “Practices are figuring outwhat their relationship is to aggregatedata. But we’re getting a better sense ofwhat it means to be an ACO, and we’re

clearer about what data we need. We’refocusing on things we think will impactour cost and reporting on them. OurACOs are a microcosm of the industry.It comes back to how you get differentEHR vendors to talk to each other.”

Behm contributes, “MedChi wouldlike to see Maryland have almost a stateutility model for interoperability. CRISPhas made incredible progress in settingup the pipeline. However, at this time,some hospitals can send a summarywithin 48 hours, while some can’t sendany summary yet.”

The lack of compensation is anotherbarrier to coordinated care. Dr.Weinstein notes, “I do a lot of homemonitoring now, but it’s not reimbursed.The ACO gives us hope that we’ll beincentivized in the long run. All of uswant to see basic issues tackled but wedon’t have a reimbursement system todo that.”

Dr. Weinstein explains, “The questionis, ‘What is the critical data coming outof an outpatient encounter?’ It’s easy tosay that someone with congestive heartfailure should be seen often and receivea special diet, but if that patient can’t getup and down the steps to come to theoffice, we may not be able to give themthe care they need.”

Behm acknowledges, “In some cases,we’re using 21st-century technology but20th-century processes. It’s easy to getfrustrated, but in two years we’ve seengreat progress. We’re no longer talkingto doctors about what Meaningful Useis, but about how they get there. Weneed to take the risk to lean forward.”

Craig Behm, executive director, MedChi

Network Services

David Horrocks, CEO, Chesapeake

Regional Information System for Our

Patients (CRISP)

Adam Weinstein, M.D., nephrologist

and medical director of the Eastern

Shore ACO

Craig Behm, executive director, MedChi NetworkServices

"We’re trying to address the ‘last mile’ of connectivity – the provider."

– Adam Weinstein, M.D.


Maryland Wellness Magazine is for the discerning healthcare consumer

engaged in health and wellness choices forthemselves and their families.

For Advertising Information Contact:Jacquie Cohen Roth

President/CEO, mojo media, llc443.837.6948 | [email protected]

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mojo media, llcPublisher of Maryland Physician Magazine – Your practice. Your life.™

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Maryland Wellness Magazine – Your health. Your life.™

Winter 2014

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VOLUME 1: ISSUE 1 FALL 2013

MA RY L A N D

YOUR HEALTH. YOUR LIFE.

Wellness

We just received our final funding, andcontracts started July 1, 2013. In Augustwe’re training staff, then they’ll hit thestreet around September, and about thesame time we’ll be rolling out a state-wide advertising multi-media campaign.We’re also receiving requests to speak athospitals and medical societies.

Q: How has your experience on theinsurance side been helpful? Havingknowledge of insurance programs hasbeen hugely helpful in my current role. I understand how people purchaseinsurance and what’s important to them.At Kaiser Permanente, I spent lots oftime negotiating and facilitating thecommunication between employers,insurers and doctors, and getting all ofthe stakeholders to agree upon what

benefits would provide the best solutionfor a group’s employees.

Q: How has being a womanaffected your career? I discovered earlyon that you have to make decisionsbased on facts, not feelings. I realizedthat people make decisions in businessbased on data. I’m often the onlywoman in the room, and I’m leadingmeetings with male CEOs, many ofwhom head multi-million-dollarcompanies. There have been weeks onend when I haven’t been home in timeto put my daughter to bed. I couldn’tdo this job without having anunderstanding husband and family.

Q: Will you be able to relax a bitonce enrollment begins? I tell peoplethat we’re racing to the start, not thefinish. Open enrollment runs for sixmonths. After October 1, we need to befocused on how to make what we put inplace for the start better, and make surewe have as many Marylanders enrolledby March 31 as possible.

Visit www.MarylandHealthConnection.gov to learn more, or visit Facebook:www.facebook.com/MarylandConnect;Twitter: @MarylandConnect andYouTube, www.youtube.com/marylandconnect

We’re not federal health insurance; we’re theconduit – the “store” – for carriers to put theirproducts on our shelves. – Rebecca Pearce

Maryland Health Connection: A New Insurance Marketplace (continued from page 25)


S THE WEATHER BEGINSto cool and the fall foliage begins topaint communities across Maryland inshades of orange, red and brown, thetown of Rock Hall braces withexcitement for its biggest event of theyear. Thousands of tourists flock to thesmall waterfront community in KentCounty to take part in “FallFest,”recognized as one of the bestcelebrations of music, dancing andoyster shucking that can be found alongthe East Coast. Held at The Mainstay, ahistorical building in town that hasserved as the venue for hundreds ofconcerts and musical performances of allgenres since its opening in 1997, the16th annual FallFest will feature a fulllineup of family-style entertainment andfun on Saturday, October 12, 2013.

“FallFest originally started as anotherway to draw people into town for a fun

weekend,” said Ron Fithian, who servesas town manager for Rock Hall. “Theweekend centers around music, crafts andfamily-friendly activities, and last year webrought in the oyster theme, which wentover very well; in fact, we shucked over13 bushels of oysters! Every year, theevent gets bigger and better.”

Rock Hall has long been recognized asa seafood town that offers easy access tothe wide open spaces of the ChesapeakeBay. Originally called Rock HallCrossroads, the town was positioned asa connection point for shipments oftobacco, seafood and other agriculturalproducts transported along the EasternSeaboard, from Baltimore and Annapolis

to northern ports in Pennsylvania andNew York, and southern ports along theVirginia coast. Production anddistribution of commercial seafood wasa town priority in the early days, withmore than 80 percent of Rock Hall’sresidents making a living that revolvedaround the “fruits” of the Chesapeake

Bay. Today, the town is best known as ascenic sailing community, offering apeaceful place to kick back and relax.

“We actually have more boat slipswithin the town limits than we do full-time residents,” said Fithian.“Sometimes you can look out on theChesapeake Bay and you will seehundreds of boats anchored. It’s thiskind of scenery that people come toRock Hall for.”

Visitors of Rock Hall have found thatgetting out on the water for the day isactually quite easy. Novices, experiencedsailors, and even those wishing tocharter a boat for a day of fishing orrelaxing on the water will find a wealth

of options, as Rock Hall has six full-service marinas, plus a handful ofsmaller ones, in operation. And forcouples or crowds who prefer to unwindon the water over dinner and a glass ofwine, a number of special sunset sailingpackages are available.

On the entertainment front, Rock Hallstrives to please locals and tourists alikethroughout the year. In addition toFallFest, the town puts on a series ofannual events and festivals, including a“Pirates and Wenches Tour” that drawsthousands of people for a few days of re-enactments and summertime fun everyAugust. There are also three museumsopen year-round that spotlight andcelebrate the history of Rock Hall and itspeople, and its notable contributions tothe seafood and sailing industries.Additionally, Bayside Landing Park,positioned alongside the Rock HallHarbor, offers a public swimming pooland dual public access boat ramps, whileFerry Park – noted as one of the bestlocal beach picnic sites – features ashaded pavilion and breathtaking viewsof the Chesapeake Bay.

“People that visit Rock Hall go homeand tell others about the waterfrontbeauty that can be found here, that islike no other,” said Fithian.

Living

Rock Hall: Capturing the Treasuresof the Chesapeake Bay

By Tracy M. Fitzgerald • Photography by Jacquie Cohen Roth

A

FallFest, held annually in Rock Hall, is recognized as one of the best celebrations of music, dancing,and oyster chucking found along the East Coast.

Sometimes you can look out on the ChesapeakeBay and you will see hundreds of boats anchored. It’s this kind of scenery that peoplecome to Rock Hall for.”—Ron Fithian, Rock Hall town manager


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Individual stocks you plan to hold for more than one year

Tax-managed stock funds, index funds, tax-managed funds and low-turnover funds

Stocks or mutual funds paying qualified dividends

Municipal bonds

Individual stocks you plan to hold for less than one year

Actively managed stock funds generating short-term capital gains

Taxable bond funds; corporate and governmentbonds producing high-income, zero-coupon bonds;inflation-protected bonds or high-yield bond funds

REITs

Taxable Accounts Tax-Deferred Accounts


Solutions

Four Tips to Tax-Efficient InvestingBy Keith I. Levitt, CFP®

HYSICIANS ARE OFTEN IN HIGHERtax brackets, making the tax implicationsof their investments especially important.If your portfolio isn’t tailored for taxefficiency, you could be costing yourselftens of thousands of dollars.

A recent study charted U.S. investmentperformance from 1926 to 2011.1 Itfound the average annual rate of returnon the stock market dropped from 9.8percent to 7.7 percent after accountingfor taxes. If you invested $100,000 at9.8 percent, after 20 years yourinvestment would be worth $700,000 –that’s $235,000 more than the sameinvestment at 7.7 percent.

A tax-efficient financial plan takesadvantage of specific strategies designedto mitigate the effect of taxes on yourinvestments. Here are four ways tax-smart investing may help you keep moreof what you earn.

Tax-Managed Mutual Funds. Althoughmutual funds are generally not knownfor their tax efficiency, tax-managedmutual funds seek to limit turnover anddistributions and use other strategies tominimize tax implications.

Separate Accounts. Through separateaccounts – that is, managed investmentsthat buy individual securities with

P pooled money – a manager can avoidpre-existing gains/losses and short-termcapital gains, strategically harvest lossesto offset gains and identify lots for sale.

Tax-Deferred Accounts. The table belowsummarizes considerations of taxableand tax-deferred accounts in seeking toimprove your portfolio’s tax-efficiency:

Knowing When and How to SellHolding investments for more than oneyear can help you take advantage of thelower long-term capital gains tax ratewhen you sell, though there may beinvestment risks to consider.

Buying the same security at differenttimes and prices (“lots”) gives youcontrol over any gains/losses you realize.

Capital losses can be used to offsetgains dollar-for-dollar plus up to $3,000of ordinary income each year, thoughrealized losses in tax-deferred accountscannot offset gains in taxable accounts.

Losses from wash sales (i.e., when yousell a security at a loss but repurchasethe same or similar security within 30days before or after the sale) cannotoffset gains or income in the current taxyear – the loss may be deferred until thereplacement property is sold orpermanently disallowed.

One other strategy worth discussing

1Taxes Can Significantly Reduce Returns data,Morningstar, Inc. March 1, 2012.

with your financial advisor is converting401(k) funds into Roth retirementaccounts. Although income contributedto a Roth 401(k) is taxable the year it isearned, it will grow and, in many cases,be distributed tax-free.

Because of market fluctuations, yourportfolio’s performance may vary.However, tax-smart strategies may helpyou gain greater control over the taxesyou pay and keep more of what you earn. Investors should consider the

investment objectives, risk, charges andexpenses of mutual funds carefullybefore investing. This and otherinformation is found in the prospectus or summary prospectus. Please read theprospectus or summary prospectuscarefully before investing.

There are many differences betweenseparately managed accounts and mutualfunds, all of which should be consideredvery carefully before investing.

All investments carry some level ofrisk and may not be suitable for allinvestors. Fixed income securities’ valuegenerally declines in a rising-interest-rateenvironment. High-yield securities maybe subject to market, interest rate orcredit risk. Dividends are not guaranteedand are subject to change or elimination.Past performance is not a guarantee offuture results.

Article provided by Robert W. Baird &Co. for Keith Levitt, Senior InvestmentConsultant and Vice President at theBaltimore office of Robert W. Baird &Co., member SIPC. He can be reached [email protected]. Robert W. Baird & Co. does not provide tax advice.

Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and CFP® in the U.S.


NAMI: Educating, Supporting and AdvocatingFor Local Patients with Mental Health Needs

VERYONE KNOWS THATmental health issues exist within thepatient population, but very few trulyunderstand the prevalence of thesemedical challenges in communitiesacross Maryland. The fact is that morethan 300,000 citizens of the state havebeen diagnosed with schizophrenia,depression, bipolar disorder or anotherserious mental illness. And that numbercontinues to grow.

Many of the patients who suffer fromthese conditions face a long line ofphysical, psychological and emotionalchallenges that can impact their day-to-day functionality and capabilities.Thankfully there is an organizationcommitted to providing education,support, outreach and advocacy on theirbehalf: The National Alliance on MentalIllness (NAMI). The local affiliate,NAMI Maryland, makes a number of

services available for patients withmental illness, with a vision to ensurethat those diagnosed receive thetreatment and support needed to leadfull and productive lives.

“Research shows that people withsevere and chronic mental illness die 25 years earlier than the averageAmerican,” said Kate Farinholt,executive director of NAMI Maryland.“These are the people who alwaysanswer ‘I am fine’ when their doctorasks how they are doing, because theyare only focused on getting through the day. They don’t even think about the

issues they actually have, like an injury, infection, acheor pain.”

NAMI Maryland hasformed six education andsupport-based programs,making tools andresources available forpatients, as well ascaregivers, relatives andsurvivors. Many groupdiscussions are led andfacilitated by people who once facedpsychological issues themselves, and canspeak from personal experience.

“We partner with the very people who originally came to us for help,”explained Farinholt. “We also work tobring physicians and other specialiststogether to talk about the issues they are seeing with patients, and how they

can work together to address them.”Increasing access to mental health

practitioners for Marylanders is a keypriority for NAMI Maryland. Accordingto Farinholt, many patients often turn totheir primary care physician as a firststep, rather than a specialist, which canlead to undiagnosed, untreated or under-treated conditions.

“We are working hard to buildrelationships and make new connections,so that primary care doctors canadequately address basic mental healthissues in a primary care setting, and willknow when and how to refer more

complex cases to a specialist for care,”Farinholt added.

According to a report published by the U.S. Department of Health andHuman Services, one in four adultsexperience a mental health disorder inany given year. That same reportconfirms that fewer than one-third ofthose individuals receive care for theirdiagnosable condition; a statistic thatdirectly motivates the work of NAMIMaryland and its sister organizations,located in each state of the country aswell as Washington, D.C.

“NAMI was created 30 years ago asan advocacy organization, and it wasclear pretty quickly that there wereopportunities to fill the gaps and createsystems to support patients and familieswho struggle with mental health issues,”said Farinholt.

NAMI Maryland has developed abrochure outlining available services andsupport programs. Physicians areencouraged to contact the organizationat 410-884-8691 to request an electroniccopy of the brochure. For furtherinformation, visit www.namimd.org.

Good Deeds

E

We are working hard to build relationships andmake new connections, so that doctors can adequately address basic mental health issues in a primary care setting, and will know whenand how to refer more complex cases to a specialist for care. –Kate Farinholt, executive director, NAMI Maryland

By Tracy M. Fitzgerald

Shown at a recent community event (left to right) is Don Slater,NAMI board president, Brian Hepburn, M.D., executive director ofMaryland’s Mental Hygiene Administration, and Kate Farinholt,executive director of NAMI Maryland.

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

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Documents

Maryland Physician Magazine September/October 2013 Issue