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Worcester Medicine
Editorial
Retail Clinics
New MinuteClinic Health Care Centers Bring
Accessible, Quality Care to Massachusetts Communities
Healthcare - Coming Soon to a Store Near You
Economics of Community
Pharmacy Legal Consult Science Corner Financial Advice for
Physicians Off Call Thanksgiving at the
Worcester Housing Authority In Memoriam President's Message We are having two forums: the first one is on the Presidential Healthcare Platforms and the next, in January, is on Retail Based Clinics. These forums arose from discussions with the Communications Committee of the Massachusetts Medical Society, who wondered how to improve the grassroots outreach of the state society. We met with Frank Fortin, the Director of Communications, and looked for ways to communicate more directly with members about issues that affected their practice. We proposed that Worcester be a test site for forums that could then be replicated around the state. When this issue of Worcester Medicine goes to press, Alex Calcagno, Director of Federal and Community Relations, Massachusetts Medical Society, will have already informed physician members, students, and guests about the Democratic and Republican approaches to healthcare and the differences between them. We expect a lively discussion. For the next topic, we chose Retail Based Clinics; Retail Based Clinics threaten our current model of primary care practice. Many of our members are not even aware of these clinics and some who are aware do not understand the nature of their threat. Therefore, we chose Retail Based Clinics for our magazine and will follow with a forum on January 21, 2009, to allow an informed discussion. We hope that other districts will want similar discussions. With the increasing separation of offices from the hospital base these opportunities to discuss our clinical life are fading and I feel that we are poorer for that loss. These forums should enrich our community. I expect topics of interest to crop up frequently and would look forward to creating a forum on those issues from time to time. Please join us for these events; we want to hear what you have to say. My thanks to the Worcester District Medical Society Editorial Board for publishing this important issue of Worcester Medicine as it offers various views on Retail Based Health Clinics. Editorial:
Retail Based Clinics- Welcomed Addition or Another Nail in the Coffin of
Primary Care? Retailed Base Clinics (RBCs) have experienced rapid growth in the past several years with planned clinics in Massachusetts now a reality. As described by Rebecca Hafner-Fogarty, MD, MBA, in her article in this issue of Worcester Medicine, Minute Clinics offer a “limited service clinic model.” RBCs treat specific, simple, acute illnesses using established clinical guidelines. So what are the concerns about RBCs? Quality, cost, convenience, and continuity of care seem to be the major issues when discussing these clinics. What has caused the growth of limited service clinics? The answer is cost and convenience. These clinics are set up to keep the cost low by treating simple acute illnesses in convenient locations. The location of care often determines the cost. The hospital, emergency room, physician offices, and limited- service clinics are all designed to offer different levels of care. Because the acuity at each level from hospital down to limited service clinics is lower, the overhead is less as well. The primary care office is designed for a higher acuity patient than are RBCs treating many patients with chronic illnesses. Treating a sore throat in the emergency room is more expensive than doing so in the primary care office, but is it less expensive in an RBC than in a primary care office? Dr Auerbach , President of the Massachusetts Medical Society, states in his article that “No evidence yet exists they will reduce costs.” Time will tell for cost comparisons. So far as convenience is concerned, primary care offices cannot match location of RBCs. Opening offices in retail facilities would be difficult to do and is impractical. In terms of extended hours of operation, that is a decision each office needs to make. Maybe if the primary care office didn’t do all the referrals, prior authorizations and data collection for the insurance companies for P4P, we would have more time for patient contact and could lower our overhead costs. But this is a topic for another day. The quality of care is likely equivalent between the primary office and RBCs. The weakness of the RBCs lies in continuity. Many patients do not see the value of routine health maintenance. You write them letters, you call them on the phone to schedule screening tests and they do nothing. But if they get a cold or cough , they are into the office immediately. As you pull this opportunity out of the office, you decrease the number of contacts to the patient’s medical home. The major concern with RBCs is that the care is fractionated. How many times do you see a patient in the office for a URI and notice cholesterol issues or that a Mammogram needs to be done. RBCs are designed for acute illness, not chronic care or routine health maintenance. One third of the reason patients are seen in the primary care physicians’ offices may be lost. The impact of this has yet to be determined. Peter Lindblad, MD, a WDMS Editorial Board member, is a board certified physician in Internal Medicine with Primary Physician Partners, St. Vincent Hospital.
Retail Clinics: Unanswered Questions Retail-based health clinics have exploded across the U.S. Nearly 1,000 operate in 35 states, with some 2,000 projected by year’s end. They’re now arriving in Massachusetts, with CVS opening sites this year and Walgreens not far behind. Business reasons are driving this rapid growth, as operators, expanding primarily by acquisition, seek their share of what’s expected to be a $4.5 billion industry by 2011. Two years ago, CVS bought MinuteClinics and its 83 clinics. Today, CVS has 520 clinics and counting, with a forecast of establishing 2,500 in the years ahead. Walgreens bought Take Care Health System in May of 2007 and doubled operations in the fourth quarter of the same year. Retailers like WalMart and Target are also adopting the model, even as some retraction – clinic closings and declining investment - is now occurring in the industry. The Deloitte Center for Health Solutions has labeled retail clinics a “disruptive innovation” because they challenge the status quo by providing service outside the traditional setting of a medical practice. A Deloitte survey concluded that “Consumers have embraced the concept” and that “They do not appear concerned about safety issues or staffing by advanced nurse practitioners.” Separately, a Wall Street Journal/Harris Interactive Study conducted in May found high levels of satisfaction with quality of care, cost, and staff qualifications. The biggest driver of satisfaction was convenience. Proponents claim these clinics offer convenience and accessibility with no long waits for appointments, reduced strain on emergency rooms, and enhanced primary care, especially as thousands more citizens are now insured under health care reform and patients have increasing difficulty finding primary care physicians. Physicians are skeptical. We warn about fragmented care, adequate public health and safety, supervision and supply of nurses, sanitation and infection control, referrals for advanced conditions, pediatric capabilities, and conflicts of interests (selling prescriptions written in the store, cigarettes where health care is delivered). And we’re adamant in our viewpoint that these clinics won’t ease the strain on emergency rooms and won’t be the cure for primary care many think they’ll be. While retail clinics have spread rapidly in other states with little public oversight, the story in Massachusetts has been quite different. When CVS asked the Department of Public Health in 2006 to waive regulations to grant full clinic licenses, physicians said, “Not so fast.” We objected to such a profound change in medical practice without public review and said retail clinics should be held to the same standards as other clinics. We called for public hearings, and waiver requests were tossed aside. A thoughtful and deliberative process began. The result? The Public Health Council approved new regulations governing an entirely new entity in Massachusetts medicine: “limited service clinics.” Among the many regulations are restrictions on what ailments (all minor) may be treated, guidelines for sanitation and infection control, prohibiting treatment for children under 2, review and credentialing for practitioners, and clear indications for back-up care and referral for serious cases. Further, DPH will dedicate resources to ensure oversight, review applications, and monitor planning and operations, and has assigned its Medical Director to oversee clinical issues and chair an advisory committee. The new regulatory framework is a substantial improvement and public health commitment over what would have been without the advocacy of physicians. Despite projections and promises, the jury’s still out on how big or important a role they’ll play in health care. No evidence yet exists that they will reduce costs, and in fact a recent multi-year study in Minnesota – the first to compare costs per episode of care for five conditions treated in physician offices, retail clinics, and urgent care settings – confirmed that overall costs of care actually increased in all settings. Physician reaction to retail clinics is still evolving. While some object to this model of care, the Massachusetts Medical Society’s Task Force on Retail Clinics (with representatives from the Worcester District) will release its report in the fall, examining the potential impact and recommending ways physicians may respond. We do know retail clinics will now be part of the Commonwealth’s medical landscape, and that patients will have the choice, and some the penchant, to use them because they’re quick and convenient. That insurers will cover visits to such clinics adds incentive and legitimacy for patients. But the physician’s message to patients should be twofold: one, that they’re best served in a relationship with a primary care physician who provides continuous, comprehensive care, and two, that quick and convenient may not equate with quality care. Dr. Auerbach is President of the Massachusetts Medical Society and Vice President of Emergency and Ambulatory Services at Sturdy Memorial Hospital in Attleboro, MA.New MinuteClinic
Health Care Centers Bring Accessible, Quality Care to Massachusetts
Communities MinuteClinic’s new limited-service clinics opening this fall inside CVS Pharmacy stores in the Bay State are contributing to Massachusetts’ precedent-setting efforts to broaden access to care and bring new innovation to medical treatment for common episodic ailments. Following a thoughtful review and regulatory process by the Department of Public Health, headed by Commissioner Auerbach, we opened our first clinic in Medway in September and have since introduced the MinuteClinic model of quality affordable care to patients in Bridgewater, Danvers, Taunton, Tewksbury and other communities surrounding Boston. By the end of this year, we hope to be serving patients in 28 locations in the state. As the pioneer of the limited service clinic model, we bring a high level of experience and expertise to patients in the Bay State. MinuteClinic currently has more than 540 locations in 27 states across the country. We are the first and only retail health care provider to receive accreditation from The Joint Commission, the national evaluation and certifying agency for nearly 15,000 health care organizations and programs in the United States, including hospitals, nursing homes and rehabilitation centers. With hundreds of thousands of Massachusetts residents now newly insured through the Commonwealth Connector, we are committed to working with the Department of Public Health and the medical community to ease the burden on primary care physicians and emergency rooms. Our clinics are open seven days a week and no appointment is necessary to see one of our nurse practitioners. Our focus is on providing consistent and high-quality care for acute illnesses such as pharyngitis, conjunctivitis, and otitis media. We also offer treatment for common skin conditions such as poison ivy and minor burns and rashes, and we offer adult vaccines and flu shots for the entire family. In Massachusetts, we only serve patients over age 24 months. Every patient assessment and treatment provided by our nurse practitioners follows the nationally established clinical practice guidelines embedded directly into our electronic medical record. We use sources such as the Institute for Clinical Systems Improvement, American Academy of Family Physicians, and the American Academy of Pediatrics to assist us in our guideline design. MinuteClinic nurse practitioners use a software program that at the conclusion of each visit generates educational material, an invoice and a prescription (when clinically appropriate), as well as a diagnostic record that is sent to the patient’s primary care provider’s office. A collaborating physician (medical director) is on call during all hours of operation. Individuals with illnesses outside MinuteClinic’s scope of services or who exhibit signs of a chronic condition are referred to their physician or, if critical, the nearest urgent care or emergency room. Patients who can’t be treated are not charged for their visit. For those without a medical home, each of our clinics in Massachusetts maintains a list of primary care providers in the community and surrounding areas who are accepting new patients. We invite physicians to contact us if they would like to be added to our referral database. We are very proud our clinical quality record. A study analyzing 51,331 MinuteClinic patient visits for pharyngitis first reported in the American Journal of Medical Quality in 2007 found a 99.15 percent adherence to clinical guidelines by not prescribing unneeded antibiotics. That percentage compared favorably to other documented rates of adherence by primary care providers. Similarly, a MN Community Measurement 2006 Health Care Quality Report studied pediatric pharyngitis treatment and rated 60 Minnesota health care providers, ranging from large medical groups such as Park Nicollet Health Services and Mayo Clinic to private Minnesota pediatric practices. MinuteClinic received the highest rating in the study. We look forward to continuing this high level of care in Massachusetts and partnering and collaborating with the medical community to serve the citizens of the state. We welcome any questions or input about our model and services. Rebecca Hafner-Fogarty, MD, MBA is the chief clinical officer for MinuteClinic. She joined MinuteClinic in 2006 as medical director for strategic alliances. Prior to joining MinuteClinic, Dr. Hafner-Fogarty worked as a primary care physician in a number of rural and urban settings in Minnesota and California. Dr. Hafner-Fogarty has been an active member and leader in both the MN Medical Association and the MN AFP. Dr. Hafner-Fogarty has also been a member of the MN Board of Medical Practice since 1998. She is currently VP of the MN BMP and serves as chair of the committee on Licensure.
Healthcare - Coming to a Store Near You I am a pediatrician practicing in the Minneapolis - St. Paul metropolitan area. Minnesota, birthplace of the Health Maintenance Organization and managed care, is now a leader in another "progressive" trend in medical care ~ retail-based clinics ("RBCs"). RBCs are staffed by nurse practitioners and physicians' assistants and see patients for a limited number of conditions. Initially appearing about 8 years ago, there are now approximately 1000 sites in 37 states. It is estimated that the number of RBCs will grow to almost 6000 in the next 5 years. The increasing prevalence of these clinics constitutes another major blow to primary care and the medical home movement. Ten clinical problems constitute 90% of RBC visits. The same ten problems comprise 13% of adult primary care visits and 30% of pediatric primary care visits. By cherry picking a limited number of common minor acute illnesses, the clinics divert patients away from pediatric, family practice, and internal medicine clinics because they are able to accept much lower reimbursement for services. They can do so not because of some magical cost-containment strategy, but because they don't have the expense of running a full-service clinic. They don't have to pay for staffing and systems for scheduling advance appointments, providing 24-hour phone access, and maintaining medical records, equipment, and more comprehensive laboratories. RBCs also have the financial support of their retail owners ~ grocery stores, retail chains, pharmacies (one operator, CVS, owns more than half of all clinics). In fact, the RBCs' primary function may not be as a source of health care, but rather a means to get retail customers in their door; clients may be given a pager so they can shop while they wait for a prescription. The medical clinic may be able to operate at a loss which is offset by the revenue generated by the patient-turned shopper. Certainly there is data to support the financial advantage to retailers of such an arrangement; no wonder RBCs are "cost effective" - per a recent study performed by a local Minnesota managed care organization. I can hardly blame a family for wanting to save $60.00 by taking their two children with sore throats to an RBC ~ some payers even waive the copay (it's cost effective!). However, if insurers continue to present patients with financial disincentives for going to their primary care clinic, I think the writing is on the wall for the medical home concept. Primary care providers will be left to care only for patients with medically complex conditions, mental health issues, and preventive care needs ~ patients for whom we will provide time-consuming services that are relatively poorly reimbursed; we will simply not be able to compete and survive. Even if we could afford to charge less for a handful of designated problems, our contracts with payers would not allow us to do so. Already the number of medical school graduates entering primary care is declining; most have substantial debt and cannot afford to pursue careers in primary care, already the lowest paying careers for physicians. The presence of RBCs will only make primary care a less financially tenable option for new physicians. It is disappointing that insurers are sending their members to the grocery store for health care. Unfortunately for those of us in pediatrics, family practice, and internal medicine, RBCs are likely here to stay. As we move toward a consumer-driven health care environment, recent polls indicate that 15% of children and 19% of adults are likely to use RBCs. Approximately 85% of RBCs now accept insurance and copayments. In opposition to this trend is ample evidence supporting the establishment of medical homes as a cost saving measure. To truly function as a patient's center of care, we need to be able to regulate access, coordinate care, and maintain comprehensive health records. The establishment of RBCs is at odds with this mission. Most feel that access to adequate health care is a right. It is a sad statement that our system supports the use of patients as marketing tools. We all know our health care system is in a fragile state. The growth of RBCs represents a further drain on the system, as it diverts dollars away from health care agencies and into the pockets of retailers whose only stake is their own financial gain. There is possibly a conflict of interest when RBCs are associated with pharmacies and copays are waived if a patient has testing done or is given a prescription (a policy employed by one local payer). The establishment of RBCs may require us to adapt. Already, hospital systems are opening "satellite care centers" in retail locations. Clinics are extending hours and accommodating walk-ins. We will need support to remain viable and continue to provide optimum comprehensive health care for our patients. We need to critically evaluate the quality of care delivered at RBCs and determine the effect that they have on the patient - primary care provider relationship. Already, Massachusetts regulates RBCs, and Illinois is considering legislation to do so. It is critical that our health departments, medical associations, and legislators recognize the genuine threat that RBCs pose to the continued provision of primary care across the country. Economics
of Community Pharmacy The face of community pharmacy has changed significantly over the past few decades not only in the physical location sense, but also in the approach to patient care. The economics of practice has been altered by higher-costing drugs and the resulting higher investment in inventory, both prescription and non-prescription. The shift from a product focus to a clinically oriented patient focus has slowly evolved. This has not been the only change, as is the case with medicine; other changes include an increased focus on cost containment and the concomitant rise in managed care. For pharmacy, this pervasive spread of managed care has affected the economics of pharmacy in a number of ways: total revenue per prescription, the method of valuation of prescription drug products, and gross margins have all decreased. These financial pressures have occurred in an environment of increased competition for consumer patronage from corporate pharmacy (chains, supermarkets, and mail order) and manpower shortages of pharmacists. The normal business cycle for a community pharmacy, chain or independent, would be to receive a prescription from a patient, fill or refill the prescription, and dispense the drug to that patient. Originally, prescriptions were priced individually, utilizing what was called a “usual and customary” pricing method in which either a percentage markup was added to the cost of the drug component of the prescription or a flat fee was added to the cost of the drug. For example, a drug costing $90.00 ~ if priced at 40% markup on cost ~ would be sold for $126.00. The same drug on the fee system ~ if the fee were $15.00 ~ would be sold for $105.00. As the private and public systems of drug reimbursement proliferated, these systems became unwieldy and expensive. Drug expenditures soared with wide variability in the marketplace and the need for cost controls were warranted and put into place. These were caused by the wide range of pricing methods and the total dollar cost of programs ~ especially in the public sector ~ exceeding budget levels. The mechanisms introduced to remedy the economics of the situation have evolved over time and appear to be aimed at the end of the prescription drug marketing channel, i.e. community pharmacy practice. In order to illustrate this point, the income statement of a business will serve for demonstration purposes. The Income Statement basically encompasses three major economic components: sales, cost of goods sold, and expenses. The interaction of these three results in net profit. In the normal business environment, the sales component reflects the total of all the prices determined by the pharmacist, with no constraints other than those of the market. The cost of goods sold would reflect the invoice cost of the drug minus any discounts realized by the pharmacist (these are not required to be considered when determining price). Sales minus cost of goods sold would result in gross margin. This margin is the aggregate dollars the pharmacist has to operate the practice. Expenses reflect the actual cost of operating the practice. The final result in this oversimplification is net profit. In the current marketplace, the first change is in price determination. The impact here is twofold since the amount added as a fee and the cost of the drug are determined by the reimbursement agency or pharmacy benefit manager. Fee structures in New England vary by state and range from $1.25 to $4.75 per prescription, depending on whether the program is public or private. The cost of the drug component is determined by utilizing a method to recognize that pharmacists who purchases more effectively will be able to accrue discounts and thereby raise their margin in a true marketplace approach. In order to reflect these discounts, Average Wholesale Price (AWP), which is analogous to the “Sticker Price,” is discounted. This is commonly referred to as the “AWP minus” approach. For example, 60 Zyban150mg Average Wholesale Price is $203.87. Using the mean Medicaid fee ($3.00) in New England and a mean AWP minus 14%, the cost of the drug reduces to $175.33 and the reimbursement agency is billed $178.33, with a resulting gross margin of $3.00 ~ if the pharmacist can purchase the drug for $175.33. If it is purchased below this amount, the margin increases. In New England, these discounts range from 11.9% to 17%. The Massachusetts Medicaid program uses a system based on WAC plus 5%, where WAC is Wholesaler’s Average Cost.1 In these approaches to pricing, it is assumed that the drug may be purchased by the pharmacies at or below the cost threshold set by the benefit manger. It is simple arithmetic and not higher mathematics that the interplay between sales and the actual cost of drug product seriously affects the gross margin of the pharmacy practice. The economic effect of these activities has resulted in a steady decline of margins over time. The National Community Pharmacists Association reported in 2007 a decline in gross margin from the previous year from 23.6% of sales to 22.8%of sales. A discussion of the effects of copayment mechanisms has been purposely avoided due to the vast number of permutations across programs. The analysis of this aspect of practice is just part of the picture. The next step in the puzzle focuses on operations management. In this area, the manager must consider how to operate the practice using the dollar amount available from the margin. Expense control hinges on both internal and external constraints. In pharmacy, salaries and wages are one of largest expense lines found in the practice. A balance must be stuck between the use of professional and paraprofessional staffing; this is not an uncommon approach across the healthcare spectrum. Pharmacist shortages have been prevalent and salaries have been on the rise ~ and that’s combined with expanded benefit packages. Starting salaries of recent pharmacy graduates have been tracked at $105,000 to $112,000. This, along with competition, has placed severe pressure on net profit. The 2007 press release of the National Community Pharmacists Association reported a 30% decrease in net profit from 3.7% to 2.6% of sales.2 Pharmacists in both independent and corporate settings have seen comparable trends relative to operating results. Both have instituted strategies to stem the economic tide. The shift of profit centers away from prescriptions to other areas of the practice has been instituted. The introduction of niche markets focusing on compounding; medication therapy management and durable medical equipment have been seen. Corporate pharmacy has expanded to partnering the pharmacy with drop-in medical clinics. These steps have been established in answer to shrinking margins and reduced net profits. In closing, and as further examination of the Zyban pricing above, if the net profit figure of 2.6% is applied, the net profit on this prescription would be $0.078. Edward T. Kelly, III, Ph.D., is Professor of Pharmacy Administration and Assistant Dean for Curriculum and Assessment, Massachusetts College of Pharmacy and Health Sciences, Worcester. References:
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Volume Factor: Study Reveals Worcester Noise The fragile inner workings of the human ear, a masterpiece of evolution and function, are increasingly under threat from the constant commotion and noise of our expanding populations and increasingly loud urban areas. This threat to our collective health has been documented in numerous studies worldwide. “Recent reviews document the relationships between noise exposure and sleep disturbance, hypertension and cardiovascular disease, mental disorder and children’s cognition.” (Seto, 2007) Two students from Worcester State College, Christopher Noonan and Renee Marion, under the guidance of Dr. William Hansen, set out to document the ambient noise levels in the city of Worcester, Massachusetts. Using an Extech Digital Sound Level Meter, students set out to measure 64 different locations throughout the city. Each reading was taken for a total of five minutes, between the hours 8 a.m. and 5 p.m. The maximum and minimum readings were entered into a GPS unit and then uploaded on a GIS map that interpolated the data to display the range of sound disbursement throughout the city. The results ranged from a high noise reading of 104.0 dB(A) on East Mountain and West Boylston Streets to a low reading of 42.9 dB(A) along Branden Road. The average sound reading for the city was 84.7 dB(A). The largest source of noise in the city of Worcester was from traffic, most notably tractor-trailer trucks, emergency vehicles, and motorcycles. Secondary noise sources included general traffic, lawn mowers, stereos, and music venues. This data does relay that Worcester is a fairly noisy city. According to a noise study reported by the New York Times in 2007, “The level of noise in the urban and rural areas we tested remained pretty consistent with the 1970 E.P.A. figures – about 59 decibels in the city and 43 in the country.” (Vitello, 2007) Worcester’s readings exceeded this average and it may be cause for concern as evidenced by a report by the World Health Organization which warns, “Heart problems can start if there’s constant night-time exposure to levels of just 50 decibels.” (Currie, 2007) Other studies have found a direct link between noise and sleep patterns, stress levels, mental illness, and overall well-being. One study noted that “The threshold of noise judged to have a negative impact on children’s learning is 55dB during night or day.” (Coghlan, 2007) Dr. Todd Sauter, Director of the Audiology Department at UMASS Medical Center, commented that “There has been a clear shift in our perspective of noise as not only a public nuisance, but also as a threat to our public health.” Clearly, Worcester demonstrates a high occurrence of noise. One reassuring factor, though, directly evidenced by this study, is that many places of very low noise can be found within the city limits. Many of the neighborhoods that we surveyed reported measurements that registered between 40 and 50 decibels, within an acceptable community range. However, the heavily trafficked streets -- Main Street, West Boylston Street, Southbridge Street, Lincoln Street, Chandler Street, Belmont Street and Park Avenue -- experience very heavy traffic, a high frequency of trucks, emergency vehicles, and motorcycles, as noted earlier. These problems are compounded by the high populations who live along these roadways. For individuals within high traffic areas, decibel readings frequently exceed 75-80 dB(A). The city of Worcester is taking measures to address the problem. Currently, the city has a noise ordinance in place. The Department of Public Health has been conducting a series of meetings to bring together a diverse group of individuals to tackle the problem. They have commissioned additional reports on traffic noise and the Commissioner of Public Health, Dr. Leonard Morse, reported that although the rise of Ipods and Mp3 players has made music readily available, it has also increased the risk of hearing loss among our younger populations. Roadways, music venues, and portable stereo systems are all modern day conveniences, but they are also all hazards to our health. Worcester is on the emerging edge of the noise curve, as other cities throughout the world take note of increased noise pollution. “By the end of this year, all European cities with populations exceeding 250,000 will be required by European law to have produced digitized noise maps showing hotspots where traffic noise volume are greatest.” (Coghlan, 2007) In 2008, Liverpool announced plans for an interactive noise map, allowing residents to “…key in their postcodes and see colour coded maps highlighting high-decibel hotspots.” (Hernon, 2008) In addition to government assessments and ordinances, a fair collection of noise abatement public interest groups have sprung up from time to time. Many groups have formed to fight additional runways at airports or to increase civic action to reduce noise. In Worcester, neighborhood groups formed and successfully persuaded officials not to build an access state highway leading to the airport and repeatedly cited noise as major threat to the integrity and well-being of their neighborhood. Choosing a home or apartment in a quiet area may be a suitable solution. Choosing to use public transportation, walking, or riding a bike can also reduce traffic- related noise. As this study reveals, background noise levels in the city need to be addressed and action steps to reduce traffic-related noise are necessary, and mounting evidence is proving that it is no longer just a nuisance, but also damaging to our health. References: Coghlan, Andy Currie, Brian Hernon, Ian Mead, Nathaniel Seto, Edmund Yet Wah; Bhatia, Rajiv;
Holt, Ashley; Rivard, Tom Vitello, Paul Christopher Noonan can be reached at cnoonan1@worcester.edu. William Hansen, PhD can be reached at whansen@worcester.edu. Renee Marion can be reached at rmarion@worcester.edu. Financial
Advice for Physicians: Your Battle for Investment Survival The mayhem of the last 2 months shows that you are on your own and must be engaged in building and protecting your “nest egg.” With the financial world, the political world, and the media all panicking, investors are extremely nervous and losing lots of their money. The S&P Index is down 25% from a year ago and things seem to be getting worse. The lesson to be learned is that your future is too important and too vulnerable to be entrusted to politicians, bureaucrats, and bankers. You need to develop your own long-term savings and investment strategy whether you are a retired 75 year old surgeon or a 45 year old couple with a joint life expectancy of 90. To build your long term financial security, you need to save a large percentage of your personal income and invest these savings in a diversified, strategic fashion. Wealth and financial security should come from what you and your spouse can save from your personal earnings. Investment markets will not make you wealthy. Your wealth will result from practice earnings and business investments. The investment markets should primarily preserve the buying power of your invested assets. Investments can generate market-driven rates of return plus additional return to offset inflation. Promises by investment advisors or personal expectations of extraordinary investment returns over long time periods are unrealistic. Your personal investment time horizon is probably between 10 and 60 years and exceeding average returns in the market will be difficult. The hardest part of this prescription is the personal savings it requires. The investment component requires you to set the Strategic Parameters and hire excellent tactical managers. With the right strategy, severe market disruptions like we are currently experiencing should not overwhelm your tactical managers and may in fact provide some opportunity. Witness that Warren Buffet just invested $5 billion in Goldman Sachs and $3 billion in General Electric. Mr. Buffett seems to think that the market sell-off presents an investment opportunity. Investing is your only alternative. Your money needs to be working somewhere. By investing you preserve purchasing power. Safe money market, CD, and treasury bill returns will not adequately fund your retirement. Today’s doctor does not have a pension beyond the one he builds for himself. Therefore, you need to save lots of money for your retirement years, which statistically will last 20 to 30 years. Your savings needs to be large and invested to grow and offset the erosion of inflation. Your “Big Picture” investment decisions will set your Asset Allocation Strategy. You can make those decisions with the help of a Certified Financial Planner or a highly recommended investment manager. Allocation of your savings should be determined by your investment time horizon, investment experience, cash flow needs, and circumstances. The asset allocation parameters will establish the actual composition of your portfolio. They will set specific percentage holdings of stocks versus bonds, international stocks versus domestic stocks, large stocks versus small stocks, value stocks versus growth stock. This variety establishes a broadly diversified portfolio which should generate market-related returns in both good and bad investment climates. The tactical implementation of your asset allocation strategy warrants hiring a small army. These style-specific investment managers will implement your grand strategy. You will have large capitalization growth stock managers and large cap value stock managers investing a specific percent of your portfolio. You will also have bond managers, international stock managers, small stock managers, plus many other styles. This allows you to capture the returns the market offers without assuming too much risk. Different investment styles perform differently over time. By attempting to have them all, you will not miss any opportunities. Markets have always gone through cycles, with bull markets followed by bear markets, followed by recovery and so on. For instance, what is happening internationally can be different than what is happening domestically. Also, bonds can give very different returns from stocks. The objective is to hire style-specific managers who can exploit the opportunities available in their specific arena. Your investment needs and opportunities are long term, 10 years, 20 years, 30 years or more. You need a process which has succeeded in the past and can continue to perform in today’s investment climate. Regular performance reviews let you monitor your tactical managers’ performance versus the market. Managers who underperform should be replaced. This active oversight of your investment program will help you achieve your long term goals. Save now, invest with a plan, get some help, and good luck. Michael Halloran, CFP is a PIAM Representative working exclusively with physicians. He holds a BS degree in Electrical Engineering from Cornell University and an MBA from Harvard University. Mike is available to meet with your practice or your department. He can be reached at: 8 Grove Street, Suite 300, Wellesley, MA 02482 781-431-8800 PIAMrequest@halloranfinancial.com. Off Call: A Day to Remember
One of our Own and to Dream of a Better World On September 17th, 2008, the members and friends of The UMASS Department of Surgery and the family of Felix Cataldo gathered at the Faculty Conference Room of the UMass Medical School to hear Dr. Barbara Barlow, the 3rd Annual Felix Cataldo Lecturer, expound on her vision of an INJURY FREE America. This year’s Cataldo Award Recipient was Dr. Francis Podbielski, a thoracic surgeon who covers indigent patients in both Central and Western Massachusetts. The Felix Cataldo Award and Lectureship was established by the Cataldo family to honor the memory of Felix Cataldo, Chief of Surgery at the venerable Worcester City Hospital for over 52 years. Felix was a beloved figure in medical and surgical circles in Worcester; he was beloved for his kindness by his patients, for his teaching by his trainees, and for his compassion by the medical and political community. He was a major force in pushing Worcester City along well into the 20th century and in continuing its mission to provide care to Central Massachusetts’ neediest patients. When Worcester City Hospital closed its doors in 1990, Felix was a tireless advocate of pushing UMass Medical Center to absorb some of Worcester City Hospital’s more vital medical services for our community, including the burn center and trauma care. Felix also was a major supporter of the Family Health Center on Main Street in Worcester, where he worked until shortly before his death in 2005. Felix’s wife Anne and 7 children, two of whom are surgeons themselves, endowed a lectureship in his honor to promote humanism in medicine and surgery. The first annual recipient of the award was Dr. Harvey Clermont, whose indefatigable work in free clinics around Worcester and his dedication to teaching have been an example for so many of us. The lecture last year was delivered by Dr. Richard Rockefeller, US Director of Doctors without Borders, and one of our local NICU Fellows, Dr. Jonathan Spector, who performed medical missionary work in Darfur and other parts of Africa. Some of our readers may be familiar with the name of this year’s speaker, Dr. Barlow, as she was featured in the July/August issue of Worcester Medicine as one of the six outstanding physicians highlighted in the 212th Annual Oration of the Worcester District Medical Society (authored by yours truly), entitled “Profiles in Medical Courage.” Dr. Barlow has singlehandedly established a National Network of Pediatric Injury Prevention Program called the Injury Free Coalition for Kids of Worcester. Her goal is to keep injury, the most common cause of death amongst the pediatric population, in check by establishing nation-wide injury surveillance and then appropriate interventions to prevent these injuries. “There are no such things as accidents” was a major part of her message. Also included was a challenge to medical systems to understand the economic impact of allowing preventable injuries to persist without action. This negligence will result in draining our precious medical resources unnecessarily. Dr. Barlow was a speaker with an agenda that clearly would have jived with Dr. Cataldo’s focus on community wellness during his many years of service to Worcester.
Thanksgiving at the Worcester Housing Authority One year shortly before the Thanksgiving holiday, I spoke to my patients and asked them about their plans for Thanksgiving. All of them responded the same way. “We will be home, and we will be alone.” I knew I could not celebrate Thanksgiving, my favorite holiday, without including them. I usually prepare a huge meal for the holiday. I invite family and friends from across the country to spend it with me. I cook for days. Everyone is involved. Aside from Hanukkah, it was always my children’s favorite holiday. Then and there I decided that we should celebrate Thanksgiving with my patients at the Worcester Housing Authority. My sons invited their friends, who all baked for the occasion. I encouraged my friends to join us and cook something special for this day. We wanted it to be exactly what we had at home, a turkey that we carved at the table with all the fixings. I wanted the room decorated for the occasion. I also wanted all the residents, of every background and nationality, to be part of the celebration. And that was exactly how our Thanksgiving was. People brought Albanian, Russian and Latino dishes. My family and friends brought traditional American food and Cuban food. Everyone came: my family, our friends, and my co-workers all participated in this event. My family said it was the best Thanksgiving they’d ever had. My patients and the residents at WHA said the same thing. Every year they asked me if I were going to do it again. I missed last year because I was having surgery. I knew they understood but all I did was think of them. Thanksgiving wasn’t the same without them. The event has become a tradition, one that grows every year. The response has been amazing. Dr. Leonard Morse, the Commissioner of Public Health, comes with his wife and helps serve the people. Congressman McGovern’s aide comes, carrying home made food. UMass has sent trays of food from their cafeteria while medical students and high school students have baked all sorts of dishes and have helped serve. Members of our synagogue come to help along with friends from everywhere. It is a wonderful experience. I realized then that our community wants to give. People want to help others and want to make sure others are not alone. It seems that all they wait for is a spark; once they are given the venue they are eager and delighted to give. It was such a rewarding experience for all of us. We may say that we are doing it for the residents and yes, we are, but we are doing it for ourselves as well. It makes us feel good. It lets us show our kids how they should act, what they should do when they grow up, and what kind of people they should become. It makes our family grow by the hundreds. Now all of us spend Thanksgiving Eve with Worcester Housing. I am privileged to work in this community, where people do care about others. I am privileged to be given the opportunity to serve this community, and we hope we have all touched residents’ lives just a bit. In reality, the feeling that they are not alone, that we care, and that they can count on us is the best health care we could give our patients. This year we are doing it again. I send out my e-mails and everyone responds. Some people ask, “How do you do it?” My response is simple. I respond that it is just part of life ~ a good life! I hope all of you can join us this year. Matilde Castiel, MD is Executive Director of the Latin American Health Alliance, Assistant Professor of Internal Medicine, and Assistant Professor of Family and Community Medicine at the University of Massachusetts Medical School and UMass Memorial Healthcare. If you want more information or would like to volunteer, please contact Matilde Castiel, MD at castielm@ummhc.org. In Memoriam: WDMS Remembers its Colleagues Daniel R. Silver, MD The Central Massachusetts medical community has lost a talented physician and musician, as Dan Silver succumbed to colon cancer in February of this year. Dan was born on February 1, 1952, in New York, NY, and grew up in Valley Stream, Long Island. He graduated from Union College in 1975, and went on to earn a Master of Science in Teaching degree from Boston College in 1977 and his MD from the University of Guadalajara School of Medicine in 1982. Following a residency in Internal Medicine at Mt. Sinai/Elmhurst Hospital, he completed a two-year fellowship in Intensive Care at Albany Medical Center in Schenectady, and subsequently became board-certified in both Internal Medicine as well as in Critical Care. After an initial position with the Guthrie Clinic satellite office in Elmira, NY, Dan joined the Fallon Clinic Internal Medicine group in Auburn in 1991, and also served on the staff of St. Vincent Hospital in the Critical Care department. He joined Leominster Hospital in 2002 to spearhead the development of their hospitalist program, but retired due to his illness in 2003. An accomplished guitarist and singer/songwriter, Dan played in a number of local bands, including The Bad Pennies, a rock band comprised of Fallon Clinic doctors, who performed at the Weld Inaugural Ball in Boston in early 1995.. A year later, he released his own CD, “Your Decision.” He went on to found a Beatles tribute band, performing with them even several years into his illness. When he wasn’t writing or playing music, Dan could be found running and cycling throughout Massachusetts and New England and reveling in his greatest joy, his family life, with his devoted wife of twenty-five years, Rosann, and their three sons, Brian, Michael and Craig. As if by divine intervention, this lifelong and loyal Giants fan witnessed their spectacular Super Bowl victory just days before he lost his battle with cancer. He was accompanied for an extended period during this time by his wife and two of his sons, who were able to take a semester’s leave from their studies at Williams and UMass to be with their beloved father in his last days. Dan passed away at far too young an age on February 15th, and will be missed by all those who practiced with him, were cared for by him, and who shared his love of music and life. Susan M. Yeomans, MD
Donald Hight, MD Donald Hight, colleague mentor and friend. Donald Hight, a distinguished surgeon in the Worcester community from the 1930s to the 1980s, died November 10th, 2007. When I joined the staff of Memorial Hospital in 1969, Don and Betty Hight welcomed our family to the area, welcoming us into their home for meals, taking us fishing and skiing in New Hampshire, and introducing us to the Worcester community. Betty would babysit for our youngest child while the rest of us went off for the day. Don Hight was a surgeon of the William Halsted School, setting an example of surgical technique and patient care. Silence reigned in his operating room and he stayed with his patient from the beginning to the end of the procedure. Bleeding was controlled with suture ligatures and an anastomosis done with interrupted silk sutures. Don set an example of excellence for future generations of surgeons by teaching the surgical house staff at the Memorial Hospital and UMass Medical School. Don enlisted in the Navy in 1942 and served as surgeon on the fast carrier U.S.S. Cowpens in the Pacific Theater. He witnessed some of the violence during the Battle of Leyte Gulf and the attacks on Iwo Jima and Okinawa. The Cowpens anchored beside the battleship Missouri at the Japanese surrender in Tokyo Bay August 1945. From his early years spending summers in New Hampshire and attending Dartmouth College, Don remained an avid outdoors man throughout his life. He continued to downhill ski and fish the waters of the Mirimichi River until he was in his late 80s. He earned the name "Deadeye" from his upland game hunting and skeet shooting companions. This Renaissance gentleman will be missed by all who knew him. Chris Durham, MD |