Laura Joszt

The controversial move to bundled payments is well underway at the Centers for Medicare and Medicaid Services (CMS).

In an effort to cut costs and get physicians to adhere closely to quality guidelines, aspects of the payment model known as “value-based care,” CMS today announced three new bundled payment models in cardiac care, an expansion on the Comprehensive Care for Joint Replacement Model (CCJR), and a highly anticipated new track in the Medicare Shared Savings Program (MSSP). Those who comply will be eligible for a 5% enhancement in reimbursement.

The cardiac payment model includes: the Acute Myocardial Infarction (AMI) Model; the Coronary Artery Bypass Graft (CABG) Model; and the Cardiac Rehabilitation Incentive Payment Model.

AMI and CABG will be implemented in 98 areas and rehabilitation model will be implemented in 90 geographic areas, half of which overlap with areas that were also selected for the AMI and CABG Models.

The CCJR is being expanded in the current CJR areas to include surgeries for hip and femur fractures.

The models will begin on July 1, 2017 and run until December 31, 2021, plus they count as participation in an Advanced APM under MACRA, which means clinicians qualify for a 5% incentive payment.   There are some who remain opposed to the mandatory nature of the bundled payment models for cardiac care and hip and knee replacement.

At the American College of Cardiology, President Richard Chazal, MD, said “this new path for cardiologists to participate in Advanced Alternative Payment models under MACRA’s Quality Payment Program is a challenging step. It is our sincere hope that the end result will be opportunities for coordinated care and improvement in quality, while also decreasing costs for patients with heart attack or who undergo bypass surgery.”

Tom Nickels, executive vice president of government relations and public policy of the American Hospital Association (AHA), called it “too much, too soon.” The pace of change leaves AHA concerned.   “While it is important to test new payment models, hospitals should not be forced to participate in complicated new programs if the government has not already proven that they will benefit the patients we serve,” he said. “We will continue to urge that any new bundled payment programs be of a voluntary nature.”  

 Another opponent? Representative Tom Price, R-Georgia, who is President-elect Donald J. Trump’s pick to run Health and Human Services. On September 29, Price and other members of Congress wrote to CMS Acting Administrator Andy Slavitt and Patrick Conway, MD, MSc, deputy administrator of innovation and quality and chief medical officer of CMS, that mandatory payment reform exceeds the authority of the Center for Medicare and Medicaid Innovation (CMMI).   “We insist CMMI stop experimenting with Americans’ health, and cease all current and future planned mandatory initiatives within the CMMI,” the letter said.   It seems likely that Price will scrap plans for the mandatory bundled payment models.   CMS also announced Track 1+, a new accountable care organization (ACO) model under MSSP. The new track has more limited downside risk than Tracks 2 and 3. The Track 1+ model qualifies participating ACOs for the Advanced APM path.

The changes also provide additional opportunities for providers to participate in the Medicare Access and CHIP Reauthorization Act (MACRA) under the Advanced Alternative Payment Model (APM) path, according to CMS.  

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Medicare Reform: Bundled Payments Announced by CMS

New York City may be the most popular tourist destination in the US (and among the most popular in the world), but few visitors likely take the time to venture outside of Manhattan to one of the other 4 boroughs that compose the city.

Just across the East River lies an up-and-coming tourist hot spot: Brooklyn. While Manhattan has the glitz of Times Square, the entertainment of Broadway, and the beauty of Central Park, Brooklyn is gaining traction because of its bars, restaurants, shopping, and views of the Manhattan skyline.

Physicians in particular might want to take a trip into Brooklyn, where they can peruse the unusual Morbid Anatomy Library. While the library has plenty of oddities, it also has artifacts relating to medical museums, anatomical art, the history of medicine, and death.

Morbid Anatomy has been open for 6 years in Brooklyn, but recently it received a facelift as it moved into a 3-floor, 4,200-square-foot building in the Gowanus. The new building officially opened June 28 to the public. Initially, the museum began as a website created by Joanna Ebenstein as a place to house her photos of medical museums. However, she found a location to house the Morbid Anatomy Library and a lecture series called Morbid Anatomy Presents.

“It never occurred to me that it would be of interest to anyone but myself,” she explains. “Interest in this material has definitely grown, recently.”

The lecture series has included guests from the Mütter Museum in Philadelphia, the National Library of Medicine in Bethesda, MD, and the New York Academy of Medicine. In addition to the lectures, the museum hosts workshops and classes, the most popular of which is the taxidermy class.

If the exhibits and artifacts within the Morbid Anatomy Library seem like they wouldn’t appeal to the public — consider again. In order to fund the larger space, Ebestein and Tracy Hurley Martin, chief executive officer and board chair of the library, took to Kickstarter to crowdfund the newly renovated museum. Not only did they reach their goal of $60,000, but they surpassed it to raise $76,013. Some people even donated $1,000 and more for special gifts, postcards from authors, and rare artwork.

The museum houses over 2,000 books, some of which are hard-to-find medical texts, and has space for temporary exhibitions among the permanent showcases. The first temporary collection is the Art of Mourning from Stanley B. Burns, MD, which includes folk art and traditional related to mourning. Visitors can find hand-colored mourning photographs, hair art shadowboxes and jewelry, memorial cards, death masks, and more. The exhibition will remain open until Dec. 4, 2014.

“The museum is dedicated to things that fall between the cracks,” Ebenstein says.

In the late 1800s Coney Island became an entertainment center for Brooklyn with carnival games and amusement park rides. Although the games and rides are typically only open through Labor Day, the beach and the boardwalk are open year-round.

The current amusement parks are Luna Park (the second iteration of the park) and Deno’s Wonder Wheel Amusement Park. Three rides at Coney Island are listed in the National Register of Historic Places: Wonder Wheel, a Ferris wheel opened in 1920 with both stationary cars and rocking cars that slide as the wheel turns; The Cyclone, built in 1927 and one of America’s oldest wooden coasters still in operation; and Parachute Jump, built at the 1939 New York World’s Fair and a Coney Island landmark, although it is has been closed since 1968.

But if rides and carnival games aren’t of interest, visitors can lie on the beach, go fishing on the pier, or grab a hot dog at the original Nathan’s restaurant, which was started in 1916 as a small hot dog stand. The Coney Island Nathan’s is also the location of annual Nathan’s Hot Dog Eating Contest. The current record is held by American Joey Chestnut who ate 69 Wonder Wheel hot dogs and buns in just 10 minutes.

If your palate is more refined than hot dogs, then Brooklyn is also a great place to get a steak. Peter Luger Steak House, located in Williamsburg, has been named New York City’s number one steakhouse for 30 years in a row by Zagat. However, the 125-year-old restaurant has prices to match its reputation, and reservations are strongly recommended.

Zagat warns that service is “gruff,” which is more than accurate. The waiters have often held the positions for years, rarely write down orders, and don’t bother bringing menus to the table unless they are requested.

While Zagat lists the price for Peter Luger’s as $83, that’s simply the cost of a porterhouse steak for 2. The restaurant doesn’t have an extensive menu, but what it serves it does well and the portions are large with most sides and appetizers enough for 2 people to share. The entrees are à la carte, so all sides are extra, but they are well worth it. Luger’s popular sides include its French fried potatoes and creamed spinach, while its well-known desserts are the Luger’s Special Holy Cow Hot Fudge Sunday and the pecan pie. All desserts are served with the restaurant’s famous homemade “schlag,” a thick whipped cream.

Diners should know to bring cash as the only credit card accepted at Luger’s is the restaurant’s own. If you forget, though, there’s an ATM outside next to the front door.

Don’t feel the need to spend a small fortune in order to get delicious food, though. There are plenty of other eateries that are both more casual and less expensive, including: Shalom Japan serving Jewish and Japanese food; gastropub Lachlan; BBQ at Fette Sau; Sweet Chick, known for its fried chicken; and old-timey Maison Premiere. Food trucks aplenty can be found in the streets peddling lobster, tacos, cupcakes, waffles, grilled cheese sandwiches, falafels and more. Or do as the locals and stop by Smorgasburg, a flea food market held at multiple Brooklyn locations, rain or shine.

Beyond Manhattan: The Borough of Brooklyn

Just a few blocks away from the Mississippi River, in New Orleans’ French Quarter, sits a piece of medical history — the apothecary shop of America’s first licensed pharmacist.

Louis Joseph Dufilho, Jr. of New Orleans became America’s first licensed pharmacist in the early 1800s and he opened the shop that is now home to the New Orleans Pharmacy Museum in 1823. The museum didn’t open until 1950 after the building had been damaged in a hurricane and abandoned.

A first glance at the museum reveals that it is packed with history. The walls are lined with shelves brimming with glass jars and bottles and an old soda fountain graces the floor. The museum doesn’t shy away from medicine’s more questionable and horrific past, either. Cases also house sharp and terrifying medical instruments (like bone saws) and even wriggling, live leeches.

Based in New Orleans, it is unsurprising that the museum would have a special exhibit dedicated to voodoo. According to Executive Director Elizabeth Sherman, there were African American-run pharmacies, or hoodoo shops, in the area but Dufilho also sold voodoo potions, which were numbered so they could be ordered discretely.

“[Dulfilho] learned how to make some of the voodoo potions from the local priestess and then he would sell them under the counter at his French pharmacy just because there was a draw for it,” Sherman explains. “In some cases it might have been socially unacceptable or against your religion to see a voodoo priestess but people were curious, wanted to experiment, so you could come to your regular pharmacist and order voodoo potions.”

Guests also can visit a re-created 19th century physician’s study. The building’s second owner, after Dufilho, was a physician who had a practice on the second floor. The study features instruments, early anesthetics and other artifacts discovered right in the museum’s backyard. The building’s old privy, which also was used to dump trash, broken bottles and other refuse, yielded a cache of both residential and apothecary artifacts, according to Sherman

, told the history of alcohol in medicine. Even during Prohibition pharmacists were administering alcohol as medicine, so people could get whiskey from the pharmacy, according to Sherman. The exhibit also highlights how absinthe started out as medicinal and the alcohol found in the original versions of Coke and 7-Up.

Sherman says that visitors to the museum are probably most shocked by the prevalent the use of narcotics in medical care. Even in the 19th century tampons were dipped in opium and belladonna to deal with menstrual cramps, she explains.

“You see the patent medicines are 25 percent or more alcohol, a lot of them have some kind of narcotic,” Sherman says. “Obviously they didn’t have any concept of drug addiction at the time.”

The New Orleans Pharmacy Museum is largely self guided, although there is a tour at noon on Thursday and Friday. The guided tour is mainly on the first floor and lasts a total of 45 minutes.

“You learn really a more in depth look at the history of 19th century New Orleans culture and how pharmacy, medical, surgical health care intertwined with that,” says Elizabeth Sherman, executive direction of the museum.

Outside, the museum bridges the past with the present day. The courtyard contains a garden of herbs used for medicinal purposes in earlier years and today. Visitors will see aloe, rue, wormwood, sage and more herbs that naturopathic doctors still use.

Since most of the present-day buildings were built under Spanish rule, the French Quarter isn’t quite as French as one might think. The entire district, which was the center of the city when New Orleans was founded in 1718, is a National Historic Landmark. Since the 1920s the historic buildings have been protected by law and cannot be demolished.

Jackson Square and the French Quarter Visitor Center are less than a five-minute walk from the Pharmacy Museum. On weekends the local artists display and sell their wares in the square, where visitors will also find street bands and even tarot readings.

Across the street from the square is St. Louis Cathedral, one of the oldest cathedrals in the United States. The site has been home to three different Roman Catholic churches: the first a wooden structure in 1718; then a brick and timber church completed in 1727 that was destroyed in the Great New Orleans Fire of 1788; and finally, the current cathedral.

No visit to the French Quarter would be complete without a walk down nearby Bourbon Street (Rue Bourbon), if only just to see the many bars. Since this area is packed with bars and taverns, expect to see people drinking on the street — New Orleans is one of just eight places in the United States where open containers are always permitted on the street.

Just a few blocks away from the Mississippi River, in New Orleans' French Quarter, sits a piece of medical history - the apothecary shop of America's first licensed pharmacist.

New Orleans: Home to America's First Licensed Pharmacy

Article updated at 2:49 am on Sept. 5, 2014.

Although the incidence of perioperative cardiac arrest primarily attributable to anesthesia is less than 1 per 10,000 anesthetics, 

, it represents the most serious complication and can have devastating results, as witnessed by the recent death of comedian Joan Rivers.

The 81-year-old’s heart stopped while under anesthesia during a throat surgery at a Manhattan clinic on Aug. 28, according to the 

. Following the complication, Rivers was hospitalized and put on life support. Although her daughter earlier said there was a chance her mother could be taken off life support by the weekend, Rivers passed away on Thursday, Sept. 4.

“Even though this is a very highly publicized event, it’s something that is very unusual,” otolaryngologist Scott Kay, MD, said. “In terms of probable risk, it’s not very likely that someone is going to have a catastrophic event with a procedure like that in any particular point in time. Having said that, it’s important for physic to always prepare for the catastrophic event. This way they can avoid an outcome that might result in death.”

, but the complications Rivers suffered reminds patients and providers that there are always risks to be considered during surgery. Some of the factors that can increase the risk of cardiac arrest during surgery include coronary artery disease, cardiomyopathy, congenital heart disease, and heart failure.

“Being 81 [years old] is a risk factor, itself,” internist Simon Murray, MD, said. “While we will never know — I don't think &mdash; the details, it seems to me that when you operate [on] a person's vocal chords, you run the risk of having laryngospasm paralysis of the vocal chords, which will lead to respiratory failure if not corrected immediately.”

Patients who suffer sudden cardiac arrest that lasts more than 10 minutes rarely survive, and those who do may show signs of brain damage.

Despite the adoption of surgical safety checklists, they are not associated significant reductions in mortality or surgical complications, according to a March 2014 

 found that while surgical checklists reduce postoperative complications, they have no significant effect on mortality.

As improvements in surgical and anesthetic techniques significantly decrease mortality rates in noncardiac surgery, preoperative cardiac stress testing is not recommended unless the patient is identified as high risk. As part of the 

, the American Society of Anesthesiologists recommended against diagnostic cardiac testing or cardiac stress testing in asymptomatic stable patients with known cardiac disease who are undergoing low or moderate risk non-cardiac surgery.

“I would try to give all the available information to the patient in terms of what potential complications do exist,” Kay said. “I would also remind patients that there are risks involved with almost everything, including getting into their car every day.”

Although the incidence of perioperative cardiac arrest primarily attributable to anesthesia is less than 1 per 10,000 anesthetics, it represents the most serious complication and can have devastating results, as witnessed by the recent death of comedian Joan Rivers.

Laura Joszt

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