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BlackCatAs Halloween draws near, we're reminded of all that is spooky and supernatural. While some of it may seem a little silly now, as a child you may have done things like avoiding the cracks in the sidewalk or agonized over cracking a mirror for fear of what would come next. Maybe you were scared of the dark, or terrified of clowns. Don't be afraid....share what types of superstitions or fears you lived with growing up in today's Throwback Thursday.

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Almost everyone expects that the new Maryland Medicare waiver will change the way the Johns Hopkins Health System operates. But what does that mean? Ed Beranek, senior director of regulatory compliance, is responsible for the health system's revenue budget—a forecast of hospital revenue—and regulatory matters involving the Health Services Cost Review Commission (HSCRC), which establishes hospital rates in Maryland. In today's Ask The Expert, Beranek answers some important questions about the waiver.

ed-beranekBeranek will also answer any questions about the Maryland Medicare waiver in the comments section below.

How does the new  waiver affect the Johns Hopkins Health System?

In the past, we generated revenue by increasing our patient  volume; that no longer is the case for our Maryland patients. Now we have a  revenue cap. That means there's a top limit over which we may not go. The  revenue cap is all-inclusive, including volume growth, inflation and growth in  expenses. If our patient volume increases, we need to lower our rates within  the limits set by the HSCRC. Likewise, if our volumes decrease, we need to  raise our rates.

It's a very different mindset. It's going to take us time to  adjust to that; not just us here at Johns Hopkins, but throughout the state.

Why do you draw a  distinction between Maryland and non-Maryland patients?

Twenty-five percent of the revenue at The Johns Hopkins  Hospital comes from outside Maryland. Although those patients are still charged  HSCRC rates, the revenue associated with those out-of-state cases is not  counted in the revenue cap. If we increase the number of patients we treat from  outside Maryland, that additional revenue is ours to keep.

What are we doing to  adjust to this new environment?

It's now more important than ever that we control costs. As an institution, we have certain fixed costs, such as our buildings and the costs of maintaining them, that are not easily reduced.   However, we can drive down our fixed cost per unit by optimizing the volume that we see in those areas. In addition, we can reduce our variable costs, such as supplies. With our large supply chain initiative, we're centralizing purchasing so we can leverage our buying power and get better pricing on medical supplies. We'll also be looking at pharmaceuticals.

The goal is to drive the cost per patient to the lowest level we can while also providing the highest quality care we can. That's how we're thinking about it. We need to focus on the value equation, which is essentially providing the highest quality care at the lowest cost. That is the value that patients and insurers are looking for in the new environment.

What does the waiver  mean for people who work here?

There should be little change, if any, in direct patient  care. We'll stay true to our mission and care for the patient the best way we  can in the most appropriate setting.

What the Maryland Medicare waiver has changed is how we  think about planning. What types of services should we be providing, and where  should we be providing them? Where should we concentrate our marketing efforts?  If a physician wants to start a new clinic, do we do it at The Johns Hopkins  Hospital or at one of our ambulatory sites, such as White Marsh or Green Spring  Station? What location will benefit the patient and Johns Hopkins Medicine the  most?

Our strategic  priority of integration must be key, to have all these individual units moving  more fluidly as a system.

Yes, integration is key to success under the waiver. We have  all the components to be successful in an integrated model. We have medical  assets like the clinics at Green Spring Station, Odenton and White Marsh. We  have community physicians. We have our hospitals.

Now we need to think as a system. For instance, stop  thinking in terms of hospital silos—The Johns Hopkins Hospital, Johns Hopkins  Bayview Medical Center, Howard County General, Suburban Hospital, Sibley  Memorial Hospital. We need to weigh whether it makes sense to take a particular  service and have it at a single site, rather than offer it at both Johns  Hopkins Bayview and The Johns Hopkins Hospital, which are only 3 miles apart.

One very important thing to keep in mind is that we can't  sit back and look at the changes under the waiver and think, "Oh, I wonder  what's going to happen?" We have to take an active role to make sure we succeed  under this system. And the only way we can do that is through integration.

From the patient's  perspective, will we look different?

Over time, we will probably look different. For instance,  wait times are a problem for us. Hopefully, as we become more integrated, long  wait times will decrease, and we can get our patients in faster and more  efficiently. This will improve our efficiency of care, which will improve our  throughput. That, in turn, helps us maximize our patient volume and lower our  costs per patient.

Where else are we  looking for efficiencies?

One initiative we're working on is Clinical Communities.  With physician leadership, we are partnering with the Armstrong Institute for  Patient Safety and Quality to bring together clinicians around a common service  and solicit their input on improving what they're doing. We ask each group,  "What types of data do you need to better manage patients?" Physicians are very  data-driven.

The Clinical Communities develop clinical pathways and best  practices. They're standardizing care, eliminating variations, making it more  efficient. Say our orthopods are using many different artificial joints. Maybe  we can narrow that down and then get better pricing.

Clinical Communities represent a step toward integration,  involving not just The Johns Hopkins Hospital, but also Hopkins Bayview, Howard  County General, Suburban and Sibley. As one of our financial directors says, "We all work for Mr. Hopkins."

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The gluten-free diet has surged in popularity in recent years. Many people are reducing or eliminating their dietary intake of the protein, which is found in wheat, rye, barley, and other grains. But did you know that only those with celiac disease should completely eliminate gluten from their diet? Others with gluten sensitivity may improve their health by simply decreasing their gluten intake. Learn more about the gluten-free diet, including symptoms of celiac disease and what foods to avoid at the Johns Hopkins What Is a Gluten-Free Diet? page.

Do you partake in a gluten-free or reduced gluten diet? If so, tell us what your diet consists of and how it may be helping to improve your health in the comments.

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As outlined in the new feature, Proper Email Netiquette, a company should implement email etiquette rules for two reasons: professionalism and efficiency. The first Netiquette tip stressed the importance of using the BCC: field when emailing large groups. This helps to avoid two things that can happen when adding a large amount of email address in the To: field: everyone using “reply all” in response and giving out all of the recipients’ email addresses without their permission. unfortunately, it can be easy to forget your e-manners when pressed for time or when sending mass amounts of communications.

What are some email habits that often bother you and what are some ways to correct them? Let us know by leaving a comment below.

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The more we age, the more we have to look back on. Everyone has those moments from the past they wish they could go back to - from the birth of a child, to a great career accomplishment, to an exciting trip to an exotic destination. In today's Throwback Thursday, tell us what unforgettable moments from your life you would experience all over again if you had the chance.

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The Johns Hopkins Center for Fetal Therapy, which specializes in diagnosing and correcting rare and complex diseases in the womb, opened its doors in July. With specialists in fetal, maternal, neonatal and pediatric care, the team is changing lives by identifying and treating a growing number of conditions before birth. The Center for Fetal Therapy takes a comprehensive approach to achieve this goal in caring for patients by integrating the full spectrum of clinical and support services.

ahmetbaschat2The director of the center, Ahmet Baschat, is a veteran in maternal-fetal medicine. He was one of the first published authors in the field regarding the potential benefits of a newly modified laser technique for twin-to-twin transfusion syndrome, which has been widely adapted as the standard of care. Baschat will be one of 32 presenters at the 20th annual A Woman's Journey conference on Sat., November 1, where he will speak about how diseases can be treated in utero to preserve life. Visit hopkinsmedicine.org/awomansjourney for more information and to register for this event.

What is fetal therapy?

Fetal therapy is the management of conditions that affect the unborn child. Fetal therapy ranges from direct surgical interventions on the baby, minimally invasive treatments such as fetoscopy, to medical treatments that are either given to the baby directly or to the mother as administered medication that cross the placenta. Part of the treatment is the surveillance for known complications and making absolutely sure that the baby is delivered in the best condition to a pediatric team that is aware of the full spectrum of problems they have to deal with. So it really is a multidisciplinary approach that initiates the treatment for a range of conditions before the baby is born.

What does the Center for Fetal Therapy do? What distinguishes it from other centers in the fetal medicine field?

The Center for Fetal Therapy offers prenatal diagnosis, prenatal assessment of specific conditions, and the counseling and support of all family-related issues that are part of preparing the family to deal with a complicated fetal problem. We offer fetal treatments, both invasive and noninvasive, such as operative fetoscopy and medications. We offer specific delivery timing in coordination with our pediatric colleagues. In addition, we provide maternal management, which is sometimes required, as fetal conditions can also affect the mother.

The important difference between the Center for Fetal Therapy at Johns Hopkins and many fetal therapy centers that exist is that here, all fetal, medicine, maternal medicine, obstetric, pediatric and long-term services are all available under one roof. That is a very unique combination that isn’t offered in many fetal therapy centers.

Why was it important to create this center at Johns Hopkins?

Prior to the opening of the Center for Fetal Therapy at Johns Hopkins, fetal treatments were offered through the Prenatal Diagnosis and Treatment Center. What is different about the Center for Fetal Therapy is it offers more prenatal treatments. We have created a dedicated service that is expanding to offer all the invasive and noninvasive treatment options that are available in the field of fetal therapy.

We also are building a research infrastructure that is absolutely essential to improve these treatments.

In addition, we are instituting a fetal intervention training program, where future physicians, who will be leading this specialty forward, can be trained in the disease-specific applications of all the other techniques that obstetricians and maternal-fetal medicine physicians may use.

How does the decision-making process work as far as how the fetus is treated?

We are trying to establish the most accurate assessment of the condition. Based on the diagnosis, we counsel patients about what the likely outcomes will be. That includes the counseling of outcomes with and without treatments. Then, we present the possible treatment options—there is always more than one option. Next, the risk-benefit ratio is discussed—this is a very individual decision that parents make. At the end of the counseling process, it is imperative for patients to understand what it is that we are dealing with, what will happen if we don’t do something, what we can achieve by doing something, and what the risks to the mother and the fetus are. Based on that, parents have to make a decision.

In conditions that are more complicated, we will sometimes include counseling from colleagues in pediatric surgery, neonatology or pediatrics. This specifically applies to conditions such as spina bifida or congenital diaphragmatic hernia, where it is expected that specific care after delivery will still be required. The prenatal treatment alleviates the amount of damage that is caused by the conditions before delivery.

Why is the management of maternal health so imperative to fetal therapy?

The ability to manage maternal health is imperative, because fetal conditions can affect maternal health, maternal health can affect the fetal conditions and sometimes the treatments we administer have side effects that are pregnancy-specific. So it really is not possible to offer comprehensive care for fetal conditions without also being able to manage complications that can arise in the mother, including preterm labor and cervical shortening. Sometimes even cardiovascular conditions arise when babies are very, very sick, and the recognition of these problems and their management fall into the area of maternal-fetal medicine.

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PlannerThere's a lot that can go into your work day, and meetings, e-mails and projects can pile up faster than you can say "personal assistant". With all that goes on during a day on the job, how do you stay organized? Feel free to leave any tips on your methods to keeping tabs on everything around you in today's Question of the Week.

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VideoGamesI Am Dolphin, an immersive video game created by a team from the Johns Hopkins University School of Medicine’s Department of Neurology, is slated for release on iTunes this month. In this game, users experience realistic simulations of sea creatures that can be controlled by swipes of a player’s hand across a touch screen. You can view the team talking about their creation in this video.

Video games have come so far from the days of Atari or Sega, to become not just a tool for entertainment, but for learning as well. What video games from the past remind you of your childhood? Were you able to beat any classic titles? Tell us your classic video game stories in today's Throwback Thursday.

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