December 2009 >> $5 Lee Zehngebot, MD PAGE 3 PHYSICIAN SPOTLIGHT PRSRT STD U.S. POSTAGE PAID FRANKLIN, TN PERMIT NO.357 ON ROUNDS April 2014 >> $5 PRINTED ON RECYCLED PAPER PROUDLY SERVING CENTRAL FLORIDA ONLINE: ORLANDO MEDICAL NEWS.COM Click on Blog and Contribute Healthcare Solutions BLOG TONIGHT www.OrlandoMedicalNews.com BE PART OF THE CONVERSATION Reflux KO Torax Medical rolls out LINX procedure for GERD patients to select specialists ... 9 The Digital Revolution is Here for Healthcare ... 13 (CONTINUED ON PAGE 5) (CONTINUED ON PAGE 4) BY LYNNE JETER THE VILLAGES – The nation’s largest 55-and-up retirement commu- nity is fertile testing ground for cost-sav- ings healthcare initiatives as American medicine shifts from fee-for-service to fee-for-quality. USF Health partnered with The Villages in 2011 to create a national model of coordinated healthcare for op- timal health in retirement, with a goal of transforming it into “America’s Healthi- est Hometown®.” On a chilly morning in late January, USF President Judy Genshaft celebrated a milestone in that journey Caring for a Graying Village New Health Specialty Care Center in the Villages Photos by Eric Younghans/USF Health L to r: Drs. David Ethier, Reed G. Panos, Adrian Finol-Hernandez, Roger Sherman, and Kathleen A. Steepy, will care for patients at the new USF Health Specialty Care Center Decoding Healthcare Fifth Third’s Mike Miller discusses capital investments and industry trends BY LYNNE JETER The growth of local collaborations and specialty pharmacies, and the significant change in focus on outcomes highlight indus- try banking trends impacting Central Florida throughout 2014. “As healthcare entities try to get their arms around surging expenses, their goal is to reduce costs,” said Michael Miller, Vice President of healthcare banking for Fifth Third Bank in Orlando. “Institutional pay- ers, insurance companies, Medicare and Medicaid are reducing what they pay for healthcare services. The only way for providers to make money is to reduce costs. The goal for payers is to focus on outcomes, not procedures, to reduce costs. They want to pay for the value and effectiveness of the treat- ment process, not the number of proce- dures in the process. Similarly, providers need to focus on improved outcomes to reduce treatment and procedural costs to be profitable under the lower reimburse- ment for payers.” Even though healthcare costs as a whole haven’t de- clined, their rate of growth has slowed significantly over the last five years, noted Miller. “However, not everyone is seeing this,” he cautioned. “There’s also a cost-shifting going on between employers, insurance payers and patients that’s led to increased payouts for some and re- duced payouts for others. Right now,
Transcript
December 2009 >> $5
Lee Zehngebot, MD
PAGE 3
PHYSICIAN SPOTLIGHT
PRSRT STDU.S.POSTAGE
PAIDFRANKLIN, TN
PERMIT NO.357
ON ROUNDS
April 2014 >> $5
PRINTED ON RECYCLED PAPER
PROUDLY SERVING CENTRAL FLORIDA
ONLINE:ORLANDOMEDICALNEWS.COM Click on Blog and Contribute Healthcare Solutions
BLOG TONIGHT www.OrlandoMedicalNews.com
BE PART OF THE CONVERSATION
Refl ux KOTorax Medical rolls out LINX procedure for GERD patients to select specialists ... 9
The Digital Revolution is Here for Healthcare ... 13
(CONTINUED ON PAGE 5)
(CONTINUED ON PAGE 4)
By lyNNE JETEr
THE VILLAGES – The nation’s largest 55-and-up retirement commu-nity is fertile testing ground for cost-sav-ings healthcare initiatives as American medicine shifts from fee-for-service to fee-for-quality.
USF Health partnered with The Villages in 2011 to create a national model of coordinated healthcare for op-timal health in retirement, with a goal of transforming it into “America’s Healthi-est Hometown®.”
On a chilly morning in late January, USF President Judy Genshaft celebrated a milestone in that journey
Caring for a Graying Village New Health Specialty Care Center in the Villages
Photos by Eric Younghans/USF Health
L to r: Drs. David Ethier, Reed G. Panos, Adrian Finol-Hernandez, Roger Sherman, and Kathleen A. Steepy, will care for patients at the new USF Health Specialty Care Center
April 2014 >> $5
(CONTINUED ON PAGE 5)
Decoding HealthcareFifth Third’s Mike Miller discusses capital investments and industry trends
By lyNNE JETEr
The growth of local collaborations and specialty pharmacies, and the significant change in focus on outcomes highlight indus-try banking trends impacting Central Florida throughout 2014.
“As healthcare entities try to get their arms around surging expenses, their goal is to reduce costs,” said Michael Miller, Vice President of healthcare banking for Fifth Third Bank in Orlando. “Institutional pay-ers, insurance companies, Medicare and
Medicaid are reducing what they pay for healthcare services. The only way for providers to make money is to reduce costs. The goal for payers is to focus on outcomes, not procedures, to reduce costs. They want to pay for the value and effectiveness of the treat-ment process, not the number of proce-dures in the process. Similarly, providers need to focus on improved outcomes to reduce treatment and procedural costs to be profi table under the lower reimburse-ment for payers.”
Even though healthcare costs as a whole haven’t de-clined, their rate of growth has
slowed signifi cantly over the last fi ve years, noted Miller.
“However, not everyone is seeing this,” he cautioned. “There’s also a cost-shifting going on between employers, insurance
payers and patients that’s led to increased payouts for some and re-
duced payouts for others. Right now,
2 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
As the nation’s largest physician-owned
medical malpractice insurer, we have an
unparalleled understanding of liability
claims against radiologists. This gives us
a signifi cant advantage in the courtroom.
It also accounts for our ability to anticipate
emerging trends and provide innovative
patient safety tools to help physicians
reduce risk. When your reputation and
livelihood are on the line, only one
medical malpractice insurer can give you
the assurance that today’s challenging
practice environment demands—
The Doctors Company. To learn more, call
our Jacksonville offi ce at 800.741.3742 or
visit WWW.THEDOCTORS.COM.
MALIGNANTNEOPLASM OF THE BRONCHUS, LUNG,
OR LARYNX
MALIGNANTNEOPLASM OF
THE BREAST
FRACTURES ANDDISLOCATIONS—ALL BONES
INTRACRANIALANEURYSM,
HEMORRHAGE,AND/OR CVA
ABSCESSES(INTRACRANIAL,
INTRASPINAL,AND LUNG)
RADIOLOGY CLAIMS MOST FREQUENTLY LINKED TO FAILURE OR DELAY IN DIAGNOSISSource: The Doctors Company
THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.
13%
16%
17%
8%
4%
DOES YOUR MEDICAL MALPRACTICEINSURER KNOW THE TOP DIAGNOSIS-RELATED ALLEGATIONS AGAINST RADIOLOGISTS?
DOES YOUR DOES YOURDOES YOUR MEDICAL MALPRACTICEMEDICAL MALPRACTICEMEDICAL MALPRACTICEINSURER KNOWINSURER KNOWINSURER KNOW THE TOP DIAGNOSIS-RELATED THE TOP DIAGNOSIS-RELATED THE TOP DIAGNOSIS-RELATED ALLEGATIONS AGAINSTALLEGATIONS AGAINST ALLEGATIONS AGAINST RADIOLOGISTS?RADIOLOGISTS?RADIOLOGISTS?
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 3
PhysicianSpotlight
By JEFF WEBB
ORLANDO - After being in the same practice for almost 30 years, Lee Zehngebot – hematologist, oncologist, husband, father, road biker and ski-bum – said his “biggest problem is I don’t have enough time and energy to get through a day and do everything I want to do.” But the 63-year-old does the best he can, he said, and the rewards make it worthwhile for all those endeavors.
Zehngebot is a senior partner at Hematology & Oncology Consultants. He went there in 1985 on the advice of a college friend who assured him “Or-lando is a great place that’s really open-ing up,” Zehngebot remembered. “He introduced me to doctors David Smith and Phil Dunn. Dr. Smith is retired now, but Phil is still in the practice,” which now has six physicians, “about 60 or 70” other employees, and a second location in Winter Park, he said.
His specialty has special challenges, Zehngebot said, noting the need to be both emotionally and scientifically support-ive. “You have to be constantly talking to people and be sensitive to their needs. On the other hand, you have to be honest with them and provide them with the informa-tion they need. It’s a balancing act.”
Zehngebot said he always tries to “do the best job for my patients, despite all the impediments.” Asked to elaborate, Zehngebot’s experience amplifies his can-dor: “Being a doctor today is an incredibly difficult job. You’re up against insurance companies, getting things authorized and paid for, getting consultations and X-rays done, getting patients admitted to the hos-pital, getting them out of the hospital, get-ting them the services and drugs they need. It’s very, very trying,” said Zehngebot. “It’s a very hard job these days and very difficult to do well. It requires a huge team. There’s nothing about (being a physician) that has become easier.”
Zehngebot said physicians are “kind of caught in the middle between the pa-tient who wants the services and a society that doesn’t necessarily want to pay for them. Everyone expects us to have the right answers and be available 24 hours a day. Trying to do that job (every day) is very hard,” he said.
But Zehngebot said fulfillment offsets frustration. “There are two things: First, sometimes people get better and that is in-credibly rewarding. And people appreciate what you do,” he said. “Second, there’s the feeling of getting up in the morning and seeking to do something to the best of your ability and getting it done. … I feel like I’m contributing. I don’t always get it right and I don’t always make people happy, but I really try,” he said.
Most days, Zehngebot starts “trying”
about 7 a.m. as he makes patient rounds at Florida Hospital, where he also is head of the Cancer Institute’s research depart-ment. He’s back at one of his clinics in Orlando or Winter Park about 9 and sees patients until 5-ish, when he does more rounds until about 7 p.m. He said he spends every Thursday, and many week-ends, in his role at the Florida Hospital’s Cancer Institute.
His latest focus is on personalized can-
cer chemotherapy. “Cancer medicine right now is evolving,” said Zehngebot. “We have the ability to do genomic test-ing, looking for specific gene mutations within the cancer. We can take cancer tissue and send it off and do genomic testing and then find drugs specifically, after the abnormalities are found, and then treat patients with those drugs and see how they respond. That is a project we are just starting to work on here (and) we are hoping will come to fruition. Be-fore, we didn’t have a target. Now the whole thing is targeted therapy,” he ex-plained.
His department at Florida Hospital also is involved in “cooperative group trials that have a lot of detail work,” Zehngebot said. “I am fortunate to have a great team that takes care of that.”
Being a physician consumes most of this time, he said. “I haven’t watched a complete television show in 25 years. All I do is practice medicine, eat, sleep, road
bike, ski and go to an occasional movie or show,” he said.
Those casual references to his outside interests should not be underrated. He is deeply involved in road biking. “There is an incredibly vibrant road biking com-munity here. I’ve met a lot of people who have helped me in biking clubs. I work out with a bunch of guys from Winter Springs.
Lee Zehngebot, MDHematology & Oncology Consultants
New location: Ocoee Offi ce1000 W. Colonial Drive, Suite 483
Ocoee, FL 34761407-648-4323
Orlando Offi ce80 W. Michigan Street
Orlando, FL 32806407-648-4323
Dr. Phillips Offi ce7460 Doc’s Grove Circle
Orlando, FL 32819407-648-4323
Clermonth Offi ce1920 Don Wickham Drive
Suite 120 • Clermonth, FL 34711352-648-4323
www.arteryandvein.com
Are you at risk for peripheral vascular disease?Vascular Specialists of Central Florida, Inc. is a single-specialty group of board-certifi ed vascular surgeons solely dedicated to the treatment of the body’s arteries and veins.
1. Do you experience aching, cramping or pain in your arms, legs, thighs or buttocks when you walk or exercise?
2. If you answered yes to question number 1, does the pain subside with rest?
3. Do you have any painful sores or ulcers on your legs or feet that don’t heal?
4. Do you now or have you ever smoked cigarettes?
5. Do you have high cholesterol?
6. Do you have diabetes?
Peripheral Vascular Disease (PVD) is a common circulation problem in which the blood vessels, which carry blood to the legs and arms, become narrowed or clogged. Please fi ll out this questionnaire to see if you have the symptoms of Peripheral Vascular Disease.
(CONTINUED ON PAGE 4)
INEFFICIENCY WILL COST YOU MONEY!
Today’s medical climate is not the same as in years past. Why are you operating the same? Let us show you how to take charge of your practice by complying with the new regulations so you can focus on being a doctor.
4 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
by officially opening the USF Health Specialty Care Center in The Villages. USF Health doctors staff the new 25,000-square-foot facility.
“We’re excited to see USF Health extending the benefits of an academic health center – all the latest, most cut-ting-edge research, education and care – to serve residents in a new region of Florida,” Genshaft told an eager and curious crowd.
The USF Health Specialty Care Center is designed to align with The Villages Health primary care centers being built in the 5-square-mile com-munity to provide a model of seamless, coordinated healthcare. It houses 32 exam rooms and four procedure rooms, with the ability to provide onsite labo-ratory work, ultrasound, stress echocar-diography, cardiac nuclear stress tests and other tests. Specialties include ob-stetrics and gynecology, cardiothoracic surgery, plastic and reconstructive sur-gery, orthopedic surgery, endocrinol-ogy, and general surgery.
“We’re already hearing great things from our patients about the oppor-tunity to visit the center,” said Elliot Suss-man MD, chair of The Villages Health. “Having specialists aligned with USF Health available right here in The Villages is vital to our patients’ health, convenience
and peace of mind. We look forward to working with the health professionals at the Specialty Care Center to provide our patients with a full range of healthcare and services … just a few steps away from home.”
Work began last year on the new spe-cialty center, following analysis of the USF College of Public Health’s comprehensive health needs survey of the The Villagers, the largest such survey of an aging popula-tion. Nearly 40,000 responded.
“What makes this center so wonder-ful is that it truly began with residents of The Villages,” said Donna Petersen, ScD, MHS, CPH, interim senior vice president of USF Health. “It began as we built our partnership with this community. We asked residents, ‘What do you need to im-prove your health?’ And you shared your vision. You want a more coordinated net-work. You want a healthcare system that works for you – not one where you have to ‘work the system.’ We set out to create the patient-centered medical home of the future in The Villages.”
The university’s statewide initiative at The Villages also includes onsite health seminars, assessments and other services. The unique partnership provides residents of The Villages the benefits of an academic health center with high-level specialty care and access to the latest clinical trials.
“Creative partnerships will provide insight into solutions that improve health-care,” said Jeff Lowenkron, MD, CEO of the USF Physicians’ Group. “This care will be integrated and coordinated by de-sign, not by accident.”
The Villages’ developer, Gary Morse, moved with his dad from Michigan to Florida in 1983 to sell homes with a spe-cial pitch: free golf. Snowbirds helped sales reach $40 million by 1987, and grow the close-knit community to 3,500 acres by 1992. Now stretching across more than 20,000 acres and three counties, The Vil-lages is expected to accommodate nearly 60,000 homes by 2018.
The timing for experimentation is ripe. By 2020, statisticians project that 45 percent of American households will be headed by someone at least 55 years old.
The Villages’ “aging in place” con-cept has taken flight across the United
States, with nearly 200 “village” pro-grams on track or in the works. (The “village” network doesn’t include The Villages in Florida.) Their common goal: helping people stay in their homes through their 70s and 80s and, in a growing number of cases, into their 90s.
Among their goals, “village” pro-grams aim to provide low-cost medi-cal care. So far, these efforts have been fragmented and minimal. For example, in Madison, Wisc., a program called SAIL (Supporting Active Independent Lives) works with a geriatric pharmacist and university pharmacy students to provide personal health coaching to its members.
“Older adults are oftentimes over-medicated,” SAIL executive director Ann Albert has said. “They’re taking
medications that over the years can build up in their systems, and have interactions that maybe a 40-year-old or 50-year-old person wouldn’t experi-ence.”
In an intensive screening program aided by volunteer pharmacy students,
four of five 30 SAIL members tested were identified with adverse drug reactions.
“Just in our home county alone, more than 1,500 seniors are hospitalized each year because of adverse drug events,” Al-bert said, noting the free screenings could produce significant savings for Medicare and Medicaid.
In a San Diego “village,” Elder-Help, a philanthropically-supported so-cial agency, is testing a unique model that provides significant support services to a largely lower-income group of seniors. Members support the services through annual dues. However, the classic village model works in affluent neighborhoods, but not so well in lower-income commu-nities. The mission is to demonstrate the village model’s cost-effective solutions that government programs have traditionally provided.
“Our vision is to make the villages a model that’s going to make an impact by serving an older population that has a higher level of chronic disease and a higher level of need, but is lower-income,” ElderHelp executive director Leane Mar-chese has said.
Even though these small efforts have helped nationwide, The Villages project that started the grass-roots movement has grabbed the spotlight.
“We’ve even had venture capitalists come see how we’re going to serve 90,000 people,” said Stephen Klasko, MD, Dean of the USF Morsani College of Medicine and CEO of USF Health from 2004 to 2013.
Klasko considers The Villages part-nership among the university’s greatest achievements during his time at USF.
“It’s probably the nation’s first true university-community partnership,” he said. “It’s very, very exciting.”
Editor’s note: Medical News’ series on The Villages’ goal as a national healthcare model con-tinues next month with Jeff Lowenkron, MD, CEO of the USF Physicians’ Group.
Caring for a Graying Village, continued from page 1
Photos by Eric Younghans/USF Health
Cutting the ribbon at the opening of the new center with USF President Judy Genshaft, center, were (l to r) USF Trustee Scott Hopes; Florida Senator Alan Hays; USF Trustee Nancy Watkins, Gary Lester, vice president of commu nity relations, The Villages; Dr. Elliot Sussman, chair of The Villages Health; Donna Petersen, interim senior vice president, USF Health, and dean, College of Public Health; and Dr. Jeffrey Lowenkron, CEO, USF Physicians Group.
We have so many places to go. It’s a great way to exercise,” he said.
One of his motivations for road biking is to stay in shape for his favorite recre-ational sports passion: Heli-skiing. Twice a year for the past 7 years he has traveled to British Columbia to “ski in places that people normally can’t get to,” he said.
“It’s not the daredevil hobby you may think it is. It’s not about jumping out of helicopters like you see on television. The helicopter lands and then you ski a nor-mal run. The big difference is this is to-tally untracked powder snow, which is the greatest,” Zehngebot said. “I don’t jump off things. I’m not that good and I really don’t even want to be that good.”
No one else in Zehngebot’s family “is crazy enough to do this with me,” he said. He usually meets a friend and fellow physi-cian who introduced him to the sport. “It’s the only kind of skiing I do any more. I’m spoiled. Once you have done this” nothing compares, he said.
Watching Zehngebot’s high-altitude adventures from afar is his wife Wendy, whom he met at a fraternity function when he was an undergraduate at Union College in Schenectady, N.Y., and she was at Vassar College. They waited until he graduated in 1976 from medical school at the University of Pennsylvania to get married, mainly be-cause “I didn’t have any money,” Zehnge-bot laughed. The couple moved to New York City, where Zehngebot completed his internship and residency at Albert Einstein
College of Medicine of Yeshiva University in the Bronx. A fellowship in hematology and oncology brought them back to the University of Pennsylvania in Philadelphia.
At first, Zehngebot thought he would follow an academic path. He spent almost three years as an Assistant Professor of Medicine at Albany Medical College, but it didn’t work out. “I just hated it. I hated the politics,” he said, and that’s when he set his sights on Orlando.
Along the way, he and Wendy had two children: daughter Corey, an architect works in Boston, and son Jay is a graduate student in computer graphics New York. “I’m very proud of them,” he said.
That parental pride takes on extra meaning when Zehngebot shares that Wendy has struggled with multiple sclerosis most of their 38-year marriage. “She was diagnosed not long after we were married but didn’t become symptomatic until the mid-90s,” he said. “Unfortunately she’s been having a more and more difficult time walking. She has a lot of guts and gets out and does a lot of things. It’s hard, but she’s keeps trucking and getting it done,” he said.
Zehngebot said he has no intention of slowing his pace. “I’ve been very fortunate that I have relatively good health and a very successful practice. And I’m very fortunate that people still want to come see me. I have a great staff and great people to work with. As long as all those things are true, I want to keep working. As long as I have something to offer, I want to keep doing that.”
Lee Zehngebot, MDPhysicianSpotlight
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 5
MANAGE YOUR MEDICAL WORLD
BY VOICEDragon Medical Practice Edition is 99% accurate “out of the box” and includes a complete range of medical vocabularies.
The software allows clinicians to dictate in their own words, generating “once and done” documentation, which they can then review.
Dictate faster and more accurately than ever before.
Dictate anywhere in your EHR and accelerate adoption.
Save clinicians 30 minutes or more a day
Spend more time with patients
Dictate in clinician’s own words.
Support higher level or reimbursement.
Sales, Training and Customization of Dragon Medical Practice Edition
Call Bonnie 877-272-8280
or Polly 866-977-3324
Visit our website 1st-Dragon.com
Subscribe to Online Medical News Free!
orlandomedicalnews.com
Get the current edition of Orlando Medical News delivered to your desktop. FREE! Simply go to the website and find Subscriptions
on the top navigation bar. Choose email subscription.
we’re in a transition phase. There’s been an upheaval in the marketplace and people don’t like change, but things are changing.”
Miller, Fifth Third Bank’s chief in-vestment strategist Jeff Korzenik, and other local experts have been making the rounds in the community, discussing healthcare’s economic impact in Orlando.
“Healthcare has been a major eco-nomic catalyst through collaborations by companies in the Lake Nona Medical City area,” said Miller. “Florida Hospital, Nemours and Sanford Burnham are all continuing to grow there and produce new jobs, not only healthcare jobs, but con-struction jobs as well. Florida Blue is also playing a major role by taking substantial space in Medical City and focusing on bet-ter delivery of health insurance.”
Specialty pharmacy is another area for growth in 2014, said Miller, noting that more than 21 specialty pharmacies in Central Florida create a sizeable pool of skilled workers to assist in pharmaceutical delivery and treatment management.
“Drug research is expensive, leading to expensive treatments,” he said. “For ex-ample, treatment for Hepatitis C can cost more than $84,000 for a 12-week treat-ment, and if the patient isn’t compliant with the treatment, sometimes they have to start over. This can lead to increased costs for the insurer. So when the specialty pharmacy is monitoring patient compliance with treat-ment and ultimately the treatment outcome, it saves money in the long run.”
Because CMS and insurance pay-ers focus on outcomes and scrutinize ex-penses, specialty pharmacy is providing better pharmaceutical services while also improving patient monitoring concerning treatment.
“They’re monitoring compliance with the treatment protocols, side effects, helping people work through health issues at home, or getting the healthcare they need at the most affordable price for ev-eryone,” said Miller.
The recent great advancement in treatments for various diseases will reduce
providers’ expenses long-term and create the best outcomes financially and for the health of the patient, said Miller.
“For diseases that we used to just be able to stabilize symptoms, we now have a cure,” he said. “For instance, Hepatitis C can now be cured with proper treatment. This means that both treatment costs are reduced by not having to treat the numer-ous medical complications the disease creates, and the numbers of deaths from the disease are being reduced in the long run.”
To help providers better control out-comes and lower costs, Fifth Third Bank provides capital and loans for physicians to acquire online reporting systems for treatment information by updating com-puters and software to make reporting more efficient.
“For example, upgraded software can allow providers to combine medical re-cords from different locations and multiple healthcare providers,” he said. “Patients can access their information through an online portal that allows them to research diseases, find doctors and specialists, view their medical and drug history and even view their billing information. Doctors and patients alike will be able to easily pull up that information in any setting.”
The capital Fifth Third Bank pro-vides will help providers create efficiencies in operations, improve client service and payment collections, said Miller.
“The technology will also ease the payment and information transmission process for healthcare providers and in-surance companies after the treatment is provided,” he said. “For example, hospi-tals receive payment from insurance com-panies in a lump sum. That lump sum can represent 200 patients and thousands of treatments. Technology can now pro-cess those payment records and funds to allocate them to the correct patient’s ac-counts. This improvement in efficiency of tracking patient records, accounts, and payments through technology can reduce costs for everyone in the long run.”
Michael Miller, Vice President, Healthcare Banking, Fifth Third Bank, Orlando.
“With reimbursements from insurance payers, Medicare and Medicaid declining, the primary way for providers to make money is to reduce costs. The goal for payers and providers is to focus on outcomes, not procedures, to reduce costs.”
Decoding Healthcare, continued from page 1
6 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
By Karl G. SiEG, MD, MrO, FaPa
Most physicians try their best to pro-vide quality care for their patients and do not anticipate being the subject of a medi-cal malpractice lawsuit. However, legal complaints are a reality with which doctors have to contend. Once the patient becomes plaintiff and their attorney proceeds with formal allegations of negligence, the parties to the lawsuit then go about collecting as much pertinent information as possible well before trial occurs. This discovery phase of litigation includes carrying out legal proce-dures like interrogatories which are written questions to the other party in the suit that must be answered under oath. Requests for documents are also made as well as the taking of oral depositions. A deposition is another discovery procedure by which a witness’s testimony is taken under oath prior to trial. A stenographer or court reporter transcribes all of the questions and answers creating a resultant manuscript. It is the de-fendant physician’s deposition which is of chief importance. During the deposition, opposing counsel typically has an expan-
sive agenda with the goal to obtain as much information as possible. Another objective that they have in mind is to “lock-down” testimony so that what was said at deposi-tion can be used for impeachment in the event there is inconsistent testimony at trial.
The deposition experience is indeed stressful as a physician suddenly finds their integrity and actions called into question. Nevertheless, the defendant needs to be well prepared. Remember that the strengths and weaknesses of the witness are being assessed so the impression being made could po-tentially influence the case in a way which would aid the defense. Preparation begins with a review of the entire database so that there is a clear recollection of the case. A pre-deposition conference with the defense attorney is also obligatory and should in-clude clarification of any potentially confus-ing matters. Do not attempt to conceal any information, even that which you perceive to be unfavorable from your defense team. Honesty and candidness are thus a neces-sity. The physician’s CV should also be checked for any discrepancies, and counsel should be alerted to any web sites or online
profiles that are relevant. It is advisable to conduct a mock deposition to further in-crease the witness’s preparedness. Despite any practice demands, the physician should plan ahead and accordingly allow sufficient time scheduling for the deposition. It is also important to be clear about the deposition’s location and do not allow it to occur at the defendant’s office. Following these sugges-tions will reinforce confidence during the deposition which will in turn be reflected in the final written transcript.
Once the deposition begins, remember that a sworn witness is required to tell the truth. Opposing counsel will ask questions in an attempt to foster answers which might reveal new facts or open up problematic areas. The physician should make every ef-fort to keep their answers clear and concise. Listen carefully and pause before answering to allow time so that each question asked receives prudent consideration. It is help-ful to remember that the written transcript itself does not reflect the length of time it takes to answer a question. Exceptions to being brief may occur when an explanation is necessary as well as when defense counsel provides specific instruction. A particularly deceptive scheme to watch out for is a pat-tern of questioning by opposing counsel intended to prompt only “yes” answers making it hard to say “no” in response to a subsequent ambiguous question. The wit-ness may ask for clarification of confusing or convoluted questions, but should never speculate, guess, or make inaccurate/un-founded statements. If the question is ul-timately not understood, it should not be answered with the response simply being “I don’t know.” Alternatively, an answer may be qualified by saying “approximately” or “to the best of my memory.” Definitely avoid the use of adjectives and superlatives such as “always” or “never” as these qualifi-ers can be later used to distort testimony. If questions are asked about a particular doc-ument, ask to see that document and take time to review it to make sure that it has not been quoted out of context or mischarac-terized. Any pertinent concerns should be noted by the witness on the record. There are circumstances where both attorneys may wish to have a discussion “off the re-
cord.” For the witness however, remember that nothing said is ever “off the record.”
Many attorneys reserve especially im-portant questions for later on into the depo-sition hoping that the defendant will be less guarded, so it is important to be well rested and ask for breaks when needed. Compo-sure and concentration must be maintained while resisting the urge to become overly emotional and hostile as there is vulnerabil-ity to behave in ways which could negatively affect the outcome of the case. Opposing counsel will test the defendant and hope for mistakes which are recorded in the tran-script. Alternatively, they may wait and later on prompt for such behavior at trial. If a mistake is made, simply state for the re-cord that you were in error and correct your statement. There are times where the phy-sician is approached in a congenial man-ner as a tactic to attempt to gain additional information. And if the attorney becomes silent after an answer, the witness should resist the compulsion to continue talking. Never volunteer extra information, agree to supply any additional documents or provide other evidence. Some physicians going into a deposition believe that if they are allowed to explain their case, opposing counsel will dismiss the complaint which is in fact un-likely to occur. If the deposition is to be vid-eotaped, realize that the recording will likely be played for the jury. It would therefore be important to dress appropriately, look di-rectly at the camera, speak clearly and avoid long pauses in this circumstance.
Fortunately, initiating a medical mal-practice lawsuit and winning it are entirely different matters for the plaintiff. Only about 7 percent of medical malpractice law-suits ultimately go to trial, and most of these, about 80 percent, result in a verdict for the defense. By being educated and thoroughly prepared, the defendant physician will not only be better able to cope with completing their deposition, but they will also enhance their likelihood of a favorable judgment.
Karl G. Sieg, MD, MRO, FAPA is Medical Director of La Amistad Behavioral Health Services located in the Orlando metropolitan area. Dr. Sieg has also served as a litigation consultant and expert witness in civil matters including medical malpractice and personal injury cases over the past twenty years.
BUSINESS OFFICE: 295 W. PINE AVE., LONGWOOD, FL 32750 • 407.339.4499
WOUND CARE CENTERSDr. P. PhillipsComprehensiveWound Care Center321.842.7320Orlando, FL
Wound Care & HyperbaricMedicine Center at SouthSeminole Hospital407.767.5843Longwood, FL
Wound Healing Center at ORMC/Lucerne Annex321.841.5469 Orlando, FL
Wound Healing &Hyperbaric Medicine Center at Health Central407.253.2780Ocoee, FL
Florida Wound Care DoctorsTaking wound care to wound healing
Front row (L to R): Dr. Michael Cascio and Dr. Walter Conlan; Back row (L to R): Dr. Barry Cook, Patrice Muse, ARNP, Deborah Tedesco, ARNP, and Dr. Ricardo Ogando.
Central Florida’s ONLY medical practice dedicated entirely to wound care and hyperbaric medicine on a full-time basis.
www.floridawoundcaredoctors.com
Coping with Medical Malpractice Depositions
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 7
8 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
A Program Licensed by the American Society of Clinical Oncology®
Florida Hospital Cancer Institute’s Best of ASCO® Meeting
This activity has been approved for 10.5 AMA PRA Category 1 Credit(s)™.
ASCO is not the CME provider for this activity.
Presented by
Scan with your mobile device to register
ORLANDO, FLORIDA
CA
NC
ER
-14
-18
00
2
The Florida Hospital Cancer Institute is proud to bring the highlights of the ASCO Annual
Meeting to Orlando, Florida through our licensed Best of ASCO® meeting, to be held at the
Buena Vista Palace Hotel, Lake Buena Vista, Florida.
For more information or to register, visit FloridaHospitalCancerInstituteEvents.com or call (407) 303-1945, toll free to 1(800) 375-7761, or via tieline x831-303-1945. Sponsored by
®
By JiM NEUMaNN
The healthcare delivery marketplace is rapidly changing and here are the facts that underscore the changes within the senior care segment of the marketplace:
• In 2014, more than 10,000 people will turn 65 every day;
• By 2025 the senior population of America will increase from 49 million to nearly 72 million;
• The population of people 85 and older is the fastest growing segment of the US population and will grow from 5.3 million to nearly 21 million by 2050;
• 89 percent of all seniors want to age in their homes for as long as possible;
• 80 percent of seniors have at least one chronic health condition and over half of them have two;
• The average annual cost of a nursing home is $90,030 and the average annual cost of assisted living facilities is $45,600.This huge shift in the age of our popula-
tion presents both challenges and opportuni-ties. Today, we stand on the brink of a home care industry that is poised for unprecedented growth. With compelling demographic, social and economic factors all favoring home care expansion it is not surprising that health ser-vices experts predict that home care, in par-
ticular non-medical companion and personal care at home, will experience exponential growth for decades to come.
Each and every day families are faced with the reality of an aging loved one slowly losing their independence and ability to live safely and securely at home. Families and their trusted advisors are turning to high quality and credible home care providers to professionally assess the situation and pro-vide immediate and long term home care service plans and solutions.
Healthcare experts also conclude that the advent of the Affordable Health Care Act will further alter the health delivery landscape which will result in more long term chronic care needs of seniors being addressed within the community, at home, rather than in tradi-tional high cost institutional settings.
The market for home care services has grown over 105 percent in the past five years, and the market is estimated to be well over $50 billion/year today. Fur-thermore over 82 percent of revenue in the home care market is paid for privately.
Home care service delivery systems are be expanded to meet both the grow-ing medical and non-medical needs of our senior population. Technology is being de-signed and retrofitted to address the long term home care needs of our seniors. The
home environment itself must be “senior-proofed” and altered to accommodate the long term needs of our aging population.
With this confluence of events and changes impacting our society, physicians are expected to play a pivotal role in the professional system of home care delivery. Physicians will be well positioned to pro-vide direction, oversight and continuity of services beyond the traditional office setting and into the home. This is a great opportu-nity for forward thinking physicians to en-hance the scope and reach of their practices while meeting the current and future needs of their patients and their families. Essen-tial aspects of home care services will be the continuity and coordination of high quality services at home.
The expanding home care market will
require the need for comprehensive home care assessments, precise home care plans and the coordination and continuity of a broad range of services and products to meet the needs of our aging population.
It is anticipated that medical practi-tioners will be at the center of this home care expansion. Alignment with home care providers who are committed to providing the highest quality home care services will be essential.
Jim Neumann, President of Best Franchise Choice, LLC, is a member of the Franchise Brokers Association where he is a Certified Franchise Broker as well as a Franchise Immigration Specialist. Jim is also licensed to help entrepreneurs buy or sell businesses in Florida and does so as a member of the Florida Business Exchange. Through Commercial Funding Services, he provides the money entrepreneurs need to get into business and to grow it. He can be reached at [email protected]
Home Care Provides Enhanced Continuity and Quality of Care for a Rapidly Changing Market
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 9
Call 800-783-8455 or visit MagMutual.com
Defending southeast physicians for more than 30 years
We invest our financial strength in you
• The best Florida attorneys
• Florida peer physician claims review
• Industry leading Patient Safety
• Doctor2Doctor® peer support
• Consistent dividends*
• Owners Circle® rewards program
Medical malpractice insurance for Florida physicians
* Dividend payments are declared at the discretion of the MAG Mutual Insurance Company Board of Directors. Since inception, MAG Mutual Insurance Company has distributed more than $120 million in dividends to our policyholders.
Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.
(CONTINUED ON PAGE 11)
By lyNNE JETEr
TAMPA—A few dozen approved surgeons special-izing in gastro-esophageal reflux disease or gastro-intes-tinal surgery across the nation are offering a revolutionary procedure for patients with gastro esophageal reflux dis-ease (GERD). It’s so new; many primary care physicians and some specialists aren’t aware of it as an option.
“The FDA approved the LINX Reflux Management System two years ago, but when the New England Journal of Medicine published an article discussing the efficacy of the system … then health-care providers, patients and the media took notice,” said Gopal Grandhige, MD, a board-certified, Yale fellowship-trained, laparoscopic general surgeon with Sun-coast Surgical Associates in Tampa, direc-tor of the Tampa Bay Reflux Center, and a LINX-approved surgeon.
Torax Medical opted to launch the procedure nationwide at approved cen-ters, one or two per state. The company develops and markets products designed to restore human lower esophageal sphinc-ter function via its technology platform,
Magnetic Sphincter Aug-mentation (MSA), which uses attraction forces to augment weak or defec-tive sphincter muscles to treat GERD that often irritates the esophagus, causes heartburn and other symptoms. Left un-treated, reflux could lead to serious complications, such as esophagitis, stric-ture, Barrett’s esophagus and esophageal cancer.
“Torax Medical has been extraordinarily concerned with patient outcomes and patients’ well-being by only releasing the LINX device to centers that do a lot of reflux work, in order that the proper evaluation and appropriate patients are chosen for this minimally invasive procedure,” said Grandhige.
The LINX System’s new device is a quarter-sized flexible band of magnets en-cased in tiny titanium beads. The magnetic attraction between the beads helps keep a weak esophageal sphincter closed to prevent reflux. Implanted around a weak sphinc-ter just above the stomach, the minimally invasive procedure typically takes less than an hour to complete. Most patients even go home the same day of the procedure.
“The force of swallowing breaks the magnetic bond to allow food and liquid to pass through, and then the magnetic attrac-tion closes the lower esophageal sphincter back to form a barrier,” said Grandhige.
A procedure developed in the 1990s called the laparoscopic Nissen fundoplica-tion currently is the most common proce-
dure performed for heartburn. “The problem with the procedure is
that each surgeon performs it differently because it’s best used for a completely dys-functional sphincter,” said Grandhige. “In this procedure, the top part of the stomach – the fundus – is wrapped around the lower esophagus to improve the reflux barrier. In patients who have severe reflux, this pro-cedure works very well and has minimal side effects of bloating and dysphagia. The problem with the Nissen fundoplication is that it works too well in those patients with mild to moderate reflux, and these patients may report gas bloating because of the de-creased ability to belch.
The LINX Reflux Management sys-tem standardizes the surgery, leading to more reproducible results, he said.
Three years after sphincter augmenta-tion with the LINX System, the majority of treated patients were able to substantially reduce or resolve their reflux symptoms, while also eliminating their use of reflux-related medications, according to the New England Journal of Medicine summary.
In 100 percent of patients, severe re-gurgitation was eliminated, and nearly all patients (93 percent) reported a sig-nificant decrease in the need for medi-cation. Ninety-four percent reported
Reflux KOTorax Medical rolls out LINX procedure for GERD patients to select specialists
Dr. Gopal Grandhige
Florida LINX-Approved Surgeons:
Florida Hospital Celebration HealthJames C. Rosser, MD
Florida Hospital Orlando Steve Eubanks, MD
Mayo Clinic in Florida, JacksonvilleKenneth R. Devault, MD C. Daniel Smith, MD
Tampa Bay Reflux CenterBrandon, Tampa, & South Tampa Gopal Grandhige, MD
10 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
Samuel P. Martin, M.D. F.A.C.S., Founder & Medical Director Dr. Samuel P. Martin one of the leaders in venous diagnosis and treatment. Since their inception, the Vascular Vein Centers have served the Central Florida community as a recognized, educated
resource with more than 25 years experience treating venous disease.
� e mainstay in treatment of venous insuf-� ency be it varicose veins, spider veins or advanced skin changes- ulcers, is elastic compression. � e elastic compression should be graduated- greater pressure at the ankle, than the upper leg. Adequate compression does not include support hose or TED stockings. TED’s give 15mm Hg compression which is adequate while a pa-tient is lying (thus the name anti-embolic stockings) but is inadequate with the leg in the dependent position. � ey really have no place other than the hospital setting. Medical grade stockings includes compres-sions over 20mm Hg. � e most commonly prescribed compression is 20-30 mm Hg. For preventative purposes in those who have jobs that entail a lot of standing- beauticians, nurses, cooks, surgeons , teachers and others 15-20 mm Hg is adequate. � e stockings only need to extend over the calf. Compression in the thigh is only useful for those with large varicosities which ache. � ey are also used with treatment and for considerations of comfort or where a dress would expose the top of a knee high.
We must persist when patients say that they are hot or di� cult to put on. Once the patient has worn compression hose they acknowledge that their legs feel better. I tell patients that we wear them when others can’t see our legs so we look good when the legs are exposed.
Use of rubber gloves or various devices can facilitate putting the stockings on. For patients who can’t put on stockings due to back problems, obesity or other physical limitations, Velcro devices are now available and a� ordable.
To eliminate varicose veins there have been signi� cant advances in the last 10 years. Previously surgery was the mainstay for therapy. Sclero-therapy with liquid, although frequently successful in the short term had a high rate of recurrence in 20 to greater than 50% of patients. Surgery, in most cases, entailed general anesthesia and multiple incisions with the attendant problems of wound healing in the obese and when incisions were placed in areas of advanced stasis changes. Dealing with perforator veins-often the underlying culprit in patients with ulcers was often challenging, especially when located under an ulcer or in an area of signi� cant lipodermatosclerosis. Even in the best of hands there was a signi� cant recurrence rate, especially if there was a subsequent pregnancy or the patient had a job than entails signi� cant standing.
With the new millennium there has been a signi� cant paradigm shift with the advent of endovenous therapy. � e two modalities available are radiofrequency closure and laser ablation with multiple devices using
di� erent wavelengths. � ere are also devices on the horizon which glue the vein, or abraid the inner vein wall and inject a sclerosant at the same time. In essence, laser and radiofrequency use heat to denature the proteins in the vein wall causing the vein to � brosis. Because the target vein isn’t actually removed, there is much less discomfort and recovery is much shorter. More importantly, the long-term results are actually better than surgery.
Another modality which shows great promise is transcatheter chemical ablation. A solution of sclerosant is converted to a foam and then injected into the vein while
pulling back on a catheter. � e results have been nearly as good as radio-frequency and laser and the procedure is very well tolerated.
After the initial procedure on the great or small saphenous vein follow up for the varicosities can be performed using ambulatory phlebectomy or ultrasound guided sclerotherapy. Ambulatory phlebectomy consists of small stab incisions over varicosities with a #11 scalpel or #18 gage needle and then removing vein segments with a small hook after inject-ing local anesthesia. Ultrasound sclerotherapy consists of identifying the target vein using ultrasound and then injecting foam scleroant. � is is my preference.
� e keystone to all thee procedures is a complete detailed ultrasound using compression maneuvers with careful attention to the perforators. Nothing can replace experience with venous and arterial disease and an understanding of venous physiology. Patients with signi� cant arterial disease or who lack mobility should generally not be treated. Treatment of patient’s with ulcers can be very. gratifying, but should be coordinated with a wound care center. Not only can wound healing be accelerated but recurrence rates are lowered.
Treatment of spider veins is generally accomplished using sclerotherapy. � is is accomplished using a very small 31g needle. Some spider veins, especially those which are very small or those on the face are best treated with the appropriate laser, Again, experience and appreciation for underlying venous insu� ciency is invaluable. Spider patterns in certain locations on the legs often indicates underlying disease which will com-promise results if not addressed.
New developments in therapy, have made treatment available to many who, in the past, would not be considered because of the risks of general anesthesia. � ere is still a need for experience that comes from years of training and practice in matching the right modality to the patient.
Therapy for Venous Insuffi ciency
Presented in Partnership by Orlando Medical News and Vascular Vein Centers
Best Practice: Evidence-Based Standards of Care
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 11
By JiM NEUMaNN
The healthcare industry is experienc-ing dynamic changes as it relates to declin-ing reimbursements, healthcare reform and increasingly stringent regulations; thus, physicians are considering sell-ing their practice, merging with other practices, integrating with hospitals, or liquidating their practice. During this transformational period, it is impera-tive that physicians develop a strategic plan that will allow them to attain the maximum value for the practice. This is best achieved by creating an exit plan well in advance and then continually monitoring the practice’s performance over time.
It is also true that in these times of regulatory change, it takes almost every waking minute just to keep up with day-to-day operations of a practice. In most cases, you seldom have time to survey where you are, where you are headed, and what you should be doing to improve and meet your future goals. Nonetheless, it is important to create and implement a high quality prac-tice valuation plan to ensure a profi table and seamless experience. This article will address strategic methods to get the most value from your practice, while having the least amount of impact on your time. Even if you are not currently planning to sell, by actively managing the value of your prac-tice each quarter, you will be prepared if an offer to purchase is made to you at an unexpected time.
Phase I – Discovering Current Val-ues – note the plural: values. Your practice does not have an inherent value that will be the same without regard to the type of buyer. Stark laws and Anti-Kickback rules can transform a practice worth $1M to an independent buyer into a practice worth $0 to a tax exempt hospital if enough rev-enue is generated between you and the buyer through referrals. The most prudent strategy to get the most defensible valua-tion with the least time, effort, and real cost, is to hire a licensed business appraiser who specializes in healthcare – ideally one which specializes in your type of practice. However, to achieve an accurate and
benefi cial valuation, you must ensure that your practice’s documentation (i.e. fi nan-cials, operating statistics, etc.) are in good order. If you have determined the type of buyer you would like to target, advise your appraiser, so they can tailor the valuation to the specifi c prospect. If your target mar-ket is more general in nature, then nego-tiate for a valuation that can apply across a broad spectrum of potential prospects. There are people who will prepare an as-sessment for free, but the money spent on a professional appraisal could be worth its “weight in gold” in terms of increased price or lower legal expenses later. (The cost of settling with the IRS over a sale to a tax exempt buyer could make the “free” assess-ment the biggest expense in the sale.)
The valuation of your practice will be a blend of methods over a set of inputs. Furniture, fi xtures, equipment, etc., will be valued using one of the cost appraisal methods. The building and real estate will be assessed based on a comparative market valuation method. It is the valuation of the intangibles that requires the highest level of expertise. Intangibles tend to be worth the present value of future cash fl ows they will generate. The valuation of intangibles is what draws the most scrutiny from the gov-ernment and astute buyers. The logic and data used here must be bulletproof.
Phase II – Value Optimization – Analyze the valuation report with the appraiser to identify which elements are increasing the value and determine the strength with which they are doing it. Conversely, identify which elements are driving the value down and determine how signifi cantly they are eroding value. Decide the most appropriate plan to maximize the value until the time of sale. Managing to the best business model may not be as simple as drive revenue up and costs down. A full analysis of value opti-mization is beyond the scope of this ar-ticle, but is critical to getting the best deal when you exit the practice.
Value Retention – There is an old saying: “It’s not what you make that counts, it’s what you keep.” Engage a fi -nancial and tax professional that special-izes in your type of practice to determine which strategy will yield the best post-sale result and build that into the plan.
Plan Management and Execu-tion - Knowing what to do and how to do it is necessary, but not suffi cient, to succeed. Having a knowledgeable third party help you stay on track can be in-valuable. Here in the Orlando area, the Florida Small Business Development Center at UCF provides experts, and ad-visory boards, at no charge. Working with them to keep the plan up-to-date and to ensure excellent execution can be the key to achieving your dream without getting sidetracked in the day-to-day urgent dis-tractions.
Phase III – Selling – When the time is right, engage a business broker to help you fi nd and close with the right buyer. Selling any business is not like selling a house. A business can lose substantial value if its employees, clients, or vendors learn it is up for sale. Business brokers are experts in marketing without disclos-ing the seller. They are also experts in managing the nuances and intricacies of a purchase and sale transaction. Hiring a professional can save a lot of time, effort, and money. Besides, it is always worth-while to have an objective view of any proposed deal.
The best time for a business owner to
start planning for, and working towards, a sale is the day the business opens its doors. The second best time is today.
Jim Neumann is a small business advocate who provides services: to entrepreneurs as a business intermediary with Florida Business Exchange helping facilitate the buying and selling of businesses ([email protected]); starting franchises and other opportunities as owner of Best Franchise Choice ([email protected]); and providing funds for entrepreneurs to buy and grow businesses as owner of Commercial Funding Services ([email protected]).
Getting Ready to Sell Your Practice
PRICED TO SELL
• 9,216± SF Unit Available• Reduced Sale Price - Owner Motivated• Former Imaging Center • Beautiful Class “A” Lobby• Monument Signage Available• 5.4/1,000 Parking
satisfaction with their overall condition after having the LINX System procedure, compared to 13 percent before treatment while taking medication.
“Surgical options such as the Nissen fundoplication offer a static solution to the treatment of refl ux which is required in late-stage disease,” said Grandhige. “The LINX procedure is dynamic because opening and closing simulates the normal sphincter, except you’re keeping it closed so you don’t have refl ux. Now we have a choice for patients that we can tailor-make the surgical approach to this problem.”
The Tampa Bay Refl ux Center offers three procedures for refl ux: one endoscopic (incision-less) procedure and two laparo-scopic procedures.
“By offering various options, we’re able to tailor an appropriate treatment for our patients, without pigeon-holing all pa-tients into one option,” said Grandhige.
Like Nissen fundoplication, the proce-dure is done laparoscopically through fi ve small punctures in the abdomen.
“Once we’re in the OR, we can decide which procedure the patient is better suited for, depending on anatomy,” he said. “For
example, the LINX procedure cannot be done if the patient has a hiatal hernia larger than three centimeters.”
Another patient benefi t is a quicker return to eating solid food.
“We try to get LINX patients to eat regular food right away to train the device,” he said. “With the Nissen procedure, they’re on a prescribed diet for at least two weeks.”
Because the procedure is new, insur-ance coverage varies by provider and is usually approved on a case-by-case basis, but Medicare has started to approve a por-tion of the procedure.
Refl ux KO, continued from page 9
12 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
By SriNiVaS SEEla, MD
Hepatitis C virus (HCV) can cause both acute and chronic hepatitis. The acute process is self-limited, rarely causes hepatic failure, and usually leads to chronic infection. Chronic HCV infection often follows a progressive course over many years and can ultimately result in cirrhosis, hepatocellular carcinoma, and the need for liver transplantation. Chronic hepatitis C is one type of hepatitis virus. It is spread when a person is exposed to
the blood of another person who has the virus. Seventy-five to 85 percent of people who are exposed to the chronic hepatitis C virus develop chronic hepatitis C. Chronic hepatitis C is a lifelong infection that may damage the liver. Three to 4 million people in the United States have chronic hepatitis C. Eighty percent of them don’t know they have it. That’s because they don’t neces-sarily look or feel sick. It is important to be tested for chronic hepatitis C if you think you may be at risk.
Risk factors:• People with tattoos or body piercing
done with non-sterile equipment• People who received an organ trans-
plant or blood transfusion before July 1992
• People with clotting problems who took blood products prior to 1987
• People receiving hemodialysis or who have a history of hemodialysis for kid-ney failure
• People with HIV infection.Since July 1992, all blood and organ
donations in the U.S. are screened for the hepatitis C virus. According to the CDC, the number of hepatitis C infections de-clined by 90 percent from 1994 to 2006, partially as a result of this. Since 2006, the number of new infections each year has remained relatively stable.
Symptoms:Many people who get hepatitis C do
not experience symptoms for a number of years. Consequently, many do not find out they have the virus until they take a blood
test for other reasons. In people with chronic hepatitis C, symptoms may include:
• Fatigue• Upset stomach and diminished ap-
petite• Joint and muscle pain• Also, patients may experience symp-
toms related to liver cirrhosis, such as:• Jaundice, which is a yellowing of the
skin and eyes• Urine of a dark yellow color• An increased tendency to bleed or bruise
The presence of hepatitis C infection can be determined by a blood test checking for the presence of antibodies to the virus. The CDC has recommended that every-one born from 1945 through 1965 get a blood test for hepatitis C.
Treatment:The goal of antiviral therapy in patients
with chronic HCV is to eradicate HCV RNA, which is predicted by attainment of a sustained virologic response (SVR). An SVR is associated with a 97 to 100 percent chance The decision to treat a patient with chronic hepatitis C virus (HCV) infection is based upon several factors, including the natural history and stage of the disease, the efficacy of therapy, and potential side ef-fects. In general, patients being considered for treatment should have histologic and vi-rologic evidence of chronic HCV infection. When identifying patients who are candi-dates for treatment, factors that are associ-ated with a favorable response (e.g., HCV genotype 2) should be weighed against fac-tors associated with a lower likelihood of response of being HCV RNA negative dur-ing long-term follow-up and can therefore be considered cure of the HCV infection . Attaining an SVR has been associated with decreases in all-cause mortality, liver-related death, need for liver transplantation, hepa-tocellular carcinoma rates, and liver-related complications, even among those patients with advanced liver fibrosis.
New Medications/TreatmentHepatitis C treatment is on the cutting
edge of medicine. Treatment of hepatitis
C evolved from monotherapy with Inter-feron to Infergen and ribavirin combina-tion to Interferon, ribavirin and protease inhibitors. Recently FDA unanimously approved Sofosbuvir for the hepatitis C genotypes 1,2, 3 and genotype 4.
Sofosbuvir and simeprevir for geno-type chronic 1 Sofosbuvir, a hepatitis C virus (HCV) polymerase inhibitor, and simeprevir, an HCV protease inhibitor, are currently becoming available in the United States and elsewhere for treatment of chronic genotype 1 HCV infection. Reg-imens that include these agents offer high sustained virological response (SVR) rates, more favorable adverse effect profiles than earlier regimens, ease of administration, and relatively short treatment durations . However, regimens for genotype 1 infection generally continue to include interferon. In-terferon-free regimens are expected in the near future, and it is reasonable for many patients to defer treatment while await-ing newer therapies. Most patients with chronic genotype 1 HCV infection who are candidates for and desire therapy at this time should be treated with peginterferon, weight-based ribavirin, and a direct-acting antiviral (DAA). If available, we recom-mend the DAAs sofosbuvir or simeprevir rather than telaprevir or boceprevir
Sofosbuvir for genotype 2 and 3 chronic hepatitis C infection
Sofosbuvir, a hepatitis C virus (HCV) polymerase inhibitor, is becoming avail-able in the United States and elsewhere for the treatment of genotype 2 and genotype 3 chronic HCV infection. Despite relatively high sustained virologic response (SVR) rates with only 24 weeks of peginterferon and ribavirin among most patients with genotype 2 or 3 infection, the many con-traindications and side effects associated with interferon have precluded therapy for many patients. Thus, the introduction of sofosbuvir, which offers the possibility of an effective, well-tolerated, all-oral, in-terferon-free regimen for most genotype 2 and 3 infected patients , represents a major milestone in the management of chronic HCV infection. Where available, for most patients with chronic genotype 2 and 3 HCV infection, we recommend the com-bination of sofosbuvir and ribavirin, rather than peginterferon and ribavirin.
For patients who are treated with interferon, the common side effect of de-pression can be prevented with antidepres-sants. Randomized trials have previously yielded conflicting results about the ben-efits of prophylactic antidepressants, but meta-analyses have found that prophylaxis is beneficial. A new analysis of eight trials including nearly 600 patients compared antidepressants (selective serotonin reup-take inhibitors) with placebo for prevent-ing depression in patients who were about to start interferon for hepatitis C or ma-lignant melanoma . Major depression was less likely to occur during interferon treat-ment in patients who received antidepres-sants (odds ratio 0.4).
Srinivas Seela, MD, completed his fellowship in Gastroenterology at Yale University School of Medicine. He is board certified in both Internal Medicine and Gastroenterology.
Hepatitis C: What’s New
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 13
By MaTT BOHaNNON
I was recently taken back by a pre-sentation done by a VP of Google in Orlando. This presentation was about the digital revolution and how technol-ogy has advanced at an accelerated pace. We all know that Google is a leader in the technology industry and it was re-ally interesting to get some insight into what they thought was the next revolu-tion in technology. During the presenta-tion they discussed how mobile searches on the Internet will outpace desktop searches in 2014. They also elaborated on pace in which our society has embraced mobile phones and tablets, 500 percent faster than the adoption of radio and TV. Think about that for a minute, TV and radio have been the staples of our lives for generations, you can’t go a single day without watching or listening to them, yet our society has adopted the use of smart phones and tablets 500 percent faster. It is undeniable that we are in the middle of a digital revolution.
So where does healthcare fit into this digital revolution? It would seem by all indicators that healthcare is a lacking industry, but that may not be the case. I was recently at the HIMSS, (Health In-
formation and Man-agement Systems Society) confer-ence in Orlando, and what I ex-perienced was a pleasant surprise. Instead of feel-ing like I was at a healthcare confer-ence, it felt more like the consumer electronics expo in Las Vegas. Every major healthcare com-pany, many startup com-panies, and healthcare professionals from around the world were there to experience the elaborate displays of technology and
the digital revolution of healthcare. Even
household names like Sony and Konika Minolta had huge displays, and that is when I began to realize
that healthcare is also in the middle of
a digital revolution. What the healthcare
industry is finally starting to understand is that to be competitive it is about patient engagement and convenience. With the rate at which we are using our mobile phones and tablets to be consum-
ers it exposes one glaring truth, technol-ogy is convenient. Technology allows us to do things on the go, it gives us what we need at our finger tips, and we can access it from anywhere. We don’t have to call, wait on hold, or drive to the store. We can take action on our own terms, when and where we want to. Technology has also allowed us to become more engaged. We can now communicate better through text message or Skype, we can find answers to our questions faster, and we can make decisions easier. In the healthcare space patient engagement will be the next fron-tier. An environment that allows patients to communicate easier with their doctors, get solutions to their problems faster, and manage their health better.
Healthcare is a 3 trillion dollar mar-ket. Population growth and the demo-graphics of consumers is why we have seen such a huge advance in healthcare IT over the past 10 years. With all of this taking place right now, healthcare is in the middle of its digital revolution.
Matt Bohannon is the President of BookThatDoc.com, a healthcare website providing a streamlined process for finding and booking healthcare providers where and when you need them with real time referrals. Matt can be reached at [email protected], or found at www.bookthatdoc.com.
The Digital Revolution is Here for Healthcare
After suffering two strokes, 47-year-old Steve Sanchez was admitted to The Rehabilitation Center at Central Florida Regional Hospital, an acute inpatient medical rehabilitation facility designed to help seriously ill patients regain their quality of life. Within three weeks, Steve was back home, enjoying his independence.
Located in Sanford, the 13-bed center offers the only program of its kind in Seminole and West Volusia counties. The Rehabilitation Center’s interdisciplinary team offers intensive, comprehensive care, including physical, occupational and speech therapy for patients with a variety of conditions including:
“I OWE THEM MY LIFE.”
To learn more about The Rehabilitation Center at Central Florida Regional Hospital or to schedule a tour, call (407) 314-3368 or visit us online at CentralFloridaRegional.com
Steve Sanchez, Stroke Survivor
• Stroke
• Spinal Cord Injuries
• Congenital Deformities
• Amputations
• Major Multiple Trauma
• Fracture of Femur
• Brain Injuries
• Burns
• Deconditioning Resulting from Extended Illness
• Neurological Disorders
• Severe Arthritis
14 > APRIL 2014 o r l a n d o m e d i c a l n e w s . c o m
SOUTHCOMMChief Executive Officer Chris FerrellChief Financial Officer Patrick Min
Chief Marketing Officer Susan TorregrossaChief Technology Officer Matt Locke
Chief Operating Officer/Group Publisher Eric Norwood
Director of Digital Sales & Marketing David WalkerController Todd Patton
Creative Director Heather PierceDirector of Content/Online
Development Patrick Rains
By SaraH GUlaTi, ESq.
When professionals begin thinking about a succession plan or an exit strat-egy for their business, many chal-lenges arise. Many professionals are so busy with day-to-day activities that they do not have time to think about planning for their business after-the-fact. I know I was once guilty of this!
One main challenge that most profes-sionals face is that they are required to be licensed, and most state professional regula-tory authorities limit ownership to licensed professionals. Unfortunately, a professional does not have the ability to pass ownership to future generations unless the profes-sional’s children happen to follow in their footsteps.
To have a plan which entails all the fundamentals of a successful business is one thing, but to have a plan that sustains a business in your absence is another. Whether you are taking a vacation or a long extended vacation with no return, what you put in place during your presence is what will essentially decide the sustain-ability of your business in the future. With healthcare being such an extremely com-plex field, it is essential for physicians with their own practice to set up a succession plan. A succession plan will ensure that in the their absence, particularly after death or retirement, the protocol put in place, will either sustain or dissolve the business in the way they want.
There are a few predominant ques-tions that you should keep in mind when creating a succession plan.
When should I prepare for business succession?How can the process of creating a business
succession plan be started?
What will be the legal implica-tions involved?
There is no better time than now to pre-pare for a business succession. It is unknown to anyone when the owner of a business will become absent either temporarily or perma-nently. If it is known that the owner will be retiring in the near future, a smooth transi-tion will be beneficial to the company, thus, having a business plan is essential.
The process of creating a business suc-cession plan can be started by gathering the right team. The defining factor regarding the success of the physician’s practice lies in the hands of the operating team. Whether this team is a long term or short term team
also plays a key role. Discussing issues and making sure the operating team and the key owners are on the same page is vital to the succession plan.
The legal implications involved in a succession plan will be over the owner-ship of the company. What is written in the succession plan and estate plan of the owner is what essentially will be followed. Attorneys will and should be involved in this process.
In case of a sudden absence such as death or illness, it is important to have each day planned out as if the owner could just walk away and the business would be sus-tainable. This will be covered by specific guidelines and procedures to be followed by the practice outlined in the succession plan. Methods of operation is the most important; this includes, customer service, payments, human resources, marketing and a chain of command.
Succession planning is not a fixed event. It must be continuously evaluated and improved to ensure it has your interest at play at all times. You need to ensure that your succession planning is aligned with your mission and core values so that you identify successors who are on the same page with your company strategy and cul-ture, who can then continue your success.
Attorney Sarah Gulati of Gulati Law, P.L., is a Florida real estate and business attorney with offices in Orlando and Jacksonville, who helps business professionals plan and protect their business ventures. She can be reached at [email protected].
Business Succession and Exit Planning for Professionals
April 23, 24 & 25, 2014Hyatt RegencyGrand CypressOrlando, FL
TO DOWNLOAD THE CONFERENCE AGENDA/BROCHUREAND REGISTER GO TO: www.fl mgma.com
in the Changing Healthcare Environment
SURVIVOROUTWIT OUTPLAY
O U T L A S T . . .
o r l a n d o m e d i c a l n e w s . c o m APRIL 2014 > 15
GrandRoundsNemours Launches Nemours Children’s Urgent Care
The thousands of Central Florida fami-lies who receive care at five different After Hours Pediatrics Urgent Care centers will now be directly connected to Nemours, one of the nation’s leading pediatric health systems. The centers located in Altamonte Springs, Dr. Phillips, Hunter’s Creek, Sanford and Waterford Lakes will now be known as Nemours Children’s Urgent Care. Nemours purchased the centers from After Hours Pediatrics, Inc., based in Tampa on March 1, 2014.
Nearly 200,000 Central Florida families will now be within five miles of a Nemours Children’s Urgent Care Center.
The board-certified pediatricians who currently provide care at the centers will join Nemours. Prices are not set to in-crease and the convenient hours of service will also remain the same.
Nemours Children’s Urgent Care will continue to provide children the treat-ment they need for flu, broken bones, cuts, burns and sports injuries during eve-nings, weekends and holidays. Nemours will also add to each center its award-win-ning electronic health record system. As a result, when doctors at Nemours Chil-dren’s Urgent Care enter information, the team at Nemours Children’s Hospital can immediately see every detail, should the child be sent to the hospital.
Nemours will be able to connect and coordinate every aspect of a child’s care through this shared electronic health re-cord according to Winder. This means less chance of a duplicated test.
Nemours will also offer a new ap-proach when a child receives an X-ray. The scan will be read by an urgent care phy-sician and, within 24 hours, it will also be reviewed by a board-certified pediatric ra-diologist at Nemours Children’s Hospital.
Nemours has a track record of success when it comes to electronic health records. The Healthcare Information and Manage-ment Systems Society (HIMSS) Analytics awarded Nemours Children’s Hospital its highest possible honor for best practices in implementing electronic health records. Nemours is the first pediatric hospital in Florida to attain this designation.
LRMC Names New Chief Clinical Officer
Central Florida Health Alliance is pleased to introduce Teri Keel, RN, MSN, Chief Clinical Officer [CCO] at Leesburg Regional Medical Center [LRMC]. Keel joined the LRMC team in June 2013 as the interim director over the Intensive Care Unit and Intermediate Care Unit. In Oc-tober 2013, she stepped into the interim CCO role. Under her leadership, LRMC has begun to see positive traction around patient perception scores and operational improvement in ER flow metrics accord-ing to Central Florida Health Alliance Se-nior VP and Chief Operating Officer, Saad Ehtisham. Keel has over 25 years of lead-ership and executive experience within multiple hospital settings inclusive of com-munity based tertiary and academic insti-tutions. She has
previously served as a Chief Nursing Officer, Chief Operating Officer and Chief Executive Officer.
Throughout her career, Keel has suc-cessfully demonstrated her leadership abilities and capacity to motivate those around her. She holds a BSN/MSN in Nurs-ing Administration from The University of Akron College of Nursing in Akron, OH.
St. Cloud Regional Medical Center Names New Chief Executive Officer
St. Cloud Regional Medical Center (SCRMC) has announced that Brent Burish has been named the new Chief Executive Officer effective April 1, 2014.
Burish comes with nearly a decade of healthcare management experience, most recently serving as chief executive officer of Shands Starke Regional Medical Center in Starke, Fla. During his tenure, the hos-pital provided high quality care as dem-onstrated by recognition from the Joint Commission as a Top Performer on Key Quality Measures based on Core Measure outcomes. He oversaw renovations to the Med/Surg floor and pharmacy, expanded surgical services, and successfully recruit-ed specialty physicians to the community, including establishing full-time Cardiology in collaboration with UF Health.
Burish previously served as Chief Op-erating Officer at Heart of Florida Regional Medical Center in Haines City, Fla. and Chief Operating Officer at Barrow Regional Medical Center in Winder, Ga. Active in the community, Burish served on the Boards of CareerSource North Florida, Haines City Economic Development Council and Bar-row County Family Connections/Communi-ties in Schools as well as participating mem-bership in Rotary and Kiwanis. He holds a Master of Business Administration and a Bachelor of Science in Biological Science from University of Notre Dame.
Anesthesiologists of Greater Orlando (AGO) welcomes Interventional Pain Medicine Physician
Anesthesiologists of Greater Orlando, has announced that interventional pain medicine physician, Jessica Sola-Aceve-do, M.D., has joined their Pain Physicians of Greater Orlando (PPGO) team.
Dr. Sola-Acevedo specializes in inter-ventional pain management and over-seeing medication management to treat acute and chronic pain conditions. Dr. Sola-Acevedo is Board Certified by the American Board of Anesthesiology. She completed her Pain Management Fellow-ship at Carolina’s Pain Institute. Dr. Sola Acevedo has privileges at South Seminole Hospital and Winnie Palmer Hospital.
PPGO centers offer a variety of ways to help relieve pain including epidural in-jections and nerve blocks, joint injections, radio frequency modulation and nerve stimulator implants
The doctors will provide pain relief from conditions, such as spine, back, neck, knee and hip pain, post laminectomy pain, cancer pain, neuropathic pain, joint pain, whiplash pain, and pain caused by chronic disease.
Dr. Jessica Sola-Acevedo is now welcom-ing new patients at the new PPGO office, at 691 Douglas Ave., Altamonte Springs.
Stroke Advocate Celebrates Milestone Year of Life’s Mission
Nearly twenty years ago, Valerie Greene almost died from two debilitating strokes. She was just 31 years old. Now, the Central Florida entrepreneur is celebrat-ing many achievements including her 50th birthday in April, a milestone that may have never happened as result of stroke. Empowered by the grace of God, Valerie is rejoicing her blessed survival by improv-ing the lives of the 15 million people who suffer strokes annually worldwide through Bcenter, the nonprofit global stroke re-source center that Greene founded to serve stroke survivors and their families.
After being told she may never fully re-gain her ability to walk or talk, Greene ex-plored and experienced diverse interven-tions on her quest to identify treatments to enhance her rehabilitation. Among many milestones, Greene was labeled a “Stroke Hero” by the American Stroke Association, raised the highest individual financial con-tribution in the history of the Train to End Stroke program, served as a lobbyist to pass the Florida Stroke Act (signed by Gov. Jeb Bush) and authored two educational stroke books. Her biggest accomplish-ment, thus far, is Bcenter’s online stroke center, which provides guidance sur-rounding cutting-edge therapies, support groups and offerings of inspiration.
Bcenter.com ‘is like a GPS for stroke survivors’ allowing easy navigation 24/7 through three main functions: Bwell, an out-line of 20+ conventional and holistic thera-pies such as hyperbaric oxygen, nutrition, stem cell and physical therapy; Bempow-ered, motivational tools including testimo-nials and uplifting resources; and Bcon-nected, an interactive map populated with stroke-related professional providers. Visit Bcenter.com or call (888) 942-Bwell (9355).
Dr. Pamela Tronetti of Parrish Medical Group Receives AGS 2014 Clinician of the Year Award
This year the American Geriatrics Soci-ety Board of Directors and its 2014 Awards Committee has chosen Parrish Medical Group’s own Pamela Tronetti, DO for the AGS 2014 Clinician of the Year Award.
This award is intended to honor clini-cians who make outstanding contribu-tions to the delivery of quality healthcare to older people, who communicate well with patients and their families, and who make generous contributions to commu-nity health efforts. Because of the exem-plary clinical care and sincere compassion that Dr. Tronetti provides to her patients, the committee felt she was the deserving recipient of this award.
Dr. Tronetti is well known for the way she and her staff care for patients. Her practice is built around the well-thought-out details that when added up, signifi-cantly increase the comfort level of her patients—such as carefully selecting magazines and providing warm blankets during cold weather. Dr. Tronetti and her
staff are so focused on delivering quality of care they celebrate their patient’s birth-days and send sympathy cards to families when they lose a patient. Dr. Tronetti’s motto is, “Once you come through those doors you are part of our family too, so if you have to call here every day, call!”
The Clinician of the Year Award will be presented during the 2014 AGS an-nual scientific meeting on Friday, May 16 between 9:15 and 10:00 a.m. at the Walt Disney World Swan and Dolphin Hotel.
Windermere Medical Center Opens
Windermere Medical Center has an-nounced that the practice is officially open and accepting new patients. Offering a comprehensive approach and complete access to primary care, pediatrics and chiropractic medical services for the en-tire family, the facility, located adjacent to Lakeside Village Plaza on SR 535, is a literal one-stop shop for Southwest Orlando’s healthcare needs.
The unique health concept also offers an urgent care facility for new and estab-lished patients open extended hours from 9 a.m. to 9 p.m. Monday-Friday and from 9 a.m. to 5 p.m. on Saturday. A physician is always on-site to see patients and no ap-pointment is necessary to visit the urgent care facility. For established patients of the practice, the co-pay for an urgent care visit is the same as for a regular visit.
www.orlandopainandspine.com407-985-4700 – O, 407-985-4702 –F
7364 Stonerock Cr., Suite A, Orlando, FL 32819Mon – Thur 8 – 5:00 PM | Friday 8-12:00 PM
Orlando Pain & Spine Center
Across from Dr. P. Phillips Hospital
• Graduate of The University of Cairo in Egypt• Completed training in Anesthesiology at Hahnemann University in Philadelphia• Fellowship training in interventional pain management at the renowned Mount Sinai Hospital in New York• Board certifi ed anesthesiologist• Board certifi ed pain medicine
Amr H. Badawy, MD
MORE than INJECTIONSPracticing pain Medicine since 2004, Dr. Badway’s philosophy leverages amultidisciplinary approach to treating pain and su� ering, o� ering many of the most advanced treatment options to restore your quality of life.
