Florida MD August/September 2020 by FloridaMD

AUGUST/SEPTEMBER 2020 â&#x20AC;¢ COVERING THE I-4 CORRIDOR

Orlando Health Celebrates Two Years of Groundbreaking In-Utero Fetal Spinal Surgery Pre-delivery Operation Reduces Nerve Damage, Defects and Improves Quality of life for Children with Spina Bifida

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ON THE COVER: Pediatric Neurosurgeon Samer Elbabaa, MD

BABY BOOMERS USE CANNABIS FOR MEDICAL REASONS TWICE AS MUCH AS MILLENNIALS

WHY REHABILITATION CAN’T WAIT, EVEN DURING A PANDEMIC

COVERING THE I-4 CORRIDOR

 COVER STORY

Most people who visit Florida are looking to soak up a few rays, visit Disney World or catch a Magic game. After all, it’s home to some of the biggest tourist attractions in the U.S. However, in 2018 the sunshine state started to attract a unique type of visitor with a quality unlike any other: they hadn’t been born yet. Intra-state “medical tourists” travel hundreds (and sometimes thousands of miles) to visit Orlando Health, which houses one of the top in-utero surgery teams in the U.S. Led by world-renowned Pediatric Neurosurgeon Dr. Samer Elbabaa, the team performs high-risk in-utero fetal repair surgeries which involve treating conditions using open surgery while a fetus is in second half of pregnancy. While highly invasive, these surgeries often allow women to carry their babies to term in otherwise precarious situations. Orlando Health’s Arnold Palmer Hospital for Children and Winnie Palmer Hospital for Women & Babies specifically specialize in the treatment of spina bifida, a condition where the spinal column fails to close causing a baby’s spine and nerves to protrude from their back. “People need to understand Spina Bifida is a condition -- not a disease,” said Elbabaa “These babies and children deserve the best care and love we can provide to them.”

PHOTO:PROVIDEDD BY ORLANDO HEALTH

AUGUST/ SEPTEMBER 2020

DEPARTMENTS 2

FROM THE PUBLISHER

3 DERMATOLOGY 8 HEALTHCARE LAW 10 MARKETING YOUR PRACTICE 12 PHARMACY UPDATE

FLORIDA MD - AUGUST/SEPTEMBER 2020

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. Human trafficking is one of the horrors in today’s society. It’s modern-day slavery and Central Florida is one of the worst places in the country. I have asked Paving The Way Foundation, an organization headquartered here in

Central Florida that helps physicians spot signs that one of their patients could be a victim. Please check out their website and help put a stop to human trafficking. Best regards,

Donald B. Rauhofer Publisher

Check out our newly redesigned website at www.floridamd.com!

According to Homeland Security, there are over 300,000 children a year trafficked in the United States. In fact, Florida ranks 3rd in the county for calls to the National Trafficking Hotline and right here in Central Florida, Orange county ranks 2nd in the state for child trafficking case. Sadly, the average age of entry is 11-14. Those facts can be frightening, leaving most people asking, who am I to do anything about this? More importantly, what can I do? Paving The Way Foundation was created to provide answers to those questions. We’ve educated over 13,000 youth, parents, teachers, and community leaders about human trafficking, the impact it has on families and the actions to take to prevent it. A surprising statistic is 88% of trafficking victims reported being in a medical setting for various concerns but did not feel safe enough to ask for help. We can prevent that from happening by training our frontline teams to learn the signs of trafficking, understand grooming and recruitment tactics and how to engage with patients about this silent crime to get them to safety. Here is one action you can take right now: put the National Trafficking Hotline number in your phone, 888-3737888, you can call 24 hours a day, 7 days a week. To learn more about what you can do or ways to get involved in ending human trafficking we invite you to join in the fight, please go to our website, www.pavingthewayfoundation.org click on programs for information on what’s available to educate you and your staff or download one of our tool kits. Together we can disrupt the cycle of human trafficking.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, M.D, Julie Tyk, JD, Michael Patterson NHA, OTR/L, CEAS, Sonda Eunus, MHA, Juan Lopez, Pharm D, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2020, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

DERMATOLOGY

Melanoma Makes Me a Real Doctor By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

Jerry was having dinner at a restaurant with his dermatologist girlfriend. Seinfield - “How’s the life-saving business? Dermatologist girlfriend - “It’s fine.” Seinfield - “It must take a really, really big zit to kill a man.” Dermatologist girlfriend - “What is with you?” Seinfield - “You called yourself lifesaver. I call you pimple popper M.D.” A restaurant patron walks up to their table and says, “Dr. Sitarides?” Dermatologist girlfriend - “Mr. Perry, how are you?” Mr. Perry - “I just want to thank you again for saving my life.” Seinfield - “She saved your life?” Jerry has a shocked look on his face. Mr. Perry - “I had skin cancer.” Seinfield - “Skin cancer, damn.” Jerry’s face twists in the agony of defeat.

The best guidance for identifying melanomas for non-dermatologists is using the mnemonic ABCDEs of melanoma evaluation, Asymmetry of the lesion, Border irregularity, Color variation, Diameter greater than 6mm and Evolution. However, dermatologists rarely use the ABCDE guide, as most of us know by looking because of intuitive expertise. When a dermatologist observes a suspicious lesion, in our mind, it pops up, “that looks suspicious.” Intuitive expertise is ubiquitous throughout all specialties and comes with experience. The ER doc that walks into a patient room and immediately diagnoses congestive heart failure with only a glance is demonstrating intuitive expertise. Intuitive expertise can be confounding to medical students who need to look up everything online. Still, it is this intuitive expertise we all gain through training and experience that makes us “real” doctors. Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF. 

PHOTO: JOHN MEISENHEIMER, VII

Melanomas come in all different shapes and sizes. They are rarely the archetypal jet black, nodular mole-like growth, in which even a first-year medical student could make the diagnosis. Melanomas may appear elevated, they can be flat, they can be multicolored, and they do not have to have pigment. Some melanomas can persist for very long periods before being discovered, such as lentigo maligna melanoma. Others can grow rapidly and deadly in a few weeks. Melanomas can develop beneath the nails, and even in non-skin areas such as the eye, oral cavity, nasal sinuses, even rectally.

Lentigo maligna melanoma.

Nodular melanoma.

PHOTO: JOHN MEISENHEIMER, VII

As a Mohs surgeon, I rarely “pop” pimples anymore, not that there is anything disgraceful about helping a patient with a disfiguring skin disease that can leave them permanently scarred. As the Seinfield episode would suggest, laypeople might seem to think unless you are saving lives, you are not a “real” doctor. So, I guess in a sense, melanomas make dermatologists “real” doctors (and let’s not forget squamous cell carcinomas and basal cell carcinomas can also kill you). I know in my practice over the last 30 years, I have found hundreds of melanomas. Even to this day, when I see a melanoma, I quietly give myself a high five. When you catch melanoma in time, you have changed a person’s life for the better, even if they may not realize it. At the same time, I am also grateful that I did not miss that melanoma. There is always a degree of stress when doing a “routine skin exam” there is nothing routine about melanoma or the potential for missing a melanoma.

PHOTO: JOHN MEISENHEIMER, VII

A superficial spreading melanoma.

PHOTO: JOHN MEISENHEIMER, VII

When I was in medical school and revealed to my classmates that I wanted to be a dermatologist, they usually gave me a flabbergasted look and said, “You want to pop zits for a living?” Immediately followed by, “You don’t want to be a real doctor?” I wish the Seinfeld episode, when Jerry was dating a dermatologist, had been released so that I could refer them to it. The Seinfeld episode went something like this:

Pathology of a melanoma.

FLORIDA MD - AUGUST/SEPTEMBER 2020 3

COVER STORY

Orlando Health Celebrates Two Years of Groundbreaking In-Utero Fetal Spinal Surgery Pre-delivery Operation Reduces Nerve Damage, Defects and Improves Quality of Life for Children with Spina Bifida By Alexandria Evensen Most people who visit Florida are looking to soak up a few rays, visit Disney World or catch a Magic game. After all, it’s home to some of the biggest tourist attractions in the U.S. However, in 2018 the sunshine state started to attract a unique type of visitor with a quality unlike any other: they hadn’t been born yet. Intra-state “medical tourists” travel hundreds (and sometimes thousands of miles) to visit Orlando Health, which houses one of the top in-utero surgery teams in the U.S. Led by world-renowned Pediatric Neurosurgeon Dr. Samer Elbabaa, the team performs high-risk in-utero fetal repair surgeries which involve treating conditions using open surgery while a fetus is in second half of pregnancy. While highly invasive, these surgeries often allow women to carry their babies to term in otherwise precarious situations. Orlando Health’s Arnold Palmer Hospital for Children and Winnie Palmer Hospital for Women & Babies specifically specialize in the treatment of spina bifida, a condition where the spinal column fails to close causing a baby’s spine and nerves to protrude from their back.

“These babies and children deserve the best care and love we can provide to them.”

FINDING HOPE Out of the 4 million babies born in the U.S. each year, around 1,500 are born with the debilitating lesion that causes spina bifida. Without fetal intervention, this often results in children with paralysis, Hypoesthesia (numbness), major motor impairment, fluid on the brain (hydrocephalus) and lack of bowel and bladdercontrol. Clinical evidence suggests the main cause of neurologic defects in spina bifida come from amniotic-fluid induced chemical trauma. This fluid progressively damages the exposed spinal tissue during gestation. Because of its digressive nature, the doctors at Orlando Health try to get the surgery completed as quickly as possible after the diagnosis -- between 19 and 26 weeks. The surgery is not without risk; uterine scarring and premature birth are issues that come up the most often. The potential benefits of the fetal surgery, though, far outweigh the risks.

Dr. Elbabaa has spent more than a decade teaching other surgeons, as well as the public, about this and other neurological “People need to understand Spina Bifida is a condition -- not conditions. He knows he can’t directly change the number of a disease,” said Elbabaa cases of spina bifida that exist, but he’s out to make sure as many babies as possible grow up to Pediatric neurosurgeon Samer Elbabaa, MD, maternal fetal medicine physician Cole Greves, MD and their walk, bike, and play like reguteam prepare for the first fetal surgery case at Orlando Health in May 2018.ment center. lar children.

PHOTO:PROVIDEDD BY ORLANDO HEALTH

“The community should be aware that we offer the most complex and most advanced treatment, management, and support for our patients , even before they are born,” he said. “As a team, we’re impacting the future prognosis of each child we serve. We’re giving them the best physical and cognitive function possible.” Dr. Elbabaa has been invested in treating spina bifida for more than 10 years. Before joining the team at Orlando Health two years ago, he served as the Reinert Endowed Chair in Pediatric Neurosur4 FLORIDA MD - AUGUST/SEPTEMBER 2020

gery, an associate professor of neurosurgery at Saint Louis University School of medicine, and a director of pediatric neurosurgery at SSM Cardinal Glennon Children’s Hospital in Saint Louis. Cardinal Glennon was the first place he performed the fetal inutero spina bifida Surgery. Over the last 8 years, he completed an astounding 75 operations. He opted to move to Orlando Health because of their incredible infrastructure and world-class staff. The program allowed him to lead his team in ground-breaking research and protocols in just a few years. The Orlando Health fetal surgery team prepares the mother’s uterus for the procedure on her unborn child. “I am so fortunate to be surrounded by great team members chael Harrison performed the first successful operation in 1981. dedicated to the same cause,” he said. It took more than a decade of breaking research to start creating THE PROCEDURE a treatment for spina bifida. Even experienced pediatric surgeons When Spenser and Jessica Trinkle took a trip to Orlando late had a hard time accepting the idea that the spinal cord could be last year, there was no talk of theme parks or beaches. Instead repaired of major damage within the uterine environment, with they were visiting Winnie Palmer Hospital when Jessica was 23 a reduction of risk from spina bifida. weeks along in her pregnancy. The couple’s unborn son, Parker, Surgeons and researchers from multiple organizations teamed had recently been diagnosed with spina bifida, and they had up over many years to develop a prospective randomized trial come to experience the renowned program first hand. (MOMS trial) for fetal spina bifida surgery. It was finally acceptOnce the diagnosis was made, they had very little time to ed for widespread use in 2011, after a ground-breaking 8-year make their decision. Because spina bifida is progressive (with clinical trial. irreversible effects as pregnancy progresses), doing in-utero surOrlando Health began laying the groundwork for their own gery is now an option for the parents to choose leading to potenprogram in the mid 2000s. In May 2017, the hospital system tial better outcomes than most post-birth operations. By making hired Dr. Elbabaa to lead out initiatives as the Director of Pedia decision quickly, the couple knew they could potentially quell atric Neurosurgery and the Director of the Leon Pediatric Neufuture damage. roscience Center of Excellence. After just a year, Elbabaa and When surgery day came, two teams (one for mom and one his team developed the protocol and practices for a fetal surgery for baby) were in the crowded room as both subjects went under program, which was launched in 2018. general anesthesia. The room contained a fetal neurosurgeon, a Dr. Elbabaa brought a wealth of experience to the hospital: maternal fetal medicine specialist, an anesthesiologist and a team He’s board certified by the American Board of Pediatric Neuroof nurses. For hours, the teams worked in perfect motion, seemlogical Surgery; has certification in microsurgery from the Uniingly choreographed in the outtake of their individual tasks. versity Hospital in Zurich Switzerland; is a fellow of the AmeriThe operation followed the typical protocol pattern found in can Association of Neurological Surgeons and of the American the 13 U.S. hospitals who administer it: An incision similar to College of Surgeons; and is a member of Congress of Neurologia c-section was made. The surgeon used an ultrasound to locate cal Surgeons and the International Society of Pediatric Neurothe fetus, exposing the back of the uterus and spina bifida lesion. surgeons. The neurosurgeon then repaired the spina bifida defect for proElbabaa’s hope is to bring more resources to the program as it tection and healing. After surgeons closed the uterus, the fetus continues to grow. Fetal surgery is still in its infancy, and there remained in the womb for the remainder of the pregnancy. are many conditions that could be aided by new discoveries and When the surgery was completed, Dr. Elbabaa and the team research. took a deep breath. To date, they’ve done 11 of these fetal sur“We’ve been very blessed, very pleased, and very thrilled at the gery operations in Orlando, and each success is a reason to be outcome of our first 11 successful spina bifida surgeries, as well grateful. as our ongoing comprehensive care programs.” he said. “We’ll PAST & FUTURE continue to grow. We are slowly advancing our surgical techFetal surgery has its roots at UC San Francisco, where Dr. Minique and in the next few years we’ll make the transition from FLORIDA MD - AUGUST/SEPTEMBER 2020

PHOTO:PROVIDEDD BY ORLANDO HEALTH

COVER STORY

COVER STORY open fetal surgery to minimally invasive operations.”

PHOTO:PROVIDEDD BY ORLANDO HEALTH

One of the outreach programs Elbabaa is especially passionate about is Arnold Palmer Hospital’s spina bifida clinic. With an established 35+ year history, the clinic provides pediatric specialists for thousands of children. It’s a collaborative effort to meet the individual needs of each individual. This includes a team of pediatric physician specialists, healthcare experts, Samer Elbabaa, MD, performs microneurosurgery to repair the defect on the fetus’ spine. therapists, nutritionists, and social workers. The aim of the clinic is to provide comprehensive care from ages 0-18, with ongoing resources to help young adults make the difficult transition into adulthood. The program provides one-on-one mentorship that opens a pathway for newly-minted adult patients to meet psychosocial and independence needs. This includes classes on all things related to adulthood, including job searching, using a wheelchair and building a resumé. Elbabaa is as adamant about continuing care as he is about fetal surgery itself. Even with the best treatment, spina bifida and other neurological disorders are often lifelong struggles that require a multidisciplinary team of doctors to manage. For this reason, he champions the Arnold Palmer Hospital’s broad post-birth program, which covers every step of condition management. “We’re continually growing the program to support families after birth with our outpatient arm. This gives us the ability to follow up for many years,” said Elbabaa. Beyond spina bifida, Arnold Palmer Hospital also provides support for a wide variety of neuro-issues including microneurosurgery, neuroendoscopy, craniofacial surgery, skull base Orlando Health’s first fetal surgery baby, Celeste, after she was “twice born.” surgery, and fetal repair of cranio-cervical junctional anomalies. Over time, Elbabaa has his eye on making these surgeries more efficient (and this safer.) “We are also constantly evaluating mothers who are pregnant with other conditions to open opportunities for future procedures.”

For more information about Orlando Health’s fetal surgery program, visit www. winniepalmerhospital.com/fetalcare. 

6 FLORIDA MD - AUGUST/SEPTEMBER 2020

PHOTO:PROVIDEDD BY ORLANDO HEALTH

BIRTH, MATURATION AND BEYOND

Baby Boomers Use Cannabis for Medical Reasons Twice As Much As Millennials By Michael Patterson, NHA, OTR/L, CEAS A recent survey by cannabis company Verilife found that baby boomers (age 56-76 years old) use cannabis medically at twice the rates of millennials (22-38 years old). Fifty percent of the baby boomers surveyed said they consumed cannabis primarily for medical reasons, with 28% saying they use cannabis solely for recreational reasons, and 22% using cannabis for both. The figures are completely opposite for millennials with 49% said they use cannabis recreationally, 22% saying they use for medical reasons, and 29% using cannabis for both medical and recreational reasons. One area in which both age groups agreed was on the medical benefit of cannabis, with 92% of millennials and 89% of baby boomers agreeing that cannabis has medical benefits. Also, if they are given the option, 68% of millennials and 61% of baby boomers would choose using cannabis for a medical condition rather than a prescription drug to relieve pain. The medical conditions millennials use cannabis for were chronic pain (27%), migraines (13%), nausea (11%), arthritis (8%), weight loss (8%), autism (8%), and irritable bowel syndrome (4 %). For boomers the most common medical conditions were arthritis (15%), chronic pain (13%), cancer (11 percent), migraines (8%), weight loss (8%), and autism (7%). In regards to using cannabis recreationally, millennials said the reason for use was relaxation (34%), social reasons (23%), anxiety (22%), sleep (9%), and enhancing physical activity (9%). For boomers, relaxation was the primary reason for recreational use (42%), followed by anxiety (17%), socialization (17%), and physical activity enhancement (17%). The most common method of cannabis use for both age groups is smoking (50% millennials, 39% boomers). However, boomers prefer edibles, capsules, vaping, and tinctures more than millennials (23% Boomers, 10% millennials). Neither age group preferred dabs or topicals for a use method for cannabis (2%). The survey was conducted from May 29 to June 5, 2020 and included 1,000 current cannabis consumers from each generation. For millennials, the average age was 31. Of this group, 63 percent were employed full-time and 80 percent completed some type of post-secondary education. For baby boomers, the average was 59, 66% were employed full-time and 79% completed some type of post-secondary education.

for your patients, eventually your patients will either seek other medical advice to use cannabis or will use cannabis and not tell you. If patients cannot trust their physician enough to verbalize they are using cannabis, then eventually the patient will find another physician. Cannabis use with seniors and boomers will continue to increase. With cannabis being legal for medical purposes in Florida (with over 350,000 medical cannabis patients and growing 5,000 patients per week), we are seeing an average patient age of 52 years old. I have been educating medical professionals and the public for years that cannabis is an accepted form of treatment for many medical ailments. Traditional healthcare must understand that patients now have a choice of which healthcare practitioner they use and patients are driving the trend to acceptance of cannabis as a medicine (regardless of how the mainstream medical community thinks). Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). Mr. Patterson is a healthcare executive with over 25 years experience in the following areas: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, and Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, and Healthcare Analytics. Michael is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) and Guidepoint. Mr. Patterson is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, and licensed Occupational Therapist in 4 states.. î Ž

ANALYSIS Cannabis is becoming more mainstream and trusted as an option for use to treat medical conditions. For the medical community, a shocking statistic is 61% of boomers would use cannabis to relieve pain rather than a prescription drug. This shows that the public trusts cannabis as a medicine more than a prescription drug. If your medical practice is not addressing cannabis as a medicine FLORIDA MD - AUGUST/SEPTEMBER 2020

HEALTHCARE LAW

Business Interruption Coverage– COVID 19 By Julie A. Tyk, JD

In March and April of 2020, as businesses were suddenly forced to close due to the COVID-19 pandemic, many business owners asked whether there was insurance coverage for the losses caused by the shutdown. Specifically, business owners asked whether “business interruption” and “civil authority” coverages typically found in Commercial General Liability policies potentially covered the staggering losses associated with the shutdowns. Business interruption coverage covers lost profits when a business cannot continue its normal business operations due to a covered loss. Civil authority coverage provides coverage for loss of business income due to civil or military orders that impair business operations. An order requiring non-essential businesses to close to prevent further spread of COVID-19, such as Florida’s “stay at home” order, arguably triggers coverages. Currently, one of the most prominent areas for class action litigation related to the COVID-19 pandemic is disputes about whether commercial insurance policies cover business interruption losses. Hundreds of businesses have sued a large number of insurance companies arguing that their insurance policies should cover any losses incurred as a result of state and local closure orders during the pandemic. There have already been over 1,000 of these actions filed nationwide, more than half of which have been filed as class actions. Plaintiff businesses argue that the terms of their “all-risk” insurance policies, including terms related to Business Income coverage and Civil Authority coverage, cover losses from closures required by state and local pandemic orders. Plaintiffs assert causes of action for breach of contract, unjust enrichment, and declaratory judgment under state/federal law. In response, insurers dispute these allegations, arguing that the insurance policies at issue only cover losses incurred as a result of direct physical damage to property, such as from an earthquake or hurricane, and not losses resulting from business disruptions due to a health emergency. Insurers also note that some policies contain explicit exclusions for losses resulting from a virus, indicating that general commercial property insurance terms were not intended to cover the losses claimed. Several state legislatures also introduced bills that would require insurers to cover COVID-19 claims, although the constitutionality of such bills is not certain. As stated above, more than 1,000 lawsuits have been filed since March 2020 addressing business interruption coverage, including several class-action suits. Currently, there is no clear consensus as to whether coverage exists for COVID-19 business interruption or civil authority claims. In cases where plaintiffs argued the forced closure of business operations was sufficient to support a claim without a showing of property damage, early decisions have favored the insurer defendants. A court in Michigan has sided with the insurers, holding that some physical damage to property was required for coverage under the policy. (Gavrilides Management Co. v. Michigan Insurance Co.). Similarly, a court in D.C. granted summary judgment to an insurer, holding that there must be some direct damage to the property itself and that loss of use as a result of government shutdown orders was not sufficient for coverage. (Rose’s 1, LLC 8 FLORIDA MD - AUGUST/SEPTEMBER 2020

v. Erie Insurance Exchange). Neither of the complaints in those cases alleged any direct physical loss or damage to the property. More recently, a Michigan federal judge freed State Farm Mutual Automobile Insurance Co. from having to cover a chiropractic office’s losses from state-ordered closures due to COVID-19, saying that the business failed to allege physical loss and that the virus exclusion bars coverage. (Turek Enterprises Inc. dba Alcona Chiropractic v. State Farm Mutual Automobile Insurance Co. et al.). A Florida federal judge handed a win to Allied Insurance Co. of America, freeing the insurer from having to pay for a dental clinic’s claimed COVID-19 related losses, holding that the policy’s virus exclusion clearly bars coverage. (Mauricio Martinez, DMD v. Allied Insurance Co. of America.) On the other hand, some plaintiffs have asserted that the presence of the COVID-19 virus on their property or other identified dangerous conditions can constitute physical loss or damage to commercial property. One federal court has denied a motion to dismiss on this basis, holding that the insurer wrongfully refused to cover a group of hair salons’ and restaurants’ losses during COVID-19 shutdowns because the businesses adequately alleged that they suffered a covered “direct physical loss.” The ruling was the first in which a court allowed a policyholder’s COVID-19 coverage suit to proceed following a motion to dismiss. (Studio 417 Inc. et al. v. The Cincinnati Insurance Co.). In this uncertain landscape, policyholders should review their policies with an attorney or insurance broker and should strongly consider submitting business interruption and civil authority claims even where the claim will likely be denied. By submitting the claim, a policyholder preserves its rights under the policy and avoids the insurer later denying the claim as being untimely. If either the courts or a state or federal legislature addresses the critical issues/exclusions in favor of policyholders, then the claimant will be in a more favorable position to obtain recovery funds. Even policyholders with CGL policies containing the virus exclusion should consider filing claims since subsequent state or federal legislation (or case authority) might impact recovery. A medical malpractice claim can have far-reaching implications. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP, is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP. Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com. 

Why Rehabilitation Can’t Wait, Even During A Pandemic By Staff Writer So much has changed during this pandemic. Schools and business have closed, and no longer are people sharing handshakes and hugs. Instead, social distancing has become the norm. Although daily life has been altered greatly by COVID-19, many things have remained the same. One of those is the need for inpatient rehabilitation. While many acute care hospitals were forced to shutter some operations as shelter in place orders were implemented across the country, the doors of Encompass Health’s inpatient rehabilitation hospitals never closed. Despite the pandemic, people will still have strokes and experience other life-changing illnesses or injuries. Many of these individuals can benefit from the intense therapy and around-theclock nursing care that inpatient rehabilitation provides. “The majority of our patients come to us after a stay in the acute care hospital, where we are finding that volume, in some markets, has not been as heavy as originally predicted,” said Dr. Lisa Charbonneau, chief medical officer at Encompass Health. That drop in volume can be explained in part because all elective surgeries stopped, but reports from hospitals nationwide indicate a drop in the number of heart attacks and strokes being treated. “Let’s be clear—that doesn’t mean heart attacks and strokes have gone away during the COVID-19 pandemic,” Charbonneau said. “It’s more likely that people are ignoring the signs and symptoms of these life-threatening conditions in fear of contracting COVID-19 in the emergency room.” It’s important that these patients still seek prompt medical care during this pandemic, Charbonneau said. After a stay in the acute care hospital, many of them will need rehabilitation afterwards to regain their independence.

BUT IS IT SAFE? Encompass Health has implemented protocols consistent with CDC guidelines and is assessing the situation daily to protect its patients and employees, Charbonneau said. “We’re also ramping up our existing infection control protocols that are specific to the inpatient rehabilitation setting,” she explained. “We are still having therapy in our gyms, but we are social distancing and thoroughly cleaning equipment after each use. When indicated, we are also conducting therapy within patient rooms.” Encompass Health restricted visitors at its hospitals nationwide to further promote patient and employees safety. Visitors to

Encompass Health Rehabilitation Hospital of Altamonte Springs are encouraged to contact the hospital before arrival. Employees are screened daily for possible signs of COVID-19, as are any essential vendors entering the hospital.

CAN REHABILITATION WAIT? Patients who need inpatient rehabilitation need a hospital level of care, and that care shouldn’t be postponed, even during a pandemic. “After an acute hospital stay, patients will need help regaining their strength, and in many cases, their cognitive capabilities,” Charbonneau said. “That’s what inpatient rehabilitation is for, and the sooner one receives that care, the more likely they can regain their independence and return to their communities, which is always the end goal in inpatient rehabilitation.” Elissa (Lisa) Charbonneau, D.O., M.S., has served as chief medical officer of Encompass Health (formerly HealthSouth) since June 2015. Prior to that role, she served as the company’s vice president of medical services. For 14 years, she served as medical director at New England Rehabilitation Hospital of Portland, a joint venture of Maine Medical Center and Encompass Health, where she held a staff physician position at the hospital since 1992. Dr. Charbonneau received her doctor of osteopathic medicine from New York Institute of Technology College of Osteopathic Medicine, a master’s degree in natural sciences/epidemiology from the State University of New York at Buffalo and a bachelor’s degree from Cornell University. She is a diplomate of the American Board of Physical Medicine and Rehabilitation and of the American Osteopathic Board of Rehabilitation Medicine. 

FLORIDA MD - AUGUST/SEPTEMBER 2020

MARKETING YOUR PRACTICE

Facebook Marketing for Medical Practices By Sonda Eunus, MHA, CMPE

For a medical practice, as for any business, it is now crucial to have a strong presence on social media platforms. However, it is often hard for medical practice leaders to know which social media platforms to focus on to get the greatest results. Whereas there are multiple great options to choose from, Facebook should always be the #1 platform to start with and to invest the most time on.

WHY FACEBOOK SHOULD BE #1 ON YOUR LIST: Facebook is currently the largest social media platform, with 2.6 BILLION monthly active users worldwide as of the first quarter of 2020 – with 1.73 billion of those using Facebook daily (1). Facebook is now the world’s 3rd most-visited website, after Google and Youtube (2). There are 90 million Facebook Business pages (2). This shows that 90 million businesses have found it beneficial to have a Facebook presence. Not only is it important because you are getting additional exposure to Facebook users, but it will also improve your online credibility and boost your search engine optimization. Social Media accounts show up in search results when someone searches for your practice – so make sure that your page is active, that you are sharing valuable content, and that you have a good amount of page followers for social proof that your business is liked and respected in the community. If you are not sure that your target audience is on Facebook, consider this: 71% of American adults use Facebook, as compared to Instagram’s 38%, and Twitter’s 23% (2). The percentages of people in specific age ranges that are active on Facebook look like this:

• 18-24: 76% • 25-29: 84% • 30-49: 79% • 50-64: 68% • 65+: 46% This is a good audience for any medical practice, as you can reach both young parents with newborns, older patients, and anyone in between.

OPTIMIZE YOUR FACEBOOK PAGE: To get started, make sure that your Facebook Business page is optimized. Here are some key steps to focus on: • You want to add as much information as possible and fill out all the sections available. • Upload a clear copy of your logo as your profile picture. • Add a nice cover photo – this could be a picture of your clinic, your staff, or another image that is relevant to your clinic and your target audience. • Make sure that there is a clear way to contact you, visit your website, etc. and add the services that you provide • Add as many photos as possible, such as pictures of your waiting room, exam rooms, doctors, staff, etc. • Ask your existing patients to add Facebook reviews to your page

GROW YOUR FACEBOOK AUDIENCE: Here are the best ways to start growing your Facebook audience: • Invite all your friends to like your new Business page • Ask the other page Administrators that you add to invite their friends to like your page • Ask your friends on Facebook to invite their friends to like your Facebook page After you have acquired an initial following by using these strategies, you will need to start focusing on more long-term strategies to engage with your existing audience and to grow your following. To do so, you will need to: • Post quality content regularly, at least once a day – you can use funny (tasteful) memes, motivational quotes, informative articles, etc. • Invite the people that engage with the content you share to like your page, respond to any comments that you receive on your page • Use engaging posts to increase engagement, such as contests, raffles, photo share requests, etc. • Share blog posts that you write

10 FLORIDA MD - AUGUST/SEPTEMBER 2020

MARKETING YOUR PRACTICE • Ask your friends, staff, and business partners to share your posts • Be active in local Facebook groups • - Start your own Facebook group

LEVERAGE FACEBOOK GROUPS TO GROW YOUR AUDIENCE: There are over 10M+ groups on Facebook, and over 1.4 billion people now use Facebook Groups every month (1). It is a good idea to start a Facebook group in addition to your Facebook Business page in order to grow your following and get more page likes. To grow your group, post valuable resources and information relevant to your target audience – and, every now and then, make announcements regarding your practice, new services that you are offering, or other updates. However, make sure that you are not using this group solely to promote your practice, or you will lose group members. What is great about groups, is that when you share a post in a group, all of your members get a notification that you have posted in the group. This way, your posts get seen by more people than the posts that you share on your Business page. Aside from creating your own Facebook group, make sure that your page also joins as many relevant local groups as possible. There are groups for everyone, and you need to find the ones that will help you gain exposure to your target audience. For example, a pediatric practice can join groups for local moms, or a specialist can join groups related to a specific ailment that they treat at their clinic. To summarize, a Facebook presence is important for any medical practice. By utilizing the steps outlined below, you will be on your way to growing your practice exposure and building up your credibility as an expert in your field. If you would like to outsource your Social Media Marketing to a team of Marketing experts, Leading Marketing Solutions can help you bring these strategies to life and grow your audience and social presence for you. Visit www.lms-plus.com for more information. References: 1. https://zephoria.com/top-15-valuable-facebook-statistics/ 2. https://blog.hootsuite.com/facebook-statistics/ 3. https://www.websitehostingrating.com/facebook-statistics/

Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.

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www.floridamd.com FLORIDA MD - AUGUST/SEPTEMBER 2020 11

COVER STORY

PHARMACY UPDATE

Nature-Throid® & WP Thyroid® Recall By Juan Lopez, PharmD, FAPC Having difficulties filling your prescription thyroid therapy for Nature-Throid® or WP Thyroid®? RLC Labs, the manufacturer of Nature-Throid® and WP Thyroid® products, announced that it is voluntarily recalling all unexpired lots of Nature-Throid® and WP Thyroid® to the consumer level. See RLC Labs’ September 2, 2020 statement below: “RLC Labs, Inc. is voluntarily recalling a total of 483 lots of Nature-Throid® and WP Thyroid® in all strengths, all counts of product within current expiry to the consumer level. The products are being recalled because testing of samples from six (6) lots by the U.S. Food and Drug Administration found the samples to be sub potent. The product may have as low as 87% of the labeled amount of Liothyronine (T3) or Levothyroxine(T4). Risk Statement: Patients being treated for hypothyroidism (underactive thyroid), who receive sub potent Nature-Throid® or WP Thyroid®, may experience signs and symptoms of hypothyroidism (underactive thyroid) which may include, fatigue, increased sensitivity to cold, constipation, dry skin, puffy face, hair loss, slow heart rate, depression, swelling of the thyroid gland and/or unexplained weight gain or difficulty losing weight. There is reasonable risk of serious injury in newborn infants or pregnant women with hypothyroidism including early miscarriage, fetal hyperthyroidism, and/ or impairments to fetal neural and skeletal development. In elderly patients and patients with underlying cardiac disease toxic cardiac manifestations of hyperthyroidism may occur, such as cardiac pain, palpitations or cardiac arrhythmia.

amount of therapy as grains (gr.) (i.e. ¼ grain, ½ grain, 1 grain, etc.) can be used to express the strength of the patient’s thyroid therapy and ensure the patient receives the same amount of T3 and T4 supplementation. Patients suffering from hypothyroidism symptoms may be sensitive to particular fillers commonly found in medications. Each brand of thyroid medication uses different fillers during the manufacturing process. Pharmacists can review inactive ingredients of each formulation with patients to help determine tolerability. It is not uncommon that patients who are unable to find their thyroid medication due to availability issues may have their therapy changed from desiccated thyroid, which supplies a standardized amount of levothyroxine (T4) and liothyronine (T3), to products that only supply T3 and/or T4 alone. The only commercially available T3/T4 combination tablet not derived from desiccated porcine thyroid was sold under the brand name Thyrolar (Liotrix). In December 2018, the Food and Drug Administration (FDA) announced the manufacturer made a business decision to discontinue production of Thyrolar tablets.

PERSONALIZED THYROID REPLACEMENT THERAPY Pharmacy Specialists can help patients and physicians design appropriate thyroid replacement therapy. We stock the pure chemical

RLC Labs, Inc. has not received any reports of adverse events related to this recall. Nature-Throid® and WP Thyroid® (thyroid tablets, USP) are composed of liothyronine and levothyroxine, and are used to treat hypothyroidism (underactive thyroid).” Patients who are currently taking Nature-Throid® and WP Thyroid® should not discontinue use without contacting their healthcare provider for further guidance and/or a replacement prescription. You are encouraged to contact your prescribing health care provider to discuss next steps. The recall of all lots may lead to a supply shortage of this thyroid therapy. In 2017 patients faced similar shortages of Nature-Throid® and WP Thyroid® due to a world-wide shortage of pharmaceutical grade Thyroid USP. NP Thyroid® (Acella Pharmaceuticals) and Armour Thyroid® (Allergan) are two commercially available alternatives that patients and their practitioners may consider if appropriate. NP Thyroid® and Armour Thyroid® are standardized using a different thyroid USP quantity as compared to Nature-Throid® and WP Thyroid® (60mg vs. 65mg). To facilitate patients converting between these different products, the 12 FLORIDA MD - AUGUST/SEPTEMBER 2020

Pain Management | HRT Prescribe topical medications in Topi-CLICK® 140 0.50 mL per CLICK • Accurate, metered dose without losing prime like pumps

• Innovative Design is user-friendly for all patients • 4Port™ for faster dosing of thicker topical medications Request FREE samples for Patient Trials and the International Journal of Pharmaceutical Compounding Peer Reviewed Accuracy Study: www.DoseLogix.com | 877.870.8448 | info.TopiCLICK@teamtech.com

PHARMACY UPDATE forms of desiccated thyroid (Thyroid USP), levothyroxine (T4) and liothyronine (T3), so that we can create a custom blend of hormones at an ideal ratio to meet patients’ individual needs and maintain their hormone balance. Desiccated thyroid, levothyroxine or liothyronine can be compounded as single ingredient or combination capsules designed to release immediately or over a prolonged period of time. When we compound customized dosages, we have the ability to omit any problem-causing inactive ingredients such as corn, gluten, starch, soy or animal by-products and substitute with non-reactive fillers. Commercially available thyroid replacement products may not be the best fit for a patient when: (1) (2) (3) (4) (5) (6)

There is a lack in availability due to drug shortages. Check out our newly redesigned They contain undesirable fillers. They are only available as immediate-release dosage forms. website at www.floridamd.com! Patients require a different strength than what is available. Patients require a unique ratio of T3 and T4 supplementation. Patients require non-porcine derived products and would benefit from both T3 and T4 supplementation.

When changing thyroid medications from one manufacturer to another, the dose may need to be optimized to meet individual needs, this is also true for a compounded personalized thyroid prescription. We can prepare a variety of strengths and combinations of thyroid therapy providing patients with a larger choice of therapy options. A little more or a little less is no problem based on your symptoms and you healthcare prescriber’s professional judgment. Our goal as personalized medicine pharmacists is to meet the individual needs and circumstances of patients and physicians. Without the ability to create customized thyroid replacement therapy patients may be at risk for suboptimal or nonexistent thyroid therapy while these medications are in short supply. REFERENCES AVAILABLE UPON REQUEST.

JuanLopez,PharmD,FAPC, is a personalized medicine pharmacist with Pharmacy Specialists Pharmacy

Compounding in

Altamonte

Springs, FL. For more information on how personalized medicine can help you, please call (407) 260-7002, or email us at Info@MakeRx.com.

2020

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market. Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

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FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

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JUNE –

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JULY –

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AUGUST –

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SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –

Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

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Please call 407.417.7400 for additional materials or information. FLORIDA MD - AUGUST/SEPTEMBER 2020 13

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