Florida md october 2014

OCTOBER 2014 • COVERING THE I-4 CORRIDOR

The Center for Women’s Oncology at Moffitt Cancer Center

Her “Best Chance for Beating Cancer” Often Has a Female Touch

_

[ [ Florida Hospital Medical Group features some of the most renowned cancer programs and award-winning doctors in Central Florida. We remain on the cutting edge of the latest innovations in cancer research, such as regional and national clinical trials. Our unique collaborative methods use revolutionary technology and advanced diagnostics that have made strides in early detection, groundbreaking treatments and exceptional outcomes. Our cancer care teams maintain a true continuum of care, making Florida Hospital Medical Group a destination treatment facility for those battling cancer.

Together, we make becoming a cancervivor possible, visit our new site to learn more.

FHMG-14-21404

www.BeACancervivor.com

FLORIDA MD - OCTOBER 2014

1

contents 6

OCTOBER 2014 COVERING THE I-4 CORRIDOR

 COVER STORY

Photo: Nick Gould / Moffitt Cancer Center

Moffitt Cancer Center belongs to an elite group of cancer centers that has achieved distinction from the National Cancer Institute (NCI). As the only NCI-designated Comprehensive Cancer Center based in Florida, Moffitt is working tirelessly in the areas of patient care, research and education – developing early-stage translational research aimed at the rapid translation of scientific discoveries to benefit patients.

We provide a level of care that stands above the rest. Our team of experts provides a plan that’s right for you, right from the start. The results are shorter treatment times, reduced hospital stays, and improved quality of life during and after treatment. For you that means better outcomes, and your best chance for beating cancer.

ON THE COVER: Dr. Patricia Judson and her team perform exploratory laparotomy to resect ovarian cancer.

Photo: Nick Gould / Moffitt Cancer Center

24 New Group Gives Voice to Independent Doctors

DEPARTMENTS 4

FROM THE PUBLISHER

11 BEHAVIORAL HEALTH 12 HEALTHCARE LAW 14 CANCER 16 PULMONARY & SLEEP DISORDERS 18 ORTHOPAEDIC UPDATE 19 FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT.

21 MARKETING YOUR PRACTice 23 FOOT & ANKLE

2

FLORIDA MD - OCTOBER 2014

Together we can make a difference.

The Breast Care Center of Osceola Regional Medical Center is an all-in-one breast imaging center committed to the prevention, early detection, diagnosis and treatment of breast disease through compassionate, coordinated care.

7i >Ài «À Õ` Ì «À Û `i Ì i >ÌiÃÌ ÌiV }Þ > ` «À viÃà > iÝ«iÀÌ Ãi v > à Ìi L >À` ViÀÌ wi` À>` } ÃÌ specializing in breast images. From digital mammography with the comfort of mammo pads, to the powerful 3T MRI and MRI-guided biopsy, we offer the most advanced treatments.

Breast Care Center at Osceola Imaging Center 730 West Oak Street Kissimmee, FL 34741

www.OsceolaRegional.com

- Tejal Patel, M.D Women’s Imaging Specialist

iÀÌ wi` in Breast Cancer

To schedule your next mammogram, please call (407) 518-4200 or visit OsceolaRegional.com for online pre-registration.

FLORIDA MD - OCTOBER 2014

3

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. “Your child has cancer” are certainly some of the most horrific words a parent can hear. Fortunately The Pediatric Cancer Foundation is actively trying to eliminate childhood cancer and the suffering it brings to families in our community and

across America. I have asked them to tell us a little about the The Sunshine Project and the research they are doing. Please join me in supporting this wonderful organization and the work they are doing to help children. I wish you all a happy, safe and healthy Thanksgiving holiday. Until next month…

Best regards,

Donald B. Rauhofer Publisher

Coming UP Next Month: The cover story focuses on Consulate Health Care centers. Editorial focus is Urology and Geriatric Medicine.

The Pediatric Cancer Foundation Every year, 13,500 children in the United States are diagnosed with cancer and on a global scale that number rises to 175,000.

Cancer remains the leading cause of death by disease in children and despite the serious effects and increasing numbers, childhood cancer research is vastly and consistently underfunded. Only 3.8% of federal government research funding goes to children.

The Pediatric Cancer Foundation is dedicated to funding research to eliminate childhood cancer. They accomplish their mission through their research initiative, The Sunshine Project. The Sunshine Project is an innovative collaboration of 14 hospitals with one goal: to bring together the nation’s top doctors and researchers to fast-track less toxic, more targeted treatments and increase the survival rate for children battling cancer. Moffitt Cancer Center administers PCF’s Sunshine Project.

Annually, the Sunshine Project doctors and researchers meet at a retreat in Tampa to discuss proposed new treatments, case studies, and to participate in an open exchange of ideas and the latest research results. After a review by the Sunshine Project participants, projects are selected for funding by the Pediatric Cancer Foundation.

PCF raises its funds through individual contributions, corporate contributions, grants, planned giving and special events. PCF holds six major events a year and two events are coming up: The Suncoast Credit Union Foundation Fore the Kids Golf Classic on Monday, November 3, 2014 at Westchase Golf Club in Tampa and the AGW Capital Advisors Fashion Funds the Cure fashion show presented by Saks Fifth Avenue, Mercedes-Benz and Bright House Networks on Saturday, February 21, 2015 at Tampa International Jet Center, Hangar #4.

Eighty-six per cent of the Pediatric Cancer Foundation’s total expenses are allocated to their program, The Sunshine Project.

PCF is proud to be a 4-star rated charity by Charity Navigator and GuideStar Gold Participant for sound fiscal management and accountability. For more information about the PCF’s Sunshine Project or special events, please visit www.fastercure.org or call 813-269-0955. 

ADVERTISE IN FLORIDA MD

PREMIUM REPRINTS

For more information on advertising in Florida MD, call Publisher Donald Rauhofer at (407) 417-7400, fax (407) 977-7773 or info@floridamd www.floridamd.com

Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products.

Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

Email press releases and all other related information to: info@floridamd.com

4 FLORIDA MD - OCTOBER 2014

Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Daniel T. Layish MD, Susan J. Hoover, MD, Christopher L. Reeves, DPM, Jamie Huysman, PsyD, Troy A. Kishbaugh, JD, Sarah L. Mancebo, JD, T. Kevin Taylor, Jennifer Thompson, Marni Jameson, Corey Gehrold 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 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

KEEP LIFE FLOWING Elite Vascular Care That’s Lightyears Ahead of the Rest.

Florida Hospital’s innovative approach to vascular care keeps our patient’s lanes clear with the most advanced technologies and less-invasive procedures. Our elite team of vascular surgeons work together to provide each patient with a comprehensive, personalized treatment plan. And, because we treat more vascular patients than any other V^b_WcMZ W] cVR ]McW^]͜ fR Y]^f V^f c^ QRZWeRa bd_RaW^a ^dcP^\Rb M]Q bV^acRa V^b_WcMZ bcMhb cVMc YRR_ ZWSR ů^fW]U͙

CARDIAC-14-19415

Learn more about our Vascular Program at KeepLifeFlowing.org or call (407) 502-5282.

Florida Hospital is ranked the #1 hospital in the state of Florida by U.S. News & World Report.

FLORIDA MD - OCTOBER 2014

5

COVER STORY

The Center for Women’s Oncology at Moffitt Cancer Center Her “Best Chance for Beating Cancer” Often Has a Female Touch

By Heidi Ketler One in three women in the United States will experience cancer in her lifetime, a frightening trend that Moffitt Cancer Center is helping to reverse, with outcomes that are better than the national average.

Ongoing outcomes research throughout Moffitt is used to identify which cancer treatments work best and determine survival rates. It confirms that survival rates at Moffitt are higher than the national average for brain, breast, colon, liver, lung, pancreas and prostate cancers and myeloma.

Moffitt’s focus on the prevention and cure of cancer is credited for its success. Each day, highly trained cancer specialists lead individualized treatment plans and recovery programs that enlist the best medical science has to offer. Multidisciplinary patient care teams, composed of physicians, surgeons, registered nurses and nurse practitioners, research scientists, genetic counselors, nutritionists and integrative medicine specialists are dedicated to screening, diagnosing and treating cancers.

Moffitt’s Center for Women’s Oncology is home to 26 physicians, all of whom are proven leaders in the field of cancer care. Each has completed a fellowship in her or his medical specialty. All have gone through the rigorous process of achieving board certification from their specialty and subspecialty organization.

Fifteen female physicians further enhance treatment at Moffitt’s Center for Women’s Oncology. Among them is gynecologic Dr. Patricia Judson

Dr. Jennifer Drukteinis

oncologist Patricia L. Judson, M.D. Gynecologic oncology is a unique specialty that combines surgery and medical oncology.

There are now approximately 1,000 board-certified gynecologic oncologists in the nation with the majority being male. There are only three female gynecologic oncologists practicing in Tampa, according to Judson. She and Moffitt colleague Hye Sook Chon, M.D., are among them.

“There are times when a female patient who has seen a male doctor will say to me, ‘Oh, my gosh, he never asked me about that.’ It’s a comment that follows quality-of-life questions like, ‘How are you doing emotionally with all of this?’” says Judson, who serves on the Gynecologic Oncology Group’s Quality of Life Committee. “It makes sense that women physicians are more in tune with personal issues that affect women.”

Integrative Medicine Judson’s clinical practice at Moffitt’s Center for Women’s Oncology specializes in minimally invasive radical surgeries – laparoscopies and robotic-assisted laparoscopies – and chemotherapeutic treatment of gynecological malignancies.

“Many gynecologic cancers can now be treated laparoscopically rather than with open surgery, which leaves large incisions,” she says. “This is particularly beneficial for women with endometrial cancer, many of whom tend to be overweight and obese, which increases the risk for complications with open surgery.”

Judson also has a special interest and advanced training in integrative medicine, which combines safe complementary therapies with conventional medical treatments to improve the quality of life for cancer patients during and after treatment.

PhotoS: Nick Gould / Moffitt Cancer Center

Her expertise complements the inpatient and outpatient services provided through the Moffitt’s Integrative Medicine Program. They include: wellness consultations, nutrition consultations, acupuncture, inpatient and outpatient massage, inpatient and outpatient individual yoga and group classes in yoga, meditation, Qigong, tai chi and stress management.

“We know that exercise and weight management play a role (in cancer 6 FLORIDA MD - OCTOBER 2014

PhotoS: Nick Gould / Moffitt Cancer Center

COVER STORY

Breast tomosynthesis, or 3D mammography, is offered at Moffitt Screening & Prevention. Tomosynthesis produces a three-dimensional view of the breast tissue that helps radiologists identify harmless abnormalities from real tumors, leading to fewer callbacks and less anxiety for women.

risk), but it’s difficult to subanalyize. Many cancers are estrogen driven such as colon, endometrial, breast and ovarian cancer. We make estrogen in our fat; therefore, being overweight or obese places one at risk for developing these cancers and also increases one’s risk of recurrence,” Judson says.

“When patients come in, they are in very different mindsets, which determine what we do in the initial appointment. I try to focus at some point either during or after their treatment on improving diet and exercise, and make sure they understand what they can do to enhance that,” she says.

Judson’s interest in integrative medicine led her to become one of only a few gynecologic oncologists to complete physician training in acupuncture, which she performs for patients during clinic visits. While effectiveness varies according to the individual, she says, acupuncture for some alleviates such side effects as pain following surgery, nausea and vomiting associated with chemotherapy, even hot flashes in women whose ovaries have been removed and who have had breast cancer and can no longer take estrogen-based supplements for hormonal relief.

“We won’t cure cancer with integrated medical technology,” Judson says. “It’s really about quality of life and making people more comfortable with the therapies they are receiving.”

Before coming to Moffitt, Judson was a tenured associate professor at the University of Minnesota, where she also served as director of the gynecological oncology fellowship program. She was a Sime research fellow at the Center for Spirituality and Healing, and there she completed a two-year research fellowship in

alternative therapies for women with gynecologic cancers. She is now an associate professor at the University of South Florida College of Medicine.

Translational Research Moffitt is one of 41 National Cancer Institute-designated comprehensive cancer centers in the country and the only one based in Florida. The designation is bestowed on institutions that have significant peer-reviewed research funding; high-quality programs in basic, translational and population research; and are dedicated to developing more effective approaches to cancer prevention, diagnosis and therapy; educating health care professionals and the public; and reaching out to underserved populations.

“Because there are numerous clinical trials open at Moffitt at any given time, patients have access to medical advances that are not otherwise available for treatment,” says Judson. She encourages her patients to participate when appropriate, though clinical trials may have requirements – such as cell type and treatment stage – that limit eligibility. “We try to have something open for every disease site and place in treatment.”

Moffitt’s research spans basic science, prevention and clinical research, with a focus on translating discoveries into better care.

Development of early-stage translational research aims for rapid “translation” of scientific discoveries into better patient care.

Judson is recognized for her role as a principal investigator of several significant clinical trials and authoring more than 60 studies. She is a member of the national Gynecological Oncology Group, and her work has examined standards of cancer treatFLORIDA MD - OCTOBER 2014

7

Photo: Nick Gould / Moffitt Cancer Center

COVER STORY

Moffitt’s automated breast ultrasound technology (ABUS) helps to increase breast cancer detection for women with dense breast tissue.

ments, including radiation and chemotherapy, as well as complementary and alternative therapies and their effects on women and cancer outcomes.

Currently, Judson is chief investigator of a human-safety study of fermented wheat germ extract (FWGE). The study is set to start this fall. Invented in the early 1990s in Hungary, FWGE differs from ordinary wheat germ in that it is fermented with baker’s yeast to concentrate biologically-active benzoquinones.

Judson’s previous study, “Characterizing the Efficacy of Fermented Wheat Germ Extract Against Ovarian Cancer and Defining Genomic Basis of Its Activity,” laid the foundation for ongoing research. Funded in part by a $10,000 Moffitt Merit Society® grant awarded to Judson in 2011, this early study confirmed that FWGE is effective in killing a wide range of ovarian cancer cells, while simultaneously enhancing the cancer-fighting qualities of certain chemotherapy treatments. The findings were published in the July 2012 issue of International Journal of Gynecological Cancer.

Prior to her FWGE studies, anecdotal observations by patients about their experiences with the natural product inspired Judson to investigate the scientific basis for effective and safe treatment.

“It’s a good example of translational – bench to bedside – medicine,” she says.

Expedited Outpatient Care on New McKinley Campus Today, patients with breast, ovarian, cervical, endometrial, vulvar, and vaginal cancers or gestational trophoblastic disease are provided state-of-the-art care in an elegant, warm and caring environment.

In the past four years, Moffitt has experienced tremendous 8 FLORIDA MD - OCTOBER 2014

growth, and Moffitt Cancer Center’s main campus at the University of South Florida is at full capacity. In the Center for Women’s Oncology, the number of breast cancer patients has increased 38 percent, and women’s cancers have risen 33 percent since 2010.

Construction of a new six-story facility on a nearly 30-acre campus on North McKinley Dr. will give Moffitt the needed space to grow and continue its mission to contribute to the prevention and cancer cure. “We needed to decompress the original campus. If we can’t grow, we can’t take on new patients; if we can’t grow we can’t do new research. If we can’t do new research we can’t find a cure,” says Vicki Caraway, R.N., B.S.N., M.B.A., administrative director of the new McKinley campus.

According to Caraway, the new McKinley campus will provide “expedited surgical services for outpatient cases, expanded clinics, radiology services, infusion and other support services.”

When it opens in the fall of 2015, the $88.8 million, 207,000square-foot McKinley building will be home to Moffitt’s breast and cutaneous cancer programs and associated imaging. Four new outpatient surgery suites will serve patients with head and neck cancer and sarcoma, as well as breast and skin cancers.

“When conceptualizing McKinley, we focused on what cancer programs involve the most outpatient surgeries and procedures and what made sense to move offsite and keep together,” says Caraway. Ongoing patient input during the design phase was key.

“We’re keeping the same level and model of care and minimizing fragmented care to maintain the integrity of Moffitt’s multidisciplinary model,” Caraway says. “Less back-and-forth reduces the burden on one’s time and stress.”

COVER STORY The new facility also will include: Centralized registration for quick check in on the first floor An infusion center A clinical research center A pharmacy and retail space Administration and faculty offices Conference rooms with video-conferencing Dining areas Seven-story parking garage with 1,300 spaces.

To assure the integrity of Moffitt’s comprehensive treatmentto-trial model of care, a host of supportive services are destined for McKinley. “The staff at the McKinley site will number around 150 people,” says Caraway. “Some of them will be moving over from the original campus, but expanded services here mean new jobs for people in the community.”

The McKinley campus “is about a mile and a half from the main campus as the crow flies and a 10-to-15-minute drive doorto-door, depending on traffic,” says Caraway. “So if a patient needs to have a CAT (computerized axial tomography) scan, they can have it done at the main campus or at the McKinley campus, whatever is more convenient.”

Cancer Prevention and Early Detection Moffitt Screening and Prevention plays a central role in Moffitt’s mission, offering a wide range of clinical cancer screening services and extensive community education outreach opportunities.

It is home to Moffitt’s more comprehensive and up-to-date breast imaging technologies, 3D mammography and automated breast ultrasound (ABUS).

Breast imaging radiologist, Jennifer Drukteinis, M.D., credits breast tomosynthesis, or 3D mammography, as the most exciting and promising new technology in breast imaging. It obtains multiple “slices” through the breast, creating a three-dimensional view of the breast tissue that helps radiologists identify and characterize individual breast structures without the confusion of overlapping tissue.

“This is particularly beneficial to patients with dense breast tissue. The images are much sharper and give us a better look at any suspicious masses or areas of architectural distortion. Tomosynthesis has been proven in multiple studies to detect 40 percent more invasive cancers than standard 2D digital mammography alone. It also reduces the number of patients we have to call back for additional imaging, eliminating much of the anxiety and inconvenience of additional imaging,” says Drukteinis Automated breast ultrasound technology is another option for women with dense breast tissue. Using ABUS, radiologists can look through hundreds of breast tissue image “slices,” viewing layers of dense tissue to find breast cancers that may have been missed on a mammogram. Moffitt is the only hospital in Florida that uses the General Electric Invenia 3rd Generation ABUS technology.

“Three-dimensional mammography and ABUS scans offer a better chance at diagnosing breast cancer early, at a more treatable stage, in women with dense breasts,” adds Drukteinis.

Moffitt Cancer Center gynecologic oncologists focus solely on women’s cancers, providing care through a comprehensive, multidisciplinary approach that aims for better patient outcomes.

Photo: Nick Gould / Moffitt Cancer Center

• • • • • • • •

FLORIDA MD - OCTOBER 2014

9

Photo: PROVIDED BY Moffitt Cancer Center

COVER STORY

In 2013, Moffitt broke ground on a $74.2 million outpatient facility on its McKinley campus.

The Moffitt McKinley Center is scheduled to open in fall 2015.

PhotoS: Nick Gould / Moffitt Cancer Center

In addition to breast cancer screening services, Moffitt Screening and Prevention offers comprehensive cancer screenings for all cancer sites, dual-energy X-ray absorptiometry bone density exams, genetic risk assessment services, smoking cessation tools and cancer survivorship services.

To schedule an appointment at Moffitt Screening and Prevention, call (813) 7453980 or (888) 860-2778.

Physician Referral Refer2Moffitt.com is an online resource for referring physicians and their staff, developed to assist in accessing Moffitt’s resources and services. Moffitt Medical Group members are dedicated to Moffitt’s mission to contribute to the prevention and cure of cancer. For more information about Moffitt Cancer Center, visit MOFFITT.org.

Dr. Patricia Judson is a gynecological oncologist in the Center for Women’s Oncology at Moffitt and an associate professor at the University of South Florida College of Medicine. She specializes in surgical and chemotherapeutic treatments for gynecologic (GYN) malignancies.

Dr. Judson has a particular interest in minimally invasive surgery, integrative medicine and therapeutic clinical trials. She serves on the national Gynecological Oncology Group Scientific Advisory Committee and is a principal investigator for numerous research studies. In addition, she completed postgraduate acupuncture physicians training and conducts research on how complementary and alternative therapies affect the outcome for GYN cancer.

A graduate of the University of Minnesota School of Medicine, Dr. Judson completed a residency in obstetrics and gynecology at the University of California, San Francisco, and a fellowship in gynecological oncology at the University of North Carolina, Chapel Hill.

Dr. Jennifer Drukteinis is an assistant member in the Department of Diagnostic Imaging at Moffitt Cancer Center. She earned her medical degree from Cornell University Medical College. She completed a Radiology Residency at Mount Sinai Medical Center and Brigham and Women’s Hospital. She also completed a Body Imaging Fellowship at Brigham and Women’s Hospital. 

Moffitt Cancer Center 12902 Magnolia Drive • Tampa, Fla. 33612 1-888-MOFFITT • www.MOFFITT.org 10 FLORIDA MD - OCTOBER 2014

Behavioral Health

Every Day Should be National Depression Screening Day COVER STORY

By James D. Huysman, PsyD, LCSW The healthcare delivery system may be changing but one thing that has not changed is the rate of depression in boomers and seniors today. For far too often, depression has gone undetected and often ignored. The healthcare system seldom looked at it as part of the medical world and instead carved it out to other providers whose responsibilities were the mental health side of medical care. Thank heavens, with the changes in healthcare, all of this will likely change.

As quality, access and costs become the mantra, so will healthcare providers and family caregivers will be much more prone to treat depression and realize that if left untreated, it will be like pouring gasoline on an open fire. Depression, in and of itself is a debilitating condition, but when you add it to heart conditions, diabetes and other chronic medical conditions, providers and family caregivers will experience poorer outcomes, less adherence to medication directives and overall poorer quality of care. In all likelihood, untreated depression will also skyrocket the costs associated with a chronic condition. Patients will surely get more comprehensive treatment, as a result. But, as always, I have to ask the question, what about the family caregivers of these patients?

Caregivers of the chronically ill are prone to grief and depression as a natural part of that journey. Current statistics support this. Grieving about the person they care for and the promise of an unknown future may lead to sleeplessness, feelings of hopelessness and sadness, fatigue, and many more.

One in four adults, approximately 61.5 million Americans, experiences mental illness in a given year according to the National Institutes of Health. One in 17, about 13.6 million, lives with a serious mental illness such as schizophrenia, major depression or bipolar disorder.

African American and Hispanic Americans used mental health services at about one-half the rate of whites in the past year and Asian Americans at about one-third the rate are the statistics reported in a 2010 report from Agency for Healthcare Research and Quality. Of course it is difficult to assess whether these numbers are a result of shame and stigma or the lack of access to mental health services. My hypothesis is that depression is also underdiagnosed and undertreated in these cultures as well.

So whether you are a clinical provider or a family caregivers, it important to recognize the symptoms of depression and find support for those feelings for your patient, your loved ones and even, yes, yourselves. You’re not crazy; you’re human, so why not be proactive and get a free screening on October 9th, which is National Depression Screening Day? When we look at ourselves, we set an example for our loved ones and patients. We say it is OK to seek help out. No one has to live with depression today. We have come so far in dealing with it pharmaceutically, psychosocially

and through integrative medicine.

National Depression Screening Day (NDSD) began in 1991 as an initiative to reach individuals across the nation with important mental health education and connect them with support services. Twenty-three years later, NDSD has expanded to thousands of colleges, community-based organizations, and military installations providing the program to the public each year.

Give yourself and/or a loved one the gift that keeps on giving.

For information on where to get your free in person or online screening, go to www.HelpYourselfHelpOthers.org.

Dr. James Huysman, PsyD, LCSW, aka Dr. Jamie, is a fierce advocate of patient-centered healthcare. He is a popular conference speaker and media guest on caregiver burnout, compassion fatigue and addictions and healthcare reform. Dr. Jamie blogs for Psychology Today and sat on the NASW committee to establish national protocols for certification and standardization of caregiving practices. He writes for Florida MD and Today’s Caregiver magazines. He co-founded the Leeza Gibbons Memory Foundation and created the signature programming for its psychosocial drop-in model, Leeza’s Place, opening 8 national locations, each with a different funding partner, in a four year period. He co-wrote the acclaimed book, Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One with Memory Loss, with Gibbons and Dr. Rosemary Laird. He currently works as Vice President of Provider Relations and Government Affairs for WellMed Medical Management in Florida, a UnitedHealthcare company. 

K]Y Fgl]k H`glg_jYh`q <gfYd\ JYm`g^]j À H`glg_jYh`]j @]Y\ K`glk :jg[`mj]k E]]laf_k =n]flk HgjljYalk 9j[al][lmjYd

,G/%,)/%/,GG FLORIDA MD - OCTOBER 2014 11

Healthcare Law

Non-Euphoric Medical Marijuana Legalized in Florida to Treat Cancer Patients

By Troy A. Kishbaugh, JD, BCS and Sarah L. Mancebo, JD The Florida Legislature passed the Compassionate Medical Cannabis Act of 2014 on May 2, 2014, known as “Charlotte’s Web,” to legalize the use and possession of medical marijuana.

Governor Rick Scott signed the law on Jun 16, 2014, making it legal in Florida.

Charlotte’s Web authorizes physicians licensed under the Florida Statutes 458 (medical doctors) and 459 (doctors of osteopathy) to order low-THC cannabis beginning January 1, 2015 to treat qualified patients for cancer or symptoms of cancer, as well as patients with physical medical conditions that chronically result in seizures or severe and persistent muscle spasms.

Low-THC medical marijuana contains 0.8 percent or less of tetrahydrocannabinol (“THC”) and more than 10 percent of cannabidiol, making this type of marijuana non-euphoric.

There are several conditions that must exist for a physician to order low-THC cannabis for a cancer patient. Some of the key conditions are as follows: • No other satisfactory alternative treatment options exist for the particular patient.

• The physician makes a determination that the risks of ordering low-THC cannabis are reasonable based on the potential benefit for the patient. A second physician must agree with the initial physician’s determination if the patient is a minor.

• The physician registers as the orderer of low-THC cannabis for the named patient on the Compassionate Use Registry that is operated and regulated by the Department of Health, Office of Compassionate Use (the “Department”). It is the physician’s duty to update the registry to reflect the contents of the patient’s order and deactivate the patient’s registration when medical use low-THC treatment is discontinued.

• The physician must maintain a patient treatment plan specifying the dose, route of administration, planned duration, and monitor the patient’s symptoms and other indicators of tolerance or reaction to the treatment.

• The physician must obtain voluntary informed consent from the patient or the patient’s legal guardian after explaining the current medical knowledge of the effectiveness of low-THC cannabis treatment, medically acceptable alternatives and the potential risks and side effects.

Charlotte’s Web also requires the Department to adopt regulatory rules by January 1, 2015 to help implement the law. These rules are currently in draft form and recently three interested parties have filed lawsuits against the Department challenging their 12 FLORIDA MD - OCTOBER 2014

enactment. It remains to be seen whether these lawsuits will delay the January 1, 2015 deadline for rule adoption and physician authority to begin ordering low-THC medical marijuana for qualifying patients.

Troy A. Kishbaugh , JD, BCS

Noteworthy, the Florida voters will also consider passage of Constitutional Amendment 2 on November 4, 2014, which if approved, would legalize a broader use and possession of medical marijuana for patients with cancer, glaucoma, HIV, AIDS, Hepatitis C, ALS, Crohn’s disease, Parkinson’s disease, multiple sclerosis and other conditions for which a Sarah Logan Mancebo, JD physician believes qualify as a debilitating medical condition.

For more information on medical marijuana, please contact Troy A. Kishbaugh or Sarah L. Mancebo with Gray Robinson’s Health Care Practice Group.

Troy A. Kishbaugh, JD, BCS, is an equity shareholder and Chair of the Health Care Practice Group with Florida’s leading law firm, GrayRobinson P.A. Troy focuses his practice in the area of health care law which includes, medical/health corporate law issues, Medicare/Medicaid, fraud and abuse, false claims, billing and reimbursement, corporate compliance, PPACA, HIPAA, health information technology, EMTALA, Stark, self-disclosure and exclusions, and daily hospital operational issues. He may be contacted by calling (407) 244-5673; troy.kishbaugh@ gray-robinson.com or by visiting www.gray-robinson.com.

Sarah L. Mancebo, JD, is an attorney in the Health Care Practice Group with Florida’s leading law firm, GrayRobinson P.A. Sarah focuses her practice in the area of health care law which includes, medical/health corporate law issues, Medicare/Medicaid, fraud and abuse, false claims, billing and reimbursement, corporate compliance, PPACA, HIPAA, health information technology, EMTALA, Stark, self-disclosure and exclusions, and daily hospital operational issues. She may be contacted by calling (407) 2445642; sarah.mancebo@gray-robinson.com or by visiting www.gray-robinson.com. 

INTRODUCING A NEW ERA IN

BLOOD & MARROW TRANSPLANTATION We are also introducing our new name. As Central Floridaâ&#x20AC;&#x2122;s first and only comprehensive blood and marrow transplant center, we have changed our name to the Blood & Marrow Transplant Center.

After more than a decade of providing successful stem cell treatments for blood disorders and hematologic malignancies, including over 900 blood and marrow transplants, we are expanding our team and the capabilities.

Yasser Khaled, MD

Wesam Ahmed, MD, PhD, MSc

Shahram Mori, MD, PhD

Rushang D. Patel, MD, PhD, FACP

PROVIDING ADVANCED TREATMENTS AND IMPROVED IMMUNE SYSTEMS

(formerly Florida Center for Cellular Therapy) 2501 North Orange Avenue, Suite 581, Orlando, FL 32804 407.303.2070 office | 407.303.2071 fax

www.BloodandMarrowTransplantCenter.com FLORIDA MD - OCTOBER 2014 FHMG-14-20708

13

CANCER

Improving Outcomes with Personalized Radiation Therapy for Breast Cancer Patients

By Susan J. Hoover, MD, FACS, Associate Member of the Center For Womenâ&#x20AC;&#x2122;s Oncology at Moffitt Cancer Center For those of us who have treated breast cancer patients for any extended period of time, we likely have tales of watching the treatment of this disease evolve to levels many of us could only have imagined. Noteworthy in the last several years is the popularization of breast conservation surgery and the advancement of radiation options that go hand-in-hand with it.

With this trend toward more minimally invasive techniques in the treatment of breast cancer, it is disappointing to see that some studies demonstrate that mastectomy rates are higher among patients that live far away from radiation centers. A 2005 study in the Journal of Clinical Oncology1 found this to be true with a 40% mastectomy rate in women that lived less than 10 miles from a radiation center and 55% in those that lived greater than 50 miles away from a center. Additionally, even among women who have elected to undergo a lumpectomy and the required radiation therapy, it has also been shown that the greater the distance the patient lives from a radiation center, the lower the patient compliance is with undergoing the radiation. A second study in the Journal of the National Cancer Institute2 (2000) showed that those Intraoperative radiation therapy (IORT) can reduce treatment times. During IORT, living less than 25 miles from a radiation facility had radiation oncologists deliver a single dose of radiation in one treatment session. surprisingly only an 84% compliance rate, which deIntraoperative radiation therapy delivers a clines even further with increasing distance such that 42% of lumpectomy patients concentrated dose of radiation therapy to the living >100 miles from a radiation facility actually completed the recommended course, tumor while preserving healthy tissue. thus leaving themselves at increased risk of breast cancer recurrence.

A whole host of radiation therapy regimens are now available to help provide women interested in breast conservation the possibility of annotated treatments, thus giving some women the option to save their breasts in lieu of mastectomy. These additional options for shorter courses of radiation are helping ensure radiation compliance and increasing feasibility of lumpectomy for some women. In addition to the gold standard of conventional whole breast radiation, given over 6 weeks, the Moffitt Cancer Center has been offering appropriately selected candidates shorter courses of radiation after lumpectomy including hypofractionated whole breast radiation therapy over 3-4 weeks, accelerated partial breast irradiation (APBI) over 1 week and intraoperative radiation therapy (IORT) given in 1 treatment while the patient is still under anesthesia at time of lumpectomy.

In respect to the employment of APBI and IORT, it is recognized through multiple clinical trials that approximately 90% of the time, local recurrences after breast conservation therapy occur within the index quadrant of the breast, near the original tumor bed. This has hence created a platform for these more localized radiation treatments designed to focus the radiotherapy to the lumpectomy cavity, which is the area most likely to fail and form a recurrence. It has also been observed in studies that partial breast radiation therapies, like IORT, lower the overall toxicity and burden of radiation by allowing the use of a lower dose of radiation, administered in fewer fractions, over a shorter period of time, while sparing the rest of the breast and the surrounding organs the effects of radiation therapy. Specifically, these therapies may also eradicate or reduce many of the possible side effects commonly seen with EBRT including: 14 FLORIDA MD - OCTOBER 2014

CANCER • • • • •

skin irritation/pigmentation changes breast tissue fibrosis fatigue heart and lung exposure effects to the normal, healthy breast tissue Moffitt has found success with the INTRABEAM® Radiotherapy device that is employed to deliver IORT. The system comes with several applicators of various sizes that are mounted on the X-ray source. The breast tissue is then conformed around the applicator/X-ray source, and then 20 Gy in one fraction is delivered to the lumpectomy cavity for approximately 20-40 minutes, depending on the size of the applicator. The INTRABEAM® was used internationally as part of the TARGeted Intraoperative radioTherapy (TARGIT-A) Trial comparing IORT to traditional whole breast external beam radiation therapy (EBRT).

The TARGIT-A trial, randomized 3451 women equally to IORT and external beam whole breast radiation therapy with the 5-year results for local control and overall survival published in Lancet February 2014. The data showed that when IORT was given with lumpectomy, the 5-year local recurrence rate was similar to EBRT. As well, breast cancer mortality between the 2 groups was also similar.

IORT has allowed some women to undergo lumpectomy who otherwise would have chosen a mastectomy due to work situations, transportation issues or personal/family circumstances that made travel to a radiation facility 5 days a week for 6 weeks difficult to execute. IORT allows for them to choose a lumpectomy, if that is their surgical treatment of choice, without the worry of completing the necessary radiation that must follow a lumpectomy.

Although an enticing option, it is key to emphasize that IORT and APBI are not for every breast cancer patient. The American Society for Radiation Oncology (ASTRO) published a consensus statement for accelerated partial breast irradiation providing guidance for patient selection and includes the following factors to be considered.

Optimal candidates: • 60 years old • Tumor size < 2cm • Surgical margins > 2mm • Estrogen receptor positive tumors • Invasive Ductal Carcinoma histology • Lymph node negative “Cautionary” candidates: • 50-59 years old • Tumor size 2.1-3.0 cm • Surgical margins < 2mm • Estrogen receptor negative tumors • Invasive Lobular Carcinoma histology • Pure DCIS < 3cm Since January 2011, Moffitt has treated over 100 women with IORT. This technique has provided our patients with early stage

Intrabeam is a miniature and mobile X-ray source which emits low energy X-ray radiation in isotropic distribution.

breast cancer an option that is state-of-the-art, allowing many of them latitude in their surgical decision making with equivalent outcomes to more traditional radiation modalities. It is vital to remember that application of such pioneering techniques as IORT requires a team approach of surgeons and radiation oncologists vigilantly selecting appropriate candidates to ensure translation to optimal outcomes and patient satisfaction.

Susan Hoover, MD, FACS, is a board certified surgical oncologist specializing in breast cancer in The Center for Women’s Oncology at Moffitt Cancer Center. She returned to Moffitt after several years of practice at the M.D. Anderson Cancer Center in Houston, Texas.

In addition to performing breast surgeries, such as mastectomies and lumpectomies, she has special expertise in minimally-invasive surgery techniques, incorporating sentinel lymph node biopsy, breast ultrasound, breast needle biopsy and accelerated partial breast irradiation into her patient care.

Dr. Hoover has held national committee appointments in the Society for Surgical Oncology, the American Society of Breast Surgeons and the Association of Women Surgeons. She has been chosen by her peers for listing in Best Doctors in America® since 2009.

Citations: 1. Shroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL Jr. Impact of Patient Distance to Radiation Therapy on Mastectomy Use in Early-Stage Breast Cancer Patients. J Clin Oncol. 2005 Oct 1; 23(28):7074-80.

2. Athas WF, Adams-Cameron M, Hunt WC, Amir-Fazli A, Key Cr. Travel Distance to Radiation Therapy and Receipt of Radiotherapy Following Breastconserving Surgery. J Natl Cancer Inst. 2000 Feb 2; 92(3): 269-71 

FLORIDA MD - OCTOBER 2014 15

PULMONARY AND SLEEP DISORDERS

Exciting New Potential Treatment Options for Patients with Idiopathic Pulmonary Fibrosis

By Daniel T. Layish, MD Idiopathic pulmonary fibrosis (IPF) is also known as usual interstitial pneumonitis (UIP). There are estimated to be 48,000 new diagnoses of IPF per year in the United States, with 40,000 deaths per year. About two thirds of patients with IPF pass away within five years of diagnosis. At this point, there is no specific therapy available. For many years, combination therapy with prednisone and azathioprine has been used. However, the PANTHER trial revealed convincingly that combination therapy with prednisone and Imuran actually resulted in greater mortality, more hospitalizations, and more serious adverse events than placebo. Therefore, combination therapy with azathioprine and prednisone is no longer recommended. At this point, treatment of IPF is essentially supportive including supplemental oxygen, pulmonary rehabilitation and vaccination against Streptococcus pneumoniae and influenza. Lung transplant can also be considered when appropriate.

addition, the average decrease in FVC from baseline was lower in the Pirfenidone group versus the Placebo group (235 versus 428 mL). Furthermore, the proportion of patients who had no decline in FVC was 132% higher in the Pirfenidone group than in the Placebo group and there was also less decline in the 6-minute walk distance in the Pirfenidone group compared to the Placebo group as well as better progression free survival. However, there

Pirfenidone is an antifibrotic agent, which has now been shown in several clinical trials to reduce disease progression and improve progression free survival in patients with IPF. Pirfenidone inhibits the synthesis of transforming growth factor Beta, which plays a role in cell proliferation and differentiation. There have been two previous phase III trials of Pirfenidone that seem to have conflicting results. One High resolution chest CT image in a patient with UIP. Features include a basilar and peripheral study (published in 2010) showed that Pirpredominance, heterogeneity, reticular opacities and honeycombing. fenidone slows disease progression while another study (published in 2011) did not meet its end point. was no significant difference in dyspnea score and all cause morHowever, this last study did have some trends that were in a positality or disease specific mortality between the two groups. tive direction; this resulted in the FDA requesting the â&#x20AC;&#x153; AssessThere has been a pooled analysis of data from all three Pirment of Pirfenidone to Confirm Efficacy and Safety in Idiopathic fenidone trials, which revealed that the overall risk for death at Pulmonary Fibrosis Studyâ&#x20AC;? (ASCEND). The result of this study 52 weeks was lower in the Pirfenidone group versus the placebo was published several months ago in the New England Journal group with a hazard ratio of 0.52. In this pooled analysis Pirfeniof Medicine. In the ASCEND study, 278 patients with IPF were done improved both all cause mortality and disease specific morrandomized to receive Pirfenidone 2403 mg per day for 52 weeks. tality. The most common side effects included gastrointestinal 277 patients were randomized to receive Placebo. The primary and skin related adverse effects, but these rarely led to treatment endpoint was forced vital capacity and secondary end points indiscontinuation. Unfortunately, patients on Pirfenidone do not cluded 6-minute walk test distance, progression free survival, dysnecessarily perceive improvement and Pirfenidone is certainly pnea, overall mortality and disease specific mortality. The propornot a cure for this serious illness. Nevertheless, it appears to be tion of patients who had an absolute reduction of at least 10% in a good option for slowing down the progression of this serious predicted forced vital capacity (FVC) or who died was 47.9% less condition and based upon the data outlined above the FDA has in the Pirfenidone group as compared to the Placebo group. In 16 FLORIDA MD - OCTOBER 2014

PULMONARY AND SLEEP DISORDERS made Pirfenidone available on an Early Access Program.

References available upon request.

Another potential option for treating UIP/IPF is Nintedanib.

This is a tyrosine kinase inhibitor that targets growth factors including the vascular endothelial growth factor receptor, fibroblast growth factor receptor and platelet derived growth factor receptor. In May 2014, Luca Richeldi et al published the results of two 52 week randomized, double blind phase 3 studies of nintedanib (150 mg twice/day) versus placebo in the New England Journal of Medicine. 1066 patients were enrolled in a 3:2 randomization.

The adjusted annual rate of change in FVC was negative 115 ml with Nintedanib versus negative 240 ml with placebo. Diarrhea occurred in over 60 percent of patients on Nintedanib but led to discontinuation in less than five percent.

In conclusion, IPF/UIP is a relatively common and progressive pulmonary disorder. There are currently no specific FDA approved therapeutic options. Pirfenidone and Nintedanib are two promising agents that appear to slow down the progression of this disease. Further research needs to be done to identify agents that can reverse pulmonary fibrosis. Pirfenidone is now available under an Early Access Program to appropriate patients with IPF, and Nintedanib will soon be available as well under such a program.

To refer a patient for either Early Access Program call 407-8411100 ext 121 or email: research@cfpulmonary.com.

RAVENHEART GRAPHIC Design • Illustration • Photography •

407-292-6609 • 407-414-3359 Coming UP Next Month: The cover story focuses on Consulate Health Care centers.

Editorial focus is Urology and Geriatric Medicine.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com.



HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

ORTHOPAEDIC SUBSPECIALTIES

UÊ Ê Ê

UÊ "7 UÊ ""/ÊEÊ UÊ ÊEÊ7, -/ UÊ * UÊ UÊ- "1 , UÊ" " " 9 UÊ* /, UÊ-*",/-Ê

UÊ* Ê / UÊ* 9- Ê/ , *9

SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE OVIEDO SATURDAY WALK-IN CLINIC NO APPOINTMENT NECESSARY | 9AM - 1PM Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona

REQUEST YOUR APPOINTMENT AT ORLANDOORTHO.COM 407.254.2500 FLORIDA MD - OCTOBER 2014 17

ORTHOPAEDIC UPDATE

In, Out and Back to What She Loves with Outpatient Partial Knee Replacement Surgery

By Corey Gehrold Does a stiff or painful knee keep you from performing activities you want or need to do? If you have severe osteoarthritis, a partial knee replacement surgery may be the best option to get you back to doing what you love.

But instead of spending several nights in the hospital, what if you could go home just a few hours after surgery? What if a highly skilled therapy team came to your house to get you back to using your knee(s) without pain again?

Thanks to advances in technology, approximately two out of every three patients in need of a partial knee replacement are candidates for the outpatient setting. Best of all, patients report higher satisfaction scores when compared to the identical procedure done in a hospital setting.

Jennifer, a patient of Orlando Orthopaedic Center’s Jeffrey P. Rosen, M.D., recently underwent the outpatient partial knee replacement and she couldn’t be happier with the results. “It has really worked,” she exclaims. “I spent about a year and a half trying to favor both knees, but I’m so glad I had the procedure and Dr. Rosen has just been great.”

surgery center, located across the street from the main downtown office, for this and many other procedures “This facility provides the surgeon with the benefit of having dedicated anesthesia and surgical staff to assist with each and every patient, again helping to ensure consisJeffrey P. Rosen, MD tent quality care,” he adds.

Recovery from Outpatient Knee Replacement

What is an Outpatient Knee Replacement?

Advances in surgical techniques and pain management have helped minimally invasive surgery revolutionize knee replacements. As a result, patients can be in and out of surgery and on their way home from a partial knee replacement the same day.

“I was out in about five hours; and [Dr. Rosen] stays right with you and tells you everything you need to know before you go in and also when you come out,” she says. “He makes sure everything’s okay before you go home.”

The outpatient partial knee replacement involves specialized techniques and instruments to enable surgeons like Dr. Rosen to perform major surgery without a large incision. The typical incision for this procedure is three to four inches, versus the standard approach and incision, which is typically eight to 12 inches.

This allows the surgeon to work between fibers of the quadriceps muscle instead of making an incision through the tendon, resulting in less tissue damage, decreased pain levels, less recovery time and better function when healed due to less scar tissue formation. The rest of the outpatient partial knee replacement works just like a traditional partial knee replacement. The damaged part of the joint is removed from the surface of the bones. The surfaces are then shaped to hold an artificial joint, attached with a special polymer. When fit together the parts form the joint of the new knee joint, providing a return to function without pain once recovered.

“Thanks to an increased emphasis on the development of preop and post-op care along with advances in technology, there’s now an environment where surgeons can perform the partial knee replacement surgery in an outpatient surgery center rather than a hospital,” says Dr. Rosen.

Orlando Orthopaedic Center utilizes their very own outpatient 18 FLORIDA MD - OCTOBER 2014

Jennifer was out of the surgery center just five hours after her outpatient partial knee procedure.

Prior to the procedure, patients are provided with essential information regarding their recovery and with the home equipment they will need for a quick recovery.

“Most patients will have completed rehabilitation and be fully healed in just six weeks,” says Dr. Rosen. “This includes two weeks of assistance from home health and in-home physical therapy. After the initial two weeks, the patient will transition to an outside rehabilitative therapy program.”

With the outpatient partial knee replacement, patients report better pain management, quicker rehabilitation, expedited return to recreational activity and the elimination of the risks of hospitalacquired infections.

An added benefit of keeping 2/3 of the knee with this procedure is patents reporting a much more natural feel when compared with a total knee replacement.

“In the partial knee replacement, we maintain all natural ligaments, most of the knee cartilage, and the surgery only affects a small part of the joint,” says Dr. Rosen. “Most patients feel the knee is ‘back to normal’ after an appropriate period of healing and rehabilitation.”

Jennifer says she has had no problems with her new partial knee and she is back to the life she had before feeling uncomfortable knee pain.

“Done with the right patient, the outpatient partial knee replacement has proven to yield excellent results,” says Dr. Rosen. 

Financial Update: Insurance • Benefits • Wealth Management

Top 10 To-Do List for 2014 YearEnd Tax Planning

By T. Kevin Taylor, JD, LLM

Are you doing everything you can to minimize your taxes this year? If not, it may be time for a fresh look. The tax law – and your tax picture – changes from year to year. A year-end review can suggest new tax-saving opportunities and show you new ways to take advantage of various planning strategies. There are far too many tools and techniques to outline in this brief article. However, here are 10 general steps you can take that may uncover ways to reduce your overall burden.

tions as you weigh any moves relating to timing deductions.

5. Factor in the AMT

Effective planning requires that you have a good understanding of your current tax situation, as well as a reasonable estimate of how your circumstances might change next year. There’s a real opportunity for tax savings when you can assess whether you’ll be paying taxes at a lower rate in one year than in the other. In addition, most strategies will be effective only if they are implemented before year end, so carve out time and begin your planning soon!

If you’re subject to the alternative minimum tax (AMT), traditional year-end maneuvers such as deferring income and accelerating deductions can have a negative effect. Essentially a separate federal income tax system with its own rates and rules, the AMT effectively disallows a number of itemized deductions, making it a significant consideration when it comes to year-end tax planning.

For example, if you’re subject to the AMT in 2014, prepaying 2015 state and local taxes probably won’t help your 2014 tax situation, but could hurt your 2015 bottom line. Taking the time to determine whether you may be subject to AMT before you make any year-end moves can save you from making a costly mistake.

2. Defer income

6. Maximize retirement savings

Consider any opportunities you have to defer income to 2015, particularly if you think you may be in a lower tax bracket then.

For example, you may be able to defer a year-end bonus or delay the collection of business debts, rents, and payments for services.

Doing so may enable you to postpone payment of tax on the income until next year.

Deductible contributions to a traditional IRA and pretax contributions to an employer-sponsored retirement plan such as a 401(k) could reduce your 2014 taxable income. Contributions to a Roth IRA (assuming you meet the income requirements) or a Roth 401(k) plan are made with after-tax dollars, so there’s no immediate tax savings. But qualified distributions are completely free from federal income tax, making Roth retirement savings vehicles appealing for many.

1. Make time to plan

3. Accelerate deductions You might also look for opportunities to accelerate deductions into the 2014 tax year. If you itemize deductions, making payments for deductible expenses such as medical expenses, qualifying interest, and state taxes before the end of the year, instead of paying them in early 2015, could make a difference on your 2014 return.

Note: If you think you’ll be paying taxes at a higher rate next year, consider the benefits of taking the opposite tack--looking for ways to accelerate income into 2014, and possibly postponing deductions.

4. Know your limits If your adjusted gross income (AGI) is more than $254,200 ($305,050 if married filing jointly, $152,525 if married filing separately, $279,650 if filing as head of household), your personal and dependent exemptions may be phased out, and your itemized deductions may be limited. If your 2014 AGI puts you in this range, consider any potential limitation on itemized deduc-

7. Take required distributions Once you reach age 70½, you generally must start taking required minimum distributions (RMDs) from traditional IRAs and employer-sponsored retirement plans (an exception may apply if you’re still working and participating in an employersponsored plan). Take any distributions by the date required--the end of the year for most individuals. The penalty for failing to do so is substantial: 50% of the amount that should have been distributed.

8. Know what’s changed A host of popular tax provisions, commonly referred to as “tax extenders,” expired at the end of 2013. Among the provisions that are no longer available: deducting state and local sales taxes in lieu of state and local income taxes; the above-the-line deduction for qualified higher-education expenses; qualified charitable distributions (QCDs) from IRAs; and increased business expense and “bonus” depreciation rules.

FLORIDA MD - OCTOBER 2014 19

Financial Update: Insurance • Benefits • Wealth Management 9. Stay up-to-date It’s always possible that legislation late in the year could retroactively extend some of the provisions above, or add new wrinkles--so stay informed.

10. Get help if you need it There’s a lot to think about when it comes to tax planning. That’s why it often makes sense to talk to a tax professional who is able to evaluate your situation, keep you apprised of legislative changes, and help you determine if any year-end moves make sense for you.

Every year we recommend our clients begin year-end tax planning by late 3rd/early 4th quarter at the latest. It never pays to wait until January to consider the impacts and it is extremely important to start early this year. So contact your tax advisor or give us a call to see if you can limit your exposure this year.

Securities and Investment Advisory Services offered through NFP Advisor Services, LLC, Member FINRA/SIPC. NFP Advisor Services, LLC is not affiliated with The Vaughn Group, Inc. NFP Advisor Services, LLC does not offer tax or legal advice.

Kevin is a principal at The Vaughn Group, Inc. and manages the Wealth Management Department. Before becoming a financial advisor, Kevin practiced law in Orlando, focusing on tax, estate, and asset protection planning for ultra-high-net-worth families. As a financial advisor, he has presented educational seminars and made presentations to the Florida Bar Association, regional Estate Planning Councils, the National Association of Retired Employees, the Arthritis Foundation, and the National Business Institute.

Kevin graduated from the University of Florida with a B.A. in Economics, a J.D. with Honors, and a Masters of Laws in Taxation. He can be reached via email at kevin@ vaughngroup.com or by phone at (407) 872-3888. The Vaughn Group, Inc.’s offices are located at 1407 E. Robinson St., Orlando, FL 32801. 

Be sure and check out our website at www.floridamd.com!

20 FLORIDA MD - OCTOBER 2014

Marketing Your Practice

Measuring Your Content Marketing ROI

By Jennifer Thompson, Co-founder, DrMarketingTips.com Do you use blogs and content to help promote your practice’s position on search engines? Has content become an important part of your SEO strategy?

Whether you want to face it or not, the internet has fundamentally changed the way people find, share, discover and connect.

In today’s digital world your online reputation can be the difference between a patient scheduling an appointment with your office or a competitor’s down the street. That’s whyso much effort is focused on inbound marketing strategies today (these include content management and social media). But, how can you tell if you’re getting a quality Return on Investment (ROI) for your content creation and management?

Whether you want to face it or not, the internet has fundamentally changed the way people find, share, discover and connect.

The truth is, it’s hard to quantify because there aren’t always “hard numbers.” If you create content once a week for a month, will you get more leads? What about twice a week? There’s really not a set way to tell. It may take up to six months or more before you start to see your leads grow. The key, however, is continuing to provide consistent, quality content in your posts even if you think no one is looking at them. After all, you have to tend to your garden if you want it to be beautiful. And we all know that doesn’t happen overnight.

Success is measured in brand awareness and lead growth. Ultimately, those factors will lead to phone calls and appointments set.

In fact, a recent study by Hubspot says that customers who practice inbound marketing (where patients find you and content is a core element) increase leads an average of 4.2 times within a few months.

Here’ show you can work on measuring your content marketing ROI.

Tip 1: Understand What You’re Measuring Let’s start with the big issue when it comes to measuring content conversion rates: what exactly are you measuring? Traditionally,

media companies would use readership, viewership and ad revenue as the measuring stick for content’s success.

But with content marketing, the goal is to achieve a conversion (like a phone call, for instance) or to build the ever ambiguous “brand awareness” of your office.

Our recommendation to measure your “immeasurable” content is to set a goal.

First, set up a baseline for a number you’d like to try and grow.

If your normal inbound call rate sits around 20 per day, plan to increase your call volume by two calls per day by the end of the quarter. Then, measure your results in a few months against the baseline. Admittedly, two calls per day doesn’t sound like a lot, that is until you realize it’s 40 new potential appointments by the end of the month.

Tip 2: Measure a Few Forms of Conversion Let’s stick with the phone call example above. You want to increase phone calls, so that’s your goal. But, content in the social media landscape is viral and evolving as it finds new ways to survive. In other words, just because your goal is to increase incoming appointment calls doesn’t mean that’s all your content is doing.

Of course you’ll want to track your target metric (phone calls) but don’t put the blinders on to other forms of success your content may be responsible for creating. And create it will.

We see it all the time with our clients, we’ll post a piece of customized healthcare content or video designed to generate website hits and suddenly we’re earning more Facebook fans and gaining quality inbound phone calls. It’s a bonus, and it’s worth tracking.

Some of the easiest ways to track how you’re doing and what’s working are free, simple to understand and provide more data than you can shake a stick at. For Facebook, simply use the Facebook Insights that come built in to every Fan Page. You’ll be able to track upticks in fan count, how many people you’re reaching with each posts, demographics and much more.

For your website we recommend using Google Analytics. After placing a simple code on your page, Google will provide you with all sorts of free data including unique visitors, time spent on each page of your site, what content is popular, demographics, search engine terms and so much more.

Tip 3: Enjoy Successes and Be Patient Odds are your practice is starting out small in the world of content management and social media integration. No worries.

FLORIDA MD - OCTOBER 2014 21

Marketing Your Practice Take a second to enjoy those small victories, and keep key measurements handy. They’re easy to track and far more encouraging (initially) than Search Engine Optimization (SEO) measurements – which may take some time to manifest.

A few ways to tell if your content is working: • Likes or comments on Facebook • Retweets on Twitter • Other shares (LinkedIn, email, etc.)

• Comments on the blog itself • Average page views per visitor (a great metric provided by Google Analytics) These factors will help you monitor how well you’re building your audience and how much they trust you. That trust will eventually turn into loyalty, which will put patients in your waiting room.

Remember to be patient.

Content creation and management take time to grow before you’ll fully see their benefits. It’s important not to expect overnight results and not to get upset when you don’t instantly jump to the top spot on Google.

It’s a different world in the digital space, and you have to adjust your expectations accordingly. Happy marketing!

Looking for more ways to attract and retain more patients? Check out DrMarketingTips.com for free articles, webinars, ebooks, audio blogs and more for your practice.

Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982

Specializing in:        

Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules

Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, M.D., F.C.C.P.

Eugene Go, M.D., F.C.C.P.

Andres Pelaez, M.D., F.C.C.P.

Daniel T. Layish, M.D., F.A.C.P., F.C.C.P.

Mahmood Ali, M.D., F.C.C.P.

Jorge E. Guerrero, M.D., F.C.C.P.

Francisco J. Calimano, M.D., F.C.C.P.

Steven Vu, M.D., F.C.C.P.

Neveen A. Malik, D.O., F.C.C.P.

Francisco J. Remy, M.D., F.C.C.P.

Ruel B. Garcia, M.D., F.C.C.P.

Roberto Santos, M.D.

Ahmed Masood, M.D., F.C.C.P.

Tabarak Qureshi, M.D., F.C.C.P. Timur Graham, M.D.

Syed Mobin, M.D., F.C.C.P.

Kevin De Boer, D.O., F.C.C.P.

Downtown Orlando: 1115 East Ridgewood Street East Orlando: 10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road

407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted 22 FLORIDA MD - OCTOBER 2014

FOOT & ANKLE

New Options for Ankle Pain

By Christopher L. Reeves, DPM We know arthritic hips and knees are replaced all the time— but did you know that arthritic ankles could also be replaced? In fact, ankle replacements in the U.S. more than doubled last year, thanks in part to technological advances in ankle implants. Ankle replacements as well as other new surgical techniques including arthroscopic ankle surgery and bone or cartilage replacement are offering hope for those wanting to remain active. This is good news for active adults who are plagued with painful ankles.

End-stage ankle arthritis is a painful condition and most often occurs after a traumatic injury, history of chronic sprains, or in patients with diseases such as rheumatoid arthritis and is one the leading cause of chronic disability in North America. Todays patient, especially those near or past retirement age are more active than ever and don’t want to be held back by painful arthritis.

Historically, ankle fusions were the gold standard for care and while it is successful in pain relief, the resulting restriction in motion can shift motion stresses to adjacent foot joints, which in time also become arthritic.

Total ankle replacement surgery—also called ankle arthroplasty—involves replacing the damaged joint with an artificial joint. Recent studies have demonstrated that the safety profile of ankle replacement surgery is equivalent to that experienced with ankle fusion. Patients undergoing ankle replacement are typically in their 50s through 70s, although older individuals who are “physiologically young” may also be good candidates. We have performed the procedure on individuals ranging in age from 45 to 83 years of age with great success, despite the age difMeet Our ferences.

to keep them on their feet and enjoying their active lifestyle.

Christopher L. Reeves, DPM, is a Fellow American College of Foot and Ankle Surgeons and practices at Orlando Foot and Ankle Clinics. The Orlando Foot & Ankle Clinic is the largest and oldest Podiatry practice in Central Florida, with Podiatric offices in 17 locations throughout Central Florida. Our 14 Podiatrists have over 100 years of combined experience and work with patients to understand their needs and provide the best treatment for their foot and ankle issues. For more information about Orlando Foot & Ankle Clinics please visit www.orlandofootandankle.com or call 407-423-1234.



Celebrating our 40th Anniversary

Principals — All working together for you!

• Corporate Retirement Plans • Complex Benefits Strategies • Individual and Family Estate Planning • HR and Benefits Compliance Solutions • Customized Insurance Products and Services • Financial Planning and Wealth Management

Not everyone is a candidate for an ankle replacement. For example, people with poor circulation (peripheral arterial disease), loss of sensation (neuropathy), or significant congenital deformity, or serious medical illness may not be a candidate.

Though still evolving, the quality and design of the implants have drastically improved over the years. Implants are now even more customized to the patient’s size, gender and uniqueness of their arthritis; it’s no longer a-one-size-fits-all world. This is especially important for maintaining functionality and range of motion in the ankle.

Today, because of the medical advancements and new surgical techniques, patients of all ages suffering from arthritis have additional, viable treatment options

Hardy Vaughn, CLU, ChFC, CAP, MSFS*

T. Kevin Taylor, JD, LLM*

Experience. Knowledge. Strategy.

1407 E. Robinson Street Orlando, FL 32801 www.vaughngroup.com

Office: (407) 898-3911 Toll Free: (800) 940-0990

Cindi Johnston

*Securities and Investment Advisory Services may be offered through NFP Securities, Inc., Member FINRA/SIPC. NFP Securities, Inc. is not affiliated with The Vaughn S. Kyle Taylor* Group, Inc.

FLORIDA MD - OCTOBER 2014 23

New Group Gives Voice to Independent Doctors

By Marni Jameson “Certainly, the only happy doctors I still know are all in private practice,” said the email from a physician who works for a large hospital system.

The email came in response to my news that I had left my job as senior health reporter of the Orlando Sentinel to run a national nonprofit trade association whose sole purpose is to represent the interests of independent doctors.

As a reporter, when a hospital system acquired a medical group, I interviewed sources on all sides: doctors, hospital executives, insurers, academics, patient advocates, consumers and government officials. Thus, I got a full-circle look at why more doctors were going to work for hospitals, and the impact that had on patient

JANUARY –

2014

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.

Digestive Disorders Diabetes

FEBRUARY – Cardiology Heart Disease & Stroke MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism OCTOBER –

Cancer Dermatology

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

Please call 407.417.7400 for additional materials or information.

24 FLORIDA MD - OCTOBER 2014

care and health-care costs.

I also saw that while the independent nature of private practitioners was mostly to their advantage, in one important respect independence was contributing to their undoing. Independent doctors are by definition not well organized. By not being allied, they didn’t have a collective bargaining voice.

Thus, their numbers were shrinking.

Unless you have been living in a yurt off the grid, you know that the rate at which hospitals have been buying doctors’ practices has been brisk in the past several years. Such roll-ups help hospitals capture market share, channel referrals to their other employed physicians and hospital-owned diagnostic and treatment centers, and receive more money for same procedures.

In 2000, well over half (57 percent) of all physicians in the United States worked for themselves; as of last year, that number was closer to one in three (36 percent), according to a report out from Accenture.

The rest went to work for hospitals.

And who can blame them? The lure to become a hospital employee -- the promise of more money, perceived job security, no more overhead, guaranteed referrals -- is strong. But, as many physicians, including the author of the email to me, learned, the move comes at a price.

The Association of Independent Doctors was formed in April 2013, when two certified public accountants in Winter Park, Fla., saw the impact that the acquisition of independent practices by hospitals was having on not only doctors, but also patients, local communities and the nation. They wanted to create a trade association to stop the trend.

I covered the inaugural meeting for the paper. About 120 doctors attended and nearly everyone joined that night. (Individual physician memberships cost $1,000 a year).

Since then, AID has grown to include members in eight states. More doctors and health-care advocates join every day. Most join because AID stands for what they care about, but don’t have the time, resources or clout to fight for: • Parity – Independent doctors receive substantially lower reimbursements from payers, compared to hospitals, which contract much higher rates for the same services.

• Education – Patients, the community and regulators need to know how this trend affects access, choice and cost

of care.

• Camaraderie – Independent physicians want to work with a network of doctors who share their practice philosophies.

• Autonomy – By working to reverse the trend of medical practice acquisitions, the association makes it easier for doctors to stay independent and enjoy greater job satisfaction.

“Physicians have a tendency to not get involved in critical changes affecting them, and specifically avoid the political end of medicine,” said Orlando orthopedic surgeon John McCutchen, who serves on the executive committee for AID. “We no longer have the luxury of doing nothing,” he said. “If physicians don’t want non-physicians telling them how to practice, they need to get engaged.”

Of course, the Florida Medical Association and the American Medical Association represent physicians, too. However, because most of their physician members are employed or in academia, they are not in a position to champion the unique interests of the independent physician.

“The future of health care is changing, and we as independent physicians need to come together to steer the boat in the right direction,” said Dr. Pamela Snook, a Winter Park ob-gyn and AID member. “I joined because this is an avenue where I feel I have a voice that I don’t have otherwise. It’s a way to be heard.”

Snook, like other physicians who have resisted hospital employment, wants to remain independent so her allegiance remains unequivocally to her patients.

As the only national organization of its kind, AID has already established itself as a formidable, articulate force. Its founders have spoken on Capitol Hill, and the association has also been asked to support the Federal Trade Commission in an important anti-trust case involving a hospital’s purchase of medical group in Idaho.

In August, the association, on behalf of its members, filed a substantive friend-ofthe-court opinion paper supporting a U.S. District’s court decision that the acquisition of a large medical group by St. Luke’s Health System violated antitrust law, and must be unwound.

The experience you demand.

The customer care you deserve. ̶̗̰ΎƤȽȱȯɂȷȽȼɁ ̴̗̰ΎƜȳȲȷȱȯɂȳȲΎƜȽȱɂȽɀɁ ̗ƨȳȲȷȯɂɀȷȱΎƛȯɀȳΎƨɀȽɄȷȲȳȲ ̗ƥȽɁɂΎơȼɁɃɀȯȼȱȳɁΎƙȱȱȳȾɂȳȲ ̗ƚȽȯɀȲΎƛȳɀɂȷ˛ȳȲΎƫɃɀȵȳȽȼɁ

St. Luke’s appealed, and the case is now before the U.S. Court of Appeals for the Ninth Circuit. The nation is watching as the court’s verdict will set an important precedent.

AID’s involvement put the voice of independent doctors on the national stage, making them part of a debate whose outcome will impact every American. Thanks to the growing support of doctors, we can collectively do what individuals alone cannot.

Join us next month as we discuss the seven consequences of hospitals acquiring physician groups.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407865-4110 or marni@aid-us.org. 

Offering soothing, effective treatments for: x x x x x x x

Foot & ankle injuries Foot disorder correction Diabetic ulcer & wound care Bunion & Hammertoes Children’s foot disorders Corns Calluses

x x x x x x x

Ingrown nails Warts Heel & arch pain Reconstructive surgery Sprains & fractures Sports Injuries/ Ankle Pain Fungal nails

Call today for your consultation.

407-423-1234 Se Habla Espanol!

www.orlandofoot.com FLORIDA MD - OCTOBER 2014 25

LEADING OUTCOMES THROUGH SUPERIOR TREATMENT FOR WOMEN WITH CANCER

At Moffitt, we offer a patient-centric approach coupled with the latest advances in breast and ��necologic oncolo��, taking into account fe�tility-sparing the�apies and sexual health counseling.

Our team utilizes comprehensive treatment plans and recove�� prog�ams provide women TO SCHEDULE ANtoAPPOINTMENT, CALL with the best quality of life before, during and after cancer treatment.

1-888-MOFFITT

TO REFER A PATIENT, CALL 1-888-MOFFITT OR VISIT REFER2MOFFITT.com

MOFFITT CANCER CENTER 12902 MAGNOLIA DRIVE, TAMPA, FL MOFFITT CANCER CENTER AT INTERNATIONAL PLAZA 4101 JIM WALTER BOULEVARD, TAMPA, FL