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The Business of Medical Marijuana Industry growth indicators mixed By P L JETER

Progress in Florida’s burgeoning medical marijuana industry has been slower than anticipated since the state law that made full strength marijuana legal for medical use went into effect last July. Now, as a sign of the ongoing troubles in the Office of Medical Marijuana Use, its director Christian Bax, has resigned his position. Michael C. Patterson, founder and CEO of U.S. Cannabis Pharmaceutical Research & Development of Melbourne, has become a go-to guy consultant for the development of the medical marijuana in-

ON ROUNDS

PHYSICIAN SPOTLIGHT Benjamin Thomasson, DO ... 3

HEALTH INNOVATORS

Peek Into Orlando’s Healthcare Startup Scene ... 5 The Power of Inclusivity: Correlating Health Data in Lesbian, Gay & Bisexual Older Adults ... 5

HEALTHCARELEADER

Osceola Regional Residency Consortium Addressing the Physician Shortage in Florida. .. 4

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dustry nationwide and in Florida. He serves as a consultant to Gerson Lehrman Group, New York and helps educate GLG partners on specific investment strategies and public policy regarding Medical Marijuana in the U.S. and Internationally. Medical News chatted with Patterson about business challenges – healthcare and beyond – associated with implementing the relatively new law.

How has Florida’s medical marijuana market progressed since state lawmakers legalized it?

MP: It’s developing quicker compared to other states, but slower from a regulatory and implementation aspect. For example, the state was supposed to award five new licenses by Oct. 3, 2017, and it still hasn’t been done. They’re almost a year behind for various reasons – lawsuits, hurricanes, and the gap between the legislative year (July 1 to June 30) and fiscal year (Oct 1 to Sept. 30) that affected funding the state Office of Medical Marijuana Use (OMMU), which only had three employees to get everything done. Also, about 1,600 Florida doctors

have signed up to write medical marijuana recommendations but that doesn’t mean all of them have done it. Every Friday, the state updates the number of patients and doctors concerning medical marijuana. The updates can be found at: http://www.floridahealth.gov/ programs-and-services/office-of-medical-marijuana-use/ommu-updates/

Lawsuits? MP: Current license holders applied in 2015, when the state awarded five licenses. Now there are 13 providers. Here’s (CONTINUED ON PAGE 2)

Orlando Health Scores Big with Sports Medicine Symposium Daryl Osbahr, MD, spearheads bar-raising event It is no secret that Orlando has become a vibrant hub for professional and high-performing amateur athletes in a wide range of sports. So, it is probably no surprise that this part of Florida has also become a center for high-performing sports medicine. Even so, the enthusiasm with which Orlando Health’s Inaugural Sports Medicine Symposium was greeted in June surprised even the event’s creator, Daryl Osbahr, MD, the internationally renowned orthopedic surgeon who serves as chief of adult and pediatric sports medicine at Orlando Health

Nearly 300 health care professionals, including athletic trainers, physical therapists, strength and conditioning specialists and physicians traveled from across Florida and southern Georgia to attend the evening reception and day-long symposium. “The feedback that we are getting from the entire healthcare community is phenomenal,” he said in a recent interview. Not bad for an event that began with the idea of drawing 50 to 100 attendees together. Osbahr and the organizers quickly realized that demand for such a symposium was so strong that there was an opportunity for a much more ambitious program. “We

knew we had to really put forward a fantastic meeting,” said Osbahr. “Our goal was to provide a top-notch medical symposium to get people excited as well as raise the bar for the quality of sports medicine for our community.” In order to make the event special, Osbahr and the administrative team developed a series of fast-paced, high-energy, panels. Besides discussions on shoulder instability, ACL injuries and concussion management, the symposium featured point/ counter-point discussions by experts on emerging topics like regenerative therapies (CONTINUED ON PAGE 23)

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The Business of Medical Marijuana, continued from page 1 what happened: the people who didn’t win a license sued the state. Because the state had such a terrible grading structure of the applications, every single challenge was lost.

Why is Florida’s medical marijuana license the most valuable in the U.S? MP: Florida has vertical integration, meaning a licensee must grow it, process it, transport it, and sell it in stores. Until 2020, every license holder can open up to 25 stores statewide. After that, there’s no limit. To show you how valuable a Florida medical marijuana license is, a publicly traded company, MedMen (CSE: MMEN), just purchased one for $53 million from a reseller. By comparison, Colorado isn’t vertically integrated; the state doesn’t have a limit on the number of licenses. An average grower license typically sells for onetimes-revenue. If that grower is generating $3 million a year, the license will sell for $3 million. As a result, a medical marijuana license to sell in states with vertical integration and restricted licenses is more valuable.

Could Florida’s medical marijuana climate lead to a monopoly? MP: I’d call it oligarchy, a somewhat limited monopoly to a certain number of groups. For example, of 13 providers, only eight are producing and selling product. The others are just getting up and running. Those eight serve 130,000 patients, with the average sale of product now at $300 to $400 a month. You do the math.

What other challenges are impeding the growth of the medical marijuana industry in Florida? MP: Banking. Because medical marijuana is federally illegal, some banks choose not to work with medical marijuana companies. Too much red tape. But the amount of money changing hands is astronomical, millions of dollars daily. If we don’t have a banking system in Florida that’s open to medical marijuana companies, we could have utter chaos. Taxes. IRS Code 280-E says you’re not allowed to deduct the cost of the sale of an illegal item. If you have a dispensary and purchase cannabis for $50 from a supplier and sell it for $100, you pay taxes on $100. This federal law of the tax code is stunting growth. A bill in Congress – the States Act – sponsored by Senators Corey Gardner (R-Colorado) and Elizabeth Warren (D-Massachusetts) would keep cannabis federally illegal but allow states to fix the banking and tax issues. President Trump said he’d sign it. We’ll see what happens. Education. When the state wrote the new medical marijuana law in 2017, $10 million was originally allocated to educate the public. Last minute, funding was slashed. Then, Florida Highway Safety 2

AUGUST 2018

took $5 million to create billboards “Drive Baked; Get Busted.” That was the extent of the state’s education program.

What’s your role in the development of Florida’s medical marijuana industry? MP: To educate the masses. For instance, I spoke July 30 at the Florida FBI National Academy State Convention to educate law enforcement about medical marijuana. We’re also educating physicians and other healthcare workers about the gap between the law and implementation into our societal and healthcare network. We bridge that gap to help people understand how medical cannabis is considered just another form of healthcare, like a pharmacy or laboratory, and importantly, what it is and what it isn’t. One of our goals is to work through medical schools to educate students on the science of cannabis because we feel strongly that going forward, most people will be on cannabis rather than opiates or anti-depressants. In states where medical cannabis is legal, patients who use it typically decrease their prescription meds.

Describe the average medical marijuana patient. MP: In the U.S., it’s between 42 and 48 years old. In Florida, the average medical marijuana user is over 50, maybe early fifties. Some doctors think younger people wanting to get high will want medical marijuana, but it’s exactly the opposite. Medical marijuana is lab-tested and created under pharmaceutical-grade conditions. Early adopters have been seniors. That age trend will continue as seniors who don’t understand marijuana began to understand its usefulness, especially with pain management. Even though it’s $300 to $400 a month now, as more patients sign up and prices come down, by this time next year, you should see it more like $200 to $300.

What are the greatest challenges to physicians prescribing medical marijuana? MP: Dosing. Many doctors are accustomed to pharmaceuticals such as antibiotics, where they may prescribe a patient 25 milligrams and if that doesn’t work, take two and call it a day. With cannabis, the challenge is the body’s endocannabinoid system; marijuana has cannabinoids. It’s a lock and key system in the body. That’s why nobody has died from cannabis. Also, everybody responds differently to cannabis. For example, you could take 20 milligrams that could leave you on the couch not wanting to get up. For another person, 20 milligrams won’t affect the body at all. Some older doctors are holding onto preconceived notions of previous ideologies because they haven’t learned about cannabis and don’t fully understand its benefits. Younger physicians are typically more open-minded. Ironically, there’s more research on cannabis than any other

UPDATE FROM FLORIDA OFFICE OF MEDICAL MARIJUANA USE AUGUST 3 • Qualified Patients: (Active ID Card): 109,749 • Total Patients: 144,557 • Qualified Ordering Physicians: 1,596 • Amount of Medical Marijuana Dispensed (July 27 – August 3): 32,448,202 mgs • Amount of Low-THC Cannabis Dispensed (July 27 – August 3): 1,602,217 mgs Approved Dispensing Locations: 46 For more information visit www.flhealth.gov/ommu OMMU Call Center: 1-800-808-9580

prescription medication. Much of the study has been in Canada and perhaps surprisingly, Israel, the world’s leading area for cannabis research. Finally, many doctors no longer own their practices. More physicians are hospital-employed. Health systems in general won’t allow doctors to write medical marijuana recommendations. Doctors who are signing up to write recommendations either have independent offices or work in small, privately-owned walk-in clinics.

How are insurance companies handling medical marijuana claims? MP: Because medical marijuana is federally illegal, the state isn’t required to pay for it. That’s slowly changing. Earlier this year in New Jersey, a judge ruled in a worker’s compensation case that insurance must pay for medical marijuana.

How do you view medical marijuana usage long-term in Florida? MP: For physicians and nurse practitioners, this isn’t going away. Medical marijuana will keep increasing on a regular basis. About 3,000 patients are signing up for it every week. We’re already at nearly 145,000 patients using medical

marijuana. By the end of this year, we’re anticipating 200,000 patients. The medical system needs to get on board because it’s beneficial for their patients and it’s not going to hinder their progress.

How will the landscape change if state lawmakers legalize marijuana for recreational use? MP: Our concern is to make sure people still use cannabis for its wellness or medicinal capacity. The problem is, if recreational marijuana is legalized, people are not necessarily going to a doctor anymore. Eventually, if it does go recreational, it’s going to happen fast. Typically, states that convert from medical to recreational marijuana notice medical marijuana numbers drop by 50 to 75 percent and that affects cost. If patients are paying an estimated $200 for a doctor’s visit for medical marijuana, they’ll stop paying for the doctor. When Colorado legalized recreational marijuana in 2012, about 120,000 to 150,000 patients were using medical marijuana. By early 2018, the number dropped to 30,000 to 40,000. Those patients converted to recreational because they don’t want to pay extra for the doctor’s visit and deal with the hassle when they can go right to the door.

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PHYSICIANSPOTLIGHT

Benjamin Thomasson, DO A quick look at improvements in orthopaedic surgery

Benjamin Thomasson, DO, with Florida Orthopaedic Associates brings the strategic mindset of a top athlete to his profession as a sports medicine and joint replacement orthopaedic surgeon. “Patients with sports-related injuries typically know their bodies well and understand that there’s a specific problem we need to correct — they simply need guidance, expertise and rehabilitation,” said Dr. Thomasson. “Both the patient and the doctor are very motivated in that relationship.” Thomasson treats athletes at all levels of competition, focusing on arthroscopy and joint replacement for the shoulder, hip, and knee. He has a special interest in complex shoulder instability, multiple ligamentous knee injuries, cartilage restoration techniques and meniscal transplantation.

FINDING A CALLING

Thomasson’s professional passion began at The University of Northern Arizona as an intramural athlete and exercise science major studying advanced treatment protocols for athletes. “I was excited about the chance to tailor rehabilitation methods to help people return to activities they enjoy and also to physically improve the structures that were injured,” he said. “The repair process and the opportunity to correct pathologies in the skeleton fascinate me.” Thomasson pursued that interest through an orthopaedic surgery residency at Rowan University in Southern New Jersey, where he gained exposure to both community hospital and research-oriented settings, including the Center for Sports Medicine at Alfred I. duPont Hospital for Children. Afterward, he completed a fellowship in sports medicine at The University of Texas Health Science Center in San Antonio. There, he assisted the physicians for multiple San Antonio-based professional, collegiate and high school teams. In 2015, Thomasson and his family relocated to Central Florida. Thomasson serves as a team physician for Pine Ridge High School in Deltona and University High School in Orange City, treats Stetson University athletes, and works as an orthopaedic consultant for Justin Sports Medicine in Central Florida, serving the Professional Rodeo Cowboys Association. He will also be on-staff at a Florida Orthopaedic Associates walk-in clinic set to open in Orange City in late 2018. In his many roles, Thomasson starts with thorough assessments, asking patients about their positions on the teams, their 3

AUGUST 2018

activity levels and whether they are at risk of overusing specific muscles, joints or tendons. Rather than treating injuries in isolation, he evaluates each patient as a whole. “People may think that the shoulder is the most important part of their range of motion, and they don’t understand why they get elbow pain, so it’s a process of educating them on shoulder and elbow mechanics,” he explained. “Or, we might talk about core strength as it relates to abdominal, back and hip muscles. Then, we discuss how we can improve their overall well-being.”

ADVANCEMENTS IN SURGICAL PROCEDURES

While Thomasson starts with nonsurgical treatments such as pain-relieving injections and physical therapy whenever possible, sometimes surgery is unavoidable. With the continued evolution of minimally invasive procedures and early rehabilitation principles, patients benefit from shorter downtime. One of the more challenging injuries to recover from is a torn rotator cuff. A relatively new procedure known as superior capsular reconstruction (SCR) is a promising alternative treatment for irreparable posterosuperior rotator cuff tears, using a graft from the superior glenoid to the greater tuberosity to stabilize the humeral head. A study cited in Orthopedics

Today found that in “patients who underwent SCR with a fascia lata autograft at a minimum of two years follow-up, the American Shoulder and Elbow Surgeons (ASES) score improved significantly from 23.5 preoperatively to 92.9.” Meanwhile, “a postoperative MRI showed 83 percent of patients had intact reconstructions with no progression of muscle atrophy.” As a result, many patients can avoid having a shoulder replacement. According to Thomasson, SCR delivers a distinct advantage. “With traditional techniques, even if you repair rotator cuff tendon back to the bone, many people won’t regain full function of the shoulder for overhead activity, or they have persistent pain or risk of re-rupture,” he said. In patients that have failed rotator cuff surgery or have tendons that are irreparable, “SCR uses a dermal graft, so we can reconstruct the superior restraint, which allows the rotator cuff to function more regularly.” As one of a handful of local surgeons conducting hip arthroscopies, Thomasson also employs minimally invasive techniques to treat femoroacetabular impingement (FAI). In this condition, extra bone grows along one or both bones that form the hip joint, causing groin pain and a “locking” sensation. FAI can be debilitating for soccer, football, baseball and softball players, as well as dancers. Thomasson uses arthrograms to evaluate the tissue and then performs

laparoscopic surgery to trim the bone and repair torn cartilage.

EMPOWERING THE PATIENT

Changes in the medical landscape are allowing orthopaedic surgeons to perform a wider range of outpatient procedures. The Centers for Medicare and Medicaid Services recently began allowing eligible Medicare patients to have total knee arthroplasty in hospital outpatient departments. Thomasson recently performed his first outpatient total knee replacement at Central Florida Regional Hospital, which holds The Joint Commission’s Total Knee Replacement Certification. The patient is an attorney and Winter Springs resident in her 40s. In the past, surgeons typically restricted joint replacement to elderly patients — but as the success rate improves, they are increasingly offering these procedures to help younger, low-risk patients maintain an active lifestyle. Educating patients about newer options and empowering them through the process is a foundational part of Thomasson’s practice. “Patients do the best when they’re the primary decision-makers,” he said. “My job is to provide counsel and reduce stress. When patients meet with me, it doesn’t necessarily mean they’re going to have surgery. We’re going to guide them toward the best treatment path, so they can return to what they love.”

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HEALTHCARELEADER

Osceola Regional Residency Consortium Addressing the Physician Shortage in Florida Philip Kondylis, MD, General Surgery Residency Program Director Philip Kondylis, MD, a board-certified colorectal surgeon affiliated with Osceola Regional Medical Center, was recently named program director of a new general surgery residency program at Osceola Regional Medical Center and the Orlando Veterans Affairs Medical Center at Lake Nona. The general surgery residency program is one of the latest additions to the five-year Graduate Medical Education (GME) residency program at Osceola Regional and part of the UCF College of Medicine-HCA Healthcare North Florida Division Consortium. The consortium aims to address a statewide physician shortage by keeping Florida’s medical school graduates in state to pursue their careers. Osceola Regional’s residency program is expected to offer 200+ residency positions by the year 2020 – including 15 positions in the surgical residency program. In addition to the surgical program

launching this summer, the hospital offers residencies in emergency medicine, neurology, internal medicine, obstetrics/gynecology, psychiatry, transitional year and anesthesia. As the physician spearheading the surgical residency, Kondylis has focused on building a program that incorporates traditional best practices with new concepts in surgical education. He brings an extensive background in Graduate Medical Education and research. For 12 years, Kondylis was a core faculty member of the Colorectal Surgery program at Saint Vincent Health Center in Erie, Penn., and for three years he served as the program director. His credentials include 34 major research presentations and 14 peer-reviewed publications. He is a member of the Alliance for Clinical Trials in Oncology, American Board of Colon and Rectal Surgery, Society for Surgery of the Alimentary Tract, Society of Laparoendo-

scopic Surgeons, and American Society of Colon and Rectal Surgeons. Kondylis is also a registered investigator with the National Cancer Institute. We talked with Dr. Kondylis to find out more about the general surgery program and why he thinks it’s the perfect fit for medical students and the community.

Why is this residency program needed? PK: There simply aren’t enough residency openings available across the country, and especially in Florida for the number of medical school graduates each year. The National Resident Matching Program announced there were a recordbreaking 44,000 applicants for 33,000 slots in 2018. The University of Central Florida, in particular, is seeing rapid growth in its number of medical school graduates, so there’s definitely a need for local students. Plus, medical students nationwide are

picking surgical specialties over primary care positions in increasing numbers. Perhaps more important, our community needs to attract top-notch doctors, and with Florida having the fourth highest physician retention percentage in the country, creating new residency programs like this one will help bring better healthcare to the region.

What makes the Osceola Regional/VA surgical program unique? PK: Since the launch of the UCFHCA residency consortium in 2015, we’ve been able to put together a remarkably broad-based experience that was intentionally planned from day one. Our faculty is fully devoted to teaching the mastery of surgical skills, not just surgical basics, with the end goal that our students become the new trainers. Our program isn’t tied to any existing sched(CONTINUED ON PAGE 6)

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HEALTH INNOVATORS

Peek Into Orlando’s Healthcare Startup Scene By JOSHUA GONZALEZ

In a city where theme parks often dominate the headlines, Orlando proves to be a complex city with far more than meets the eye. The Orlando Economic partnership’s branding campaign, “You Don’t Know the Half of It,” captures the spirit of the current state of Orlando as a multi-faceted city full of pride and hunger for innovation. With a burgeoning healthcare entrepreneurship scene that grows by the day, Orlando continues to develop and make its mark as a prominent metropolitan area. Orlando has begun to present itself as an on-trend area for entrepreneurs with the openings of coworking spaces such as Starter Studio, Catalyst, and the newly opened Industrious Office. As it stands, Orlando recently ranked #4 in the nation for high-growth healthcare startups and #22 in new startup creation, according to the Kauffman Foundation. Forbes also listed Orlando as the 3rdranked city for future job growth, 4th fastest growing city in 2018, and a top 10 city for minority entrepreneurs. In addition to the modeling and simulation capital of the world, Orlando is quickly establishing a reputation as

a fantastic place for healthcare companies. With an array of hospitals sprinkled throughout the region and the creation of Lake Nona’s Medical City, which Forbes magazine once named as “the next great American city” – the healthcare industry is thriving in Orlando. The proximity of large players in healthcare help provide a foundation to the healthcare startups that are beginning to make waves. Large institutions such as the University of Central Florida and Florida Hospital offer incubator and innovation labs to help further transformational ideas and startups. “Florida is one of the premier states for university technologies ready for commercialization,” said Joe Condon, president and CEO of Auxadyne, a company utilizing auxetic foam for prosthetic and medical device applications. “I think Florida is fruitful, with a tremendous amount of resources available and folks willing to help. Obviously, the entrepreneur and the startup team need to do most of the heavy lifting but there are lots of resources around to help connect entrepreneurs with investors.” NEXUS, a local network of investors, is one of those resources. Joe Condon says the group offered help, guidance, and facilitated introductions that helped

INNOVATION HEADLINES FLORIDA HOSPITAL SYSTEM his startup grow. Organizations like these keep the heart of entrepreneurship alive in Central Florida. Blaire Martin, co-founder and CEO of NEXUS set out to fill some of the gaps between entrepreneurs and accredited investors by establishing an angel investing network. “We’ve founded multiple funds and use crowdfunding platforms to fill that early stage capital gap of seed through series A,” said Martin, who describes the NEXUS brand as promoting “the idea of what’s driving innovation and showcasing the deal flow here to get investors writing checks.” NEXUS has gone on to help fund 68 companies, 8 of which have been healthcare related. According to the PitchBook-NVCA venture monitor, Orlando startups have managed to attract more than $20.99 million in venture capital during the first quarter of 2018. “I think there is a cultural operating model in Florida for young tech companies that is more down to earth than you would get in California,” said John Cooper, a 25-year investing veteran who resides in both Florida and California. (CONTINUED ON PAGE 6)

The Power of Inclusivity: Earlier this year we read of a growing trend of LGBTQ+ seniors going “back into the closet” out of fear of discrimination as they entered long term care facilities. Shocked and saddened, we researched solutions, hoping to write an article on resources for aging LGBTQ+ individuals. What we found was sobering. There was little information on the population, and even fewer support resources. When we dug a little deeper, we found that this was often because of a simple fact: there is little to no data on LGBTQ+ patient populations. Sexual orientation and gender identity questions are almost never asked upon patient intake, and there is no way to correlate data that is never requested. So instead we wrote an article highlighting the importance of Sexual Orientation and Gender Identity (SOGI) data collection, and in particular, what that data could mean for sexual minority older adults. We had the pleasure of speaking with Dr. Jason Flatt, assistant professor at the Institute for Health & Aging for the School of Nursing at the University of California San Francisco 5

AUGUST 2018

on the matter, and he detailed the importance of SOGI collection for both trust building and for identifying health disparities. Not included in the article was a longer conversation with Flatt regarding his ongoing research on sexual minority seniors and their rate of dementia risk. Flatt and his team’s findings were recently announced at the 2018 Alzheimer’s Association International Conference in Chicago. As the first dementia prevalence data from a large population of lesbian, gay and bisexual older adults, it offers the very first look at the correlation between a life lived as a sexual minority individual and quantifiable health data.

FINDINGS AT A GLANCE: • The crude prevalence for dementia in lesbian, gay, and bisexual older adults was 8 percent, or roughly 1 in 13 lesbian, gay or bisexual seniors in the United States. • Nearly 70 percent of the lesbian, gay, and bisexual older adults surveyed had hypertension. • Almost 60 percent of the individuals surveyed had been diagnosed with heart disease.

ORLANDO TEDX featured local thought leader, Kelli Murray, who gave a talk about powering innovation through community. A Facebook Live of the talk can be found here: ow.ly/vppV30l6aDH TSOLIFE, a digital legacy preservation platform for seniors, landed its first corporate contract with Meridian Senior Living, having closed the deal on the tradeshow floor at the Florida Assisted Living Conference in Ft. Lauderdale. They will be launching in several communities in early August with the intent to scale the program across 140 of Meridian’s national locations. Disclosure: Readers, please take note that the companies featured in the Health Innovators section have not paid for or bartered for these acknowledgements. All companies are selected based on merit, intrigue, and their potential to move healthcare forward towards the Quadruple Aim. In a noisy and biased market, we believe this to be a valuable distinction.

UPCOMING EVENTS

Correlating Health Data in Lesbian, Gay & Bisexual Older Adults By NINA TALLEY, MedSpeaks

CEO & President, Daryl Tol, recently spoke at a Florida Health Innovators event about their secret innovation team known as FULCRUM. Its mission is to “kill the old healthcare model.” Here’s what we know: https://bit.ly/2A6nzm5

• 35 percent of the lesbian, gay, and bisexual older adults surveyed had medically diagnosed depression, almost double the rate found in heterosexuals. So how did Flatt conduct his research if SOGI data is so hard to come by? In 2007 Kaiser Permanente’s Northern California Medical Region rolled out a study which asked 200,000 of their patients 60 years of age and older, questions regarding their sexual orientation. By partnering with Kaiser Permanente, Flatt and his team were able to leverage this dataset, and, as an integrated medical center, the data provided was in regard to all medical care given to those surveyed. This provided the clinical background for Flatt’s research. This is a powerful testament to the impact private healthcare institutions can have on the health outlook for minority populations, because it has effectively created the foundational dataset for all senior population sexual minority research to come. Flatt isn’t satisfied though. He wants to see gender identity information included in those surveyed as well, and have SOGI (CONTINUED ON PAGE 6)

HealthARCH

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Health Innovators: Happy Hour, Golf, & Connected HealthTech SEPTEMBER 13TH | 4PM Featuring Orlando Health’s Chief Technology Officer. Drive Shack in Lake Nona. Register: www.healthinnovators.info

IHA’s Changing Healthcare With 3D Printing Technology OCTOBER 16-17

GuideWell Innovation Center | Lake Nona Register: https://bit.ly/2v4pUJi

Opioids & Florida: The Collaboration Imperative OCTOBER 22 | 10AM

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MedSpeaksTM showcases the most exciting experts, events and innovations in Central Florida by bringing together the state’s largest community network of Health Innovators. We have converged over 1,400 healthcare professionals including clinicians, entrepreneurs, and technologists to discuss and promote the problems facing healthcare today and the innovations reshaping the future. www.medspeaks.com

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Beginning September ’18, Integrated Independent Physicians Network will feature one of it’s members! IPN Physicians wishing to be featured should email the following to Editor@orlandomedicalnews.com Include a short nomination, current CV and contact person to schedule the interview. Featured Physicians will be limited to IPN Members & decided by the Orlando Medical News Editor

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HEALTH INNOVATORS Peek Into Orlando’s Healthcare Startup Scene, continued from page 5

Orlando has also emerged as a tech hub. The fintech company, Fattmerchant, Inc., recently raised $10.5 million in venture funding, prompting a discussion on how to keep startups born in Orlando within the city. To ensure that great startups stay in the area, proper networks and infrastructure for entrepreneurs have to consistently be nurtured at the grassroots level. Entrepreneurs need to be enabled and given opportunities to have conversations with business leaders, executives, and investors about innovating and moving the needle on some of the biggest problems in healthcare and tech. Kelli Murray, who co-founded the largest innovation group in the SouthEast known as Health Innovators, curates events and develops ways to fuse the different factions in healthcare to get leaders into a room conversing about problems and solutions. Just last month, a Health Innovator’s event featured Daryl Tol, president and CEO of Florida Hospital System, who discussed the issues and challenges in healthcare from his vantage point with a group of 150 local entrepreneurs and startups. “We engage leaders

like Daryl Tol because they know that transformation cannot happen in a silo,” said Murray who is CEO of MedSpeaks, an inclusive platform that establishes innovation powered social communities. She added, “To help Orlando (and cities like it) prosper and build a reputation for pioneering health and wellness, we have taken action to create a community-centric hub that raises awareness and builds bridges of trust between entrepreneurs, startups, and healthcare stakeholders.” By giving a platform to forwardthinking pioneers, we can begin to see what’s holding us back, what’s possible, and what’s the way forward. The beauty of genuine communication is that it algorithmically leads to reframing; viewing problems with a different mental model. To that end, breaking down barriers between stakeholders is key to advancing healthcare and Orlando together. Many entrepreneurs and investors in Orlando may find themselves asking where their tribe is. Where are the innovators, the dreamers who are hungry for change? With Orlando’s current trajectory, the answer is not very far at all.

The Power of Inclusivity, data collection integrated into standard intake practices across the board. “We need to think about really providing more LGBTQ affirming services that are going to meet people where they’re at, but also acknowledge who they are.” said Flatt. “This may require changing medical forms, or acknowledging families of choice, whether that’s a domestic

continued from page 5

partner or friends.” “They’re twice as likely to live alone compared to heterosexuals, so there’s a concern around really having support.” Flatt continued. “We hope that this data provides some support for thinking about training medical providers around meeting the needs of this community.”

HEALTHCARELEADER Philip Kondylis, MD, continued from page 4 ule, so we do not just check off requirements but rather optimize training based on need. The rotations are tailored to the quality of the educational experience, not the volume of work required. To achieve this, the surgical residency program has partnered with three core local training sites that specialize in minimally invasive surgical procedures (handand-stick laparoscopy, robotic-assisted surgery and trans-orifice surgery): Osceola Regional Medical Center, Orlando Veterans Affairs Medical Center and Nemours Children’s Hospital. In addition, residents will also have rotations at three specialty sites: Florida Hospital Tampa (minimally invasive hepatopancreatic biliary service), Kendall Medical Center in Miami (comprehensive acute and chronic care for burn patients) and Methodist Hospital San Antonio (top transplant center). Perhaps most exciting, is that through our partnership with the VA Medical Center at Lake Nona, medical residents will have access to an excellent surgical

simulation facility. Then there are the demographics of Osceola County, which has experienced a population explosion in recent years, including many new arrivals from Puerto Rico. Our residents benefit by gaining exposure to a diverse patient population. Finally, in the past, residents had to travel to Orlando to perform certain surgeries. Offering surgical training at Osceola Regional Medical Center will give physicians the ability to complete their education here in Kissimmee.

What does this residency program bring to the Kissimmee area? PK: As our region has grown, so has the need for quality and comprehensive medical services, including surgical options. We know that people want specialty care when they have complex medical conditions and having those specialists in their own community makes all the difference. That’s why Osceola Regional is investing heavily to become the “go-to” facility for care for our population. orlandomedicalnews

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Community Banks: A Viable Financial Resource for the Physician Business Model By TED SHEPPE

For physicians, who spend their careers caring for patients, it can often be a daunting task to manage financial aspects of the business, in addition to running a medical practice. For that reason, it’s critical to have experienced advisors, including a trusted banker, who can serve as resources as you plan for the future. Whether you’re a surgeon looking to buy an existing practice, a specialist seeking to purchase new equipment, or a family physician who wants to build a new office or hire more staff, business moves of this magnitude may require a commercial loan. The first question is often, “Where should I look?” While there are numerous options from which to choose, not all deliver the same benefits. Make a short list of potential lenders by shopping around to compare offers. As you go through the process, keep in mind that bigger isn’t always better – or safer. Big banks offer name recognition, and thus on the surface might seem like the best option. However, smaller community banks provide their own set of benefits. For example, your connection with the community bank is typically built around a keen understanding of your practice’s needs, and a focus on long-term relationships. Community bankers strive to understand the nuances of their client’s business in order to create strategies that prioritize the owner’s best interests. Community banks are also often nimbler and able to craft more flexible, customized solutions. Another advantage of working with a community bank is that lending decisions are usually made locally … which can translate into a more efficient experience with fewer layers of organizational bureaucracy. Key decision-makers may well be people you know. In addition, because community bankers rely heavily on personal relationships, they can be a good fit for physicians who also want to expand their presence locally. Of course, whichever financial institution you choose, make sure it is healthy and in good standing with regulators. The Federal Deposit Insurance Corporation is an ideal resource for checking a bank’s financial stability. Once you’ve done the requisite due diligence, schedule an in-person meeting with the prospective lender. Be prepared to come to the table with a firm command of your business goals, current financial standing and plans for the future. Here are some suggestions to ensure that the conversation is productive: Business Plan: Prior to meeting with a banker or lender, it is important to have 8

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a business plan in place – preferably one that has been reviewed by your certified public accountant. The plan should include articulated short- and long-term financial goals. Maybe you need a loan immediately to purchase new equipment, and you’d also like to open a second office within five years. With that in mind, look for a banker who thinks beyond temporary solutions, can anticipate the growth of your business, and will craft a lending solution to get you there. Cash-Flow Cycle: Make sure you have a solid grasp of your accounts receivable and that your banker understands your payment mix. For example, how much of your revenue is private pay vs. insurance, Medicare or Medicaid? All of these payers operate on different payment cycles, some with a delay of 60-90 days. Talk with your banker about how these factors affect your cash flow, so he or she can design an appropriate solution. In some cases, your bank can offer a working capital line of credit against your receivables. Expenses: Do you have a realistic understanding of both current and potential expenses? Take a look at the size of your practice and its growth potential. If you have one office, you may not need a controller or human resources professional now — but that could change dramati-

cally if you open multiple locations. Your vision for growth needs the infrastructure to match. Risk: Conversations about risk should happen upfront. Banks look at debt levels, cash flow, and liquidity carefully. It is important to understand your bank’s guidelines in these areas. Once banks start lending outside of a 3-to-1 debt-toworth ratio, the loan request tends to get much more scrutiny, as it appears to be riskier. As an example, a high debt/equity ratio generally means that a company has been aggressive in financing its growth with debt – practices often associated with high levels of risk. It’s also important to be transparent about weaknesses in your business model or financial history. If you disclose these issues in advance, you and your banker can approach them proactively. Types of Loans: Where are you in your business life cycle? A well-qualified banker will want to know where you are professionally to determine the appropriate metrics needed for a conventional bank loan. In some cases, an SBA 7A loan may be a better fit. This government-guaranteed loan program assists borrowers who have strong financial indicators even if they lack collateral or an established track record. Securing a loan can be a complex undertaking, and your relationship with your

lender is a vital component to your growth. In making an educated decision about your financial future, choose a banker who reflects the principles that your practice has been built upon: personalized care with a vision for success. Ted Sheppe is the Executive Vice President for commercial banking at Axiom Bank, N.A., a Maitland-based nationally chartered community bank that serves the financial needs of its customers through a wide range of financial products. Axiom Bank is a SBA preferred lender that also specializes in commercial loans, treasury management and other merchant services. Additionally, Axiom Bank offers asset-based lending and factoring solutions through its Allied Affiliated Funding division. Visit www.AxiomBanking.com. Member FDIC. Equal Housing Lender. Ted can be reached at tsheppe@axiombanking.com or 321-249-7847. Johan Cardenas is the Vice-President of Commercial Lending at Axiom Bank, N.A., a Maitland-based nationally chartered community bank that serves the financial needs of its customers through a wide range of financial products. Axiom Bank is a SBA preferred lender that also specializes in commercial loans, treasury management and other merchant services. Additionally, Axiom Bank offers asset-based lending and factoring solutions through its Allied Affiliated Funding division. Visit www.AxiomBanking.com. Member FDIC. Equal Housing Lender. Johan can be reached at jcardena@axiombanking.com or 305-5285370.

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Welcome Radiology Specialists Of Florida’s New Sub-Specialized Radiologists Body Radiology

Darel Heitkamp, MD

Jay Patel, MD

August 20, 2018

July 16, 2018

Midhir Patel, MD August 13, 2018

Hsiang-Jer Tseng, MD

Women’s Radiology

Elizabeth Berrill, MD July 16, 2018

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July 9, 2018

Neuroradiology

Ronak Patel, MD

Sean Dodson, MD

July 16, 2018

July 23 2018

Dana Poletto MD July 23, 2018

Pediatric & Interventional Radiology

Interventional Radiology

Musculoskeletal Radiology

Matthew Cody O’Dell, MD

Brandon Perry, MD

Gary LiMarzi, MD

July 2, 2018

Christopher Smith, MD

July 9, 2018

September 10, 2018

July 16, 2018

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GrandRounds Adventist Health Physician Services Medical Director, Dr. Roy Schutzengel, Joins Elite Medical Administrators Conference Adventist Health—a faith-based, nonprofit integrated health system serving more than 80 communities in the western U.S. states of California, Oregon and Hawaii—is proud to announce Medical Director for Adventist Health Physician Services, Roy Schutzengel, MD, MBA, has been invited to join the Medical Administrators Conference (MAC), a national group of elite physician leaders. MAC is a closed group of physicians who have shifted their full-time focus from individual patient care to innovative physician leadership to discuss and influence ongoing trends within the healthcare field. Dr. Schutzengel joins the illustrious group whose membership includes physician leaders from the Harvard School of Public Health, Institute for Healthcare Improvement, American Public Health Association and the Institute of Medicine, National Academy of Sciences and other organizations. A licensed physician, accomplished business leader and a pioneer in transforming healthcare through the implementation of leading-edge technology, Dr. Schutzengel is one of three new members inducted into the national physician leaders group where he plans to serve in a technology leadership position. “It was a great honor to be invited to this elite group of medical professionals who are at the top echelon of the healthcare field,” Dr. Schutzengel said. “I look forward to contributing to the influential work MAC is doing for the healthcare industry, physicians and patients.” Dr. Schutzengel joined Adventist Health in 2012 after a lengthy clinical and administrative career in healthcare. Since 1939, MAC has become one of the most distinguished organizations of physicians engaged in administrative responsibilities with a range of healthcare organizations. Members have been drawn from the ranks of academic medicine and public health; managed care organizations; local, state and federal governments; consulting firms; for-profit healthcare service and product companies and Fortune 500 companies. Physicians join MAC by invitation only and the organization’s membership is limited to 50 active members.

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Medical Organizations Urge CMS to Reconsider Decision on ACA Risk-Adjustment Payments Twenty-eight medical organizations, including the American Medical Association (AMA), sent the following letter to the Centers for Medicare & Medicaid Services (CMS) expressing concern with the agency’s decision to suspend billions of dollars in annual payments to insurers as required under the Affordable Care Act’s (ACA) risk-adjustment program. The letter was sent to CMS Administrator Seema Verma. Dear Administrator Verma: On behalf of the undersigned organizations, we are writing regarding the decision announced on July 7 by the Centers for Medicare & Medicaid Services (CMS) to suspend billions of dollars in annual payments to insurers as required under the Affordable Care Act’s (ACA) risk-adjustment program. This action comes at a particularly sensitive time, when health plans are making decisions about whether to participate in the individual marketplace and developing premiums for 2019, and states are reviewing rates. We are very concerned that this move will create further uncertainty in the marketplace, negatively impacting patients’ access to affordable and comprehensive coverage, and lead to higher premium increases next year. The risk adjustment program protects insurers from unanticipated costs in the event that their enrollees are less healthy, as well as minimizes any incentives for insurers to target healthier individuals only for enrollment. Of the three premium stabilization programs authorized by the ACA, the risk adjustment program is the only one that is permanent. Therefore, it is particularly critical that the program remain operational. It works by transferring funds from plans with healthier enrollees in the individual and small group markets to plans with less healthy enrollees. CMS’ announcement means that almost $10.4 billion in risk adjustment transfers for 2017, expected to be paid in the fall of 2018, will not be made until the litigation is resolved in New Mexico Health Connections v. HHS, a case where the U.S. District Court in New Mexico invalidated the methodology used to calculate risk adjustment payments based on the statewide average premium. The Court’s invalidation was based on the need for further explanation by CMS for operating the risk adjustment program in a budget neutral manner. This ruling is in conflict with the federal court decision in Massachusetts that upheld the risk adjustment methodology. CMS’ decision to delay these

Doctor's Innovative Response to Hospital's Overbilling Patients, Under-paying Doctors Offers Hope This video of Dr. Keith Smith, founder of the Surgery Center of Oklahoma, which posts all prices and charges far less than hospitals nationwide, will leave you standing and applauding at the end. Please watch it. Dr. Smith is also cofounder of the Free Market Medical Association, a national organization working to change the health-care system by matching willing sellers to willing buyers.

A supporter of AID, FMMA helps identify patients willing to pay cash with doctors willing to list their prices, while helping businesses provide employees affordable options. AID's Executive Director Marni Jameson Carey will be a featured speaker at the FMMA's next national conference, April 11-13, 2019, in Dallas.

Central Florida Regional Hospital Offers Innovative TCAR Procedure To Treat Carotid Artery Disease Central Florida Regional Hospital in Sanford now offers a minimally invasive alternative to treat carotid artery disease and prevent future strokes. The new procedure, called TransCarotid Artery Revascularization (TCAR), is a clinically proven, minimally invasive and safe approach for high surgical risk patients who need carotid artery treatment. Carotid artery disease is a form of atherosclerosis, or a buildup of plaque, in the two main arteries in the neck that supply oxygen-rich blood to the brain. If left untreated, carotid artery disease can often lead to stroke. It is estimated to be the source of stroke in up to a third of cases, with 400,000 new diagnoses of the disease made every year in the U.S. alone. Prior to TCAR, the main treatment option for severe carotid artery disease was an open surgical procedure called carotid endarterectomy (CEA). CEA removes plaque from inside the carotid artery to restore normal blood flow to the brain, but the procedure carries risks of surgical complications, including bleeding, infection, heart attack and stroke. TCAR is unique in that blood flow is temporarily reversed during the procedure so that any small bits

of plaque that may break off are diverted away from the brain, preventing a stroke from happening. A stent is then placed inside the artery to stabilize the plaque, minimizing the risk of a future stroke. “TCAR is an important new option in the fight against stroke, and is particularly suited for the large portion of patients we see who are at higher risk of complications from carotid surgery due to age, anatomy or other medical conditions,” said Robert Winter, M.D., vascular surgeon at Central Florida Regional Hospital. “Because of its low stroke risk and faster patient recovery, I believe TCAR represents the future of carotid repair.”

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GrandRounds transfers jeopardizes patients’ ability to access affordable coverage as well as lifesaving care and treatment. Insurers may be unwilling to sell coverage under such uncertain conditions, and those that do will likely increase premiums. The implications of a delay in calculating, collecting, and making the risk adjustment payments to insurers are significant for both patients and providers. Therefore, we urge CMS to reconsider its decision and seek other possible options to resolve the issues raised by the New Mexico risk adjustment litigation. For example, CMS could issue an expedited rule using the same rationale it used for the risk adjustment payment methodology in the final rule on Notice of Benefit and Payment Parameters for 2019. We appreciate your consideration of this urgent matter. Sincerely, AARP Alliance of Specialty Medicine American Academy of Family Physicians American Cancer Society Cancer Action Network American College of Physicians American College of Surgeons American Diabetes Association American Heart Association American Hospital Association American Liver Foundation American Lung Association American Medical Association Arthritis Foundation Association of American Medical Colleges Crohn’s & Colitis Foundation Cystic Fibrosis Foundation Epilepsy Foundation Family Voices Federation of American Hospitals Hemophilia Federation of America Leukemia & Lymphoma Society Lutheran Services in America March of Dimes Mended Little Hearts National Alliance on Mental Illness National Multiple Sclerosis Society National Organization for Rare Disorders National Patient Advocate Foundation

Orlando Based Law Firm Files Class Action on Behalf of Doctors Fighting Medical Boards The Health Law Firm filed a class action lawsuit in the Middle District of Florida on July 11, 2018, on behalf of three dermatologists who allege they represent a class of dermatologists in a similar situation. The suit alleges that the American Board of Medical Specialties, Inc. (ABMS), and the American Board of Dermatology, Inc. (ABD), are planning or committing actions in restraint of trade. The plaintiffs allege that the ABMS and the ABD are planning to take action to approve a medical subspecialty in Mohs surgery, an effective treatment for skin cancer. They state in their suit, that this will result in a reduction in the number of doctors who can perform the procedure and be paid for it. The doctors claim 11

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Poinciana Medical Center recently recognized employees around the hospital for outstanding performance and exceptional work. Rommel De La Rosa and Lt. Mike Diaz were honored as employees of the month, and Xiomara Durieux was presented with the Patient Safety Award.

the specialty certification for Mohs surgery, also known as "micrographic dermatologic surgery," would limit the number of physicians who could be reimbursed by government programs, such as Medicare and Tricare, and by private insurers. As a result, patient access to the simple skin cancer surgery would be greatly reduced, according to the suit. If the defendants are successful in their plans to create this new medical subspecialty, doctors who want to be board certified in Mohs surgery would have to complete a separate fellowship, either a one-year or two-year additional post-residency academic program limited to Mohs surgery. Doctors, such as the three plaintiffs, may lose clinical privileges at hospitals, despite the fact that they may have performed the simple surgical procedure thousands of times, according to the suit. The doctors are seeking an injunction restraining the defendants from limiting "in any way" their ability to perform and charge for Mohs surgery. Attorney George F. Indest III, President of The Health Law Firm, and the attorney to file the class action case stated: "If the proposal to be considered by the ABMS passes, in order to become board certified in Mohs surgery, these dermatologists would have to meet a number of requirements that they may not otherwise be able to meet. In most cases, it's not feasible for the physicians." To view the complaint in full, click here. To view additional court documents, visit the "Case and Litigation Documents" section of our website.

Study Points to Need for Performance Standards for EHR Usability and Safety A novel new study involving clinicians using electronic health records (EHRs) to perform certain common tasks provides compelling evidence

that the design, development and implementation of these systems need to be improved to make them easier to use by clinicians and, ultimately, safer for patients. The study, entitled “A usability and safety analysis of electronic health records: a multi-center study,” was published July 2 by the Journal of the American Medical Informatics Association. It was conducted by researchers with MedStar Health’s National Center for Human Factors in Healthcare, the American Medical Association (AMA), and others, and was funded by the AMA. Researchers focused on the two largest EHR vendors, Epic and Cerner, who comprise more than 50 percent of the market. They conducted the study at two sites per vendor, or four health systems. Twelve to 15 emergency physicians per site were given common tasks mimicking real patient cases— placing orders for medical imaging, lab tests, and medications. Researchers collected data pertaining to length of time and number of clicks to complete each task plus the degree of accuracy. The findings showed huge variability in performance across the sites. For example, time to complete an imaging order varied from 25 seconds at one site to more than a minute at another. Placing an imaging order required an average of eight clicks at one site, while the same task at a different site averaged 31. For a medication order, one site recorded no errors while another had a 30 percent error rate. To have their products certified, EHR vendors are required by the federal government to employ user-centered design as they develop systems and to conduct usability testing near the end of the process. But EHR usability challenges persist due to several reasons outlined in the study. One large factor is that EHRs are configured and customized by the vendor and health system during implementation, and the resulting product may be significantly different from the one

that was tested by the vendor to meet government requirements for usability and safety. “Our findings reaffirm the importance of considering patient care and physician input in the development and implementation of EHRs,” said study co-author Michael Hodgkins, MD, chief medical information officer of the AMA. “There are multiple variables impacting the end user experience that contribute to physician burnout, a diminished patient-physician relationship, and unrealized cost savings. While design can be an important factor, so too can implementation choices made onsite. Increased collaboration between vendors, information technology purchasers and physicians is needed to optimize experiences and address current needs.” The study’s authors conclude, “Our results suggest that basic performance standards for all implemented EHRs should be considered in order to ensure usable and safe systems. Both EHR vendors and providers should work together to ensure that usable and safe products are implemented and used.”

Oviedo Medical Center Awarded Advanced Certification For Primary Stroke Centers Oviedo Medical Center announced that it has earned The Joint Commission’s Gold Seal of Approval® and the American Heart Association/American Stroke Association’s Heart-Check mark for Advanced Certification for Primary Stroke Centers. The Gold Seal of Approval® and the Heart-Check mark represent symbols of quality from their respective organizations. Oviedo Medical Center underwent a rigorous onsite review on April 20, 2018. Joint Commission experts evaluated compliance with strokerelated standards and requirements, including program management, the orlandomedicalnews

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GrandRounds delivery of clinical care and performance improvement. “Oviedo Medical Center has thoroughly demonstrated the greatest level of commitment to the care of stroke patients through its Advanced Certification for Primary Stroke Centers,” said Patrick Phelan, executive director, Hospital Business Development, The Joint Commission. “We commend Oviedo Medical Center for becoming a leader in stroke care, potentially providing a higher standard of service for stroke patients in its community.” Established in 2003, Advanced Certification for Primary Stroke Centers is awarded for a two-year period to Joint Commission-accredited acute care hospitals. The certification was derived from the Brain Attack Coalition’s “Recommendations for the Establishment of Primary Stroke Centers” (JAMA, 2000) and the “Revised and Updated Recommendations for the Establishment of Primary Stroke Centers” (Stroke, 2011).

Osceola Regional Medical Center Adds Advanced CT Scanner Allowing A Virtual Catheterization Of The Heart Cardiac, emergency, trauma, stroke and pediatric care at Osceola Regional Medical Center just became more efficient with the latest imaging technology of its kind in Central Florida. With the recent addition of the sophisticated GE Revolution 80mm, 256-slice CT scanner, the hospital can now provide faster than ever, more comprehensive diagnoses in a single imaging exam. Osceola Regional is the first hospital in Central Florida to implement this new technology. The 256-slice scanner allows physicians to scan entire organs such as the heart, brain, liver and pancreas in a single 0.28-second rotation. For cardiac patients, this allows a virtual, non-invasive diagnostic catheterization procedure in less than a 2-sec-

ond acquisition time. Patients who previously would have needed to undergo several tests over multiple days are now able to be diagnosed after a single scan, allowing them to move toward recovery more quickly. The scanner can perform: • Cardiac exams in a single heartbeat • Whole brain imaging in less than a second • Low dose, whole organ diagnosis and follow-up for cancer patients • Detailed bone imaging, even for patients with metal implants • Low-dose scans for pediatric patients Less administration of contrast With a Certified Level II Trauma Center, Comprehensive Stroke Center, Pediatric ER, Pediatric Unit and ICU, in addition to the Heart and Vascular Institute, Osceola Regional will continue to provide advanced non-invasive technology to patients in the region, in particular to patients who may be at risk for invasive diagnostic procedures. “The addition of the 256-slice CT allows our medical team to offer an elevated level of care to Osceola County,” said Tejal Patel, MD, Medical Staff Department of Radiology Chairperson. “With the opportunity to receive quicker diagnoses, patients can get a head start on their road to recovery.”

CMS Moves toward transparency, price parity In the last two weeks, the Centers for Medicare & Medicaid Services have proposed two rulings that would directly advance two of AID's main goals: price transparency and site neutrality. Here's a summary of what the moves would mean for patients and doctors, and how we can help make sure the rulings -- which both face hospital opposition -- take effect Jan. 1. Transparency Under a rule finalized Thursday by the Trump administration, hospitals will be required to post online a list of their standard charges, according to a

New Chief Medical Officer at Heart of Florida Regional Medical Center Vincent Carifi, M.D. is trading in his surgical scrubs for a suit and tie as he becomes the first Chief Medical Officer for Heart of Florida Regional Medical Center. In his new role, Dr. Carifi, who has been general surgeon for 40 years and a breast surgeon for the last 14, will act as a liaison between physicians practicing at the hospital and hospital administration. Heart of Florida CEO Ann Barnhart said the decision to appoint Dr. Carifi as the CMO was an easy one. “Vinny Carifi is the perfect fit for this new position at Heart of Florida. He knows the physicians, he understands their needs, he knows how the hospital works, and understands the importance of aligning our interests.’’ Barnhart said. “More and more hospitals are using Chief Medical Officers to serve as another connection between medical staff and administration. The CMO provides an understanding to the Medical Staff of the hospital’s imperatives and in turn provides the clinical perspective to the Administration’s strategic plan and vision. It makes sense to have a

well-respected and objective person in that position. I know Dr. Carifi will do a great job leading us through this necessary alignment of goals.’’ Dr. Carifi said one of the things he plans to look at first is the length of a patient’s stay in the hospital. “We want to make sure that the patient is staying in the hospital only for as long as they need to be here. We want to successfully address what brought them here in the first place and to make sure they are on the road to recovery before we discharge them,’’ he said. Dr. Carifi, who came to Florida from New Jersey in 1977, has been a general surgeon, a breast surgeon and a breast care physician for his entire career. When asked about the transition away from direct patient care, Dr. Carifi said: “I loved what I was doing, but I was ready for a change. It was time for a change and when (CEO) Ann (Barnhart) approached me about this position, it seemed like a perfect fit.” Although he is ready for the change, he did admit it was a little strange to not be doing any surgeries on a recent Thursday.

Orlando Regional Medical Center Announces New Medical Chief Quality Officer Orlando Health has named George Ralls, MD, as the new medical chief quality officer for Orlando Regional Medical Center (ORMC) effective Aug. 1. In this position, Dr. Ralls will serve as the chief influencer to lead and implement strategic plans for quality improvement, regulatory compliance, and the medical aspects of patient care. Dr. Ralls will provide direction and support to ORMC medical staff and leadership to achieve quality and performance goals. 12

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Dr. Ralls started his medical career as a firefighter-paramedic with MiamiDade Fire Rescue. He later earned a medical degree from the University of Miami School of Medicine and then completed emergency medicine residency training at ORMC, serving as chief resident during his senior year. He then went on to complete a physician fellowship in Emergency Medical Services (EMS), and is certified as a diplomate of the American Board of Emergency Medicine.

In coordination with Orlando Health’s Graduate Medical Education team, Dr. Ralls instituted Florida’s first EMS physician fellowship in 2007. He has held a number of leadership positions with Orange County Government, including EMS medical director, health services director and most recently director of health and public safety. Since 1998, he has dedicated his time to the people of Orlando and will continue serving the community with Orlando Health. orlandomedicalnews

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GrandRounds report published in The Hill. Starting Jan. 1, hospitals will be required to update the information annually. CMS said the new rule would require hospitals to post the information online to "encourage price transparency" and improve "public accessibility." "This is a small step towards providing our beneficiaries with price transparency, but our work in this area is only just beginning," CMS Administrator Seema Verma said in a speech last month. "Price transparency is core to patient empowerment and making sure American patients have the tools they need so they can make the best decisions for them and their families." Site Neutrality On July 25, CMS released a rather murky announcement, which several media reports mischaracterized, about a proposal to extend site neutrality to hospital outpatient clinics. Such a move would level out payments between hospital-owned clinics and private physicians' offices. If these payments were equal, hospitals would be far less interested in buying medical groups and turning independent doctors into more profitable employees for the hospital, a trend that has caused health-care prices to soar. AID spoke with a top CMS official to gain clarity on what the proposal really means. As AID has reported in the past, full site neutrality would require a change in the law, which would require an act of Congress. Though CMS supports full site neutrality, the law does not grant CMS the authority to require it. Thus, the proposed change goes only as far as CMS believes the law allows the agency to go, and stops short of full site neutrality. If enacted, the proposal would allow the following: • The change would affect reimbursements only for office visits at clinics that are not part of a hospital’s campus. Thus, reimbursements for procedures and for on-campus clinic visits would not change. For office visits at hospital-owned off-campus clinics, hospitals would receive the same payment that independent physician offices receive for visits. • The proposal extends the ruling that went into effect last year that requires hospital-owned off-campus clinics (those that aren’t part of the hospital campus), purchased after Nov. 2, 2015, to receive the same payment for visits (not procedures) as physician offices. The new proposal removes the grandfather clause and extends the ruling to apply to all off-campus clinics regardless of when they were acquired, so all office visits to off-campus clinics would be reimbursed at the physician rate. 13

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• Once site-neutrality is achieved for these office visits, Medicare and Medicare beneficiaries would save an estimated $760 million a year. • If site neutrality for procedures at all hospital-owned clinics were mandated, taxpayers and Medicare beneficiaries would save close to $1 billion a year ($900 million), according to the Medicare Payment Advisory Commission. • Full site neutrality for both visits and procedures would achieve an annual savings of $1.66 billion for just Medicare, and far more if commercial insurers followed suit. • For site-neutrality to apply to all procedures and all clinics, we need a change in the law. AID is working with a U.S. Congressman who has agreed to help draft that law. • The proposal is now in its 60-day comment period. (AID will be submitting a comment.) After the comment period ends Sept. 24, CMS will review all comments and come out with a decision Nov. 1, which will take effect Jan. 1, 2019. We encourage you to submit your comments to CMS directly, or to AID for us to include in our response.

Florida Hospital Celebration Health breaks ground on new patient tower Florida Hospital Celebration Health today broke ground on a new patient tower, which will allow the hospital to keep pace with increasing demand for health care in fast-growing Osceola County. The expansion coincides with the hospital celebrating 20 years of service to the community. The five-story, Mediterraneanthemed tower will hold 76 all-private patient rooms when it opens, and 160 at buildout. It will also allow for the expansion and addition of important health-care services. “Embarking on this expansion of our capacity and services is a fitting way to celebrate our 20th anniversary,” said Doug Harcombe, administrator of Florida Hospital Celebration Health. “We are looking forward to serving the health needs of our community for the next 20 years.” The new tower will also include additional mother-baby space and a larger Progressive Care Unit, which is for patients who need close monitoring but not the acute level of services provided by an intensive care unit. The new patient tower will allow for the expansion of multiple programs and services, including a new open-heart program that will begin in January 2019.

The Orlando Fire Rescue Clinical Awareness Program Meets in Orlando

Marie Gumá-Jelinek, PsyD (ABD) VIce President, Business and Program Development for Elan Recovery + Wellness, speaking with the firefighters who ran the live fire simulation for the clinicians. The Florida Firefighters Safety and Health Collaborative (FFSHC) hosted the two day Clinical Awareness Training in Orlando, Florida. The Florida Firefighters Safety & Health Collaborative is a FREE Program to Fire Departments looking to enhance, and maintain an effective Safety Committee and/or Safety Program. The Clinician Awareness class was held at the Central Florida Fire Training Facility. Instructors Chris Bator, Jeremy Hurd, Larry Doelling, and Dustin Hawkins utilized this intensive class to provide licensed clinicians an opportunity to learn more about the firefighter culture in order to be more effective in treatment of firefighters. The class was full with 45 attendees who enjoyed the unique learning experience and intimate insight. The intensive 16 hour program's content immerses the student immediately into the unique language, dynamic personality, and trauma immersed life of the first responder. The Second portion of day 1 allowed the Clinicians a hands-on perspective of the intensity and physically demanding nature of what it means to "walk a mile in our boots". The clinicians "gear up" and got to work in the training tower in a simulated smoke environment with the goal of better understanding

how the first responders function as a cohesive unit by preforming a building search and victim rescue. Day two allows the Clinicians to interact one on one with first responders whom have successfully developed resiliency skills through professional programs to better understand the mindset of first responders in crisis and how to bridge the gaps in treatment. The participating clinicians and mental health professionals are being utilized to populate a resource map which is being shared state wide to increase the support options to all first responder agencies across Flora to meet the expanding metal wellness needs. We are thankful to Lt Jeff Orrange City of Orlando Fire Department and Lt Anthony Willis from Orange County Fire rescue and the FFSHC Central Region for coordinating and planning this event. The Central Florida Fire Consortium provided an amazing facility and all the local Departments that committed resources made this event a huge success. In addition, we are very proud to have the support of the Central Florida fire service, Fire Chiefs Association, Cigna, University of Central Florida Restores program as well as the vendor support for this event from Ten-8 Fire Equipment.

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GrandRounds Orlando Health Magazine Recognized for Excellence Choose Health Wins APEX Award Choose Health, the Orlando Health community education and lifestyle magazine, has received national recognition. The publication, which is distributed to more than 100,000 Central Florida households three times a year, was honored with an APEX 2018 Award of Excellence in the Magazines/ Journals-Print, 32+ pages category. “We’re extremely pleased to be recognized in this manner,” said Andrew Snyder, senior vice president marketing and communications for Orlando Health. “Chose Health is a labor of love for the nearly two dozen team members who contribute to each issue. I am very proud of each of them.” APEX Awards are based on excellence in graphic design, editorial content and the ability to achieve overall

With the new tower, Florida Hospital Celebration Health will eventually have about 400 patient beds. “This new tower means more patients will be able to get treatment close to home, rather than traveling out of the area,” said Dr. Omayra Mansfield, chief of staff of Florida Hospital Celebration Health. “Treating patients close to home, where it’s easier for loved ones to visit or stay with them if needed, is important to the healing process.” The new patient tower is expected to open by January 2020.

15th Annual Caribbean Health Summit is Gearing up to provide a thousand more Free Health Screenings in Central Florida The Center for Multicultural Wellness and Prevention Inc. will host the 15th Annual Caribbean Health Summit on September 8, 2018 at the Central Florida Fair & Exposition Park (Fairgrounds), 4603 West Colonial Drive, Orlando. Doors will open at 8:00 am. and the event will continue to 2:00 pm. This free community event is planned and implemented in collaboration with the Caribbean American Chamber of Commerce of Florida Inc., the Greater Haitian American Chamber of Commerce of Orlando, and Florida Department of Health in Orange County. The event Co-chairs are City of Orlando Commissioner Regina Hill 14

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Orlando Health Breaks Ground on new Emergency Room and Medical Pavilion in Lake Mary

communications excellence. APEX Awards of Excellence recognize exceptional entries in each of 100 individual categories. This year’s competition included more than 1,400 entries. APEX 2018 is the 30th annual awards program recognizing excellence in publishing by professional communicators.

and Orange County Commissioner Victoria P. Siplin, who stated "The Caribbean Health Summit provides residents access to free, on-site health screenings and educational resources to help them take control of their wellbeing." Commissioner Regina Hill said, "He who has health has life, he who has life has HOPE!" The theme of this year’s health summit is “Healthy Body, Mind & Spirit,” which emphasizes taking care of not only your body but your mind, and spirit as well. At the summit, health experts will share important strategies to embrace your health through prevention of diseases; improving wellness and quality of life. Health screenings will include Prostate Specific Antigen (PSA) exams, Eye exams, Dental exams, Body Mass Index (BMI), Cholesterol, Glucose (blood sugar), Blood pressure, HIV/Syphilis, Mental Health assessment, and lots more. The summit will offer mammogram screenings on Friday, September 7th and on Saturday, September 8th by appointment only. To schedule a free mammogram screening, please call (407) 648-9440 ext. 0. For more information about CMWP, please call (407)648-9440 or visit our website at www.cmwp.org.

New, Expanded Cancer Center Reaches Completion in Southwest Orlando The final phase of construction is complete for Orlando Health UF Health Cancer Center – Dr. Phil-

Orlando Health has broken ground on its new emergency room and medical pavilion in Lake Mary. At $42 million, the 30-acre project will be a part of a medical complex on the northwest corner of Manderley Run and Rinehart Road. The first phase of construction will feature a freestanding emergency room on the first floor that is provided as a service of Orlando Health’s Seminole Hospital. The two-story 40,000 square-foot emergency room will include 24 exam rooms, an imaging department, ambulance bays and a helipad. Adjacent to the pavilion will be a three-story, 60,000-squarefoot medical office building that houses specialty physician offic-

lips, offering patients in communities throughout southwest Orlando convenient access to advanced cancer care right in their back yard. “We’re very excited to be able to reach our patients in this part of the community with the advanced cancer care they’ve come to expect from us,” said Mark Roh, M.D., president of Orlando Health UF Health Cancer Center. “Now that this new facility is complete, our patients won’t have to endure the difficulties of traveling downtown for appointments; for most treatments, they’ll enjoy the benefit of being close to home.” Located on the campus of Orlando Health Dr. P. Phillips Hospital, the new Cancer Center occupies an 18,000 square-foot facility previously held by Orlando Health Physician Associates. Patients will have access to full-service cancer treatment with expanded chemotherapy and radiation treatment areas, medical oncology services, surgical oncology consultations, oncologic pharmacy services, laboratory facilities, and Cancer Support Community programs. The facility address is 7472 Docs Grove Circle, Orlando, Florida 32819. “As southwest Orlando continues to evolve, we want to ensure we are continuing to meet the needs of our community,” says Thibaut van Marcke, president of Orlando Health Dr. P. Phillips Hospital. “Our new, expanded cancer center will allow our patients to receive the same high level of care they are accustomed to from our downtown campus in their own backyard.” The new Cancer Center celebrated its grand opening with a ribbon

es, an ambulatory surgery center, and outpatient imaging and laboratory services. “Orlando Health is dedicated to excellence in supporting and serving our patients. The Orlando Health Lake Mary Emergency Room and Medical Pavilion will allow us to continue in our commitment to provide individuals in the Lake Mary community with access to the highest quality of care that’s close to home,” said Shawn Molsberger, President, Orlando Health-South Seminole Hospital. For more information on Orlando Health’s new emergency room and medical pavilion, please visit http://www.orlandohealth.com/LakeMaryER.

cutting ceremony attended by Orlando Health leadership, physicians and team members, as well as Dr. Phillipsarea business and community leaders.

Florida Hospital surgeon performs 1stin-the-nation procedures with new surgical robot Florida Hospital is the first health care system in the nation using an innovative new surgical robotic system, which offers haptic feedback and allows physicians to control the device with their eyes. Known as the TransEnterix Senhance system, it’s the first new robotic surgical system to receive FDA approval since 2000. Colorectal surgeon Dr. Teresa DeBeche-Adams recently performed the nation’s first Senhance-assisted operation on Timothy Kerley, who suffered from bleeding ulcers that had led to his being hospitalized last year. He is recovering well after having 14 inches of his small intestine removed. “I felt pretty good right from the get-go,” Kerley said of his experience following the surgery. “The nurses had me up and walking all around the hospital pretty much right away.” Kerley added that, aside from minor soreness, he’s had no pain in the weeks since the procedure and his incisions have healed. The Senhance’s instruments are just 5 millimeters in diameter, and the system senses and minimizes forces at the patient’s small skin incisions. orlandomedicalnews

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GrandRounds As a result, current minimally invasive surgery may become even more so, which means quick and easy recovery for patients, with little to no scarring. The controls for the Senhance mimic traditional laparoscopic surgery, allowing for an accelerated adaptation for surgeons currently performing surgeries with these tools. The surgeon sits in an ergonomically comfortable position, and can see inside the body with 3D visualization. Optical sensors allow surgeons to move the camera and select commands simply by moving their eyes. The Senhance also is the first robotic system that offers haptic feedback, which re-creates the sense of force feedback for surgeons so that they can “feel” forces encountered via the system’s robotic arms. DeBeche-Adams said the benefits of Senhance extend to the physician too. “The ergonomics are great — I did three cases in one day, and was not physically fatigued. This has the potential to extend surgeons’ careers,” she said. “Setup is easy and the three-dimensional eye tracking is impressive as well.” While currently only approved for gynecological and colorectal procedures, DeBeche-Adams believes the Senhance will also eventually become a popular option for general surgery.

Zika Viruses Show Potential as Treatment for High-Risk Childhood Cancer Zika virus, long feared for its severe effects on pregnant mothers and unborn babies, may hold potential as a cancer treatment for neuroblastoma, a rare- but-deadly childhood cancer, according to early findings from basic research published in PLOS One. This basic research provides the groundwork for future investigations, but more studies are required to determine if it will lead to new treatments. Neuroblastoma, the second most common childhood tumor, typically develops along the sympathetic nervous system or adrenal glands. While these cancers account for only 6 percent of all childhood cancers, affecting 1 in 7,000 children, they cause a disproportionately high number of childhood cancer deaths (15 percent). Most cases do not respond well to current standard treatments of aggressive chemotherapy and radiation, resulting in high mortality and a desperate need to identify new therapies for high-risk cases. “The same thing that makes Zika so detrimental to developing infants gives it promise as a cancer treatment. Its attack on developing nerve 15

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Orange County Medical Society and Seminole County Medical Society held a Controlled Substances Education Seminar for 7.5 CMEs with 300 physicians in attendance at the Orlando Doubletree. The next seminar will be held on August 18th at 8:00 am at Westgate Resorts in Orlando. Go here for more information and to register.

Nemours Children’s Health System Names Chief Marketing Officer Nemours Children’s Health System has announced that Sarah C. Sanders has been named Senior Vice President & Chief Marketing Officer. In this newly created role, Sanders will lead the multi-state health system’s local, regional and national marketing strategy to help advance the health of children and their families. She will report to David J. Bailey, MD, MBA, president and CEO of Nemours. “I am delighted to welcome Sarah to Nemours where she will help elevate our enterprise-wide marketing strategy and brand evolution. Her background and experience are a wonderful complement to our strong educational and academic mission,” said Bailey. “With her expertise and leadership, we will be able to reach even more families in the U.S. and internationally, fulfilling our promise to help every child in our care reach his or her full potential.” Sanders brings an extensive background in academic healthcare to her new role at Nemours. She most recently served as Associate Chief Marketing Officer at the Uni-

versity of Pennsylvania Health System (Penn Medicine), one of the country’s top 10 ranked health systems. At Penn Medicine, she transformed the organization’s marketing approach by establishing a customer relationship management platform (CRM) and building a precision marketing competency. Additionally, as an avid proponent of brand leadership, she is known for generating business value and driving intensive digital marketing strategy through employing new technologies to achieve results. As the inaugural Chief Marketing Officer, Sanders will lead the advancement of marketing and communications as an increasingly vital partner in promoting the organization’s mission and robust patient-focused environment. In this role, she will manage Nemours’ marketing and communications Associates in the areas of branding, public relations, internal communications and clinical service line support. These geographically diverse teams are located in Central Florida, the Delaware Valley, and North Florida.

cells, the same type of cells neuroblastoma is derived, allows the virus to selectively target cancer cells and leave normal cells alone,” said Tamarah Westmoreland, MD, PhD, a Pediatric General and Thoracic surgeon at Nemours Children’s Hospital. Researchers at Nemours Children’s Hospital in the laboratories of Drs. Tamarah Westmoreland and Kenneth Alexander as well as Dr. Griffith Parks at the University of Central FL College of Medicine examined the impact of Zika viruses on neuroblastoma cells by infecting different types of cultured neuroblastoma cells with Zika and then measuring the impact. Ten days after infection, most neuroblastoma cells were killed. However, most surprising was that one specific neuroblastoma cell line, SK-N-AS, showed resistance to Zika infection. Upon closer examination, these researchers found that this cell

line had poorly expressed levels of the protein, CD24, a membrane protein, than any of the other neuroblastoma cell lines. They also determined that CD24 on neuroblastoma cells was required for Zika viral infection, which could be used as a potential cancer treatment. “While this mosquito-borne illness is not usually something you chose to contract, very few children and adults who are infected with the virus have symptoms and those who do usually experience a mild reaction, such as conjunctivitis, fever, and rash. Given these limited symptoms, the virus’ ability to fight cancer could present far fewer side effects than current treatments,” said Kenneth Alexander, MD, PhD, Chief of the Division of Infectious Diseases at Nemours Children’s Hospital.

“The Nemours organization is truly patient-centric. For a marketer, this is an exciting opportunity to apply my expertise in data and technology to create personalized, relevant and value-added engagement opportunities for patients and their families,” said Sanders. “As a parent of three children, including a special needs child, I understand first-hand the challenges of navigating a complex health situation.”

CareSpot and Orlando Health Continue Expansion with New CareSpot Urgent Care A new CareSpot Urgent Care | Orlando Health center in Ocoee opened in July, becoming the partnership’s tenth facility and its second expansion location. In June 2017, CareSpot Urgent Care and Orlando Health announced they had entered into a definitive agreement to partner in urgent care throughout greater Orlando. The agreement included eight existing Orlando-area CareSpot urgent care centers and future centers. “We’re pleased to continue our expansion into the West Orange County area and introduce the Ocoee community to this new center which offers a variety of urgent care services,” said Eric Enderle, CEO of orlandomedicalnews

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Three Tips for Dealing with Mean Nurses By NANCY CONGLETON, RN

Regardless of the career you choose, you are likely to face mean people in the workplace. But in the medical profession the stakes are higher because someone’s life or well-being is on the line. In some occupations, if you have a disagreement with someone you can walk away and take ten; as a nurse you don’t usually have this option. Mean nurses have an exaggerated sense of self and want to be in control of all aspects of the work environment, including other nurses: how they take care of patients, their happiness at work, and what others think of them. While it can be tempting to hold your ground, point out the issue/unfairness, and even run to HR, there is a better option. In my experience, the best way to deal with a mean nurse is to acknowledge that life isn’t fair, keep your cool, and face this nonsense with as much grace and dignity as you can possibly muster. Here are three important things you need to know when dealing with a mean nurse: • Don’t go to war. Nurses working in the same department must be able to work as a team and depend on each other. If you need help and the only nurse available is one you’ve gone to war with, you’re not likely to get the support you need. Can a mean nurse make excuses or refuse to help even if you don’t go to war with them? Abso-

lutely, but it’s less likely. From my experience, when you remain kind and professional towards a mean nurse and sincerely ask for help, it’s hard for them to say no. Go to war with them, and you’ll find it’s a different story. • Don’t became withdrawn, downtrodden, or tell everyone your side. If there’s a situation between you and a mean nurse that’s constantly affecting patient care and could yield negative patient outcomes, then you have an ethical obligation to address it. Otherwise, keep smiling, remain engaged with others, and support your fellow nurses. People are far more intuitive than we give them credit for; eventually, they figure out the truth all on their own. • It’s not just new nurses who are targeted, but it gets easier with experience. I’ve seen nurses of all ages and experience levels deal with this. The main difference is because older nurses have usually endured more trials, they know how to get a handle on these situations more easily.

Wednesday August 15, 2018

SPEAKER:

Denise Hudson, NR-CMA Health Informatics Specialist with Health Services Advisory Group (HSAG

TOPIC:

MIPS Changes & Updates for 2019

• Lesson learned • Year 2 program eligibility & requirements • Using your data to be successful

NEW LOCATION SOROSIS OF ORLANDO 501 E. LIVINGSTON STREET • ORLANDO, FL 323803

Nancy Congleton is a Registered Nurse and author of Autopsy of the NP: Dissecting the Nursing Profession Piece by Piece which will be out September 5, 2018. Learn more at: www.nursenancyrn.com

GrandRounds CareSpot Urgent Care. “This makes the tenth CareSpot location in partnership with Orlando Health and this facility will provide the residents of this area convenient, sameday treatment for illnesses and injuries that do not require an emergency room visit. If a patient requires more specialized care or ongoing treatment following an urgent care visit, he or she has the option of seamlessly connecting to the broader resources in the Orlando Health network.” Patients who experience nonemergent medical conditions, such as 16

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sprains, cuts, minor burns, or upper respiratory infections, may visit the center seven days a week between 8 a.m. and 8 p.m., including holidays. Located at 10959 W. Colonial Drive in Ocoee, Florida, the new CareSpot Urgent Care center in partnership with Orlando Health also offers wellness care and occupational healthcare services, including X-rays, vaccinations, lab tests, and physicals. Patients are not required to make an appointment, but online scheduling and call-ahead options are available.

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Hypnotherapy: Finding its Place in Today’s Medicine By GLORIA DANVERS, CCHt

The elderly woman in the doctor’s office had recently moved to a new city and was visiting her new primary care physician for the first time. Weak from a recent illness, and uncomfortable with her new surroundings, she listened to the doctor discuss changing her medications with the nurse practitioners with rising panic. Tears came to her eyes as she tried to describe a particularly terrifying episode involving an adverse reaction to the medication the doctor intended to put her on. She became short of breath, agitated and even though she was on oxygen, her struggle to breathe and calm herself down was obvious. Her companion moved to her side and with a few measured words delivered in a soothing tone, began passing her fingers in front of the woman’s face in a back and forth metronomic pattern that she could track visually. Within a minute, the panic attack was averted, and the elderly woman became calm. She was able to express herself succinctly and without upset, and the intake was able to continue in a most productive way. The nursing staff simply stared. This type of treatment for a panic attack was not in the scope of their practice. It was, however, in mine. That woman was my mother, and I was her companion that day. I am a Clinical Hypnotherapist trained in the Eye Movement Therapy that I used in conjunction with the hypnosis techniques of breathing and mindful focus. It is quiet and amazingly effective. Those are just two of the many highly successful techniques that a Clinical Hypnotherapist can utilize to immediately decrease discomfort in a medical setting. Hypnosis has been around for thousands of years. It is spoken of under various names and descriptions in ancient cultures as a powerful adjunct to medical procedures performed since man first crushed an herb or held a scalpel. Physicians and dentists have long known about and used hypnosis to treat their patients in a variety of ways that range from pain management to increasing physical and mental comfort in a potentially stressful situation. A clinical hypnotherapist can assist and work with a physician in a variety of ways. In dental settings, hypnotherapy is particularly effective in managing the pain of extensive surgery such as wisdom tooth extraction. The patient is referred to the hypnotherapist by the doctor. A referral is required to practice clinical hypnotherapy, and treatment can very often can be done in the doctor’s office but is more likely to be done at the hypnotherapists office. The hypnotherapist will work with each client several times, teaching them the methods by which they can control 17

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their own pain, or calm down their anxiety without the use of an anti-anxiety medication such as alprazolam. This can be particularly desirable if the client is on the medications that may be contra-indicated, or simply has an adverse reaction to the drug. Teaching the client simple yet powerful methods of using their own resource states to gain a measure of control in stressful situations, or for chronic pain assuages some of the hopelessness a person may feel in suffering from injury or a long-term illness. There are many applications of hypnotherapy in modern medicine that deliver real and measurable results. Weight loss and smoking cessation are two that are the most well-known to lay people. There has also been great success at treating IBS, high blood pressure, and many other health problems. These results are well documented and a Google search of clinical hypnotherapy will provide anyone who is interested with the research and studies that these results are based on. Quite a few physicians, psychologists, licensed social workers, and therapists are now learning and incorporating hypnotherapy into their therapy regime. Many more are using and referring hypnotherapists on a regular basis for issues such as anxiety, stress management, depression, insomnia and many other chronic problems that interfere with their patient’s quality of life. These medical professionals understand the value of integrative health care, in which the patient’s own natural resources are identified and utilized to promote healing and general well-being with increased quality of life. In a world where the answer to every problem is medication, the benefits of empowering the patient’s/client’s own natural abilities and resources to strengthen the body and mind cannot be overstated. A clinical hypnotherapist is not trained as a diagnostician. That is why it is important to discuss your interest in using hypnotherapy with your physician, who can then write a referral for your treatment. the hypnotherapist must know what medications you are on, and that is particularly important if the client is on anti-depressants or stimulants.

In working closely with the physician, the hypnotherapist is able to achieve maximum results in most cases, which can greatly reduce or even eliminate certain types of medication while allowing the client to become an empowered partner in his or her own wellness. Physicians in these advanced technological times are finding that there are many old medical modalities that, once seen as superstitious and ineffective, have actually been proven to be powerful healing tools for the mind and the body. A Holistic approach to medicine and healing is the wave of the future of medi-

cine, and it would without a doubt, benefit the medical community to delve more deeply into the mind/body connection that hypnotherapy utilizes. Gloria Danvers is a clinical hypnotherapist in Winter Park, Florida. One of her specialties is stress management through which she teaches her clients how to take control of their own anxious feelings and reframe them through breathing exercises, guided visualizations and mindful awareness of how the body and mind can work together. She works with a variety of other issues as well. You can find out more about Gloria on her website www.gloriadanvershypnosis.com

A Society Member Value Program by PNC Healthcare

MEDICAL & DENTAL SOCIETY MIXER

Tuesday, August 28, 2018 MAJORS MOTORS | 6:00 - 10:00 PM

2 0 0 0 N . O R A N G E AV E . | O R L A N D O , F L O R I D A 3 2 8 0 4 Physicians, Dentists, and Practice Managers in Central Florida, please join us for a fun social evening event at M Motors on Tuesday, August 28th. Mingle with medical and dental professionals while sipping a cocktail and checking out the collection of unique cars from the 1950s, ’60s and ’70s. Play a game of pool on a table built into a Mustang, classic arcade games or ping pong while being entertained by live music.

S U P P O RT E D B Y:

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THE HR LADY

sponsored by

THE

y d a L HR By WENDY SELLERS

Q: As a small practice owner, I am constantly dealing with conflict between my staff members. The conflict is never about anything major but takes up so much of my time. Why can’t everyone just get along? A: The age-old question of ‘why can’t we all just get along?’ When dealing with human beings, differences are abundant yet necessary. While it would be ideal to never have any type of conflict – conflict creates change, and change creates innovation and growth – including growth of your revenue and profit. Having everyone be complacent without any conflict is actually not good for business. In order to determine the root cause of the conflict, ask yourself a few questions (1) Is there a common denominator; such as one specific person always involved in the conflict or perhaps a lack of clear communication coming from you? (2) Is there an easy manner to resolve this conflict; such as weekly office meetings to discuss deadlines and tasks, or even daily coffee sessions to check in on fast moving project deadlines (hint: this is very important if you have a lot of change occurring) and (3) Are you part of the problem? Should someone

else in the office be responsible for assigning tasks and their deadlines and holding people accountable? Truly reflect on this. No one is an expert at everything. It may be time to delegate administrative responsibility to someone else and focus on what you do well. Attend a BlackRain Partners complimentary Leadership Incite Series event for more free advice.

Q: I can’t afford a consultant, but I need HR assistance to be in legal compliance. What are my options? A: You are in luck. HR and business resources are abundant in Central Florida. Check out the Society of Human Resources Management (www.shrm. org) for free advice and articles as an online guest – you will need a membership for certain areas of the website; SHRM has local chapter meetings such as www. GOSHRM.org that you can visit as a non-member and learn more about HR. There are plenty of resources in the Small Business Resource Network www.sbrn.org as well as SCORE Orlando and the SBA. Also ask your payroll and business insurance providers for assistance. They often have access to large databases for HR, employment law and other type of advice, case studies and reports.

LEADERSHIP ADVICE:

Excerpt from The HR Lady’s new book Even if you are a natural-born leader, it doesn’t mean you’re leading anyone to greatness. It just means you are really good at getting people to follow you and sometimes that is over a cliff rather than down the path to safety. Effective, positive leadership skills can be learned with discipline and dedication. There are negative leaders and positive leaders. This book is about helping you become an effective, positive leader who inspires and motivates others to do what you want them to do out of satisfaction, not fear. Fear is a short-term motivator, and yes, sometimes it is necessary, especially in an emergency situation. Satisfaction is a long-term motivator and a heck of a lot easier on both your blood pressure levels and theirs. Authentic leadership requires one to be self-accountable while holding others accountable, to take the blame, not point fingers, and to bring out the best in people in a genuine and trusting manner. Leadership is not about control and power. “The HR Lady,” is Wendy Sellers, leadership coach, author, speaker and COO of BlackRain Partners www.blackrainpartners.com, a business consulting company focused on coaching, training, development and HR. She has a Master of Healthcare Administration, a masters in human resources, SHRM-SCP and SPHR certifications. Wendy’s leadership book, “Suck It Up, Buttercup” is on www.Amazon.com 18

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Q: How do I measure employee engagement with a small team and limited resources? A: I am glad you asked about employee engagement and not just satisfaction. According to a Forbes article employee engagement is the emotional commitment the employee has to the organization and its goals. Think of ways for you to engage your employees by providing information to them that will make them emotionally commit to the company as if they were the owner. Answer these questions and then discuss them with your employees often: Why does your business exist? What is your mission? Why do each employees’ tasks matter to achieving that mission? Then consider the honest answers to these questions: What do you do on an ongoing basis that keep employees emotionally committed to going above and beyond every day? Do you sincerely

say thank you? Do you lay out your expectations and hold everyone accountable in the same manner or do you let certain people get away with missing deadlines or slacking on their job duties? Do you reward people for great actions and behaviors? Employee engagement starts with you. Employee satisfaction is part of engagement, but it is so much more. The war for talent is here – do what you can to keep great employees before someone else comes looking for them. “The HR Lady,” Wendy Sellers, is a leadership coach, author, speaker and COO of BlackRain Partners, a business consulting company focused on coaching, training, development and HR. She has a master’s in healthcare administration, a master’s in human resources, SHRM-SCP and SPHR certifications. Wendy’s leadership book, “Suck It Up, Buttercup” is available on Amazon. com. Download the eBook today and learn how not to be a jerk leader. Why? You might be part of the problem. Visit www.blackrainpartners.com

People. Performance. Profit.

Do you want to reach your Revenue Goal in 6 months vs 6 years? Do you want to be a Best Employer and Retain Top Talent? Do you want consistent Best Practices & Procedures? Do you want your managers to hold staff Accountable? Do you want to Improve Customer Service?

WWW.BLACKRAINPARTNERS.COM

Change Starts Today Call us 407.367.0883 #Leadership #Engagement

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Introduction to Protected Identifiable Information

Econ Professional Plaza Phase II By DEBI CARR

Protected Identifiable Information, or PII, for short. Forty-eight states now have privacy laws that require businesses to protect a consumers’ Protected Identifiable Information or PII. This is already established in healthcare, since we are required to safeguard patients’ Protected Health Information (PHI). Any information, or combination of information that could possibly be used to identify individuals should be protected. Healthcare entities have been required to secure patients’ PHI since 1996 under the Health Insurance Portability and Accountability Act. However, considering recent data breaches like we’ve seen with Equifax and Uber, forty-eight states and three territories have enacted privacy laws meant to protect general consumers. In fact, as of March 2018, a bill was introduced to make Alabama the forty-ninth state to enact privacy laws requiring business entities to protect consumers’ PII. Senator Bill Nelson (D) of Florida upheld the current trend in privacy protection by introducing a bill in November of 2017 that would federally require businesses to report any sort of data breach that compromises PII, not only to their customers, but the government as well. So, what is considered Protected Identifiable Information? Simply, any information that could identify or locate an individual. In most states, this is considered the First Name or Initial in combination with any of the following: • Address • Phone Number • SSN • Account Numbers • Email Address • DOB • Vehicle Information • Digital Signature • Any Medical Records • Finger Prints • a physical image • Retina scans, iris scans, etc. This trend in data privacy protection brings a new level of vulnerability to medical practices. Protocol states that in the 19

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event of a theft or data breach that compromises PHI, the practice must report to the Office of Civil Rights. The fines for failing to safeguard this sensitive information can be up to $50,000 per record. Now, because most medical practices are also considered by states to be businesses, that sensitive information is also treated as PII. This means that the state government can fine, and in some cases, impose jail time when an executive (doctor) fails to safeguard and report a data breach in a timely manner. To complicate the issue further, several states strive to protect their citizens beyond state lines. For example, if you are a New York resident, but you visit a business or medical practice in Florida that experiences a data breach, said practice is required to notify you in accordance with both Florida laws, and New York laws. Practices that have patients that primarily reside within the European Union may be subject to the newly enacted General Data Protection Requirements or GDPR. This requires that any business providing services to EU residents, including healthcare providers, will insure that adequate security controls are in place. This includes data encryption at rest and in transit, backups, redundancy, and intrusion detection mechanisms to ensure that data is not compromised in any way. Cyber-attacks are quickly becoming the new battle ground, and the risks will only increase as new technology is introduced. As a result, businesses, including healthcare entities must implement a comprehensive security plan. This requires a well-educated team, recognized security controls, and continuous system monitoring and training. The consequences of failing to protect PHI and PII could be too great to recover from. Debi Carr is the CEO of D. K. Carr and Associates, LLC a Security and HIPAA consulting firm. She has over 23 plus years of dental practice management experience and over 30 years of experience in technology and security. She assists dentists in obtaining and maintaining HIPAA compliance including performing annual risk analysis and team security awareness training. She also leads a team of security professionals that respond to cyber-attacks. Debi holds several certifications including HealthCare Information Security and Privacy Practitioner, Certified Associate Healthcare Information and Management Systems provider, HIPAA Certified Professional, Certified Ethical Associate-IT. She is a member of AADOM, ADMC, HIMSS, and ISC2. Visit www.dkcarr.com

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Danna-Gracey: Cultivating Insurance Solutions for Cannabis Companies Sponsored by JESSICA HOEHN

For Jessica Hoehn, medical marijuana liability insurance is not just another business expense—it has become a necessity. “Whether you are a medical marijuana physician, clinic, or dispensary, the potential legal costs of uninsured suits are astronomical and could have disastrous consequences on someone’s practice,” says Hoehn, an insurance agent for DannaGracey, the leading independent medical malpractice insurance agency in the state of Florida and the top agency for several of the leading insurers in Florida. It’s a common misconception that medical marijuana coverage needs are very expensive or unattainable, but it is actually very reasonable priced, she notes. The agency works closely with clients to identify insurance needs specific to their medical specialties and practices. “We understand the complex landscape of insurance coverage for medical professionals,” says Hoehn. “Our personalized attention and command of the insurance marketplace enable us to effectively negotiate competitive rates.” Since 1981, Matt Gracey and the team at Danna-Gracey have become well known

throughout the state as strong advocates for health care providers, as well as creators of society and network insurance purchasing programs. When it comes to the medical marijuana industry, Hoehn says that it was a no-brainer for them to continue to provide the best coverages for those looking to provide alternative care options. “This isn’t your great grandfather’s insurance company,” says Hoehn. “We always aim to be a progressive company that is willing to assist growing and support alternatives to the normal healthcare avenues. And we are right here locally. We aren’t an out of state company that cannot relate to the ever-changing climate of the insurance industry in the state of Florida.”

business should a negligence claim be made against you. This can also include mistakes, oversights or errors that are made by accident.

Types of Insurance Protection The types of insurance protection Danna-Gracey offers include: • Workers’ Compensation Insurance: If you have four or more employees, you are required to have workers’ compensation insurance. This will cover your employees if they get injured on the job. These rates are

mandated by the state but the agency has a great program which can get you up to 30% back in dividends annually. • Professional Liability Insurance: Professional Liability Insurance (Malpractice) covers your

• Cyber Liability Insurance: With major companies recently in the headlines for having their personal client information hacked, you want to be sure your business is protected should that happen to you. Cyber liability insurance is especially important if your website collects personal information or you sell items online. “If you think you won’t ever get breached, you are wrong,” says Hoehn. “It’s not a matter of if but when. Look at the MJ Freeway cyber attack that happened in 2017.The attack took out their production and backup server. You are storing personal client information and it needs to be protected.” • Employment Practices Liability Insurance (EPLI): If your employees interact with the general public as part of your operations, it is smart to get EPLI Insurance. (CONTINUED ON PAGE 22)

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The Courage to Trust Medical Care to Patients and Physicians By MARILYN M. SINGLETON, MD, JD

The days of trusting your legislators to have your best interests at heart are in the rearview mirror. Apparently, their main interest is parroting the buzzwords of the moment to get elected and then being too busy banking lobbying money to listen to the voters. Our legislators have become spectators who wait for the perfect moment to pounce on their political “enemy” and then go on cable news shows to boast about it. The “us against them” attitude, punctuated by hyperbolic, apocalyptic rhetoric closes the door to finding solutions. Our interests would be better served by having town hall meetings where voters could state their concerns, air their differences, and learn what legislators are doing about their issues. Caution: meetings at 9 a.m. on Wednesday when paid activists are guaranteed to outflank the working general public are prohibited. There are strong differences of opinion on how to attain a healthy citizenry. Educating potential patients about what drives up medical care expenditures can start the conversation. Well-informed patients would demand solutions based not on corporate interests or government or political agendas, but on a fair, competitive market that maximizes choices and achieves lower costs. Eight years of the Affordable Care Act have borne out Congressional Budget Office predictions that abandoning basic principles of insurance—which compensates only for events beyond the insured’s con-

trol and is priced according to the degree of risk—would lead to higher and higher premiums, fewer participating insurers, and unsustainable government expenditures to subsidize insurance premiums. The data in three recent Centers for Medicare and Medicaid reports on ACA exchanges show “individual market erosion and increasing taxpayer liability.” The average monthly premium for coverage purchased through the exchanges rose 27 percent in 2018, and federal premium subsidies increased 39 percent from 2017 to 2018. A less frequently discussed cost driver is the disturbing trend of private doctors’ offices being scooped up by hospitals, health insurance companies, and venture capital groups. Prices tend to rise when health systems merge, because of decreased competition. And not only do hospitals and health systems generally charge more than private physicians’ offices, the government compounds this problem by paying more to hospitals than independent offices for the same service. A review of 2015 Medicare payments showed that Medicare paid $1.6 billion more for basic visits at hospital outpatient clinics than for visits to private offices. Patients are the biggest losers: they paid $400 million more out of pocket and had their tax dollars wasted. The study also found hospital-employed physicians’ practice patterns in cardiology, orthopedic, and gastroenterology services led to a 27 percent increase in Medicare costs. This translated to a 21 percent increase in outof-pocket costs for patients. Similarly, a U.C. Berkeley School of Public Health study of consolidation of

California’s hospital, physician, and insurance markets from 2010 to 2016 concluded “highly concentrated markets are associated with higher prices for a number of hospital and physician services and Affordable Care Act (ACA) premiums.” In consolidated markets (defined by the Federal Trade Commission’s Horizontal Merger Guidelines), prices for inpatient procedures were 79 percent higher and outpatient physician prices ranged from 35 percent to 63 percent higher (depending on the physician specialty) than less concentrated markets. Big medicine and third-party financing are taking the cost curve in the wrong direction. This speaks to the urgency of encouraging cash friendly practices that bypass insurance and direct primary care (DPC) practices. With DPC, all primary care services and access to low-priced commonly used medications are included in an affordable upfront price. Importantly, DPC’s time-intensive and individualized management of chronic diseases decreases hospital admissions, paring down Medicare’s $17 billion spent on avoidable readmissions. Why corporations want to marginalize private practice seems clear; the government’s motive is open to debate. Surveys consistently find that patients overwhelmingly want “personalized provider interactions.” Thus, herding patients into government-directed programs is not the solution. One core problem with government systems is their reliance on the goodwill of politicians. As President Ford said, “a government big enough to give

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you everything you want is a government big enough to take everything you have.” It’s time for Congress to scrutinize anti-competitive health system mergers. It’s time to bring to the floor over a dozen bills to expand and improve Health Savings Accounts (HSAs) to give patients more control over all facets of their medical care. Congress, the clock is ticking on this legislative session. Stand up for patients. Or did the dog eat your courage?

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THE LOWEDOWN ON HEALTH LAW

Defense Coverage and/or Proceedings Defense Coverage, continued from page 7 The Healthcare Team at Forster Boughman Lefkowitz and Lowe understand the hard work and sacrifices it takes to become a health professional or provider and aggressively defend health professionals regarding protecting their license, practice, career, assets and reputation. Using our experience and expertise, we navigate the obstacles our clients face, serving not only as their attorneys, but also as their legal strategists, trusted advisors and protectors of their rights and interest against government investigations and lawsuits when necessary, and we help chart a course through the maze of state and federal health care laws, rules and regulations.

As with any overview, this insurance information is general and intended to help you make informed decisions. The actual policies available in your state may contain features not discussed above. There are many variations. Some companies offer hybrid versions of claims made and occurrence policies. Exclusions vary from company to company. It is important to read your policy and understand its terms. If you are switching insurers, make sure the new policy correctly picks up retroactive coverage from the previous insurer. The importance of understanding your coverage cannot be understated. An insurance policy is a contract between you

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and an insurance company. You should read and understand any policy that you purchase. If you have any questions, have the company or insurance broker or agent take as much time as you need to explain policy terms to your satisfaction. Michael R. Lowe, Esquire is a boardcertified health law attorney at Forster, Boughman, Lefkowitz & Lowe. Mr. Lowe and our law firm regularly represent providers, physicians and other licensed health care professionals and facilities in a wide variety of health care law matters. For more information regarding health care law and such matters please visit our website www.FBL-Law.com or call our office at (407) 255-2055.

Danna-Gracey: Cultivating Insurance Solutions for Cannabis Companies, continued from page 20 “EPLI insurance covers claims against your company for sexual harassment, wrongful termination and discrimination,” says Hoehn. “These allegations can come from the employees or the general public. This insurance would cover your legal costs and potential payouts you may be responsible for.” Hoehn adds that General Liability Insurance and Commercial Property Insurance are important too and as a result, they partner with some excellent individuals to get clients those coverages as well.

Getting Your Business Insured If you want to get insured, it is a short application process that Danna-Gracey will gladly assist you in completing. “We will shop the market in order to

present you with several offers and we can then compare and decide which avenue is best for you,” says Hoehn. The cost of insurance depends on which type of insurance you’re seeking. For example, for cyber insurance, Hoehn says that they are going to need to know some details about what you currently do to protect yourself, how many files you store roughly, etc. For Medical Professional Liability, they need to know how many doctors you employ, their backgrounds, what coverages they may currently have, and so on. “The cannabis industry is susceptible to the same types of claims as any medical profession,” says Hoehn. “The liability may be a bit less since medical marijuana clinics are recommending and not actually prescribing but the suits that incur are the

same as any other.” Jessica Hoehn epitomizes integrity, energy, hard work, detail and creative service in every detail of insurance needs. Jessica grew up in the Central Florida area and quickly noticed she displayed characteristics of both a right brained and left brained individual. While being passionate for all things artistic, she has a strong financial background which led her into opening her own booking firm dedicated to the servicing of those small businesses and individuals in creative fields. Jessica uses her experience and foresight to proactively review your financial details in every policy and makes sure you are receiving the right coverage and the best price. For more information, contact Jessica Hoehn at jessica@dannagracey.com

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Orlando Health Scores Big with Sports Medicine Symposium, continued from page 1 and how much “bang for the buck” nutrition can deliver for elite athlete wellness. The innovative curriculum on hot topics and streamlined presentation format helped drive up the energy level with both the presenters and the audience, Osbahr said. Capping the discussion panels was a keynote address from the world’s leading sports surgeon, James Andrews, MD. Andrews, who was a pioneer in arthroscopic surgery in the 1970s, has treated scores of marquee athletes, and he was instrumental in Osbahr’s career. Osbahr completed an orthopedic sports medicine fellowship at Andrews’ American Sports Medicine Institute in Birmingham, Alabama. “He’s a father figure, mentor and friend,” said Osbahr. Andrews, 75, provided historical context the for the evolving practice of sports medicine. Multi-disciplinary collaboration was a recurring theme of Andrews’ remarks and throughout the symposium. “It is most important to have a multi-disciplinary approach,” said Osbahr. “We need to have everybody on the healthcare team – athletic trainers, physical therapists, strength and conditioning specialists, nutritionists and physicians functioning on all cylinders.

“Our meeting was really set up to have everyone participating in dialogue and sharing knowledge to really give the big picture of sports medicine one pathology at a time. That was our goal going into it.” The imperative of multi-disciplinary collaboration has been growing for decades. And now it is essential to truly be able to provide high quality and effective treatment in modern day sports medicine, said Osbahr. “We have to provide solutions to our sports medicine patients that are not only based on the injury but most importantly on the individual patient. There are so many factors that go into the successful prevention and treatment of injuries which necessitates us taking this kind of approach. When people think about treating an injury they usually think only about the doctors, including how the doctor is going to evaluate and treat that injury and get someone back to play. However, doctors are one piece of the successful sports medicine algorithm which guides successful evaluation, treatment and prevention of injuries. Successful patient and athlete rehabilitation is only as good as the weakest link in the sports medicine team, which is why we work really hard to make sure our entire team has the highest quality training, ex-

perience, and goals.” And that philosophy guided the structure of the symposium. Developing the symposium was a logical step for Osbahr, who in addition to leading the sports medicine practice at Orlando Health serves as the fellowship director for the Orlando Health Orthopedic Sports Medicine Fellowship, research director for Orlando Health Sports Medicine, and director of the Orlando Health Orthopedic Sports Medicine Residency Education. A Florida native, Dr. Osbahr, who is Board Certified in orthopedic surgery and sports medicine, was practicing in Maryland, where he treated athletes from Major League Baseball and National Football League teams, when Orlando Health recruited him back to the Sunshine State four years ago. His mandate was to build a nationally and internationally acclaimed sports medicine program that treats all levels of athletes with the highest levels of care. “I was thrilled,” he said. “We are fortunate at Orlando Heath to have a fantastic multidisciplinary team approach that works collaboratively with each other. In addition to treating patients, we have a top-notch education program with pri-

mary care and orthopedic sports medicine fellowships. We also have a research program with staff dedicated to pushing the envelope forward for new techniques and that is always questioning what we are doing and how we can improve it.” Osbahr currently serves as the chief medical director and head orthopedic team physician for the Orlando City Soccer Club, including Orlando City Soccer, Orlando Pride, and Orlando City B. In addition, he is a team physician and orthopedic consultant for the Atlanta Braves, USA Baseball, US Soccer, Professional Golf Association (PGA), Ladies Professional Golf Association (LPGA), Symetra Tour, World Wrestling Entertainment (WWE), and the Orlando Ballet. “The best part about our relationships with these programs is that they set the tone for our ability to provide the highest quality of care to our sports medicine patients, and we can then provide the same quality of care to everyone who comes into our office, not just elite athletes” he said. Now, Osbahr and his team will be turning to their next big challenge: Making the June 2019 Sports Medicine Symposium even better than this year’s.

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BEST PRACTICES

EVIDENCE-BASED STANDARDS OF CARE

Venous Disease/Pearls and Pitfalls in Recognition and Treatment Venous disease is estimated to affect 25 million people in the United States. Venous ulcers, the most significant complication, affect approximately 500 thousand people. More than 2 million working days are lost each year and approximately 3 billion dollars is spent treating venous disease. In addition, venous disease is estimated to account for 1 to 3 percent of the total healthcare budget. Although venous disease cannot be avoided, greater awareness in the general population and especially among physicians can diminish the impact. Risk factors include heredity, age, gender (females > males), hormonal (estrogen and progesterone), Corona Phlebetatica pregnancy, obesity, jobs with prolonged standing, trauma, and previous superficial or deep vein thrombosis. Graduated compression stockings are the first line of therapy for spider telangiectasias, ankle edema and skin changes, pregnant women, or those who have jobs that entail standing for prolonged periods of time. Patients sometimes complain they are hot or hard to get on, but we must be firm and tell them about the problems that can follow. Insurance companies often insist on 3 to 6 months of conservative therapy with compression stockings prior to approving any treatment. The majority of patients with advanced skin changes have superficial venous valvular insufficiency. Many will also have perforator or deep vein involvement. Patients with peripheral arterial disease and/or significant type 1 diabetes must be treated cautiously. If pulses canâ&#x20AC;&#x2122;t be detected, or the patient has ankle/arm index less than 0.5, compression is contraindicated. In patients with chronic swelling or pain in an extremity, obvious varicosities, or florid patterns of telangiectasia (spider vein), the vascular lab is the first step in the treatment algorithm. But, a word of warning, when a venous evaluation is ordered, most hospitals and diagnostic labs perform a test for venous thrombosis. One must specifically ask for an evaluation for venous insufficiency, and even then, most exams are inadequate. A study should be performed with the patient standing using valsalva and compression maneuvers to check for valvular reflux. The deep, superficial and perforator systems should be studied and reflux times should be noted along with the vein diameters. This exam reveals whether a patient has evidence of old deep vein thrombosis with scarring or obstruction. Therapy for superficial veins should not be undertaken if there is a significant obstructive component in the deep system. I see a large number of patients who have had a venous evaluation at an outside lab and 99% of these exams are inadequate for evaluation of venous insufficiency. Patients with severe type 1 diabetes or known arterial disease should have an arterial evaluation

to rule out significant disease, which might contraindicate compression or venous therapy. Early skin changes consist of pink to red discoloration which may be blotchy and dry (stasis dermatitis). The underlying tissue may be firm. These areas should be lubricated and massaged at least two times a day. With time, a darker brown discoloration develops and the tissue becomes firmer. This is referred to as a lipodermatosclerosis. The cause is inflammation, secondary to metalloproteinases, lymphocytes, macrophages, and red cells that traverse the capillary membrane because of the Lipodermatosclerosis hydrostatic pressure of gravity. The brown discoloration is the result of red cell destruction with deposition of feratin. This tissue is very vulnerable to ulceration. Some patients will go on to develop lymphedema with swelling of the foot because the lymphatics in the lower legs are fibrosed by the inflammation. Flare ups of this tissue frequently occur with long periods of standing, and the tissue can become erythematous and even exude fluid. Sometimes this fluid has a scaly appearance or can even appear as a white exudare. It is important to recognize this as an exacerbation of stasis dermatitis, an inflammation, not cellulitis, an infection. In these times of concern about nosocomial and opportunistic infections, we must avoid using antibiotics for this condition. The erythema will often persist for weeks, and if left on antibiotics for that period of time, patients are vulnerable to fungal infections, MRSA, and clostridia difficil colitis. The best treatment is to focus on the underlying veins, but this takes time. Use of hydrocortisone cream, elastic compression, and elevation are bridge maneuvers. Biopsy of the skin should never be an option. The only place for a biopsy is at a site of long standing ulceration, or an ulcer, which is refractory to optimal therapy to rule out cancer. We must be aware of patientâ&#x20AC;&#x2122;s complaints of aching, heaviness in the leg, and swelling as the day progresses. Varicose veins can lead to significant problems and should not treated as merely a cosmetic concern. Early attention can avoid later problems. Venous Ulcer

Presented in Partnership by Orlando Medical News and Vascular Vein Centers

Dr. Hugo V. Hart Dr. Hugo V. Hart is a board certified general surgeon with over 29 years experience. His educational background includes a B.A. from Southern Connecticut State University, a M.D. from Universidad Nacional Pedro Henriquez Urena, Dominican Republic, and a general surgery residency at Bridgeport General Hospital. He is certified with the American College of Surgeons and the American Board of Surgeons. He has been practicing in the Central Florida Area for over 30 years. Dr. Hart is an active member of the American College of Phlebology, the society for vein professionals. In addition to doing volunteer work for the underserved in Central Florida, Dr. Hart is an active member of the Hispaniola Medical Charity, the medical mission organization that has been established to provide medical care to the impoverished people in the Dominican Republic. Dr. Hart is fluent in both English and Spanish.