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PHYSICIAN SPOTLIGHT PAGE 3
Robert S. Gold, MD ON ROUNDS
Leadership Shift
Orlando Health makes changes at the top to continue the organization’s momentum of positive change ... 8
Bending the Healthcare Cost Curve Florida Chamber unveils Healthcare Alliance at 2013 Forum ... 11
POCD or Delirium?
UCF family medicine professor weighs in on controversial studies linking dementia to anesthesia and surgery By LyNNE JETER
“Preoperative cognitive testing helps establish the distinction between dementia and delirium in elderly patients that develop confusion after surgery.”
A noted Orlando family medicine physician specializing in geriatrics addresses the controversy on whether elderly patients undergoing anesthesia for surgery may suffer from postoperative cognitive dysfunction (POCD), leading to early onset dementia, or delirium, a temporary state of confusion. Mariana Dangiolo, MD, assistant professor of family medicine, director of geriatrics at the UCF College of Medicine, and a geriatrician for UCF Pegasus Health, said preoperative cognitive
– Mariana Dangiolo, MD, assistant professor of family medicine and geriatrics, UCF College of Medicine.
(CONTINUED ON PAGE 7)
Dominican Mission Vascular Vein Centers serves poor Dominicans on second annual medical mission trip By LyNNE JETER
Last Thanksgiving, on the inaugural mission trip to the Dominican Republic, the team from Vascular Vein Centers of Central Florida completed 56 vein procedures on 11 patients in five days, including a man who had been shopping local doctors to amputate his diseased leg. On their second annual trip in late
October, the medical volunteers treated nearly double the number of patients, mostly men with venous ulcers in the inner part of their ankle, primarily caused by chronic muffler burns from motor scooters. “It was very emotional to work with these patients, who were poor and rode the bus for several hours to see us, and not just once, but several times during the short time we were there,” said Michele Borton,
marketing director for Vascular Vein Centers. “These patients won’t die from venous ulcers, which all but one patient had, but it’s a miserable chronic condition. The wounds can get infected, and constantly weep.” Hugo Hart, MD, a general surgeon with Vascular Vein Centers and native Dominican, initiated the practice’s participation in Hispaniola Medical Charity, the (CONTINUED ON PAGE 4)
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PhysicianSpotlight
Robert S. Gold, MD Eye Physicians of Central Florida By JEFF WEBB
MAITLAND - Visitors to an ophthalmologist expect to have a full-on experience with sight, but at Robert Gold’s office, it often is one of sight and sound. “In each of our examination rooms we have videos that play while the children and parents are waiting,” said Gold, a pediatric ophthalmologist. That sometimes results in a singalong when Gold enters the room. “We have movies like Rio, Madagascar, Toy Story … lots of Disney songs,” said the affable 56-year-old. “The kids know a lot of these songs and I sing with them. Parents sometimes join in, too,” he said, and it’s important that they, in addition to their child, are at ease. Such levity is purpose-driven. “It’s all about making people less edgy during a very nerve-racking time. Just telling them that their cute little 2-year old girl or guy needs glasses and may need them forever can be a traumatic thing,” said Gold. “So, being able to present it in a very positive way makes things easier for everybody.” That approach is standard for Gold, who described himself as “a very energetic person. It’s been my style for many, many years.” Gold said that “when someone likes what they do as much as I do, it doesn’t take much effort to go in with a big smile on your face and make the child and parents comfortable. My goal is to be very friendly and try to have a good time with the kids.” The time to be serious comes later as he talks to parents and tries to make the news palpable. “There is nothing more serious for a physician than to say to the parent of a 6-year-old ‘Your child needs to have surgery,’” Gold said. But that task “is easier if you are building up to it in a friendly, calm, professional way,” he said. Most of the children Gold treats, which account for about 75-percent of his patient base, he said, have eye muscle disorders strabismus (crossing eyes) amblyopia (lazy eyes), tear duct obstructions, stigmatism, or near- or far-sightedness. The remaining patients are adults who may have similar problems, or complications from diabetes, strokes, thyroid eye disease, eyelid abnormalities or dry eyes, he said. And, as one might expect of a physician who has been in the same practice for almost 27 years, Gold has a few patients he sees for general ophthalmology reasons, “mostly friends and family I’ve known a long time,” he said. Gold came to the Orlando area in 1987, joining his cousin, Michael Zamore, MD, renaming the practice Eye Physicians of Central Florida. The practice now has 10 physicians, although Zamore is not with them. “In September 2000, my cousin passed away suddenly at the age of 48. He was universally loved by his patients and for me, he was more than a cousin and orlandomedicalnews
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business partner, he was my best friend and confidant,” Gold said. The event “changed my life, because it made me a stronger person, not only as a doctor, but as a husband and father, and taught me that every day is a good day and that we should be so thankful …” he said. Gold said he spends two mornings a week in surgery and does “about 98 percent of those procedures at the Maitland Surgery Center, which is downstairs from his office. In addition to his late cousin, Gold has more physicians in his family. His younger brother is a dermatologist in Nashville, and their father is an infectious disease specialist “who was prominent in antibiotic development and the rubella vaccine,” he said. Both parents are 85 and live in south Florida,” Gold said. Gold’s father influenced not only his decision to become a physician, but also where he studied and trained. “My father worked all over the country with pharmaceutical firms and one of the places he loved was New Orleans,” Gold explained. Gold said that after graduating high school in Haverford, Pa., he chose to pursue his undergraduate degree at Tulane University – sight unseen. “I had never visited Tulane before I got in the car with my parents in Philadelphia and drove down,” he said. Gold wound up spending the next 12
years in the Crescent City where he earned his bachelor’s degree in biology and medical doctorate at Tulane. He completed his internal medicine internship at the Ochsner Foundation Hospital and Clinic and then did his residency in ophthalmology at Louisiana State University in New Orleans. He moved to Atlanta to complete a fellowship in pediatric ophthalmology and adult strabismus at Scottish Rite Children’s Hospital before moving to Florida. But Gold’s time in New Orleans yielded more than an education; it also is where he met Gail, to whom he has been married for 33 years. “I met Gail her first week at Tulane. She’s two years younger than me. I was the rush chairman for my fraternity and she came to the house. I was in the kitchen carving a turkey. I looked at her and she looked at me, we started talking … I met my soulmate,” he said. They married while he was in medical school. “Gail was a pharmacy sales representative when we were in New Orleans,” Gold said, and she was pregnant when they moved to Atlanta for his fellowship. Since then, “she has been doing a job harder than
mine – being the boss of the house,” he said. The couple raised two children who have strengthened the family’s link to New Orleans: Lisa was married last year to her Tulane University sweetheart and lives in San Francisco, and Gold’s son Peter is a second-year medical student at Tulane. When he’s not wearing his white coat or surgical scrubs, Gold’s passions are golf and photography. His office is adorned with framed photos he took while on an African safari. And, even after all this time in sunny Florida, he still marvels “that I can play golf almost 52 weeks a year,” he said. Gold said he is reassured every day that the subspecialty he chose all those years ago was the perfect fit for him. “I’m able to combine my love for pediatrics with the medicine and surgery of ophthalmology,” he said. “I honestly could not think of being in any other profession but medicine. There is nothing more rewarding than helping people see better each and every day.” After more than 26 years at Eye Physicians of Central Florida “I still love going to work each and every day,” Gold said. Sometimes with a song in his heart.
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Dominican Mission, continued from page 1 medical mission organization he and his brother, anesthesiologist Umberto Hart, MD, of Bryan, Texas established as a tribute to their late father, also a doctor. Their mission: to provide medical, surgical and dental care to the impoverished people on the island of Hispaniola, home of Haiti on the western side of the Caribbean island and the Dominican Republic on the eastern seaboard. Hispaniola Medical Charity recently awarded the first scholarship to Vianna Denise, a Haitian medical student training in the Dominican Republic. “Our dad was always very interested in the betterment of the poor people in the Dominican Republic,” said Hart, who earned his medical degree from the Universidad Nacional Pedro Henriquez Urena in the Dominican Republic, and completed a general surgery residency in the United States, at Bridgeport General Hospital in Connecticut, before relocating to Florida. “After he retired as a physician, he remained very involved in the community in various ways. One example, he worked with a group to raise money and build homes in five or six communities. He didn’t stop there. He also helped make sure the homes had running water, and that the communities had medical facilities. When you go there, you see the tremendous need in the medical field and we can bring a little bit of our technology for venous care to them.” The first trip was to Hospital Buen Samaritano in La Romana, in the eastern part of the Dominican Republic. In addition to the vein team’s contributions, the surgical team saw 77 patients and performed 105 procedures, while the dental team saw 178 patients and performed 193 1
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procedures, for a total of 266 patients and MADE IN 354 procedures in GERMANY less than a week. This year, the Vascular Vein Centers team of 10 joined more than 30 nurses and volunteers from Texas to travel to the Dominican capital city of Puerto Plata. “Every patient has a story,” said Hart.
“The most dramatic one was the young man in his early forties who had quite large ulcers in his legs. Local doctors he talked to knew there wasn’t a reason to amputate his leg, but he was desperate for relief. Before treatment, he wasn’t able to work. Now he can.”
Hart would like to see more patients during the time spent in the Dominican Republic, but the number of visits patients need to complete the treatment hinders the caseload. “The first day is almost a wash because we’re doing comprehensive screening evaluations on patients and coming up with a plan,” explained Borton. “Then each patient has multiple procedures. We’ll treat one leg and wrap it in compressions. The next day, we’ll treat the opposite leg. On day 4, we see them again to make sure they don’t have complications. We could’ve done more patients last year, but we ran out of supplies, such as exam paper. We took additional supplies this year.” Hart hopes to expand the practice’s medical mission work. “Right now, we’re looking at one week a year,” he said. “Everybody has to take off time. It’s a big financial endeavor for the staff. It takes a lot of equipment. But it’s definitely worthwhile. We’re really excited about keeping this going. If I could, that’s what I’d do all the time.” To prepare for the 2013 trip, Vascular Vein Centers set a fundraising goal of $8,000 to cover expenses, promoting the mission work on a website donated by the practice’s webmaster. Local providers and vendors donated medications, medical and surgical supplies, and equipment. Even patients at the practice’s six locations – Davenport, Kissimmee, Lake Mary, The Villages, Waterford Lakes and Orlando – chipped in. “Our team was truly blessed by this experience,” said Hart. “Thank you all for your support.”
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POCD or Delirium?, continued from page 1 testing for elderly patients establishes a baseline that takes the guesswork out of determining their postoperative cognitive state. “Preoperative cognitive testing helps establish the distinction between dementia and delirium in elderly patients that become confused and disoriented after surgery,” said Dangiolo. “Delirium Mariana isn’t easy to recognize Dangiolo, MD because a cluster of problems may lead to a patient’s state of deep confusion. Usually, there’s more than one underlying symptom in the presentation. A baseline status would be needed to validate dementia.” Unfortunately, preoperative cognitive testing isn’t standard procedure. In fact, it’s rarely done, with some anesthesiologists saying it takes too much time and health insurance won’t cover it. “A mental status exam to evaluate different areas of the brain can be quickly given by the physician who’s performing pre-operative clinical evaluation of a patient,” said Dangiolo, who includes it as a routine part of physical exams with geriatric patients. “Other cognitive baseline tests, especially comprehensive ones, may take several hours. Those typically aren’t covered by insurers, and aren’t usually what you need to establish a baseline status. Something simple, such as asking patient and/or family about patient’s daily level of functioning before surgery, can certainly provide a lot of information.” Many times, when Dangiolo is conducting an initial geriatric assessment and cannot administer a complete mental status exam, she’ll use a mini cognitive test to provide a baseline reference. “The Mini Cog test has three components and takes about five minutes to complete,” she said. “It tests orientation, short term three-word recall, and planning and execution function by asking patients to draw a clock. If there’s a problem in any of those areas, there are grounds to proceed to a longer baseline test.” Postoperative Difference When assessing the patient’s postoperative mental state, it’s important for healthcare providers to discern the distinction between dementia and delirium, said Dangiolo, pointing to various recent studies that suggest a certain link to dementia and anesthesia in elderly patients. A recent Duke clinical study published in the Journal of Anesthesiology confirms earlier findings from an important 1998 Lancet publication, showing significant
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numbers of elderly patients experiencing changes in higher order brain function after anesthesia and surgery. • At discharge from the hospital, signs of POCD were present in roughly one in three patients. • At the 3-month mark, 12.7 percent of patients over the age of 50 still showed cognitive impairment. • Elderly patients are at risk of POCD, but the study doesn’t specify whether it’s due to anesthesia, surgery, or post-surgery recovery aspects, such as pain, pain medication, other medications, infection, inflammation, sleep disruption. A study by French doctors released earlier this year at a European Society of Anesthesiology congress in Barcelona, Spain, said general anesthesia for the elderly boosts the risks of dementia by more than a third. • Researchers led by Francois Sztark at the University of Bordeaux in France analyzed data from a long-term study into cognitive decline covering 9,300 elderly people in three French cities. The volunteers – average age 75 – were interviewed when they were recruited into the study and then two, four, seven and 10 years post-surgery. • The data showed a link between the onset of dementia and a general anesthetic that had been administered two or three years earlier. • Some experiments suggest that various anesthetics inflame neural tissues, causing protein plaques and tangles to develop that are precursors of Alzheimer’s disease. Another recent study examining the incidence of POCD after major non lifethreatening procedures shows how certain risk factors have been identified and demonstrated a number of correlates and risk factors, even though much remains to be clarified about the true incidence, etiology, prevention, and treatment.
• In the study of 200 patients age 60 and older undergoing hip surgery, postoperative delirium was a strong independent predictor of the development of subsequent cognitive impairment, subjective memory decline, and the need for long-term care. • Interestingly, the correlation with the development of POCD isn’t shown whether the patients had regional or general anesthesia. Several theories have been posed to anesthesiologists regarding the possible link between dementia and anesthesia and surgery in patients 85 and older: • In the traditional view, anesthetic agents are rapidly metabolized and/ or excreted from the body, and therefore are unlikely to cause neurologic injury long term. Also, certain anesthetic agents appear to protect, not injure, the brain. Recent research challenges the belief that a well-done anesthetic and complication-free surgical procedure is totally neurologically benign. • Researchers suggest that, in patients who develop POCD, limited brain “reserve” has been somehow “unmasked” by anesthesia and surgery, or that anesthesia and surgery somehow accelerates the aging process in the brain. Inflammation might be the culprit. Previous research has shown signs of inflammation in cerebrospinal fluid after surgery, but it’s not clear whether this is the cause or the result of POCD. • A significant limitation of POCD studies is exclusion of a standardized preoperative neurological examination, in addition to the neuropsychological testing, making it very difficult to separate the relationship between surgery and anesthesia and subsequent cognitive decline and death from the cognitive decline and death that occur among older adults without surgery.
Difference Makers “We (healthcare providers) can prevent a lot of confusion in the hospital not only with the preoperative cognitive evaluation, but also with some very simple modifications in postoperative care,” she said. “For example, we know hospitals can be very noisy, yet the patient needs to maintain uninterrupted sleep while there. Nurses go into the room every two hours or so, along with other interruptions such as blood tests that hinder a patient’s rest.” The unfamiliar environment also breeds confusion for some patients, Dangiolo said. “Having family photos, a clock, or other items from home to orient the patient will help,” she said. “Keeping the lights on from 7 a.m. to 7 p.m. will help regulate the sleep cycle.” Many times, physicians busy making their rounds may forget to ask patients whether they wear glasses or use hearing aids, resulting in perceived patient confusion. “Also, anything that restrains patient activity in the hospital, such as being connected to an IV or catheter, adds to confusion,” she said. “If the patient has a catheter, it should be removed as soon as possible. Otherwise, it could lead to infection, which could lead to confusion and more.” Pain affects patients in a way that creates temporary confusion, and unnecessary guests create an environment not conducive to rest, Dangiolo said. “Elderly people take an average of six prescription drugs or more, plus over-thecounter drugs and supplements,” she said, noting that all medications should be carefully reviewed, with special attention to those that affect the brain such as sedatives, antidepressants, hypnotics and antispasmodics. “When you combine all these elements, it’s easy to see how elderly patients could become confused,” she said. “These simple modifications after surgery can make a big difference in the assessment of a patient’s postoperative cognitive state.”
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Leadership Shift
Orlando Health makes changes at the top to continue the organization’s momentum of positive change By LYNNE JETER
Before the end of the third quarter of 2013, with marketplace pressures, record layoffs impacting the hospital campus, and threatening unionization action bearing down, Sherrie SiDr. Jamal tarik departed and Jamal Hakim Hakim, MD, stepped up as leader of Central Florida’s second largest healthcare system, Orlando Health. On the heels of Sitarik’s departure came recognition of the need for change by the Orlando Health board of directors. “We do so with deep gratitude for Sherrie’s service,” said board chair Dianna Morgan. Sitarik succeeded John Hillenmeyer as CEO, who retired in 2010. “Sherrie has made treDianna mendous contributions Morgan to this great institution for more than 30 years. In many ways, she’s responsible for our outstanding progress in quality and patient care and the fact that today, we’re an A-graded hospital system by the Leapfrog Group,”
a nationwide, independent hospital safety organization. In a strongly worded letter to the hospital board in August, Sitarik came under fire as head of the 8-hospital system. Employee advocates at the region’s fifth largest employer had requested a leadership change at the top, citing a “disconnect” between administration and medical staff, and a sustained trend of significant financial losses. Record layoffs that began last August continue to reverberate through the system, and Sitarik’s announcement at summer’s end to decrease pay up to 20 percent for night and weekend workers beginning Oct. 6 hit a sour note. The decision to remove differential pay could save the hospital $18 million annually. Following Sitarik’s departure, Orlando Health’s chief of staff and board member Jamal Hakim, MD, was tapped to serve as interim president and CEO while a nationwide search began for a replacement. “I’ll focus on three key areas – providing superior patient care, listening to our team’s concerns, and continuing to focus on working smarter and strengthening our bottom line,” said Hakim. A pediatric anesthesiologist at the Winnie Palmer Hospital for Women and Infants who has served Orlando Health
in various leadership roles since 1991, Hakim grew up in small town Indiana, studied chemistry at Duke University, and earned an MD at Indiana University before completing his anesthesiology residency at the University of Florida. “His leadership will keep us focused appropriately on patient care, the important relationships we have with physicians, and our business needs as we engage in a nationwide search for our new president and CEO,” said Morgan, noting that Hakim was appointed chief of quality and transformation for the healthcare system in 2011. Among Hakim’s first tasks: addressing nurse unionization threats. Three years ago, the National Nurses Union (NNU) gained a solid foothold in Florida via HCA hospitals, beginning with registered nurses at Central Florida hospitals voting 74 percent in favor of joining the nation’s largest union and professional organization of RNs. Nurses at Osceola Regional Medical Center in Kissimmee and Central Florida Regional Medical Center in Sanford voted to unionize. So did nurses at Community Hospital in New Port Richey, Fawcett Memorial Hospital in Port Charlotte, Largo Medical Center in Largo, and Oak Hill Hospital in Brooksville.
“Everyone wants their voice to be heard,” said Sarah Collins, RN, an Orlando Health nurse who filed a 5,133-signature petition on Aug. 9 to block deep pay cuts to the night shift. Since 2011, the NNU has successfully organized RNs at Blake Medical Center in Bradenton, Doctors Hospital of Sarasota, Florida Medical Center in Fort Lauderdale, Largo Medical Center-Indian Rocks in Largo, Northside Hospital in St. Petersburg, and Palmetto General Hospital in Hialeah, according to NNU. “Yes, we’re organizing in Orlando,” Liz Jacobs, spokesperson for the NNU, confirmed in late October. She declined further comment. Nurse differential pay cuts were made around the same time Orlando Health acquired the 95-doctor Physician Associates in Altamonte Springs for $50 million, each receiving roughly $500,000 and system wide perks. Hakim has made clear his opposition to unionization at Orlando Health, saying it would disrupt the “progress and progression” of the hospital’s quality efforts, and that a union would make collaboration “very difficult, if not downright impossible.”
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CENTRAL FLORIDA COMMERCIAL HEALTHCARE REAL ESTATE CLASSIFIEDS
Bending the Healthcare Cost Curve
Florida Chamber unveils Healthcare Alliance at 2013 Forum By LyNNE JETER
During the Florida Chamber Foundation’s 2013 Future of Florida Forum in mid-October, state chamber leaders unveiled a new tool for “bending the healthcare cost curve.” The chamber’s Florida Business Alliance for Competitive Healthcare Solutions (Healthcare Alliance) will focus on innovations occurring across Florida’s healthcare industry to control costs, increase access to care, and improve the quality of care. Job creators, technology leaders and healthcare providers comprise the Healthcare Alliance. “As job creators across Florida are preparing for the implementation of the Affordable Care Act, the Florida Chamber’s Healthcare Alliance will provide employers a strong platform to share ideas on what’s working to improve the quality of care and reduce health costs,” said Steve Payment, healthcare executive for IBM and chair of the Florida Chamber’s Healthcare Alliance. By 2030, an estimated two-thirds of Florida’s population, the nation’s fourth largest state, is expected to be 65 and older. By focusing attention toward programs that can be used as statewide models, Florida’s leaders plan to balance the future of medicine with the needs of an ever-growing and ever-aging population. Following the announcement of the Florida Chamber’s Healthcare Alliance, delegates attending the Florida Chamber Foundation’s Future of Florida Forum participated in a Healthcare Summit. Discussions included: • Legislative Panel – The Policy Vision of the Future • Healthcare Innovation – Bending the Cost Curve, Securing the Future • Healthcare Scorecard • Preparing the Healthcare Workforce of the Future Key speakers included: • Florida Surgeon General John Armstrong. • Florida Rep. Matt Hudson (R-Naples), chair of the Health Care Appropriations Subcommittee. • Florida Rep. Cary Pigman (R-Avon Park), vice chair of the Select Committee on Health Care Workforce In-
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novation. • Connie Barden, director of telehealth initiatives for Baptist Health South Florida • Michael Good, MD, dean of the University of Florida College of Medicine. • Steve Payment, healthcare executive
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Gaining Perspective on the Reimbursement Landscape: Glass Half Empty … or Half Full By CINDy SANDERS
To see something in a different light often requires a shift in perspective. David A. Williams, CPA, MPH, FHFMA, leader of healthcare reimbursement and advisory services for HORNE David A. Williams LLP, believes this certainly holds true for practices and facilities facing ever-increasing budget pressures. Glass Half Empty Williams, a partner in HORNE’s Ridgeland, Miss. office, noted for many healthcare providers, any incremental increase in revenue is eaten up by rising costs — from increased wages to higher prices for supplies to hikes in rent and utilities. He pointed out that for hospitals, the largest revenue stream is for inpatient stays, and the largest single payer is Medicare, which can represent from the low 40s to the high 60s in terms of percentage of patients. “There has been a market basket update, but for the last couple of years, it’s been less than 2 percent,” he said. Williams noted the government puts in the full market basket update but then begins reducing the rate by looking at
adjustments tied to value-based purchasing, readmission rates and acquired conditions, in addition to other factors. “Normally you’re seeing very minimal increases. It’s caused a flattening of revenue per patient,” he said. Then, Williams continued, after payment increases are netted out, “Medicare is subject to a 2 percent reduction to fulfill the sequestration order.” He added that Medicaid, which typically covers anywhere from 5-15 percent of patients … or higher depending on location and a hospital’s safety net status, is not currently subjected to sequestration. Yet, he said, hospitals are faced with mounting concerns about Medicaid expansion, uncompensated care, and cuts to disproportionate share hospital payments. For hospitals in states that didn’t opt to expand Medicaid rolls, administrators are worried about rising levels of uncompensated care for those that fall into the gap in the Affordable Care Act between traditional Medicaid eligibility and qualifying for federal subsidies on the healthcare exchange. Even for providers who
are in states that did expand Medicaid, Williams said uncertainty still exists about how reimbursement will actually net out. Traditionally, Medicaid has reimbursed providers at a set match rate for direct patient services and a 50 percent rate for the administrative portion of the episode of care. Although the ACA Medicaid expansion plan covers 100 percent of patient services for three years and then
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rolls down incrementally to 90 percent over subsequent years, the administrative match remains at 50 percent so the state does incur additional cost by expanding rolls. Additionally, Williams said certain provisions of the ACA require mandatory changes for states regardless of expansion, including: welcome mat population or those who were eligible for Medicaid but had not enrolled previously, foster children expansion to age 26, expanded eligibility for children, primary care physician fee increase, and health insurer fee. In Mississippi, a non-expansion state, the estimated amount of the mandatory changes is between a $272 - $436 million increase in spending. With this amount of growth, the state is not expected to increase the reimbursement rate for a full episode of care. Medicare DSH payments also are causing administrators to lose sleep at night. Initially, the ACA plan called for a 75 percent reduction in Medicare DSH payments. However, Williams said part of the final regulation that went into effect Oct. 1 of this year moderated that number a bit by moving to an empirical DSH payment for uncompensated costs … a complex, calculated cut that softens the blow some by looking at a hospital’s relative share of Medicaid inpatient utilization as a proxy for uncompensated patients. Williams said that for one hospital in the Mississippi Delta, the original Medicare DSH reduction would have meant a loss of $5.6 million. “But,” he continued, “because of the additional payment to fund the uncompensated cost, it was actually a reduction of $2 million.” While that is still a significant loss, “It could have been worse,” Williams noted. Still, he continued, “You’re faced with the fact your revenue isn’t growing as fast as your expenses. It’s very concerning to most every healthcare organization around.” Glass Half Full So if revenue isn’t going up, the logical place to increase margins is to decrease costs. Yet, healthcare providers want to make sure they provide the best care possible without sacrificing a patient’s well being simply to save a few dollars. “A lot of people equate higher quality with higher cost, but that’s not necessarily true,” Williams pointed out. In fact, he said, doing the right thing in the right way is often significantly more cost efficient. “A major cost in providing care to (CONTINUED ON PAGE 17)
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Inroads to Defeating Lung Cancer By ALAN D. JOHNSTON, MD
As a thoracic surgeon with 30 years’ experience and a former American Lung Association of the Southeast board chair, I know too well the startling and sad statistics associated with lung cancer. This is the number one cancer killer in the United States. I am also aware of the need for better detection and treatments for lung cancer before it becomes advanced – lung cancer five-year survival rates still remain at about 13-15 percent. Finally, as a healthcare professional, I understand that we support our patients in many different ways besides just diagnosis and treatment – from listening to them and answering their questions and fears to connecting them with resources that can meet other needs, such as emotional and social support. Lung Cancer Screenings One reason lung cancer is so serious is because it usually is not found until it has spread and is more difficult to treat, but screening for cancer before a person has any symptoms can make a significant difference. Screening may provide new hope for early detection and treatment of lung cancer. Scientists study screening tests to find those with the fewest risks and most benefits. They look at results over time to see if finding the cancer early decreases a person’s chance of dying from the disease. In August of 2011, the National Cancer Institute released results from its National Lung Screening Trial (NLST) that randomly screened at-risk smokers with either low dose computed tomography (CT) or standard chest x-ray. The study found that screening with low dose CT scans would reduce lung cancer mortality by 20 percent compared to chest x-ray. This type of evidence, along with other studies, led the U.S. Preventive Services Taskforce to issue draft recommendations calling for annual low-dose CT screenings for individuals at high risk for lung cancer. Prevention of disease and improving survival with CT screening involves detecting disease at an early stage and intervening with immediate treatment. Chest x-ray and sputum cytology are two screening tests that have typically been used to check for signs of lung cancer but do not decrease the risk of dying from lung cancer. Although these results provide an optimistic outlook on increasing lung cancer survival rates, low dose CT scans are not recommended for everyone and carry risks as well as benefits. The NLST released specific guidelines as to who qualifies as a good candidate for lung cancer screening. The criteria are all of the following: a current or former smoker having quit within the past 15 years, in the age group from 55 to 74 years, with a smoking history of at least 30 pack-years (1 pack/ day for 30 years or 2 packs per day for 15 years, etc.) and no history of lung cancer. There is currently no evidence that shows orlandomedicalnews
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other high-risk groups would benefit from being screened. Lung Cancer Research We know research can provide hope and save lives by helping us to better understand the causes of lung cancer, how it can be detected and the best forms of treatment and prevention. More research is needed since not all our questions have been answered. Lung cancer still remains the leading cause of cancer deaths, claiming more lives each year than breast, colon and prostate cancer combined. Yet lung cancer receives significantly less research funding than these other cancers. We are just beginning to discover answers to these questions and that is why the American Lung Association is committed to funding more research on lung cancer. Clinical Trials Additionally, patients taking part in lung cancer clinical trials have the opportunity to not only receive high-quality care from experts in the field, they also get to be part of advances in fighting their disease. It is important to remind patients when explaining about clinical trials that they may not be part of the randomly selected group to receive the new treatment or medicine. However, no matter the circumstances, they will still be closely monitored by a team of doctors committed to providing the best care and will never be treated as just a test case. Patient and Family Support Even though our primary concern for our patients is providing treatment to get them better, we cannot ignore the significance of emotional and social support for them and their caregivers. It is important that the resources and connections we do provide for more information and assistance be from trusted organizations and resources, like the American Lung Association. The Lung Association’s MyLungCancerSupport.org site has a vast array of information for patients, caregivers and healthcare professionals including information on finding resources to pay for care, information on staying healthy, and finding local support groups and caregiver tools. November is Lung Cancer Awareness Month. Let’s take this opportunity to lend support to helping fight this deadly disease. For more information about lung cancer, how to talk with your patients about low dose CT screenings or to find resources for support and education, visit MyLungCancerSupport.org. Alan D. Johnston, MD, is a retired thoracic surgeon who spent more than 30 years practicing thoracic surgical oncology. A dedicated volunteer and leader for the American Lung Association of the Southeast, Inc., Johnston has served as its Chairman of the Board of Directors. For more information about the American Lung Association in Florida, please visit lungfla. org or email alaf@lungfla.org
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Ischemic Colitis: What is? What is the prognosis? By SRINIVAS SEELA, MD
Introduction Ischemic colitis is a medical condition in which inflammation and injury of the large intestine results from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation (e.g. low blood pressure) or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified. The diminished blood flow provides insufficient oxygen for the cells in the digestive system. It can cause pain and can damage the colon. Ischemic colitis can affect any part of the colon, but most people experience pain on the left side of the belly area (abdomen) and it’s more common among people older than age 60. Pathophysiology Colonic ischemia is usually the result of a sudden and usually temporary reduction in blood flow that is insufficient to meet the metabolic demands of discrete
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regions of the colon. Blood flow can be compromised by changes in the systemic circulation or by anatomic or functional changes in the local mesenteric vasculature. In the majority of patients with colonic ischemia, a specific occluding lesion of a major artery to the colon cannot be identified on arteriography. Non-occlusive colonic ischemia most commonly affects the “watershed” areas of the colon that have limited collateralization, such as the splenic flexure and rectosigmoid junction . A study of more than 1000 patients with ischemic colitis demonstrated that the left colon was involved in approximately 75 percent of patients, with about one-quarter of lesions affecting the splenic flexure . The rectum was involved in only 5 percent of patients, which can be explained because of collateralization of the inferior mesenteric artery with the systemic circulation through the hemorrhoidal vessels Signs and symptoms • Pain, tenderness or cramping in the belly, which can occur suddenly or gradually • Bright red or maroon-colored blood in the stool or, at times, passage of blood alone without stool • A feeling of urgency to move the bowels • Diarrhea The risk of severe complications is higher when there are symptoms on the right side of the abdomen. That’s because the arteries that feed the right side of the colon also feed part of the small intestine. When blood flow is blocked on the right side of the colon, it’s likely that flow is blocked to part of the small intestine as well. Pain tends to be more severe with this type of ischemic colitis. Causes Several factors can increase risk of colon ischemia: • Atherosclerosis • Hypotension associated with heart failure, major surgery, trauma or shock • Venous thrombosis • Bowel obstruction caused by a hernia, scar tissue or a tumor • Surgery involving the heart or blood vessels, or the digestive or gynecological systems • Other medical disorders that affect the blood, such as inflammation of the blood vessels (vasculitis), lupus or sickle cell anemia • Cocaine or methamphetamine use
Treatments and drugs Treatment for ischemic colitis depends on the severity of the condition. Signs and symptoms often diminish in two to three days in mild cases. • Antibiotics, to prevent infections • Intravenous fluids • Treatment for any underlying medical condition, such as congestive heart failure or an irregular heartbeat • Avoiding medications that constrict blood vessels, such as migraine drugs, hormone medications and some heart drugs • Colon cancer (rare) • Medications Risk factor • Age • High cholesterol, which can lead to atherosclerosis • Certain medical conditions, including previous abdominal surgery, heart failure, low blood pressure and shock • Irritable bowel syndrome (IBS). Ischemic colitis is diagnosed three times more frequently in people with IBS than in people without that disorder • Heavy exercise, such as marathon running, which can lead to reduced blood flow to the colon • Surgery involving the aorta Complications Ischemic colitis usually gets better on its own within two to three days. In moresevere cases, complications can include: • Tissue death (gangrene) resulting from diminished blood flow • perforation, or persistent bleeding • Bowel inflammation (segmented ulcerating colitis) • Bowel obstruction (ischemic stricture) Tests and Diagnosis Ischemic colitis can be misdiagnosed because it is often confused with other disorders, especially inflammatory bowel disease (IBD). The following tests can aid in diagnosis based on symptoms. • Ultrasound and abdominal CT scans, to provide images of the colon that can be helpful in ruling out other disorders, such as IBD • Stool analysis, to rule out infection as a cause of symptoms • CT or MR angiography, to provide detailed images of blood flow in the small intestine and to look for blocked arteries – This test is usually used only if ischemia is suspected in the small bowel as well as in the colon
Surgery If ischemic colitis is severe or the colon has been damaged, surgery may be needed. Prevention Since the cause of ischemic colitis isn’t always clear, there’s no certain way to prevent the disorder. Most people who have ischemic colitis recover quickly and may never have another episode. • Avoiding certain medications that can diminish blood flow • Ongoing treatment for underlying conditions such as heart disease, high blood pressure and diabetes • Cholesterol-lowering medication • Regular exercise Prognosis Most patients with ischemic colitis recover fully, although the prognosis depends on the severity of the ischemia. Patients with pre-existing peripheral vascular disease or ischemia of the ascending (right) colon may be at increased risk for complications or death. Non-gangrenous ischemic colitis, which comprises the vast majority of cases, is associated with a mortality rate of approximately 6 percent. However, the minority of patients who develop gangrene as a result of colonic ischemia have a mortality rate of 50-75 percent with surgical treatment; the mortality rate is almost 100 percent without surgical intervention. Ischemic colitis often occurs without an obvious predisposing event, may involve all segments of the large intestine, and frequently requires surgery. While its course may be self-limited, elderly and diabetic patients, as well as those developing ischemia following aortic surgery or hypotension, continue to have a poor prognosis. Srinivas Seela, MD, completed his fellowship in Gastroenterology at Yale University School of Medicine. He is board certified in both Internal Medicine and Gastroenterology.
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Gaining Perspective, continued from page 12 patients is variation in the clinical process of care,” Williams said. He added it is easy to find real world examples of this type of variation where one hospital’s cost for an average hip replacement is $45,000, yet another one might have an average cost of $22,000. “What’s the disconnect?” he asked of the two cost scenarios. “A lack of standardization of using evidence-based protocols,” he answered. By using data available through electronic health records coupled with a partnership with technology company Health Catalyst, Williams said HORNE is able to mine the available information to look at clinical pathways and search out deviation from standard protocols that adds to the cost of care. He was quick to add that the technology doesn’t seek to stop physicians from exercising their medical judgment but does highlight where there are outliers when it comes to following clinical protocols. “Best practices and evidence-based medicine say that these are the best protocols out there,” he pointed out. Following those protocols not only saves money, but also should optimize quality. With increased transparency, payers and patients will have access to information regarding those positive outcomes and lower costs, which could ultimately drive volume. A Foot in Both Boats Administrators and chief financial officers are caught between the fee-forservice and value-based payment worlds right now. Williams said they are trying to keep their heads above water in the current payment system … and now reimbursement experts want them to shift their focus to population management. Although making the move is understandably frustrating, Williams believes it is also the best option to ultimately improve the bottom line. “There has to be a change in culture from what it’s been in the past,” he noted. “We tell them, ‘Let’s prepare for it by being the most efficient, effective deliverer of care and eliminating patient waste.’ That puts you in a competitive advantage over those providers that have a higher cost structure.” It is a different mindset, Williams continued, to stop attacking reimbursement from the top and instead improve revenue by cutting costs. “If you deliver high quality at a lower cost, then your margins are going to be greater. We see opportunities,” he concluded.
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It was the first note I ever got in crayon. “Thank you for making my daddy feel better.” I keep it on my desk, where I pore over patient records and cash flow statements. Because even if the medical field seems to be changing by the day, the reasons I practice never do.
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GrandRounds Florida Cancer Specialists & Research Institute Announces Executive Team Promotions Florida Cancer Specialists & Research Institute (FCS) is pleased to announce the addition of Sarah Cevallos and Christina Sievert to the Executive Leadership team. Sarah Cevallos Sarah Cevallos has been named Vice President Revenue Cycle. Sarah has led the effort to reduce inefficiencies and maximize revenue by improving the insurance billing and collections funcChristina tions. She will continue to Sievert oversee these areas, and in addition, she will be responsible for the strategic direction of payer contracting and credentialing. Sarah has an MBA in Healthcare Management Sharon Dill and has been with FCS for five years. Christina Sievert has been named Vice President of Clinic Financial Services. Ms. Sievert directed the overall performance of the managed Shelly Glenn care and patient collections departments. She led these departments and has been directly responsible for improved front- end patient collections, core values, customer service, patient advocacy with various foundations and pharmaceutical companies. A member of the FCS team for 10 years, Ms. Sievert has held numerous positions within the organization and brings more than 25 years of experience in the healthcare industry to her current position. FCS is also pleased to announce two
additional promotions within the Executive Leadership team. Sharon Dill has been named Chief Human Resources Officer;Shelly Glenn has been named Chief Marketing & Sales Officer. The promotions reflect the roles that Ms. Dill and Ms. Glenn have had in successfully managing the significant growth of the organization, as well as their leadership and contributions to the communities in which they live and work.
UCF REC Launches Patient Centered Medical Home Services, Signs agreement with Primary Partners ACO The UCF Regional Extension Center announced the launch of its Patient Centered Medical Home (PCMH) recognition and transformation support services last month. The PCMH model focuses on improving healthcare by transforming how primary care is organized and delivered by strengthening the physician-patient relationship with coordinated teambased care. Soon after, UCF REC also announced they have signed an agreement with Primary Partners, an Accountable Care Organization, to assist their providers with achieving Patient Centered Medical Home recognition. The UCF Regional Extension Center’s PCMH experts will help Primary Partner providers navigate PCMH requirements and reporting as well as the use of electronic health records and other Health IT solutions. Primary Partners has more than 60 providers and 40 practices across Central Florida, serving over 14,000 Medicare beneficiaries through their ACOs. Since 2009, the UCF REC has been at the forefront of healthcare transformation through Health IT, including the adoption and implementation of Electronic Health Records (EHR), and achievement of meaningful use of EHRs. The PCMH model builds from that foundation of
data management and coordinated care. Major insurers nationwide are also driving this transformation through payment model reform, emphasizing quality outcomes, increased access to care, and greater patient satisfaction. The UCF Regional Extension Center is part of the UCF College of Medicine, and has helped more than 2,300 physicians transition to electronic health records. The center is one of 62 RECs established nationwide to help primary care providers adopt, implement and reach meaningful use of electronic health records.
Volusia Hand Surgery Clinic, P.A. Welcomes Hand Surgeon - Srikanth Eathiraju, M.D. Volusia Hand Surgery Clinic, PA is pleased to announce the addition Srikanth Eathiraju, M.D., the third surgeon to join their group. Dr. Eathiraju is a Fellowship-Trained Hand Dr. Srikanth Eathiraju Surgeon who recently completed his training at the University of Connecticut. In addition, he completed a residency in general surgery from New York Methodist Hospital in Brooklyn, New York, and his orthopedic residency at VIMS, Bellary and St. Martha’s Hospital, in Bangalore, India. Dr. Eathiraju joins established orthopedic surgeons-Dr. Richard Tessler and Dr.Tamara Clancy. Dr. Clancy states, “we are very excited about Dr. Eathiraju’s contribution to our team. He is personable, with a great skill set, and will be a welcomed addition. His expertise will enhance the orthopedic care that Volusia Hand Surgery Clinic extends to the residents of Volusia County and beyond.” Volusia Hand Surgery Clinic, PA offers comprehensive surgical and non-surgical care of the hand, wrist and elbow.
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GrandRounds Seminole State’s PTA grads receive perfect pass rate on licensure exam For the sixth time in the last decade, Seminole State College of Florida’s Physical Therapist Assistant (PTA) graduates achieved a perfect pass rate on the licensure exam. All 25 graduates of the PTA Program’s class of 2013 passed the National Physical Therapy Exam (NPTE) on their first attempt, which, sometimes in conjunction with local jurisprudence exams, licenses them to begin work as physical therapist assistants. A perfect programwide pass rate is somewhat rare. Last year, only 17 percent of the country’s PTA programs – 53 of 309 – received a 100 percent pass rate. Seminole State’s PTA Program also boasted perfect pass rates for the NPTE in 2011, 2010, 2007, 2005 and 2004. The exam, presented by the Federation of State Boards of Physical Therapy, is generally the final step graduates must take before entering the workforce. To sit for the test, students must already have graduated from an accredited physical therapist assistant program. Many of the program’s graduates already have accepted jobs, and some utilized temporary licenses that allowed them to begin practicing physical therapy without waiting for the results of the NPTE. Graduates in Seminole State’s Nursing Program (RN) also had a perfect 100 percent pass rate on their licensing exam for 2012. Scores for 2013 RN grads will be announced next month. Seminole State College’s Physical Therapist Assistant Program, based at the Altamonte Springs Campus, is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).
Innovation of the Year in Patient Care Awarded to South Lake Hospital’s Emergency Department South Lake Hospital received the 2013 Innovation of the Year in Patient Care Award from the Florida Hospital Association (FHA) in October at the Annual FHA Celebration of Achievement in Quality and Service Awards in Orlando. The Innovation of the Year in Patient Care Award is given to one large (over 150 beds) and one small (under 150 beds) each year and honors hospitals and health systems that have developed or implemented creative, new methods and models for delivering patient care. South Lake Hospital was recognized for its implementation of a rapid treatment unit (RTU) in the emergency department. The RTU was launched in January 2013 and greatly increases the speed at which lower severity patients are treated. Incoming patients that are classified as acuity levels “4 or 5” with symptoms such as ear infections, small cuts and headaches are sent directly to the RTU area. RTU patients are then seen in the RTU treatment room by a dedicated nurse and provider. This allows the patient to be quickly diagnosed, treated and released in a much more efficient orlandomedicalnews
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and timely manner and leaves the other emergency department rooms open for those who have higher acuity levels. In the past six months, the triage to bed wait time for level 4 and 5 patients has been reduced by 50 percent with a medium of nine minutes. In addition, RTU patients have seen the average length of stay decreased by 40 percent and the provider to disposition decision decrease by 33 percent. Providers have found that they are seeing the same number of patients in one exam room than they used to see using four exam rooms. The RTU has created a greater capacity so that all patients can be seen quicker; including those have higher acuity levels. The RTU, although still in its first year of implementation, has already proven to achieve the goal of improving throughput times for all patients and getting patients to the right setting of care each time. The winners are selected by FHA leadership and a team of judges from outside of the state of Florida. This is the second consecutive year South Lake Hospital has received an award. In 2012, South Lake Hospital received the FHA Community Benefit Achievement Award.
Florida Hospital Appoints Dr. Steven R. Smith as Chief Scientific Officer Florida Hospital has appointed Dr. Steven R. Smith Chief Scientific Officer (CSO) of Florida Hospital Research Services. In this new role, Dr. Smith will organize and streamline Dr. Steven Smith clinical and translational research across the eight Florida Hospital campuses in Central Florida. The appointment of Dr. Smith is a commitment to building upon existing research activities and developing a defined research agenda for Florida Hospital. In his new role as CSO, Dr. Smith will be responsible for leading the Florida Hospital research enterprise and external scientific and academic relations. He has over 20 years of experience as a physician/scientist. For the past four years, Dr. Smith has led the development of the Florida Hospital – Sanford-Burnham Translational Research Institute for Metabolism and Diabetes (TRI) as scientific director, and he will continue in this role. Working alongside Dr. Smith in his new role is Robert Deininger. He has been appointed Vice President for Research Operations. In his new role, Deininger will lead the operations Dr. Robert and administrative activiDeininger ties of the research enterprise. In addition, he will work with Florida Hospital in setting and implementing strategies to insure research is adequately supported. Deininger has an extensive background in team management, performance improvement and research operations. He has been with Florida Hospital since 2008 and has worked closely with Dr. Smith since 2010 at the TRI.
Seminole State College of Florida signs partnership with Denmark college Seminole State College of Florida and Basic Health Care College of Fredericia-Vejle-Horsens, Denmark, have signed to a five-year partnership, the first agreement between Seminole State and an international college or university. As part of the memorandum of understanding signed on Oct. 2, the two colleges agree to develop faculty and staff exchanges, and also to share educational materials. Seminole State hosted 20 faculty and administrators from the college, located in southwest Denmark, to gain a better understanding of programs in each country and to discuss collaborative exchanges. During the three-day tour of Seminole State, which included stops at the Altamonte Springs and Sanford/Lake Mary campuses, the Danish educators sat in on healthcare classes, learned more about healthcare simulation labs, received an overview of the college’s early childhood development program; and learned about DirectConnect to UCF, the College’s partnership with the University of Central Florida. The visit is part of a renewed international effort as the College builds a Center for Global Engagement, Ross added. The center, created in 2012, promotes service learning, study abroad and internationalization efforts.
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Florida Hospital Urologic Surgeon Launches Prostate Cancer Survivorship Program The American Cancer Society estimates 238,590 men will be diagnosed with prostate cancer in 2013. While surgical treatment for prostate cancer can be extremely effective, there can Dr. Vipul Patel be some post surgical side effects after the prostate is removed that can impact men and their partners. Dr. Vipul Patel, director of the Global Robotics Institute (GRI) and director of urologic oncology at Florida Hospital Cancer Institute, has created a Prostate Cancer Survivorship Program called Blueprint for Men’s Health: A GRI Survivorship Programfor patients addressing after effects of prostate cancer. Dr. Patel specializes in robotic prostatectomy (removal of the prostate) with superior outcomes that remove the cancer and preserve urinary continence and sexual function. But over time patients often have concerns after surgery including questions about diet and exercise to physiological issues with their partner or fears of cancer re-occurrence or passing cancer genetically to their children. The program is a blueprint for patients to achieve a healthy lifestyle and an enhanced quality of life. The Global Robotic Institute launched the program in September as part of prostate cancer awareness month with 85 of Dr. Patel’s patients at the Florida Hospital Nicholson Center.
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