Orlando Medical News November 2015

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PHYSICIAN SPOTLIGHT PAGE 3

Jerry Shuster, MD ON ROUNDS

Florida Telehealth Summit Slated for Orlando Dec. 2-4 Event Will Take Place at The Alfond Inn

By LyNNE JETER

Editor’s Note: “Accelerating Telehealth” is the second of a two-part series about the upcoming Florida TeleHealth Summit. In this edition, Medical News highlights the agenda lineup.

Medical Missions at the Top of the World Medical Trek: Bringing Healthcare to the People of Nepal Since 2012, Trekt Himalaya, an Orlando-based tourism agency has been focused on medical care in Nepal.

Through a project called Medical Trek Nepal, they take volunteers to remote villages in Nepal as part of a field team of doctors, nurses and medics. This mission trek provides healthcare to people who have very little or no access to any kind of treatment or medicine ... 4

ONLINE: ORLANDO MEDICAL NEWS.COM

Pushing telehealth to the forefront of Florida politics will top the agenda at the second annual Florida TeleHealth Summit, slated Dec. 2-4 at The Alfond Inn in Winter Park. The Southeastern Telehealth Resource Center, Florida State University (FSU) College of Medicine, and Florida Partnership for Telehealth are sponsoring the statewide event.

“This summit is the event to attend if you’re interested in being part of the movement to advance telehealth in Florida,” said Rena Brewer, CEO of Global Partnership for Telehealth Inc., and principal investigator (PI) of the Southeastern Telehealth Resource Center (SETRC). “Come to meet, and network with those who are using technology to profoundly impact how healthcare is being delivered in Florida.”

For the keynote luncheon on Dec. 3, Curtis Lowery, MD, director of Maternal-Fetal Medicine at the University of Arkansas Medical Sciences (UAMS), (CONTINUED ON PAGE 8)

Adventist Health System Reaches Settlement in Whistleblower Lawsuit

By DANIEL CASCIATO

The U.S. Justice Department and Adventist Health System have agreed to settle a whistleblower (qui tam) lawsuit filed in December 2012 by three former employees for $118.7 million to be shared by the federal government and four states, including Florida.

The former employees were the first to expose that Adventist was running afoul of the Stark Law, which was initially created to curb perceived unnecessary referrals and overutilization of services by physicians within groups or at facilities to referral recipients with which they have ownership or financial interests.

The plaintiffs, represented by whistle-

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blower law firm Phillips & Cohen LLP, exposed an alleged scheme by Adventist to pay physicians excessive compensation to lock in their patient referrals to Adventist-owned hospitals, clinics and other outpatient services in Florida, North Carolina, Tennessee and Texas. Those hospitals include Florida Hospital Altamonte, Florida Hospital Apopka, Florida Hospital Celebration Health, Florida Hospital Kissimmee, Florida Hospital Orlando, Florida Hospital Waterman (Tavares, Fla.), Florida Hospital for Children (Orlando, Fla.) and Winter Park Memorial Hospital.

“The settlement with Adventist was (CONTINUED ON PAGE 12)

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PhysicianSpotlight

Ophthalmologist Had Early Focus Jerry Shuster had Smart Guidance from Friends and Mentors

By JEFF WEBB

MAITLAND When Jerry Shuster left Miami and enrolled at the University of Florida in Gainesville, engineering was foremost on his mind. But within a year, he not only had decided to become a physician, he was enrolled in medical school.

“I had been a good student in high school, but not exceptional,” said Shuster. “Then I met Bob Safian, Steve Lottenberg and Todd Snyder. Bob was one of the smartest guys I have ever known; Steve, one of the hardest workers; and Todd, one of the nicest and most generous people I have ever met,” Shuster recalled. “We all became good friends and spent a lot of time together. I learned how to study from Bob and Steve,” who were pre-med students, said Shuster. Todd was studying architecture, but he and Shuster were freshman talent on the UF tennis team.

“I was in my sophomore year and, up to that point, I spent most of my time studying, foregoing many of the things that makes college fun. I applied to medical school though an early admission medical program called Junior Honors,” said Shuster. The program only accepted 15 students per year.

“I was interviewed by the Chairman of Neurology. He asked only a few questions, the last of which was ‘Why do you want to be a doctor?’ I replied and he stopped. He gave me some pointers about what kinds of answers he generally is looking for during an interview and told me he was giving me this advice in the hope I would be accepted to the program and that I would not have to interview again,” Shuster said.

Shuster made the cut, which allowed him to complete his undergraduate degree while also attending medical school.

“I did get in, but that did not mean no more interviews. There have been others — many others. But, those kind words validated all of the hard work that l had been doing up to that point and encouraged me to continue in the years ahead,” he said. Being accepted into the program “takes a lot of pressure off,” said Shuster.

Most undergrads “are working hard and the primary objective is to get into medical school. This type of program takes away that pressure.”

After earning his medical degree in 1978, Shuster did his internship in internal medicine at UF’s premiere teaching hospital, Shands. Shuster said he met many role models along the way, but the one who influenced him the most to purorlandomedicalnews

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sue ophthalmology as a specialty, and glaucoma as a subspecialty, was Dan Welch, MD, whom he described as “a real rock star. … It really clicked for me.”

Shuster stayed at Shands for his residency, and that is where he met neuroophthalmologist Lyn Sedwick, whom he married in 1982 before they both headed to St. Louis for fellowships at Washington University School of Medicine. In 1983 they returned to Florida and settled in Orlando, “glad to leave the St. Louis weather behind us,” he said.

Sedwick opened a private practice in Orlando and Shuster went to work for Tully Patrowicz, MD, in Mount Dora, but soon left to accept a teaching position at UF. That, too, was short-lived, but Shuster still regards it as a rewarding experience. “If I could not be a physician, I would be happy to be in education,” he said.

In 1984 Shuster hung his shingle with his wife and spent the next 23 years in private practice treating mostly glaucoma patients. “Our goals were in the same direction, and obviously our philosophies

line up. Patient care was always number one,” he said. And, Shuster said, he valued having a combined professional and life partner. “Patients don’t always do well, and that’s tough. It’s so easy to take that home with you. Lyn’s always been so understanding. On those nights when you are worried about a patient, it’s good to have a sounding board who is really knowledgeable,” he said.

Shuster had earned an MBA at Rollins College in 2005, and in 2007 he left private practice and put it to use as a healthcare consultant. “Initially, it was a lot of fun. As a team, we traveled around the country, working to make hospitals safer and more efficient. However, over time, the constant travel and time away from the family wore me down and I decided to come back to medical practice,” he said.

In 2012, Shuster joined Eye Physicians of Central Florida a large multispecialty group in Maitland, where he keeps clinic hours four days a week and performs surgeries one day a week at Florida Hospital in downtown Orlando.

The understated 62-year-old said he has no plans to retire. “I like getting up every day with a purpose in mind. Until I feel like I physically can’t do what I’m doing, I’m certainly not entertaining any ideas of retirement,” he said. Besides, I still have one on the payroll,” he joked, referring to

26-year-old son Eric, a graduate student at Embry Riddle Aeronautical University.

Shuster and Sedwick also have a daughter Jill, 23, who lives in North Carolina.

Shuster loves to fish. “I’ve really enjoyed it as a way to get away from the pressures of the practice. It’s certainly nice to have some distractions,” said Shuster, who also plays tennis several times a week. But the role fishing has played in his family life is even more special. “I’ve been fishing with Eric since he was 4. It became a real connection for us,” said Shuster, seizing the occasion to reminisce about the 48-inch-redfish his son caught in a junior tournament when he was just 8 years old.

About five years ago, Shuster said, he took another step in in his angling adventures. “Across from Lyn’s office is a grassy field and there were about eight guys out there practicing their fly-casting strokes.

I wandered over and struck up a conversation. They were part of a club called the Backcountry Fly Fishing Association.

They invited me to join,” he said. Today, he is on the board of directors of the organization, which promotes fly fishing for beginners as well as seasoned anglers.

A photo of a 35-inch snook caught fly fishing on Sanibel Island sits on his office desk. It’s another symbol, like his early entry into medical school, that Shuster is a quick study.

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Medical Missions at the Top of the World Medical Trek: Bringing Healthcare to the People of Nepal

By DANIEL CASCIATO

Since 2012, Trekt Himalaya, an Orlando-based tourism agency has been focused on medical care in Nepal. Through a project called Medical Trek Nepal, they take volunteers to remote villages in Nepal as part of a field team of doctors, nurses and medics. This mission trek provides healthcare to people who have very little or no access to any kind of treatment or medicine.

“It is very rare for these people to see a doctor ever in their life because their villages are days walk Volunteers with Medical Trek Nepal set up shop wherever they can find it. from any kind of public road, and program. The medical teams camp and teers who would like to serve in Peru. This then another arduous journey to any kind trek for 10 to 11 days in the foothills of the will serve remote villages in the Andes. of hospital,” said Sandra Krasa BK, founder Himalayas, with the option to extend for There are plenty of benefits as to why of the project. “Even if they could go, many two weeks (4 weeks total) in a Kathmandu Orlando physicians and medical personnel would not have the money to do so.” hospital. Those who need internship credshould become involved with Medical Trek At Medical Trek its usually do the 4-week option. “This is a Nepal, said BK. Nepal, doctors, nurses, mission and an adventure,” said BK. “Many of our doctors and nurses comand medical students “The views are breathtaking, and the ment that there is no way to get the type of from around the world cultural immersion is something that one experience they have on Medical Trek in a volunteer to trek to these does not find in any other type of travel vaclassroom or in a hospital ward,” said BK. villages, where medical cation,” she said.

“This type of field medicine forces you to clinics are set up and they Sandra Krasa To date, Medical Trek has helped over confront diseases that have been eradicated provide check-ups and BK 20,000 people, treating up to 400 people in the U.S., like TB and polio. It teaches medicine. According to in each of its medical camps, serving only you to work without the aid of technology BK, they take a moving pharmacy with the regions in Nepal where there is a clear just using basic tools and medication; it is them, and treat what they can. A Nepali hardship and no healthcare for the local truly treating those who need care, there is medical team serves as translators for the people. This project has been so incredibly no elective medicine here.” foreign doctors and nurses. They are also successful that it decided to go from four Mostly, she added, they should beinstrumental in educating the villagers treks per year to eight. In summer 2016, come involved because they will have an about common illnesses, prevention, and they will start Medical Trek Peru, offering amazing journey, and get to share their seeking further treatment. a similar itinerary and experience to volungifts to help people who are very cut-off Medical Trek Nepal is a two-week

from the modern western world.

To help prepare volunteers before they go abroad, Medical Trek Nepal stays in constant contact with its volunteers.

“We encourage them to email with questions,” said BK. “We also have a monthly newsletter that goes out monthly as they count down to Medical Trek Nepal.”

The biggest adjustment for volunteers is cultural since Nepal is a developing country. Things are very basic and simple; the country is very poor, noted BK. When they camp, everything is provided for the trekkers including tents, sleeping bags and meals, but this is not a luxury trek in any way.

“We are roughing it,” she said. “Also, they are completely foreign, and quite a novelty to some of the villagers who have never seen western people before.”

While this is considered a volunteer experience, there is a fee of $1,500 which goes towards supporting the trek itself.

“The trekkers get both the experience of trekking in Nepal and volunteering to help,” said BK. “Most volunteer experiences in Nepal offer to place you in a hospital, where volunteers observe only, for a fee. Any extra activities you would want to do, you would have to pay for. So, our trek is unique in that you get to experience the wonders of trekking through the remote regions of Nepal, and you also get to volunteer in the medical camps we set up.”

If you have never been on a medical trek before, BK encourages you to bring your skills, eagerness to help humanity, and a spirit of adventure.

“Expect the unexpected because that is Nepal,” she said. “Everyone loves this trek, but the people who have the absolutely best time are those who embrace the fact that they are in a place where everything is a bit wild, and flexibility is a must.”

Medical Trek Nepal Doubles Trekking Dates for 2016

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The promise of a life in motion.

Hip dysplasia, a common cause of hip pain in adolescents and young adults, belongs in the differential diagnosis for patients presenting with unilateral or bilateral activity-limiting pain localizing to the hip, groin, buttock or knee. Clicking or snapping may be reported; locking may occur if the acetabular cartilage has torn. Hip dysplasia may be missed on radiographs if recently updated measurement criteria aren’t applied.

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Early Stage Breast Cancer Patients Can Now Choose Single Dose Radiotherapy Clinical Trials Promising for this Highly Efficient Treatment

By OLGA IVANOV

The statistics are alarming. Up to one in three women fail to complete their post-lumpectomy standard radiation treatment. Why? Traditional radiotherapy is time consuming and stressful; requiring daily radiation to the whole breast for a total of three to six weeks. Consequently, thirty-five to forty percent of patients who did not follow through on their treatment experienced a reoccurrence of breast cancer.

Today, a more efficient option is available to women with early stage breast cancer. Intraoperative Radiation Therapy (IORT) is a single dose of radiation that is administered directly into the tumor bed immediately following a lumpectomy.

Who is a Potential Candidate?

To be eligible for IORT at the Comprehensive Breast Health Center at Celebration Health, women must be 45 or older with a new diagnosis of early stage breast cancer (a tumor size less than or equal to 3 cm and no positive lymph nodes).

Targit-A Trial Summary 3,451 women ages 45 or older diagnosed with early stage breast cancer (Size: < 3.5 cm) were randomly assigned to have either intraoperative radiation therapy or whole-breast external beam radiation therapy: • 1,721 women got intraoperative radiation therapy (15.2 percent of these women had to have additional whole-breast external beam radiation therapy after surgery because their pathology report showed the cancer had more advanced characteristics than originally thought.)

Is IORT the Better Option?

Promising Clinical Trials: The TARGIT clinical trial showed a similar risk of cancer recurrence within the breast among women treated with IORT compared to standard breast radiotherapy. A TARGIT summary is included below.

Less Stress and Travel Time: When compared to three to six weeks of traditional radiation therapy, IORT offers patients reduced stress and less travel

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• 1,730 women got whole-breast external beam radiation therapy After 5 years of follow-up, researchers found that both radiation techniques had about the same breast cancer survival rates: • 97.4 percent for intraoperative radiation therapy • 98.1 percent for whole-breast external beam radiation therapy

time. In addition, all radiation side effects are confined to the tumor bed.

Minimizes Exposure to Health Tissue: With the standard treatment, radiation must first pass through the breast skin before reaching the inside. IORT minimizes exposure to healthy tissue and critical organs (including the skin, ribs and heart) by delivering less radiation and allowing for the skin to be pulled away during the procedure.

The Five-Step IORT Procedure IORT is relatively fast and straightforward. The first step is a biopsy of the lymph nodes to ensure there is no involvement with cancer. Next, the surgeon performs a lumpectomy, leaving a cavity where the tumor was located. In the third step, the radiation oncologist places the

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Xoft® ballon applicator into lumpectomy cavity to administer the one-time dose of radiation intraoperatively. Retention sutures secure the Xoft® balloon applicator.

Radiation is delivered to the surrounding tissue for 9-15 minutes. Lastly, the Xoft® balloon applicator is removed and the surgeon closes the incision.

Clinical Results Are Consistently Positive Studies suggest that the new technique offers about the same overall survival rates as whole-breast traditional radiation therapy for women diagnosed with early stage breast cancer. In an article published in the Lancet in February of 2014, researchers calculated that the five-year risk of cancer recurrence was 3.3 percent for the women who had IORT, compared with 1.3 percent for the control group—a margin that was within the trial’s predetermined definition of “noninferiority.” There was no difference in the long term survival between recipients of IORT or standard radiotherapy. The study also revealed that women who had IORT had fewer severe skin problems.

Olga Ivanov, MD, FACS, is a leader in the field of breast health and specialized breast surgery. A board-certified and fellowship-trained breast surgeon, Dr. Ivanov serves as the Medical Director of the Comprehensive Breast Health Center at Celebration Health. She received her medical degree from the Medical College of Ohio, completed her residency in general surgery at Loyola and, in 2005, completed her breast surgery fellowship training at Northwestern Memorial Hospital. Dr. Olga Ivanov is one of a few breast surgeons in the United States to lead the clinical trials into Intraoperative Radiation Therapy (IORT).

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Florida Telehealth Summit, continued from page 1 and medical director of the ANGELS Telehealth Program at UAMS, will share his story about how the university’s telehealth has transformed healthcare delivery to many underserved and previously Rena Brewer unreached residents in rural communities nationwide.

Conference registration begins late afternoon Dec. 2, and continues the following morning, as exhibits, sponsors and poster presentations are unveiled. Brewer and SETRC director Lloyd Sirmons will open the summit before introducing Mike

Smith, MA, program director for the Center for Strategic Public Health Preparedness and PI for the Center for Universal Research to Eradicate Disease at FSU, to provide an update on Florida Telehealth Policy.

In August, the Florida TeleHealth Workgroup – an all-volunteer, multi-disciplinary group of industry leaders tasked with providing insight and direction concerning the advancement of telehealth in Florida and encouraging collaboration among existing telehealth networks and programs – developed a priority list of 2016 telehealth policy priorities and guiding principles.

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Highlights include: • No legislation is preferred to poorlydrafted legislation that would curtail good telehealth practice or create unnecessary restrictions.

• At minimum, telehealth legislation is worthwhile to provide standard of care and recordkeeping clarity to clinicians and protections to patients.

• While reimbursement remains a top priority for the majority of telehealth providers, even if state lawmakers don’t seek a mandate, having simple foundational legislation in place will facilitate reimbursement discussions with payers.

• Telehealth, the broader use of telecommunication for the provision of health-related services, shouldn’t be confused with the practice of medicine; clarifying language is needed.

Ann Burdick, MD, MPH, associate dean of telemedicine and clinical outreach at the University of Miami Miller School of Medicine, will moderate a Telehealth Outcomes Panel on telehealth initiatives in Florida. The discussion – designed to provide perspectives from the patient, provider, rural community and urban health system – will highlight TeleGenetics, provider of specialist services to underserved areas in Florida, and Robert Zori, MD, professor and chief of the University of Florida’s Division of Pediatric Genetics & Metabolism.

After lunch, the first afternoon session will focus on telehealth payment models in

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Florida, moderated by Ken Peach, executive director of the Health Council of East Central Florida. In the second one, the Florida Medical Association and Florida TaxWatch will address telehealth’s “State of the State.”

A mid-afternoon session, “Telehealth: Let the Data Speak,” will be moderated by Leslee Gross, MHCA, RN, assistant vice president of operations for Baptist Health South Florida. The discussion will feature William Freeman, MD, a neurologist with the Mayo Clinic, and Michael Pizzi, MD. In the last Day 1 afternoon session, Lauren Faison, telehealth administrator for Tallahassee Memorial Healthcare, will moderate a panel discussion on “Telehealth Best Practices.”

Day 2 will begin will a panel discussion focusing on mobile telehealth technology, moderated by Wayne Hodges, RN, PMD, telemedicine clinical manager of UF Health in Jacksonville.

Paloma Costa, manager of customer service and outreach for the University Service Administration Company (USAC), will moderate a discussion on “Telecom and Broadband Funding via the Rural Health Care Program.” A discussion on telehealth’s legal landscape will be moderated by telehealth consultant Deborah Randall, JD, and featuring Nathaniel Lacktman, JD, of Foley & Lardner LLP in Tampa, and Justin Stone, JD. To address the financial aspect of telehealth delivery, Sirmons will moderate a panel discussion, “ROI: The Business Case.” The panel will include Jeff Robbins, director of telemedicine at Tift Regional Medical Center in Tifton, Ga.; Joseph Ebberwein, principal of Longitudinal Health; and Donna Jennings, RRT, MBA, of Telemedicine Programming Solutions, as they discuss how telehealth can positively impact the financial and social bottom line of providers and health systems.

Late morning, a 30-minute session on how telehealth is impacting the treatment of tuberculosis in Florida will be presented by the Florida Department of Health in Orange County. The final half-hour session will focus on understanding the direct-to-consumer telehealth model and its implications for patients and healthcare organizations.

“The exciting lineup of speakers includes policy makers, physician telehealth practitioners, payers, implementers of successful programs, legal experts, and many others who have a telehealth story to tell,” said Brewer.

Immediately following the summit: a free hands-on lab for registrants who wish to experience the clinical side of telehealth.

“This lab will allow an opportunity for attendees to interact with telehealth experts who are implementing programs across the region,” Brewer said, “as well as to evaluate and become familiar with a variety of telehealth devices and services.”

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Assembling the Right Team to Open a New Office

By KEN JORGENSON

One of the most significant business decisions you will make is the strategic choice of your office’s location. In many markets, the incentives offered by landlords to new tenants make relocation more appealing than renewing a lease in your existing space, and before signing any lease renewal you should evaluate all the options in your area.

If you decide to open a new office, whether as a relocation, new start-up practice, property purchase, or second office, having the right team in place is paramount and can make the process successful, profitable, and maybe even fun!

The unique office needs of healthcare providers are foreign to most real estate brokers, architects, and other service providers. Experienced professionals with a healthcare focus provide the expertise needed to address issues such as patient flow, privacy and compliance, medical technology integration, parking and accessibility requirements, and aesthetics. When choosing your team, seek out experienced, healthcare-focused professionals to fill each role and you will end up with an office that will serve you and your patients for years to come.

Here are some guidelines and ideas for putting your team together to help you find the best possible location and terms, keep your costs low, and create an ideal office to meet your patients’ needs.

Real estate agent The real estate agent helps to make sure the entire new office process goes smoothly, and is one of the first roles you will need to identify and fill. Your agent should provide guidance in choosing the best location, negotiate the most competitive rates and terms with the landlord or seller, and assist in assembling the rest of the team. He or she will be able to advise you on current market conditions, vacancies, costs to open a new office, and help you avoid common pitfalls in choosing a suitable space. Should you choose to lease an office, your agent’s experience in representing healthcare tenants can also help you achieve concessions that landlords only make available to the highest quality tenants. If the agent is well-connected within the healthcare community, he or she can also introduce you to the other players you will need on your team and help them all to work together on your behalf. Your agent’s services are typically paid for by the landlord or seller, so there is usually no out of pocket cost to you.

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Attorney A real estate attorney plays a critical role to ensure that all the legal terms of the lease or purchase are drafted to protect your interests in the short term and long term. Choosing an attorney who specializes in real estate transactions will help the legal negotiations with the landlord or seller to move faster and thereby reduce legal fees.

Lender Many office projects will require financing for additional build-out, equipment and furniture, and operating capital, and it is essential to bring in a practice lending specialist. Many major banks now have special departments that exclusively deal with commercial loans for healthcare providers and are able to provide rates and terms not available to other customers.

The lender will be closely involved with the agent and the attorney to ensure that the requirements of the underwriters are included in the terms of the lease or sale, and will help to determine the size and quality of office that you can afford.

Architect An experienced, healthcare-specific architect is the key to transforming your new space into your ideal office. He or she will meet with you, your equipment and technology providers, and building engineers and determine the best way to achieve your design ideas while completing your new office. The architect is responsible for the overall design, obtaining permits and complying with building codes, and is also in charge of coordinating the work of the engineers, contractors and suppliers.

Through constant oversight and communication with the whole team, the architect holds everyone accountable to meet deadlines and makes sure your space is done on time, on budget, and will meet your functional and aesthetic requirements.

Equipment and technology providers If your new office will require new

equipment or technologies, your providers will meet with the real estate agent and architect early in the process to ensure that the design can accommodate the new equipment and they will coordinate delivery and installation within the proper timeframe set by the architect. The terms you negotiate during the lease or purchase combined with the loan package you receive will usually determine the amount you can invest in your new office’s initial equipment, so it is very helpful for these providers to work with your lender and real estate agent early in the process as well.

General contractors and subcontractors: Your architect will be able to recommend several general contractors with a good track record for their quality of service. The contractor has the task of building what was designed—within the budget and on time. Your architect will recommend whether it makes the most sense to hire a general contractor on a negotiated basis, or to competitively bid the project to multiple contractors. In either scenario, costs, communication, and service are key determinants in choosing the right contractor.

When you assemble your team, you want to ensure that everyone is an expert in his or her specialty and collaboratively works together with the goal of making the process go as smoothly as possible. Having the right team causes the project to be on time and on budget and of the highest quality. Equally as important, having the right team protects your time and frees you to focus on your practice and enjoy your new office.

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, hundreds of medical, dental, veterinary, and other healthcare practices trust Carr Healthcare Realty to help them achieve the most favorable terms on their lease and purchase negotiations. By not representing landlords or sellers, Carr Healthcare Realty is able to strongly advocate for healthcare providers and avoid conflicts of interest while saving their clients hundreds of thousands of dollars. Carr Healthcare Realty’s team of experts can assist with all types of real estate transactions, including lease renewals, expansions, relocations, startup offices, purchases, and practice transitions.

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Adventist Health System Reaches Settlement, continued from page 1 the largest ever made in a case involving physician referrals to hospitals,” said Peter Chatfield, a partner at Phillips & Cohen LLP who represented the whistleblowers in the Adventist case. “Congress enacted the Stark Law to try to ensure that doctors consider only the patients’ needs when making treatment decisions and that Peter referrals aren’t influenced Chatfield by financial relationships with healthcare facilities that provide treatment.”

In a prepared statement, Adventist Health System said, “Adventist Health System regrets these oversights, and while some of its hospitals had no violations, the organization has improved monitoring and business practices system-wide as a result of lessons learned from this experience so that it can continue to uphold the highest standards of compliance with regulations.”

The Stark Law provisions apply when a practice has an ownership or other financial arrangement with a referral recipient that provides certain “designated health services” (DHS) to a Medicare patient.

DHS is defined by statute and include: Clinical laboratory services • Physical therapy services • Occupational therapy services • Outpatient speech-language pathology services • Radiology and certain other imaging services

• Radiation therapy services and supplies • Durable medical equipment and supplies • Parenteral and enteral nutrients, equipment, and supplies • Prosthetics, orthotics, and prosthetic devices and supplies • Home health services • Outpatient prescription drugs • Inpatient and outpatient hospital services The settlement agreement also covers a separate qui tam lawsuit filed in 2013 that made the same allegations as some of those made earlier in Phillips & Cohen’s qui tam lawsuit. The False Claims Act allows private citizens to file qui tam lawsuits against any entity defrauding the government to recover funds for the government.

“I expect to see more Stark cases against hospitals, since the Justice Department takes these violations very seriously,” said Chatfield. “Hospital employees often will object to their managers about improper financial relationships with doctors, but nothing changes. That is when they turn to us and the False Claims Act.” One misunderstanding of Stark Law is that if the patients are not Medicare or Medicaid recipients, then Stark does not apply. This is only half true. While Stark may not apply, many states have miniStark laws that pick up the slack and apply to cash and insurance patients.

For example, Florida has the Patient Self-Referral Act that prohibits referrals

for non-Medicare and Medicaid patients.

Many times these laws incorporate the exceptions found in federal law and apply them to the referrals not covered by Stark.

Some states, like California, apply their mini-Stark laws to all patients, regardless of payor source so that patient referrals are still impacted even if the Stark Law does not apply. In addition, Stark does not apply to referrals for other types of federal health care program patients, such as Veterans Administration, Railroad Retirement Board, Public Health Services and other federally-funded health programs.

Brian Mahany, a False Claims Act attorney from Tampa, FL, calls the Adventist settlement a major win for patients.

“Healthcare decisions should be made on what’s best for the patient, not how much a doctor or hospital can squeeze out of Medicare,” said Mahany, principal at Mahany Law. Further, by their nature, he said, these kickback schemes also involve more in-hospital treatment than patients actually need.

“Anything that stops fraud against federal healthcare programs like Medicare, helps every U.S. taxpayer and this big settlement sends a message to other healthcare providers that they should stay on the straight and narrow or face severe consequences.”

Mahany added that there have been a tremendous number of False Claims Act cases in the last 12 months regarding physician referrals and kickbacks. “They’re a priority for the Department of Justice. As hospitals have tried to get creative in how

they disguise kickbacks, from small hospitals to the Adventist settlement, the Department of Justice has drawn a line in the sand.”

John Maa, MD, a general surgeon in practice at Marin General Hospital in Greenbrae, CA, said inappropriate incentives to physicians for referral to the facilities that employed them likely will be an increasing problem in the future.

“It does work across sectors, and has increasingly been invoked in the healthcare industry over the past decade,” said Maa, a member of the Board of Directors of the San Francisco Medical Society and Past President of the Northern California Chapter of the American College of Surgeons.

“After the Affordable Care Act passage and the emphasis on accountable care organizations—there is the possibility that this type of relationship will become a greater concern, as hospitals and healthcare practitioners are encouraged to align incentives.”

While settlements like this usually cause a ripple in the healthcare community, Maa said most hospitals recover.

“Patients still need treatment and seek care at the most convenient facilities,” he said. “There have been a number of institutions that have paid massive settlements, and with time I think the process makes them stronger and better, and the settlements largely forgotten. The key to the institution is to implement processes to prevent the situation from recurring, and to reassure the public that those who are responsible for the wrongdoing have been held accountable.”

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Endowment-Style Investing Offers Stability with Less Volatility the past 10 years. The figure below compares 10-year investment returns for endowments against the S&P 500 and an investment grade bond index. Notice how the larger endowments held a considerably higher portion of alternative assets and achieved higher returns.

By SCOTT L. OLSON

Endowment-style investing is an asset allocation methodology that seeks to generate high risk-adjusted returns with lower volatility by expanding the number of asset classes and strategies used to create a portfolio.

Rather than just two main asset classes of stocks & bonds (including funds which own stock and bonds) endowments and many wealthy investors have expanded their portfolios to include alternative investments such as real estate, oil & energy drilling and royalties, hedge funds, private equity, private debt, and real assets, in addition to traditional stocks and bonds.

This type of investing is most widely attributed to major university endowments such as Yale, Harvard and Johns Hopkins University and, therefore, is often referred to as endowment-style investing.

What is an Endowment?

An endowment represents an institution’s investments and is typically organized as a public charity, private foundation or trust. Institutions that commonly have endowments include colleges and universities, museums, hospitals, large specialty clinics and religious organizations. Yale and Harvard endowments have had the most notoriety, both having been very public about their actively managed portfolios, stellar performances and their wide variety of allocated assets. According to their annual reports they will re-allocate in, and out almost entirely from asset-style

Why have Endowments Outperformed Traditional Investments?

Two factors help to explain the performance gap between endowments and traditional investments:

to asset-style as their advisors recommend.

Why endowments invest in alternative assets?

Over half of the typical endowment portfolio is invested in alternative investment strategies. As of June 30, 2012, the average endowment allocated 52 percent of its total portfolio to alternative investments. Yale University’s endowment, widely considered the pioneer in alternative investing, has allocated more than 65 percent of its portfolio to alternative investments.

Endowments have out-performed traditional investments Large endowments, which have significant allocations to alternative investments, generally outperformed traditional investments such as stocks and bonds over

The alternatives effect By investing in NonCorrelated, Less-liquid, or Non-Liquid Alternatives, endowments are typically able to construct a higher yielding portfolio with less correlation to the broader markets. NonCorrelated, Less-Liquid or Non-Liquid Alternative assets typically do not have the volatility of traditional stocks, bonds and funds. They don’t get caught up in the wild, volatile swings of the stock markets.

The quality of the manager Illiquid, alternative investments are more difficult to evaluate than publicly traded securities. Skilled managers that are adept at taking advantage of pricing inefficiencies in illiquid securities will have a greater impact on returns than skilled managers operating in the public markets, where price inefficiencies are fewer in number and there is generally less return potential.

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Why don’t individuals invest more heavily in alternatives?

While many institutions invest heavily in alternatives to build diversification, stability and generate higher returns, most individual investors have historically lacked access to alternatives due to, among other things, high investment minimums. Over the past several decades this has changed.

Investor access to popular alternatives has improved Individual investors have longed for higher income, better overall returns, more stability and less volatility, however a small percentage of financial advisors have these asset classes available to their clients.

Typically, the largest investment companies, wire-houses and broker-dealer firms do not have these popular assets. Could this be because the larger firms make their money in selling stocks and bonds to their clients, then a short time later trading that same dollar out of the first stock into another, then another then another. Could it be because the largest firms make their money by taking companies public, and they need customers to sell this stock to?

With 37 years’ experience in financial and estate-planning, wealth preservation and wealth transfer, Scott has been a popular speaker to groups of attorneys, CPAs, financial and estate planning professionals. He provides continuing education to attorneys and CPAs and has presented at the Florida Bar Tax-Section annual conference, and their 1-hour March CLE teleconference.

Scott L. Olson can be reached at Scott@ AtlanticFinancialAdvisors.com Securities offered through Financial West Group - member FINRA/SIPC. Atlantic Financial Advisors, LLC, Registered Investment Advisor not FWG affiliated.

Past performance is not indicative of future results. Not an offer to buy or sell any security. Senior Secured Debt offerings and CLO’s only offered by prospectus and like all investments have varied levels of risk. Many Alternative investments are Private Placements and/or Partnerships, may be speculative and are only offered to accredited investors.

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Mercy Launches World’s First Virtual Care Center

By LYNNE JETER

ST. LOUIS, MO — Last month, Mercy unveiled the world’s first Virtual Care Center in the heartland of America.

Bishop Edward Rice of the St. Louis Archdiocese officially blessed the nonprofit Catholic health system’s newest facility Oct. 6 in Chesterfield, Mo., a suburb located 15 miles west of St. Louis.

The new $54 million building on a 38-acre campus houses the nation’s largest single-hub electronic intensive care unit (ICU/Mercy SafeWatch), and also provides a center for telemedicine innovation and a testing ground for new healthcare products and services. More than 300 physicians, nurses, specialists, researchers and support staff at the four-story, 125,000-square-foot center are tapping into technology to deliver care to patients around the clock via audio, video and data connections to locations across Mercy and around the country through partnerships with other health care providers and large employers.

“This is a huge and impactful step forward for telehealth and I appreciate that Mercy leadership had the vision and determination to demonstrate to their community and the world how telehealth is one powerful and effective solution to the issue of diminished access to healthcare

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More than 300 physicians, nurses, specialists, researchers and support staff at the Virtual Care Center are tapping into technology to deliver care to patients around the clock via audio, video and data connections to locations across Mercy and around the country.

that many citizens in America and across the globe are experiencing,” said Rena Brewer, CEO of Global Partnership for Telehealth Inc., and director of the Southeastern Telehealth Resource Center.

Randall Moore, MD, MBA, Mercy Virtual president, spoke with Medical News exclusively about establishing the Virtual Care Center and the positive impact it’s already making on practices, clinics and hospitals across the United States.

How did the idea of Mercy creating a Virtual Care Center originate?

It was an evolutionary process. We launched our first virtual program – Mercy SafeWatch, our electronic ICU– in 2006, and we’ve experienced great success. As the team continued to build programs and saw the importance of virtual care becoming a transformational pathway for our health system, a light bulb went on. It made sense to create a Virtual Care Center that worked like a hospital to bring together teams, resources and infrastructure to care for patients in a much more coor-

dinated manner and to offer a care continuum that extends 24/7/365. We needed a facility for this conduit of care, just as we’d need one for a particular service like cancer care.

How did the concept evolve into the world’s first-of-its-kind telehealth center?

The Virtual Care Center evolves from the culture and charism of Mercy. The Sisters of Mercy who founded our health system were famously known as ‘the walking sisters.’ That goes back 187 years, when nuns were mostly cloistered and did good deeds from their convent for people in need. The walking sisters, who were quite independent, didn’t want to wait for people to find them. Instead, they searched for people in need and addressed those needs on the spot. They were an anomaly for their time.

When you think about hospitals in general, we wait for people to come to us, and we give them exceptional care.

The idea permeating our culture was to seek those needing medical care by tak-

ing virtual care teams from our clinics and hospitals and proactively identifying their healthcare needs, intervening with them earlier and more completely. It translates to a lower cost, high impact option to keep a person from deteriorating.

At the board level and leadership level, (Mercy president and CEO) Lynn Britton and (Mercy CFO) Shannon Sock were the primary drivers of this project, understanding the Virtual Care Center is 100 percent consistent with our organizational mission – and also a model for us to progressively replace our hospital-based care with care when and where people need it. If we do this well, we’ll be able to realign our contracts to be rewarded for keeping people well.

How have you made the Virtual Care Center a sustainable business model while also dealing with the complexities of regulations, interstate commerce, and the like?

First, it’s important to know we didn’t (CONTINUED ON PAGE 16)

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Mercy Launches World’s First Virtual, continued from page 15 go into the Virtual Care Center stay is running 20 to 30 percent less thinking that a fee-for-service equivthan predicted in the ICU, and 30 alent would make it a sustainable to 35 percent less than predicted on business model. We weren’t expectthe whole hospitalization. If we can ing, though we’d have welcomed it, get a sick person well faster, that’s very much direct reimbursement as less time for the patient in the ICU. has panned out. In Missouri, our Looking at it financially, the direct parity laws have helped. variable ICU costs us about of $900 We’re broadening it to enable a day. If it costs us $650 a day to us to move our teams and our pause Mercy SafeWatch, then we’re tient centricity from our facilities, getting 100 percent return on our which are somewhat limiting, to investment of virtual care without virtual care anytime, anywhere. If being paid directly for it. we did that with something like perBut the most important aspect formance-based, population health is that a third of the ICU patients contracts, we could intervene ear- President of Mercy Virtual, Dr. Randy Moore, addresses a group of predicted to die aren’t dying. That’s lier and more effectively, and then visitors. This room, like many areas of the Virtual Care Center, has the just the tip of the iceberg, and it Group it would pay for itself. implies that patients accessing the latest in audiovisual technology. Benefits For example, here’s how it Virtual Care Center are doing betworks in today’s environment in the hos-Life ter. We expect to deliver more efficient, Disability has& been running around Insurance 50 to 55 percent. pital ICU vs. the floor. In the hospital effective, and higher impact care as we inIn other words, 45 to 50 percent of the paICU, the hospital is paid a lump sum for tients who ‘should’ve’ died didn’t.

That Investments & Asset Protectiontegrate virtual into bedside and clinic care. a patient with a given condition and it’s a statistic doesn’t help much with finances, fixed amount of money. The ICU is more What’s Mercy’s longer-term right? It should helpPreparation us with market differRetirement expensive, and the patient usually doesn’t goal for the Virtual Care entiation; by having Mercy SafeWatch in have as good an outcome. One result of Center? place, we can do a better job taking care of Tax Strategies our Mercy SafeWatch program shows the One of our key growth areas for our people. But here’s another example: Lookactual v. predicted mortality for the last mission is to create the Virtual Care Cening at the risk-predicted length of stay, both few quarters in our Joplin (Mo.) hospital ter as a conduit of care anyone, anywhere in the hospital and the ICU, our length of can access. We’ve been on a 10-year, several hundred million dollar journey to get where we are. We’ve learned many positive things, and we continue to learn from missteps.

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While many physicians pursue board certification in their medical specialty, the ABAM offers an opportunity for certification in the administrative side of medicine. This allows our Diplomates to further demonstrate their strong business acumen to employers, hospital CEOs, boards of trustees, and other stakeholders.

The ABAM credential is designed to recognize physician leaders who hold a Master’s degree in a related field or have significantly relevant and practical administrative experience. There are multiple pathways to apply for, and earn, the credential.

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GrandRounds Parrish Medical Center Receives High Marks for its Healing Work Environment Parrish Medical Center (PMC) has earned a top award for excellence in how employees view their workplace from The Jackson Group, a company serving more than 200 healthcare organizations in the U.S. and Great Britain.

The Laureate Award for Workplace Excellence is earned by fewer than five percent of healthcare organizations surveyed by the company.

The Laureate Award is earned only after employee survey results are certified and the surveyed organization’s internal work plans for continuous improvement are reviewed.

The Jackson Group, based in Hickory, N.C., works with some 220 clients in 38 states and Great Britain.

Some 76.5 percent of PMCs workforce responded to the survey; a 68 percent response rate is considered statistically significant. Survey results showed that 93.3 percent of employees indicated they are proud to work for PMC, and 92 percent indicated the person to whom they report seriously considers staff suggestions for improving safety or preventing errors. PMC exceeded established workplace excellence criteria.

Staircase (left to right): Billie Fitzgerald, Secretary, PMC Board of Directors; Alan Jackson, President, The Jackson Group; Maureen Rupe, PMC Board of Directors; Herman A. Cole Jr., Chairman, PMC Board of Directors; Natalie Sellers, MS, APR, FACHE, Vice President, Communications, Community & Corporate Services; George Mikitarian, DHA, FACHE, PMC President/CEO; Stanley Retz, CPA, PMC Board of Directors.

Armon Jadidian, MD, Joins Ear, Nose, Throat & Plastic Surgery Associates The Ear, Nose, Throat & Plastic Surgery Associates officially announced the addition of Armon Jadidian, MD, a surgeon fellowship trained in sinus and skull base surgery. Dr. Jadidian is now accepting patients at the Dr. Armon Winter Park and downJadidian town Orlando locations.

Dr. Jadidian was born and raised in Clearwater. He attended University of Florida where he earned his Bachelor of Science Degree in Nutritional Sciences and Zoology. He went on to graduate from University of Florida College of Medicine, where he was a Lawrence M. Goodman Trust Recipient.

He completed his Head and Neck Surgery Residency at University of Florida College of Medicine, and decided to pursue additional fellowship with nationally-renowned rhinologist, Dr. Frederick A. Kuhn, M.D., at Georgia Nasal and Sinus Institute in Savannah, Georgia.

Dr. Jadidian is a board certified in otolaryngology-head and neck surgery and is fellowship trained in rhinologyskull base surgery. He is a member of the American Rhinologic Society and the American Academy of Otolaryngology-Head and Neck Surgery.

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GrandRounds

Payment disruptions causing headaches?

Nemours Wins Innovation in Patient Care Award A program that shortens time in the emergency department and wins rave reviews from families was honored by the Florida Hospital Association at their annual conference. The Boo-Boo Care Team is made up of specially-trained paramedics who stitch up children’s wounds in the Nemours Children’s Hospital Emergency Department. The team won the Innovation in Patient Care award, which recognizes new approaches to care delivery.

The paramedics are trained for six months on how to repair lacerations, treat nail-bed injuries and remove foreign bodies in soft tissue. The team always operates under the supervision of pediatric emergency medicine physicians.

Since the program was launched in the summer of 2014, the total length of stay for patients needing a suture has been reduced a full hour per patient. In addition, the average time each child has to wait to receive topical anesthetic has decreased by 30 minutes. Families have provided an average satisfaction score of 4.8 on a scale of 5.

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Osceola Regional Medical Center And Poinciana Medical Center Name Carrie Biggar As CFO Osceola Regional Medical Center and Poinciana Medical Center, part of HCA’s North Florida division, recently hired Carrie Biggar as chief financial officer. Biggar will oversee financial operations at both Osceola County hospitals.

Biggar brings 15 years of experience to her new role. Prior to joining Osceola Regional and Poinciana Medical Center, she served as chief financial officer for St. Lucie Medical Center in Port St. Lucie, Fla. She has also worked at HCA hospitals in Gainesville and Jacksonville. She earned her Bachelor of Science in Accounting from the University of North Florida.

The Orange County Medical Society Announces Women In Medicine Focus Group The Orange County Medical Society, Inc. (OCMS) announces the creation of a Special Interest Group focusing on Women In Medicine. The purpose of the Women In Medicine is to bring together female medical students and physicians; to promote their education and training; to educate the public on health issues of women; and to encourage women to pursue and succeed in the practice of medicine.

The OCMS cordially invites female physicians who are practicing in the area to attend this casual and well anticipated event. Join us as we share common experiences and practice expertise with other Women in Medicine and facilitate networking, friendships and fun. Please RSVP to April@ocms.org

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