Tampa Bay Medical News May 2015

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PHYSICIAN SPOTLIGHT PAGE 3

Karen Hamad, MD ON ROUNDS

Population Health Advances

Physicians are buzzing about the new healthcare paradigm ... 10

Five Ways Millennials Have Shaken Up Healthcare They prefer alternative to single-source, PCP favored by older generations

By JULIE PARKER

The most powerful demographic group – millennials, ages 21-32, empowered by advances in technology – are turning America’s healthcare landscape upside down.

In a recently released survey commissioned by PNC Healthcare, more than 5,000 participants nationwide explored the impact of patientcentered care among various age groups, including millennials, Generation X or Gen-Xers (ages 33-49), baby boomers (ages 50-71) and seniors (72+). The most significant finding: online shopping for doctors, web(CONTINUED ON PAGE 4)

Changing Trends in Medicine

Dr. Tom Dooley Foundation to be highlighted at AAPS annual awards dinner ... 7

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Advancing Treatments in PAD Largo Medical Center is the first Pinellas County hospital to use Medtronic’s newly FDA-approved, drug-coated balloon

By JULIE PARKER

LARGO—On March 2 at Largo Medical Center, Chris Wagner checked in at 6 am for a new minimally invasive procedure to treat peripheral arterial disease (PAD) in his right leg. For nine years, he’d suffered from PAD, a debilitating condition that occurs when arteries in the leg become narrowed or blocked by plaque. He’d heard about a promising new procedure that would significantly reduce the risk of re-interventions in PAD. By 5 pm, the successful procedure completed, he was

headed home with a big smile on his face.

“Now I’m in no pain,” said Wagner, 80.

“I can walk up and down 17 stairs with no problem – and I don’t have stop.”

For the procedure, Merrill Krolick, DO, an interventional cardiologist at the Largobased hospital, used Medtronic’s IN.PACT Admiral drug-coated balloon (DCB). Six weeks earlier, the Food and Drug Administration (FDA) had approved use of the medical device to treat PAD in the superficial femoral and popliteal arteries of the upper leg. Kro(CONTINUED ON PAGE 4)

To promote your business or practice in this high profile spot, contact James Howard at Tampa Bay Medical News. james.howard@creativeloafing.com 813.956.4428 PRINTED ON RECYCLED PAPER

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PhysicianSpotlight

wFirst Physicians Group, Sarasota Memorial Health Care System SARASOTA - “If you had told me 5 years ago that one day I would be chief of staff of an 800-bed hospital I would have said you were crazy,” said Karen Hamad.

But later this year that casual disbelief will become reality when Hamad assumes the position at Sarasota Memorial Health Care System’s flagship facility.

Hamad, an internist and pediatrician with First Physicians Group, said that despite being humbled by the opportunity, she is excited by it. “I never dreamed I would work for such an amazing hospital and health system. I have been thrilled with my position with First Physicians Group for 13 years. It was a huge honor to be asked by the staff of the hospital to become chief of staff,” said Hamad, who works with four other dual-boarded “med-ped” physicians at the clinic in Osprey.

“The (SMH) administration is extremely supportive of the medical staff. They have a wonderful mission and work very closely with the hospital board, whose members are an amazing array of volunteers.

Deep down they care about what’s right for the patient,” she said. “It’s been a very nice transition into a leadership role that was very unexpected.”

But the upbeat 45-year-old who exudes enthusiasm today was in a very different place a few years ago, and much less certain about her professional future.

In 2008, Hamad’s father, Samuel Hamad, was diagnosed with liver cancer. A lifelong sufferer of hepatitis C that he contracted as a child in Egypt, Samuel, a native of Palestine, had lived the American dream, said Hamad. He moved his family first to Montreal, where she was born, and then to New Jersey, where he eventually rose to become president of pharmaceutical giant Bristol-Myers Squibb. After he and wife Renee, an Egyptian, raised their daughter and her younger brother with “love and a firm hand,” Hamad said, they retired and moved to Sarasota in the late 1990s.

Her parents instilled “an impeccable work ethic, which I think has helped me get to where I am today,” said Hamad, adding that her father’s mantra was both inspirational and unwavering: “I could do whatever I wanted, there was nothing there to stop me, and he would do whatever he could to support me. But I had to work for it,” said Hamad.

And she did work. Even though she knew from a young age she wanted to be a physician, Hamad graduated from Middlebury College in Vermont. It was there she learned Spanish, which added to her language repertoire of being fluent in English, French and Arabic. “I always thought of medicine as taking care of people, and you have to be able to communicate. To me, it’s an art of relating to your patients. ta m pa b ay m e d i c a l n e w s

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If you’re smart enough, you can learn the science, and I knew I would get that in medical school. But I wanted to make sure I got enough of the other stuff,” Hamad said.

Armed with a degree in World Literature, Hamad headed to medical school at Tulane University in New Orleans, which is where she was “introduced to the combined specialty of internal medicine/pediatrics. I loved the idea that my patients would never outgrow me,” she said.

Tulane also is where she grew to love classmate Jon Yenari, a native of the Crescent City. They did not connect until match day, when both learned they would be staying at Tulane. “We had a big party and about 2 in the morning he was holding my hand. We decided we might go on a date,” she recalled. A year-and-a-half later they wed and have been together for 18 years,” she said. After completing their residencies, Yenari, a gynecologist, had a four-year active duty commitment to the U.S. Navy, so they moved to Portsmouth, Va., where Hamad gave birth to her first daughter. They moved to Sarasota in 2003, “literally across the street from my parents,” she laughed, comparing it to the family depicted in the 2002 movie My Big Fat Greek Wedding. Hamad gave birth to her second daughter in 2004.

All was right with her world – until her father received a liver transplant in 2008. It

was, she said, “the greatest challenge of my life, personally and professionally.”

“Medicine had always been a calling, and I had dedicated my life to the art and practice of caring for people,” she said. “He survived the transplant, but then got sicker.

He spent nine weeks comatose on a ventilator. We eventually had to take him off life support,” said Hamad, who was, at her dad’s request, by his side the whole time. “Then the unspeakable happened, and it turned out to be a medical error” that involved a screening test of the donor liver, she said.

“Losing my father in this manner nearly broke me. I completely lost my mojo,” said Hamad. “Medicine had been my rock. I could not see or explain my way out of the dark place I found myself in after realizing our medical system is fallible, and human error could take something so precious from me,” she said. “I made a conscious decision to turn to God, and look deep inside my faith, to help me decide if I could continue to be a doctor. I prayed to be shown if medicine was what I was meant to continue to do. Slowly, I was able to find my way back to the profession. It has been a long, painful journey, but I think I am stronger because of it, and I know now that being a doctor is what God intended for me,” said Hamad.

A lifelong Christian, Hamad said the divine affirmation she sought was delivered by her patients. “It was kind of strange. People thanked me and told me how much I had changed their lives, sending me cards, flowers and calling. For the next year or so I got a lot of clear messages. I assumed there was a higher power governing all that. God was telling me this IS what I’m supposed to do, and that what I’m supposed to learn from losing my dad is that I am not in control, that I am here by the grace of God to do what he wants,” said Hamad. “I can just do as best I can with good intentions. I feel like I’m a bet(CONTINUED ON PAGE 7)

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Five Ways Millennials Have Shaken Up Healthcare, continued from page 1 based diagnostic tools and research about treatment options have a role in healthcare decisions for millennials, replacing the single-source, primary care physician (PCP) favored by older generations.

“As millennials overtake boomers as the nation’s biggest consumer buying group, they will expect more efficient ways to make healthcare payments via digital channels that are consistent with their experiences in other industries,” said Shane Print, vice president of PNC Healthcare for Florida, Alabama and Georgia. “It’ll be important for payers and providers to work together to meet these payment expectations by progressing further along the technology continuum, especially considering that much of the growth in the healthcare payments industry has been driven by a rise in patient responsibility.

Those insurers and healthcare providers that thrive will be those that adapt sooner than later to the preferences of this fastpaced, technology-driven generation.”

Growing trends among the millennials that are driving change in healthcare include: Speedy delivery When it comes to the drive-thru generation, millennials prefer retail (34 percent) and acute care clinics (25 percent) double that of boomers (17 and 14 percent, respectively) and seniors (15 and 11 percent, respectively). On the flip side, seniors (85 percent) and boomers (80 percent) visited their PCP significantly more than mil-

Nearly 50 percent of millennials and Gen-Xers use online reviews, such as Yelp and Healthgrades, when shopping for a healthcare provider, compared to 40 percent of baby boomers and 28 percent for seniors. lennials at 61 percent.

In Florida, Print noted that urgent, specialty and retail clinics over the last four years have grown dramatically. “Quick Care” availability has been recognized as a top priority by many healthcare organizations, and even large retailers and several pharmacy chains. Millennials expressed concern about this method of care and the quality of the patient’s care, based on who’s consulting with the patient (level of education), possible lack of patient’s accurate healthcare background, and pressure of being a “quick appointment.”

Word-of-mouth marketing Nearly 50 percent of millennials and Gen-Xers use online reviews, such as Yelp and Healthgrades, when shopping for a healthcare provider, compared to 40 percent of baby boomers and 28 percent for seniors.

“The timely management of social media is critically important to the growth and success of healthcare,” said Print. “Bad patient reviews can come too easy, so making sure positive reviews

greatly outnumber the negative ones is a constant challenge for all practices. Getting happy patients engaged with sharing their positive experience will continue to be important for a practice’s success.”

Kick the tires online before buying Half of millennials and 52 percent of Gen X-ers checked online information about their insurance options during their last enrollment period, compared to 25 percent of seniors, who prefer printed materials (48 percent) or a company representative (38 percent) before selecting their plan.

Good faith, upfront estimates One of five people surveyed by PNC listed unexpected/surprise bills as the No. 1 billing-related issue. With out-of-pocket costs on the rise, millennials are more inclined (41 percent) to request and receive estimates before undergoing treatment.

Only 18 percent of seniors and 21 percent of boomers reported asking for or receiving information on costs upfront. Unfortunately, 34 percent noted the final bill was

higher than the estimate; only 8 percent reported a bill lower than estimate.

“What we’ve found with our clients in the southeast is that healthcare practices are now more motivated than before to improve the patient’s experience around billing, payment plans, and care and insurance coverage education due to the need to comply with healthcare reform requirements and for the sake of improving the profitability of the practice,” added Print.

Kicking care down the road.

All age groups agreed that medical care is too expensive (79 percent) and healthcare costs are unpredictable (77 percent). But more than half of millennials (54 percent) and Gen-Xers (53 percent) reported delaying or avoiding treatment because of cost, compared to seniors (18 percent) and boomers (37 percent).

“What we’ve found locally,” added Print, “is that with many patients neglecting their care due to costs, practices are addressing this issues by offering free/low cost healthcare clinics, healthcare education, and automated patient payment programs.”

PNC Healthcare is a member of The PNC Financial Services Group Inc. The survey was conducted by Shapiro+Raj in January.

Advancing Treatments in PAD, continued from page 1

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lick is only the second doctor on the Florida West Coast to perform the procedure.

“Of all the technologies out now, Medtronic’s drug-coated balloon has the lowest incidence of comeback rates within a year at 2.4 percent, compared to 20.6 percent treated with percutaneous transluminal angioplasty,” said Krolick. “That’s the home run.”

Medtronic’s DCB arm of the IN.PACT SFA Trial demonstrated the lowest clinically-driven target lesion revascularization (CD-TLR) rate ever reported for an interventional treatment of PAD in the superficial femoral artery (SFA). The IN.PACT Admiral has proven effective in maintaining patency of the arterial lumen after one year in a trial, compared with traditional percutaneous transluminal angioplasty.

Data also revealed the highest reported rates of primary patency, which measures sustained restoration of adequate blood flow through the treated segment of the artery. Based on Kaplan-Meier survival estimates for primary patency at 360 days, the data showed an 89.8 percent sustained restoration of blood flow in the DCB group, compared to 66.8 percent for the percutaneous transluminal angioplasty (PTA) group. Using the trial’s protocol definition, primary patency assessed at 12 months of follow-up was 82.2 percent for the DCB group, and 52.4 percent for the

PTA group.

“This is the best balloon technology out that has better results than conventional balloon angioplasty,” said Krolick.

“Save the metal for a later time. Arteries don’t like metal.”

Exceptionally positive clinical data on Medtronic’s solution, including study results and comeback rates, were revealed from the pivotal IN.PACT SFA Trial at the Vascular Interventions Advances (VIVA) annual conference last November.

During the IN.PACT Admiral DCB procedure, the balloon is inflated and emits paclitaxel, an antiproliferative medication, to prevent scar tissue from forming around the treatment site and newly blocking the artery. The inflated balloon pushes plaque away to create a channel for blood flow; the medication on the balloon surface is absorbed into the artery wall. The balloon is then removed with only the medication left behind. The procedure is usually done on an outpatient basis.

Other key features of Medtronic’s DCB: the highest rate of restored blood flow in the treated artery, a minimized need for durable implants that carry a risk of fracture in the vessel, and an exceptional safety profile. Sizes range from 4-7 mm, and lengths of 40, 60, 80, and 120 mm.

Studies also show that a medication

to the artery wall, as done with these balloons, helps keep the artery open longer than many other procedures and therapies available, and is more effective than stents at keeping the artery open long-term, while also reducing pain and downtime. The device has been cleared in Europe since 2009 and has already been used in approximately 100,000 patients.

“With Largo Medical Center being an academic medical hospital, we’re excited to offer Anthony the physician expertise Degina behind these kinds of innovations in the field of healthcare for patients like Mr. Wagner,” said Anthony Degina, CEO at Largo Medical Center, a 425-bed teaching hospital with three local campuses. The medical center’s Graduate Medical Education (GME) program is NOVA Southeastern University’s West Coast Academic Center. Also affiliated with the USF Morsani College of Medicine, the hospital will soon be home of a kidney transplantation program at the Transplant Institute of Florida.

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Changing Trends in Medicine Dr. Tom Dooley Foundation to be highlighted at AAPS annual awards dinner

By JULIE PARKER

During the American Association of Physician Specialists, Inc.’s (AAPS) 2015 House of Delegates and Annual Scientific Meeting June 26-July 1 at the Hilton Clearwater Beach in Clearwater Beach, a very special guest will keynote the June 27 President’s Awards Dinner: Richard Lavely, MD, JD, MS, MPH, president of the Dr. Tom Dooley Foundation, an organization that provides medical supplies and training to hospitals and medical doctors in African countries.

According to Lavely, the recent Ebola epidemic’s death toll stands at 9,000 victims, with a projected total of 17,000. In his presentation, Lavely plans to share how the foundation has played an unprecedented role in curtailing and fighting the recent Ebola outbreak, and also highlight the progressive medical and leadership insights involving indigenous African healthcare and public world health.

Lavely’s insight is unique to the industry; his career has been multi-faceted.

After earning an undergraduate degree in math from the University of Notre Dame, he earned a medical degree from the University of Michigan. In the middle of his emergency medicine career, he earned a law degree from the University of Connecticut, and completed business school at

PhysicianSpotlight

New Board Certification Programs Also a conversation-starter at the American Association of Physician Specialists (AAPS) annual meeting: new board certification programs. Prompted by physician and public demand, AAPS plans to unveil a board certification program for physicians who have leadership posts or are seeking CEO posts. Eligibility requirements to be board-certified in administrative medicine will be revealed this month.

Last November, the American Board of Physician Specialties (ABPS) – the third largest national organization certifying MDs and DOs – became the first multi-specialty certifying body to offer physicians board certification in integrative medicine. By mid-February, 121 integrative medicine physicians had attained board certification in the field as a result of successfully completing the initial board examinations, which emphasizes psychometrically evaluated testing and advanced testing, and also moral character and experience.

“These integrative medicine board-certified physicians are able to present themselves as doctors who incorporate the concepts of disease management, health promotion, illness prevention and healthy lifestyle into their medical practices,” said American Board of Integrative Medicine (ABOIM) Chair Randy Horwitz, MD, PhD.

Harvard University’s OPM entrepreneurial program while also studying graduatelevel public health at Yale University.

Lavely continued to practice emergency medicine, eventually at five emergency departments in three states, while also practicing healthcare law. A Louisville, Ky., native, he has served as commissioner of the Connecticut Medicolegal Investigations Commission, senior vice president of Emedicine.com, and managing director of Fairhaven Association. He’s the fourth

president of the Dr. Tom Dooley Foundation, established in 1973 to fulfill the vision of Dooley (1927-1961) to provide medical care to the impoverished population of third-world countries. Norman M. Baker of the U.S. Navy described the foundation’s mission as people committed to helping those “who ain’t got it so good.”

Agenda Items The overall meeting objectives of the AAPS’s House of Delegates & Annual Sci-

entific Meeting: • Provide physician specialists with upto-date information related to Changing Trends in Medicine through continuing medical education (CME); • Plan and conduct business that will further strengthen the mission of AAPS, its affiliated Academies of Medicine and its Boards of Certification; • Provide a forum to discuss developing and emerging issues in medical specialties; and • Encourage collegial relations that enable individual members to pursue their professional goals’ participation in the association’s activities.

“Our 2015 House of Delegates & Annual Scientific Meeting in Clearwater is an opportunity for fellow Diplomates, members and other healthcare professionals to discuss up-to-date information on physician board certification and changing trends in medicine,” said AAPS President Ken Flowe, MD, FAAEP, MBA. AAPS is headquartered in Tampa and governs the American Board of Physician Specialties (ABPS), one of three nationally recognized multi-specialty organizations.

For more information on the event, contact AAPS at (813) 433-2277.

Karen Hamad, MD, continued from page 3

ter doctor and a better person for it.”

Feeling more grounded in that regard, Hamad is sharing her experience with those she mentors, including high school seniors Florida State University College of Medicine students. “I make sure my students know that you have to be honest with your patients and (ac-

knowledge) that when mistakes happen you have to own up to them. These patients are counting on you for their lives.

If you order a test, it is your test. There is accountability and ownership.”

When Hamad is not wearing her white coat, she said she is at home cooking dinner “four or five nights a week” for

her husband and “amazing daughters,” now 14 and 11, who are competitive swimmers. On weekends, Hamad cooks Arabic dishes, sometimes harvesting grape leaves from her back yard and stuffing them with lamb, rice or zucchini. “It’s labor intensive, but it is delicious!” she said.

A hobby that has endured since she

was pregnant with her first child is scrapbooking. “I love playing with paper and scissors,” she said. “It’s a kind of therapy.

The conversation at home is ‘If the big hurricane comes, mommy has to choose between the scrapbooks or the family.’ I have not made my decision,” Hamad laughed.

Doctor Raises Funds for Middle East Peace

By JEFF WEBB SARASOTA - “I’m an Arab-American.”

Karen Hamad said that when she made that declaration at a fundraiser for the Daughters for Life Foundation in February, it surprised not only many of the 350 attendees, but also caused her some anxiety.

“I said that not very lightly and not very easily. I said it with an air of coming out of the closet because that has not been a very popular adjective to describe yourself growing up in this county,” said Hamad, who was born in Canada and has lived in the U.S. since she was a year old.

“I could hear my dad’s voice from the grave saying ‘Don’t get involved,’” said Hamad, referring to her late father Samuel, who counseled his children to be “very circumspect” about their heritage. “I am very proud to be American and very patriotic,”

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Hamad said, while acknowledging that sometimes it is difficult to overcome the headlines that create stereotypes of people who have roots in the Middle East. Her father was a native of Palestine and her mother, Renee, an Egyptian, but neither is Muslim. “We’re Christians going back to the time of Jesus in Bethlehem and Nazareth,” she said.

“All of my life I have wanted to do something to help that part of the world, but I was always afraid,” said Hamad.

She began to confront those fears after reading I Shall Not Hate, A Gaza Doctor’s Journey, a best-selling book by Izzeldin Abuelaish, a Palestinian physician whose personal tragedy inspired the Canadianbased Daughters for Life Foundation.

In 2009, an Israeli tank shelled his home in the Gaza Strip killing three of his daughters, and a niece, aged 13-21. That heartbreaking tragedy came minutes before Abuelaish

spoke live on an Israeli TV program about bettering Jewish-Muslim relations.

Instead of seeking revenge or sinking into despair and hatred, Abuelaish, a Muslim, called for the people of the Middle East to work together to end the bloodshed.

After publishing his book, he established the Daughters for Life Foundation in memory of his slain girls. Abuelaish’s premise is that lasting peace in the Middle East depends on empowering young women through education to develop strong voices for the betterment of life throughout the Middle East. To that end, the foundation provides scholarships that enable them to pursue studies in Canada, the U.S. and the United Kingdom.

“He believes that the only way to change the violence is through the nonviolent, one-by-one education of Middle Eastern girls, taking them out of that oppressive environment, bringing them to the

West and giving them a full, four-year ride somewhere,” said Hamad. “Then, when they go back home, they are more educated and they will not marry oppressive guys, they will fight their families on the arranged marriages, and they are not going to raise children who will have bombs strapped to them,” she explained.

Abuelaish has been a speaker in Sarasota, the guest of the Jewish community at Temple Beth Shalom, Hamad said. Now there are five girls receiving scholarships at New College and she is hopeful for another class of five scholars next year.

The February event at Michael’s on East was Hamad’s first foray into philanthropy and it was a huge success; $300,000 was raised for the Daughters for Life Foundation, said Hamad. “I am so proud to be making a change in the world toward peace, one young woman at a time,” she said.

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The Challenge: Getting Paid This partner in patient receivables doesn’t get paid until hospitals save money

By JULIE PARKER

As the American culture shifts to grind more financial responsibility onto patients, hospitals are facing more costly hurtles.

A few sobering facts: 81 percent of true self-pay responsibilities are never recovered; 75 percent of patient responsibilities are never collected; and self-pay is the third most frequent payment method after Medicaid and Medicare. On average, only 10 percent of patient receivables is collected at the time of service. More than half of all bad consumer debt relates to medical bills, leading an unprecedented number of patients to file for bankruptcy protection.

“Hospitals have been dealing with self-pay for some time, but not in the volume or dollars we see now,” said Sheila Schweitzer, CEO of PatientMatters, a 30year veteran in healthcare administration – half on the payor side; half on the provider end. “The cash at stake is substantial and harder to collect than a third party.

It’s imperative to have a patient receivables strategy in place, or bad debt and charity care will continue to skyrocket.”

David Shelton, COO of PatientMatters pointed out the predicament: “The

A few sobering facts: 81 percent of true self-pay responsibilities are never recovered; 75 percent of patient responsibilities are never collected; and self-pay is the third most frequent payment method after Medicaid and Medicare. On average, only 10 percent of patient receivables is collected at the time of service.

More than half of all bad consumer debt relates to medical bills, leading an unprecedented number of patients to file for bankruptcy protection.

challenge we must address is helping our hospitals adapt, and adapt quickly.”

For Schweitzer, PatientMatters was preceded by CareMedic Systems Inc., a healthcare technology revenue cycle firm with 1,600 hospitals and 1,000 ancillary facilities at the time it was sold in 2009.

CareMedic successfully brought to market the first enterprise class revenue management system: the electronic Financial Record (eFR).

“Even though we focused on thirdparty billing and management, it became very obvious that patient receivables

When you need it.

Medical professional liability insurance specialists providing a single-source solution

would be the next big challenge,” said Schweitzer, noting that in 2007, only 4 percent of revenues were coming from patients. By 2011, patient revenues averaged 32 percent. “The problem was growing really fast. Hospitals and physicians just aren’t accustomed to healing patients and then asking for money. We felt there had to be a real behavior change of hospital staff and patients to improve the collection ratio of patient receivables.”

Schweitzer and her executive team researched the market and couldn’t find a company with the technology infrastructure that adequately supported the data needed to convert patients’ complexities around their coverage.

“We found that even the tightestrun patient access departments are having difficulty getting their arms around the evolving patient receivable,” she said.

“The fact is, though healthcare reform may be a notable accelerant, the issue runs much deeper. Hospitals are seeing their revenue sources change completely as patients leapfrog private insurance (as) the third-largest payor.”

Before opening PatientMatters, Schweitzer made two strategic acquisitions, including MASH (Medical Advocacy Services for Healthcare), a Medicaid eligibility service since 1988, and Kramer Technologies, a technology firm.

“We took our time to really understand our market and hone our training, communications and processes to satisfy the hospitals and the patients,” she said.

“We’re very bullish on where we are.”

Since the firm opened in 2012, revenues have reached $25 million and employment tops 200. Based in Orlando, with offices in Houston and Ft. Worth,

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Texas, PatientMatters has hospital partnerships across the United States. The most recent hospital contract inked was St. Luke’s Cornwall Hospital, with campuses in Newburgh and Cornwall, NY. “We guarantee cost savings,” said Schweitzer. “We put resources on staff at the hospital. We only generate revenue after the hospital has seen an improvement. We’re not subscription- or feebased. We actually align with the hospital.

We only win when they win.”

PatientMatters focuses strongly on the unique market of community hospitals, which cannot afford to have high patient receivables to continue to provide a sustained high level of care.

“We feel so strongly that community hospitals are vital to this country,” said Schweitzer. “They’re usually the largest employer in the community and provide very good care. We worked on modeling our processes and approach for that midtier market.”

PatientMatters places personnel with significant hospital operations experience in contracted hospital roles such as executive director of patient access and patient advocates.

“We bring in statements we’ve carefully and thoughtfully designed with great input from focus groups of patients,” she explained. “On the back of the statement, we describe what everything means. We bring in many programs to help patients find ways to pay their bills. We find that most patients want to pay their bills if they understand what they’re being charged.”

When PatientMatters co-sponsored Orlando’s first annual C3 CFO Summit held mid-January at the Waldorf Astoria, 12 CFOs representing 27 hospitals in nearly a dozen states discussed their most immediate cash flow concerns.

“All hospitals struggle with the same patient receivables issues, whether expansion, community, or part of a large healthcare system,” said Schweitzer. “The biggest surprise of the summit was the lack of education of the patient on the financial aspects of medical care. Hospitals and caregivers have been put in the position of educating the patient around their insurance benefits. Hospitals don’t really like it.

They weren’t anticipating assuming that role, but they’ve had to. The insurance exchanges are very confusing.”

Fred Brown, chairman of Fred L. Brown & Associates, noted the conference-themed Courageous CFO Conversations “presented attendees with an unstructured, spirited discussion about the big financial issues facing hospitals today.”

“Sponsors invested the time and money to sit down and ask the tough questions,” he said. Nixon Peabody and PNC Bank were also event co-sponsors. “The attending hospital CFOs responded with enthusiasm. It was a risk that most companies would be unwilling to take. It was dynamic.”

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The Rise and Fall of Nuclear Cardiology

By J.B. BITAR, MD, FACC

Nuclear cardiology became a cornerstone of the cardiology specialty in early 1980s.

It was an innovative technology that provided better, more accurate non-invasive testing. It helped screen, assess and quantitate cardiac ischemia. It greatly expanded the horizon of conventional treadmill stress test to include those with abnormal resting ECG and those who couldn’t exercise. It’s far more sensitive and specific than the plain old treadmill stress test.

When a new medical technology is introduced to the market by a private vender, the healthcare industry’s first reaction is to determine safety and efficacy, a process that may involve federal regulatory bodies. After it’s been shown to be safe and effective, it’s approved for clinical use as a standard of care, the vender then markets the product to the hospitals and physicians at large.

The medical facility would usually set a charge per test, based on the time and skill required, cost, expected volume, and expected return on the upfront investment. In the past, the attitude of Medicare and private payers was to embrace and welcome new high-tech medical equipment to help the advancement of medicine and to reward innovation. Hospitals and physicians using the new technology would overcharge for the new and improved test and the private payers would historically pay the high dollar charge because the payer appreciated new medical technology and understood the research and investment it took to introduce it.

A Turning Point In 1989, the Senate House & Means Committee in the Senate sought expert advice from national physician leaders on how to control the escalating cost of the Medicare program. A task force expert panel was formed with physician representatives from various medical societies such as the American Medical Association (AMA). When the panel spoke before a Senate hearing, one of the key points raised was the expert consensus that the cost of medical care is technology driven.

New medical technology costs more than existing technology and the cost of escalating healthcare can be mitigated by not rewarding new medical technology by making it less profitable and to discourage physicians from using existing high-tech medical testing by taking away the financial incentive.

In the 1990s, the Health Care Financing Administration (HCFA), now known as the Center for Medicare and Medicaid services (CMS), decided to discourage the use of new expensive medical technology by paying significantly less than the requested charge. This turned away physicians from ordering new and advanced tests because the profit became marginal, especially when the predecessor test has

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been grandfathered in at a high payment bracket and yielded a higher return to the hospitals and physicians alike.

For example, positron emission tomography (PET) cardiac scanning was introduced in the cardiology field in the early 1990s and was superior to the conventional single photon emission computerized tomography (SPECT) scanning. The refusal of payers to cover the high cost of PET scanning limited its use by cardiologists. As a result, its use became limited to large centers and university hospitals, which could afford to compensate for the marginal profit – or denial of payment – on the test, by using it for research, academic and teaching purposes. To this day, PET scanning utilization isn’t widespread.

The Medicare program went a step further and started reducing payment for established high-tech medical testing on a yearly basis. Every year a new Medicare fee schedule is released and an expert panel from HCFA would study each CPT code and slash down the reimbursement of what it deemed as an overpaid code.

The existing medical technology that was already grandfathered in and was already highly compensated for decades, slowly lost its luster.

Compensation Plummets In the cardiology field, Medicare allowed professional payment for Percutaneous Transluminal Coronary Angioplasty (PTCA) to slowly drop in its fee schedule from $2,700 in 1990 to $680 in 2015. In all fairness, the PTCA has become safer, easier to perform, and requires less time from the invasive cardiologist due to better catheters and better balloons, so a slightly lower payment is somewhat fair, but a reduction over 25 years to 25 percent of the total 1990 fee – not factoring in inflation – is grossly unfair.

The nuclear cardiology story is slightly unique. The field was booming during 1980-2000 and the test was so well-compensated that it spilled over profit to a whole industry surrounding nuclear cardiology medicine. The SPECT nuclear camera manufacturing and sales was a big business for GE, Phillips, ADAC, Digirad, and Inme. Financing the expensive nuclear camera – typically over $200,000 – was big business; maintaining and repairing the camera was inflated and overpriced because the camera was considered the “goose that laid golden eggs.” Nuclear technicians were highly compensated and in high demand, nuclear physicists were paid well, venders for the radioactive pharmaceutical drugs were making a profit, and the state maintained a high fee for licensing radioactive pharmaceutical use from the State Radiation Safety Department.

Unfortunately, unlike other medical technologies, the cost of owning, operating and maintaining the nuclear medicine laboratory increased over time as payments/reimbursement kept shrinking.

Over the past 15 years, the Medicare fee schedule repeatedly targeted the cardiac nuclear stress test with more cuts almost every year. It was perceived by the panel advising on the Medicare Fee Schedule as one of the highest overpaid CPT codes. In more than a decade, global reimbursement dropped from $2,200 to a mere $770 per study. Ironically, the cost of the test escalated.

In 2012, Medicare adopted a regulation requiring that all nuclear cardiology laboratories be accredited by one of two governing bodies: Intersocietal Commission for Accreditation of Nuclear Medicine Laboratories (ICANL) or American College of Radiology (ACR). The accreditation ensures that the nuclear camera, lab, technician, and reading physician meet a certain standard set by the certifying entity. Of course, this comes at a high cost. The application fee starts at $2,000 per nuclear camera per reading physician.

As one of the most expensive and widely used ambulatory tests in cardiology, the nuclear stress test became closely monitored by private payers, which started requiring prior authorization. Over time, the third party payer modified the authorization process to be more stringent. Currently, each request is reviewed by a payer physician reviewer. Nowadays, the test is no longer authorized as a screening test; it was previously authorized for patients with established previous coronary disease or those with active chest pain. The third party payer wouldn’t authorize the test for those with known coronary disease if they didn’t have symptoms. In some low risk cases, the payer reviewer didn’t authorize the test even when the patient was having symptoms and required an abnormal plain treadmill stress test prior to proceeding to nuclear stress testing. The insurance plan shifted a large portion of the test cost to the patient by imposing a high co-pay or deductible.

resistance from the payer by asking me: why do you need to do the test? Or telling me: your request is denied, or you need to have a peer-to-peer review with a physician from the insurance plan. There’s also resistance from the patient who usually tries to talk the physician out of doing the test because of its high out-of-pocket deductible.

As a cardiologist for 25 years, I must defend a good old test that proved its utility over the decades. It was a great screening test for those without symptoms, yet at high risk for heart disease.

It was a great test to monitor those who already had heart disease. It was also a great test to determine when to intervene or operate on a cardiac lesion, when to allow non-cardiac surgery to proceed. It gave risk stratification even when nothing was expected to be done; it helped the care by merely quantitating the ischemic burden and providing prognosis.

The indication for the test is now questioned by the payers, the cardiologist is restricted in how and when to use the costly test. The financial return on the test is so marginal and the authorization process is so cumbersome, the ordering cardiologist is throwing in the towel.

Each year, the numbers of nuclear stress tests performed in this country are less than the year before. The lower volume per lab, the lower payment per test, the rising fees to comply with regulations, all lead to one end result: it’s time to abandon what was once “a gold mine.”

Jay Bitar, MD, FACC, is an interventional cardiologist at Cardiology Care Center in Lake Mary. He may be reached at JBBitar@aol.com.

Resistance & End Result In 2015, as a cardiologist, every time I order a nuclear stress test, I’m faced with MAY 2015

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Population Health Advances Physicians are buzzing about the new healthcare paradigm

By JULIE PARKER

America’s independent physicians met mid-March in San Antonio, Texas, for the 20th annual national meeting of TIPAAA – The IPA Association of America, the largest trade association serving independent and integrated physicians in the United States.

The focal point: population health, a relatively new front burner issue unfamiliar to many practitioners. Congress included the model as a component of mandates in the Patient Protection and Affordable Care Act (ACA) (See box).

“We covered a lot of ground at our annual meeting to educate independent physicians about population health,” said Al Holloway, founder and president of TIPAAA. “Once we fully understand what it is, then we’ll find tools, products and services that can assist independent physicians in their daily practice.”

One question that repeatedly popped up: What’s the difference between population health and public health?

“Some view population health as a more modern version of public health, which itself – improving the health of the public – may be a goal, a measurement system, and a conceptual framework that undergirds a profession and a scientific field,” wrote Michael A. Stoto, PhD, in “Population Health in the Affordable Care Act Era,” published by Academy Health (Feb. 21, 2013).

“Population health differs from public health, at least perceptually, in at least two respects,” Stoto explained. “First, it’s less directly tied to governmental health departments. Second, it explicitly includes the healthcare delivery system, which is sometimes seen as separate from or even in opposition to governmental public health.”

David B. Nash, MD, MBA, founding dean of the Thomas Jefferson University School of Population Health, pointed out that population health “builds on public health foundaDr. David Nash tions.”

Among the building blocks, according to Nash:

• Connecting prevention, wellness and behavioral health science with healthcare delivery, quality and safety, disease prevention/management and economic issues of value and risk – all in the service of a specific population. Examples: a city, provider’s practice, employee group, hospital’s primary service area or pre-school children.

• Identifying socioeconomic and cultural factors that determine the health of populations, and developing policies that address the impact of these determinants.

• Applying epidemiology and biostatistics in new ways to model disease states, map their incidence and predict their impact.

• Using data analysis to design social and community interventions and new models of healthcare delivery that emphasize care coordination and ease of accessibility.

“When applied to healthcare delivery, population health differs from conventional healthcare by emphasizing value rather than volume of services rendered,” said Nash.

How will population health affect physicians?

Monumentally, said Kathy Jordan, president of Jordan Search Consultants.

“The primary care practice of the future will look much different than it does today,” she said. “Instead of one-on-one encounters between the patient and their provider, the patient interaction process will include phone visits, email consultations, group visits, education programs and encounters with a variety of care team members. Out-of-office contact will become the new norm as patient health improves. Additionally, primary care physicians of the future must exhibit leadership and interpersonal skills, as well as a passion for top-tier service delivery. How well they manage the team will directly translate to how well the health of their patient population is being managed, which will directly impact future compensation models.”

Important financially: To be eligible for incentivized government funding, organizations must prove their commitment to, and implementation of, population

health, said Jordan.

“They’ll be required to improve the patient care experience, the overall health of populations, and lower per capita costs of case,” she said. “As a more comprehensively integrated system focused on population health begins to dominate, the healthcare industry, healthcare experience and provider recruitment initiatives must also evolve.”

Enter population health management.

Regina Levison, vice president of client development for Jordan Search Consultants, said that “while population health is defined as the health outcomes of a group of individuals comprising a specific demographic population, population health management is a business model centered on the delivery of comprehensive care and management of total risk.”

The foundational shift in the healthcare experience will morph from an industry driven by reactivity to an industry driven by proactive measures, said Levison.

“The goal of population health is to keep Regina a patient population as Levison healthy as possible and minimize the need for costly interventions, procedures, emergency room visits, and hospitalizations,” she said.

As an increasing number of healthcare organizations move to models of accountable care, the overall healthcare experience will be reconstructed, said Jordan.

“Within this transformation, we’ll see an altered patient and physician experience,” she said. “With an emphasis on proactive preventative care, evidencebased protocols, managed care teams, care coordination, and multidisciplinary teams, population health management will reward value in care, versus volume of patients seen.

“Although the results of these initiatives won’t manifest for a decade or more, population health management will almost certainly improve the quality of lives for millions of individuals throughout the country.”

The ACA and Population Health The Patient Protection and Affordable Care Act (ACA) addresses population health in four significant ways: • Provisions to expand insurance coverage target the advancement of population health by improving access to the healthcare delivery system.

• Other provisions seek to enhance the quality of care delivered.

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• Lesser known provisions aim to improve prevention and health promotion measures within the healthcare delivery system.

• The final set promotes community- and population-health based activities, including the establishment of the National

Prevention, Health Promotion and Public Health Council, which has already produced the mandated National Prevention Strategy and Prevention and Public Health Fund for monetizing Community Transformation Grants.

PUBLISHED BY: SouthComm, Inc. PUBLISHER James Howard james.howard@cln.com 813.956.4428 BUSINESS DEVELOPMENT DIRECTOR Chris Madalena chris@cln.com 813785-8073 NATIONAL EDITOR Pepper Jeter editor@medicalnewsinc.com LOCAL EDITOR Julie Parker jparker@medicalnewsinc.com CONTRIBUTING WRITERS Julie Parker, Cindy Sanders Jeff Webb CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com GRAPHIC DESIGNERS Katy Barrett-Alley Amy Gomoljak, James Osborne CIRCULATION subscriptions@southcomm.com —— All editorial submissions and press releases should be emailed to: editor@medicalnewsinc.com —— Subscription requests or address changes should be mailed to: Medical News, Inc. 210 12th Ave S. • Suite 100 Nashville, TN 37203 615.244.7989 • (FAX) 615.244.8578 or e-mailed to: subscriptions@southcomm.com Subscriptions: One year $48 • Two years $78

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GrandRounds HCA West Florida Names Chief Nurse Executive HCA West Florida announces the appointment of Nancy Simon, RN, BSN, MA as Chief Nurse Executive. She is responsible for the division’s clinical quality and service initiatives including patient experience, nursing recruitment and retention, and nursing management development.

Ms. Simon joins us from Baptist Medical Center in Jacksonville where for the last three years she has served as Vice President for Patient Care Services and Chief Nurse Executive. Prior to that, she served as the System CNE for Methodist Health System in Dallas where she oversaw the operations of nursing services within their four acute care hospitals and academic clinic. She began her management career with HCA at Columbia Suburban Hospital in Louisville, Kentucky and later moved to Frankfort Regional Medical Center in 2003 as CNO/COO and continued at Orange Park Medical Center.

Nancy is Board Certified in Nurse Executive Advanced with the American Nurses Credentialing Center and is a Fellow with the American College of Health Care Executives. She is currently pursuing a Doctorate in Nursing Practice.

Moffitt Cancer Center Receives Cancer Center of Excellence Award Moffitt received the Cancer Center of Excellence Award from State Surgeon General and Secretary of Health Dr. John Armstrong. The Cancer Center of Excellence program promotes excellence in cancer care, encourages the recruitment of the best cancer care pro-

fessionals and recognizes state institutions as a preferred destination for patient-centered cancer care. Established by the Florida Legislature in 2013, the designation is based on measured success in delivering quality cancer care to patients and family members.

This is the first time the Florida Department of Health has bestowed the Cancer Center of Excellence award.

Moffitt is one of four institutions that received the designation.

Moffitt’s Center Director Thomas A. Sellers, Ph.D., M.P.H, and Physician-InChief G. Douglas Letson, M.D., accepted the award.

Leadership of USF Health and Florida Hospital Tampa as well as medical faculty and student volunteers pose for a photo on opening night of the BRIDGE Clinic at Florida Hospital.

Tampa Community Hospital Named One of Top Workplaces Tampa Community Hospital was recently named one of Tampa Bay’s top workplaces in 2015 by the Tampa Bay Times. Members of the hospital’s staff nominated Tampa Community Hospital and employees were surveyed about several topics, including practices and policies that make companies the top places to work.

In the Tampa Bay region, nearly 200 leading employers were nominated by their employees. To be considered for participation, companies or government entities had to employ at least 50 workers in Florida and be at least a year old.

The Top Workplaces 2015 in Tampa Bay program was created by the Tampa Bay Times and WorkplaceDynamics.

The companies were ranked based on leadership, compensation and training, workplace flexibility, and diversity.

The rankings were published on TampaBay.com, in the April 12 edition of the Tampa Bay Times.

USF medical student volunteer Jordant Vanzant checks the blood pressure of BRIDGE Clinic patient Sandra Avilez.

L to R: Dr. Theron Ebel, a physician at Florida Hospital Tampa, with USF Health Morsani College of Medicine faculty members Dr. Eduardo Gonzalez and Dr. Lucy Guerra, co-medical directors of the BRIDGE Clinic, and USF medical student Kathryn Dean.

USF Health and Florida Hospital Tampa Partner to Expand BRIDGE Clinic

Tampa General Hospital pediatric trauma surgeon Dr. Carrie Laituri, center, describes the function of the pediatric trauma room as students from Bishop McLaughlin Catholic High School visit the Tampa General Hospital Trauma Department on Friday, April 24, 2015. MORE HEALTH presented a $1,000 check to the school for achieving a 100 percent participation in pledging to not text and drive. In all, 42 students took a field trip to Tampa General Hospital with the theme “Trauma is no Accident” with advice to avoid distracted driving, helmet use and a tour of the Trauma Department as well as Aeromed. ta m pa b ay m e d i c a l n e w s

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Further strengthening ties between the two institutions, Florida Hospital Tampa has committed $1.2 million in donated goods and services to the University of South Florida to help expand community-centered care through the USF Health BRIDGE Healthcare Clinic.

The BRIDGE clinic – a nationally recognized, student-run free community clinic in its eighth year – provides primary medical care to more than 800 underserved patients a year one night a week inside the USF Health Morsani Center for Advanced Healthcare. Paired with USF physicians, USF medical students along with students from colleges and schools of pharmacy, physical therapy, public health and social work donate their time as volunteers to care for uninsured University Area Community residents. The expanded BRIDGE clinic at Florida Hospital Tampa is located inside the Florida Hospital Pepin Heart Institute on Fletcher Avenue, just north of USF and will initially operate one night each month.

Expanding the multidisciplinary clinic into the walls of Florida Hospital Tampa matches both institutions’ core mission of providing good health for all who need it, and is expected to enhance both the patient and the student experience.

The expanded BRIDGE clinic, like the current one, continues to team medical and other health professions students with physicians. In addition to the USF Health doctors who volunteer at the Morsani Center site, the new site will bring in physician volunteers from Florida Hospital Tampa to supervise the student volunteers. As the numbers of participating hospital physicians grow, the clinic at the hospital may increase its capacity from one Thursday night each month to as many as four nights monthly. Officials from both institutions say the partnership adds to their ongoing research and patient care collaborations between the two institutions- which share a common mission to care for all patients in need across the Tampa Bay region.

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