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PHYSICIAN SPOTLIGHT PAGE 3

Alissa Shulman, MD ON ROUNDS

Empowering Coalitions to Make a Difference in Public Health Issues Case study shows how USF’s Florida Prevention Research Center developed successful community programs that attracted the CDC’s attention

TAMPA – The Florida Prevention Research Center (FPRC) at the University of South Florida’s School of Public Health led a community-based, obesityprevention coalition to complete ... 5

Reimbursement Revisit A look at payment innovation

While physicians and facilities have long had to keep up with different negotiated contract rates among payers, the reimbursement landscape has become ... 7

Understanding FIPA

New state law is unique, broader and stricter than similar data breach laws By LyNNE JETER

First there was HIPAA. Now there’s an added layer with FIPA, the Florida Information Protection Act of 2014 that Gov. Rick Scott signed into law June 20. Unanimously passed by Florida lawmakers on April 30, the new legislation took effect July 1. Legal analysts have described FIPA as the nation’s broadest and most encompassing data protection law. It requires companies to take reasonable measures to protect the covered electronic data of Floridians, while also mandating notifications to individuals of even the smallest security breaches involving their personal information. “The law is rather unique among the various states and, argu-

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(CONTINUED ON PAGE 10)

Passing the Reins

Florida Prevention Research Center’s Carol Bryant partners with Julie Baldwin on transition to 2016 retirement By LyNNE JETER

TAMPA—This month, Carol Bryant, PhD, distinguished USF Health professor and director of the Florida Prevention Research Center (FPRC) at the University of South Florida’s (USF) School of Public Health, will begin officially passing the torch to Julie Baldwin, PhD, professor of community and family health at USF. Baldwin and Bryant will co-direct the center as Bryant transitions to retirement in 2016. “We’re thrilled with the center’s progress and Dr. Baldwin’s growing role,” said Bryant, ebullient about the FPRC receiving another five-year round of funding from the Centers for Disease Control and Prevention (CDC), totaling $4.35 million. (CONTINUED ON PAGE 8)

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ably, is stricter than similar data breach laws in other states,” said Tatiana Melnik, a Tampa healthcare attorney, focusing on healthcare information technology (HIT), and licensed to practice law in Florida and Michigan. “Additionally, the law is broad in application, covering almost all businesses that have customers in Florida or that maintain ‘personal information’ about Florida residents. The law also requires that companies use ‘reasonable measures’ to secure data, without defining ‘reasonable measures.’” Even though statute provisions are similar to data breach laws in other states, FIPA defines covered personal information differently. If a breach occurs, the organization has 30 days to notify affected individuals – once the breach has been discovered.

Julie Baldwin, PhD (left) and Carol Bryant, PhD,

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PhysicianSpotlight

Alissa Shulman, MD Sovereign Plastic Surgery, Sarasota By JEFF WEBB

SARASOTA - Being different has defined Alissa Shulman since she was a child. Today, Shulman’s ability to see things a bit differently continues to shape her perspective as a plastic surgeon. In high school in suburban Buffalo, N.Y., Shulman said she was regarded as an eccentric misfit who was “the sole member of the unofficial Biology club.” She was nicknamed “Roadkill” because, living on a country road, she took advantage of many opportunities to “pick up dead animals and skin and study them,” she said. Shulman also designed and made her own clothes, including a cape made from the pelts of animal carcasses. It weighed 30 pounds and made a fashion statement that complemented her underground 1980s goth look. “According to my mother, I didn’t wear clothes; I wore costumes,” she said. Her mom, Charlene, was “a little leery when I was putting dead animals in the freezer,’ Shulman laughed, but encouraged her daughter’s explorations wholeheartedly. “She’s always been my strongest supporter and influence. She made sure I knew I could accomplish anything if I wanted it and worked for it,” said Shulman. Being a “female nerd” paid off, Shulman said, when she “walked across the graduation stage with two scholarships and many awards.” By that time, Shulman already had decided she wanted to be a physician. That seed was planted when she was just 5 years old, secretly consumed half a box of double chocolate cookies and then developed “a whole body inflammatory reaction,” Shulman said. After an alarming misdiagnosis by an on-call physician, the family doctor correctly concluded that “I had OD’d on chocolate,” Shulman said. “I was so impressed I told my mother I wanted to be a nurse. Her first question was ‘Why don’t you want to be a doctor?’… My impression was girls were always nurses and boys became doctors. She set me straight immediately!” Shulman said. But Shulman had other interests. “I knew I wanted to be a doctor very early, but I also knew I was an artist even earlier,” she said. “Once I started animal dissection (from the first frog) I also knew surgery was the goal,” she said. In her teens, she “figured out how to combine those two areas. I participated in a special ‘volunteer internship’ program at Buffalo General Hospital. I worked in the instrument room and was allowed to observe a couple surgeries. One day I was watching a breast implant surgery and the plastic surgeon said he, too, had been a visual artist long before medical school, and that plastic surgery was a perfect marriage ta m pa b ay m e d i c a l n e w s

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of art and surgery. BAM! That became my life goal. Every hobby (sewing, fashion, sculpture, jewelry-making) seemed to relate to potentially making me a better plastic surgeon.” Shulman took her aspirations for art and medicine – and her tendencies to be different – to undergraduate school at SUNY at Buffalo, where she majored in both anatomy and sculpture and figure drawing, and then on to the School of Medicine campus. “I rebelled every chance I got,” she said. But as she went

through her internship at University of Texas Medical School at Houston, and scouted her options for surgical residency training, she came to the realization that her take-me-as-I-am outlook had limits. The four piercings in each ear were OK, but a tattoo of a black-and-white eyeball at the base of her neck was not well-received. “I thought it was covered, but when I scrubbed in and put on my (surgery) bonnet, it wasn’t. ... It literally threatened my future. I was told ‘You will not get your plastic surgery residency unless you get that removed.’ I said ‘Yes sir!’” and had it removed, leaving a very decorative scar,” she said. “It took me a little while to take that ‘kick me’ label off. That’s the problem with being a loner; you really don’t know what everyone else does because you ignore them. I learned that for some things you cannot buck the system, and apparently tattoos is one of them.” Another lasting discovery during her medical training was Bill Edwards, an exU.S. Marine who shared her tastes in goth music and fashion. They met in a dance club and “He couldn’t believe I was a doctor (because of the way she looked). We clicked and then he stuck around for 7 years, which she remembers as “a blur … some of the most trying of my life” because of her work schedule. After her residency, Shulman joined a practice in South Bend, Ind., where she

worked eight years, married Edwards and gave birth to their two daughters, Ayla and Mallory, now 8 and 6 years old, respectively. “Poor guy. I made him wait 10 years until I was board-certified. He survived the worst years and gave rise to the best years (raising a family), putting aside his career as an electrician and studies in psychology to help raise our family,” she said. They’ve been together 20 years now. Disenchanted with her business arrangement in Indiana, Shulman visited a close friend in Sarasota, with whom she had attended medical school. Internist and pediatrics specialist Kristen Paulus, MD. Shulman liked what she saw. She and her family, with a newborn in her arms, made the move and she opened her solo practice, Sovereign Plastic Surgery in 2008. Shulman and her mother – her “always best friend and now my office manager and babysitter” – marketed the practice by introducing themselves with home-baked muffins to area physicians who might provide patient referrals. Such a grass roots marketing approach probably wouldn’t surprise Paulus, who has fond memories of Shulman from medical school at SUNY. “We rode in the ‘Alissa-mobile,’” said Paulus. In keeping with the goth scene, “The car was black. She had a Barbie (doll) in it. It had a mohawk and no clothes. Alissa had used (CONTINUED ON PAGE 4)

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Alissa Shulman,

Surgery Preserves Nipple

continued from page 1

May reduce cancer risk SARASOTA - As a board-certified plastic surgeon, Alissa Shulman, MD, is capable of altering, enhancing and healing the human anatomy in many ways. But when she can help a patient who has been diagnosed with cancer, she said it’s an especially satisfying opportunity. Shulman, chief of plastic surgery at Sarasota Memorial Hospital, recently partnered with general surgeon Russell Novak, MD, to perform breast reconstruction surgery that gives qualified patients an option that not too long ago was available only at specialized cancer or academic medical centers. The surgical treatment is for women newly diagnosed with certain breast cancers, or whose genetics put them at high risk and wish to undergo preventive procedures to reduce the long-term risk. The most talked-about example of the bilateral nipple-sparing mastectomy came last year when actor Angelina Jolie underwent it. Her very public decision elevated discussion about the surgical option. SMH spokeswoman Kim Savage explained the procedure: “In a traditional mastectomy, surgeons remove the entire breast – breast tissue, skin, nipple and areola. The nipple-sparing approach removes the patient’s underlying breast tissue, but preserves the nipple-areola complex and most of the breast skin.” Shulman elaborated, “Until recently, women undergoing mastectomies were left with a less-than-natural-looking appearance, even with the best reconstruction efforts. With the nipple-sparing Alissa Shulman, MD, and Russell Novak, MD approach, they can reduce their cancer risk by as much as 95 percent and still be left with naturally appearing breasts,” she said. General surgeon Novak cautioned that not every woman who needs a mastectomy is a good candidate for the surgery. It depends on several factors, including the size of the cancer, the size of the breast and the location of the cancer within the breast. “Our highest priority is making sure the breast is completely cancer free,” he said. “But for those who meet the criteria – those with tumors that are not near the nipple area or those whose genetic testing reveals they are at high risk – it is a viable option.” Gynecologic oncologist James Fiorica, MD, medical director of SMH’s Women’s Cancer Program said that “As the quality of life benefits become clear, (the nipple-sparing mastectomy) may become the new standard of care for women with certain breast cancers.”

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markers to hand-paint one half of the doll with arteries and veins. The other half had the bones.” “You never knew what kind of hair Alissa would have. She’s been bleach bond, jet black, red, purple and (just recently) she had a shock of pink for breast cancer awareness month,” said Paulus, who remembers Shulman’s “road kill cape” from back in the day. None of Shulman’s outward styling has ever detracted from excellent patient care, Paulus said. “People love her. She’s never grumpy or moody. And she’s in medicine for the right reason. She wants to help people and make them feel better. She is awesome at what she does. The human body is her (artistic) media and she is able to sculpt it, restore it and make it beautiful,” said Paulus. Shulman still dabbles in art, especially with her daughters, but surgery is what satisfies that yearning now, she said. Her surgeries are split almost evenly between reconstruction vs. cosmetic, Shulman said. “My favorite things are below the neck. I really love liposuction because I’m a sculptor. I do that both with reconstruction and cosmetics and it makes me feel like I’m still the artist. Breast reductions are fun because they look good and feel good afterward,” she said. “I’m not the practice that does too many augmentations. I tend to do much more complex work than that. A lot of revision work for patients who have had surgery elsewhere and decide to redo it … And I love helping cancer patients. It’s emotionally rewarding,” said Shulman, 47. Shulman performs most of her surgeries at Sarasota Memorial Hospital, adjacent to her office, where the “staff is very supportive and I get the very best assistance. … The nurses are wonderful.” she said. “I’m pretty easy-going in the operating room. It’s one of my favorite places to be. You’ve got a whole room that revolves around taking care of you and your patient.” But when Shulman scrubs out and goes home, she is defined by difference once again, and it’s a role she relishes. “I’m mom and I wait on my children hand and foot.”

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TAMPA – The Florida Prevention Research Center (FPRC) at the University of South Florida’s School of Public Health led a community-based, obesityprevention coalition to complete the Community-Based Prevention Marketing (CBPM)-Policy Development process, following eight action steps, and resulting in Better Bites: Snack Strong and Good Neighbor Stores pilot programs. Here’s a play-by-play synopsis: Step 1: Build a strong foundation. The initial step helped the coalition, established in 2003 to prevent obesity among local youth, understand the CBPM-Policy Development process and the resources needed for successful implementation. “Even though the coalition was uniformly enthusiastic about the project, it became apparent later in the process that the coalition needed clearer distinctions between program development and

policy development, and clarification that policy change includes less formal rules and regulations enacted by government and other community organizations besides formal legislation,” explained Carol Bryant, PhD, distinguished USF Health professor and FPRC director. Step 2: What should we change? The coalition reviewed evidencebased policies and eliminated those it was either unwilling or unable to promote. The goal: to winnow the policy options to no more than 10, enabling more thorough analysis in subsequent steps. “During the meeting, coalition members were invited to nominate policies they felt should remain on the list, and speak briefly about the reasons their policy deserved further consideration,” said Bryant. “Each of the 13 nominated policies was written on paper and posted on the wall in the meeting room. Coalition members were given six stickers to cast votes. They were instructed to limit their votes to one sticker per policy. This voting procedure enabled the coalition members and the

university-based social marketers to visualize the strength of support for each of the identified policies.” Six policy options that made the short list: requiring government agencies to purchase local foods; developing an outdoor ice skating rink; promoting electronic benefits transfer (EBT) machines in farmers’ markets; increasing access to healthy foods in food deserts; promoting joint agreements allowing school facilities to be used for community physical activity programming; and zoning for/promotion of facilities allowing the processing and preparation of local foods by small scale entrepreneurs. Step 3: What Policy Should We Promote? Once a set of policy options was defined, marketing’s return-on-investment (ROI) concept was applied to options to help the coalition select one or two policies. Coalition members then compared the ROI assessments for each policy and selected ones that gave them the optimal balance of impact and likelihood of adop-

tion. Subcommittees were formed. Step 4: Identify Priority Audiences The coalition identified beneficiaries affected directly by the policy. It identified three audience groups: owners of small stores in food deserts; residents living in these communities; and local politicians, including council members and the mayor. Specific subcategories were generated within each group, such as residents living in food deserts that also receive governmental assistance, people who typically do the food shopping for a household, residents without cars, and youth who regularly buy snacks at neighborhood stores. Step 5: Listen With priority segments in mind, the coalition held listening sessions to gain understanding of how beneficiaries, stakeholders, and policymakers view the policy issues. The goal: to obtain information needed to modify the policy to optimize support from each audience group. (CONTINUED ON PAGE 12)

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OCTOBER 2014

Manage Time and Decrease Turnover Costs By DAWN RIVERA

Turnover, not to be described and associated as a lightly toasted, flakey filled pastry with a decadent warm inside, is rather in the medical industry a frightening statistic. Turnover can be expensive. In fact recent surveys report that a poor-performing employee takes up about 17 percent of a manager’s time. That equals one wasted day per week. Now, factor in the time it takes to train a replacement and you’re looking at a lot of lost hours. Statistics will also tell you that 84 percent of new hires do not live up to the new employers expectations. With the time and money associated with the hiring process this can be a daunting and discouraging fact. You’ll hear people discuss the high rate of turnover frequently, but when did you ever hear them talk about the exact cost of turnover? After all it doesn’t hit your profit and loss statement and it won’t be found in your annual budget. Employers who spread the extra workload across existing staff to fill in gaps can quickly see a drop in productivity. Employees working long hours and wearing too many hats can quickly become overwhelmed and unmotivated. Whether you are seeking direct hire, temp-hire, or temporary per diem services there are numerous advantages to partnering with a staffing agency. According

to statistics, the average time from interview to offer is 22 days. Take into consideration the time it takes to advertise the position, accumulate resumes, scheduling interviews, pay advertising costs and check references and you have quickly lost a large amount of time. To adequately screen an employee in a frequently challenging competitive market such as the medical field you will need drug screening services in place, perhaps local and federal background screenings, health screenings, education verification’s, competency testing, employment reference checks, and extended time for credentialing. It seems like a lot to write, now wait until you have to stop in the middle of a busy work day and actually apply these to a “potential” new hire. Each level of the hiring process costs time and money. Then there is the Lost Productivity Factor –calculate the cost of lost productivity at a minimum of 50 percent of the missing employees total compensation for each week the position is vacant, if there are people filling in for that employee. (This is due to fact that these workers may not understand the process involved and may have little or no training.) Or consider Bad Hire Cost – making a bad hire can cost anywhere from 1.5x

to 3.5x or more of that person’s annual salary. One of the most commonly quoted benefits of using a recruitment or staffing agency is time management. For anyone looking to hire an employee, time is of the essence. In a continually thriving market you need to stay ahead of the curve, move quickly and maximize your chance of finding a qualified candidate. Partnering with an agency will help you manage your time by matching employees to your needs based on your criteria and skills. A staffing service can provide you with a predictable cost per hire, as well as providing you an employee that will fall under the company’s unemployment

and workers compensation claims. This will quickly decrease costly overhead and employee turnover, not to mention the ever growing expense of employee benefits and liability. Whether you need a temporary employee to cover a vacation, medical leave, or you are experiencing an increase in work load, having an established partner can quickly provide you with additional resources. Established staffing agencies work with professionals who are open to short term, project or part time work and have strong backgrounds in their field. You must admit that having experienced talent that can quickly come in and adapt to your position quickly saves you time and renders more flexibility. If you’re reading this and wondering how I came about this knowledge and these statistics it’s very simple; I spent numerous years as a practice manager and administrator for large dermatology groups, rural healthcare clinics, pediatrics and internal medicine facilities. My knowledge was learned and beaten into me through 60 hour work weeks running overtime and on a short staff. One cough on a Monday morning sometimes leads to 2-3 staff members out by Friday. My white lab coat hanging next to my desk was a constant reminder that on any given day I was triage nurse, front desk assistant, phlebotomist or even x-ray tech. Pediatric offices are always subject to more germs than you can run from, as sticky little fingers touch everything and noses continue to run and drip through the hallways. Call in’s and weekends became part of every dinner topic in my house and home life. Let’s face it, almost all of us could use a little more time in our day. Recruiting, screening and hiring a new employee takes a significant part of your day, your week, and your dollars. Small to medium sized businesses are usually more leery of using staffing agencies but can benefit the most from them since they typically are wearing ‘many hats’ and may not have the ability to add yet one more task to daily activities. Change is inevitable and the world around us in doing just that. Manage your time and limit your turnover cost’s. Take a few minutes out of your day and enjoy that flakey warm pasty, after all you work hard to meet the needs of your patients, clients and staff. Dawn M Rivera is Building and Development Specialist at Arbor Medical Staffing. She can be reached at dawn@ arborstaff.com.

OCTOBER 2014

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Reimbursement Revisit A look at payment innovation By CINDY SANDERS

While physicians and facilities have long had to keep up with different negotiated contract rates among payers, the reimbursement landscape has become much more varied over the last few years as a push toward payment innovation has ushered in a host of reimbursement options ranging from shared savings programs to bundled payments to carrot-and-stick compensation as applied to quality and efficiency metrics. Rob Lazerow, practice manager for Research & Insight at The Advisory Board Company, recently analyzed some of the payment changes providers are navigating as the healthcare system begins to shift away from a fee-for-service model. While the traditional payment method based on volume still makes up the majority of healthcare reimbursements, Lazerow said it appears the shift toward accountability models is picking up steam … albeit slowly. Lazerow, who is based in Washington, D.C., has created a ‘Field Guide to Medicare Payment Innovation’ (advisory. com). However, he was quick to note the transformation isn’t limited to the Centers for Medicare & Medicaid Services. “There is a lot of payment innovation happening right now, and it’s happening in both the public and private sectors,” he said. Lazerow added CMS, commercial payers, state Medicaid programs and employers are all experimenting with new payment models in markets across the country. While there is any number of subtle variations within the pilot projects, Lazerow said there are generally three big categories of payment innovation being rolled out at this time — pay-for-performance initiatives, bundled payments, and shared savings reimbursement models. Pay-For-Performance “It’s still a fee-for-service payment, but a portion is withheld and linked to predefined metrics, including process, outcomes and patient satisfaction measures,” he said. “Medicare has a lot of experience here,” Lazerow added of the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program and hospital-acquired conditions (HAC) penalties. Lazerow said in some cases, it could mean hospitals must invest in performance software or additional manpower to provide the necessary outcomes data … effectively making it cost more to capture the same reimbursement rate compared to the pre-pay-for-performance world. However, as Lazerow pointed out, this isn’t a ‘request’ from CMS. These are mandatory programs for all hospitals that accept Medicare prospective payments with two of the three already in place and the HAC penalties set to begin in fiscal year 2015. “We’re seeing pay-for-performance in hospitals and physician practices,” Lazerow ta m pa b ay m e d i c a l n e w s

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said, noting the reimbursement model has spread past the Medicare population. “The challenge then becomes having different payers with different metrics.” Even when broad categories of data collection apply to multiple payers, it isn’t uncommon for each to ask providers to drill down to different outcomes measures within the umbrella category. “As you can imagine, the reporting and compliance burden continues to grow,” Lazerow noted. Bundled Payments Lazerow said bundled payments offer a different take on volume-driven reimbursement by coordinating care among all providers responsible for a patient’s diagnosis, treatment and rehabilitation and inserting a level of accountability into the group dynamic. “In a traditional fee-for-service world, all these providers are paid individually and have no aligned incentives or mutual accountability,” he explained. Although bundled payments are still volume-based … the more you do, the more you are paid … Lazerow said the concept focuses on costs and outcomes. “A bundled payment drives efficiency and quality within a discreet episode of care.” For payers, Lazerow said the reimbursement model creates both savings and price predictability. The sum for the bundle of care is generally less than would have been paid individually to those involved. On the provider side, the reimbursement option helps drive efficiency and care coordination with a goal of having the patient receive the right care in the right setting to maximize outcomes and minimize costs. While Medicare has a big program around bundled payments, Lazerow said this model has been adopted by the spectrum of payers including private employers. Wal-Mart, he noted, has established a bundled payment program around certain cardiac care and orthopaedic procedures. Although most current bundled payment programs are designed around specific procedures such as hip replacement or cardiac bypass surgery, Lazerow noted, “We’re starting to hear more interest around medical admissions, as well as the procedures.” Shared Savings Models Although bundled payments might be highly effective for unavoidable care, the concept doesn’t address preventive care. That’s where accountable care models … also known as shared savings … step in to apply population health metrics to mitigate potentially avoidable healthcare spending. The intent with these reimbursement models is typically to spend some in order to save more. “The big focus right now is on shared savings models,” Lazerow pointed out. He added providers work together against (CONTINUED ON PAGE 12)

OCTOBER 2014

Passing the Reins, continued from page 1 Bryant’s tireless work ethic was evident during a sabbatical in 2003, when she returned to the Lexington Fayette County Health Department in Kentucky, where she had previously served as deputy commissioner for nutrition and health education. “I worked with some of my very best friends who were still employed at the health department. We had a blast working together again on this project,” she said. “We got a tremendous amount of great work done.” “All prevention research centers share a commitment to work with community partners,” she explained. “It’s the best case scenario. The community partner picks the problem they want to solve. The center provides the research expertise, training and evaluation as that community learns from the center how to use different methods to design an intervention to solve that problem.”

The Impetus Each prevention research center has a particular community in mind for a project, sometimes focusing on a segment of the population, such as the underserved, and other times paying attention to a particular health problem, such as deafness, the elderly, or physical activity, noted Bryant. “In Sarasota,” she explained, “the community picked abstinence from smoking and drinking as the health issue, targeting middle schoolchildren. We worked with them for more than 10 years. The result was a program, ‘Believe in all your possibilities.’” Next, the FPRC at USF targeted eye injuries as the public health issue among citrus pickers in South Florida’s robust citrus harvesting industry. “We developed an intervention program to encourage the pickers to wear

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safety glasses,” she said. “We were quite successful. Those are examples of our first iteration of community-based prevention marketing.” In Kentucky, the community picked childhood obesity as the public health issue, Bryant recalled. “We worked with the Lexington Tweens Nutrition and Fitness Coalition to design Scorecard, a physical activity program for children ages 9 to13 that was quite successful there and in 22 other communities,” said Bryant. “In fact, it was far more successful than we estimated.” Formed in September 2003, the coalition was a pilot project of the Florida Prevention Research Center, Kentucky Physical Activity and Nutrition Program for the Prevention of Obesity, and Lexington Fayette County Health Department. The health department staff and the Coalition Youth Board led 27 focus groups with tweens and 24 focus groups with parents to gain a better understanding of their perspectives on nutrition and physical activity in their homes, community and schools. The variety of projects implemented since its formation include Get Out and Play groups, Grab N Go Breakfast, Fresh Take, School Wellness Programs, and the VERB Summer Scorecard that encourages tweens to be physically active every day. The CDC launched the VERB campaign in 2002.

From Program Development to Systems Change “For the last five years, we’ve switched from program development to policy change because programs require taxpayer money on an ongoing basis,” explained Bryant. “We were looking for a more-sustainable change, so we reworked our model to use community-based prevention marketing for policy development (CBPM-Policy Development) and taught the new approach to the same coalition. They’ve used it to tremendous success to start Better Bites: Snack Strong, a program focusing on a set of healthy menu items for children or adults that’s exploded.” The third iteration of CBPM-Policy Development allows for systems change, an area in which Bryant and Baldwin are working in tandem. “This third iteration isn’t about just program or policy change,” Bryant said. “With our new focus on colorectal cancer screening, it’s about understanding each ‘touchpoint’ from start-to-finish how a Floridian realizes the need to be screened, the referral process, where to go, how to pay for it, and at what point in their experience are they likely to be deterred for whatever reason. Is it discomfort or the length of time it takes to register? Regarding systems thinking, we also wanted to look at what happens if the diagnosis was negative, meaning cancer was detected. We hope to improve the entire system in the Tampa Bay area and then scale up through the state.”

We’rE IN THIS FIGHT TOGETHER. Tampa Community Hospital supports Breast Cancer Awareness Month.

OCTOBER 2014

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AssistRx to Introduce New Version of iAssist In First Quarter iAssist’s capabilities:

Technology streamlines prescribing of specialty therapies

“It eliminates unnecessary paperwork and follow-up calls, and removes the AssistRx plans to roll out a new verhuman interpretation of prescriber handsion of its iAssist software next year that will writing,” Hensley said. It also electronisit inside of physicians’ electronic medical cally tracks patient prescription history and records. sends prescriptions directly to the preferred The Orlando-based healthcare techpharmacy. nology solutions company plans to launch The technology decreases the time lag “One Click” in the first quarter of next between a patient receiving a prescription year. The software will have the same capaand filling it from two and a half weeks to bilities as iAssist but rather about 24 hours, Hensley said. than requiring physicians to Hensley, AssistRx’s chief “When we created use the iAssist website, the brand and business developsoftware will be embedded AssistRx, we were focused ment officer, and Jeff Spafford, in the physicians’ own elecpresident and CEO, together on finding ways to make the tronic medical record. created and launched the techprocess more efficient and AssistRx’s original iAsnology. easier for everyone involved.” sist software was developed “When we created Assisto simplify the prescribing tRx, we were focused on find— Edward Hensley, co-founder of AssistRx of high-cost specialty mediing ways to make the process cations (including orphan more efficient and easier for drugs) by streamlining communications Edward Hensley, co-founder of Orlandoeveryone involved,” Hensley said. between prescribers, pharmacies, patients based AssistRx. AssistRx, which has 75 employees, and manufacturers. The technology also gives users acalso collects Health Insurance Portability Since iAssist launched two years ago, cess to patient-specific protected healthand Accountability Act (HIPAA) consents 19 manufacturers have contracted to use care information and securely transmits from patients, further simplifying the prothe web-based technology for nearly 30 that information between providers. Drug cess. different specialty medications, which repmanufacturers pay for the software, which According to Hensley, AssistRx is on resent more than $17 billion in sales. For is free for physicians to use. track to collect more than 150,000 HIPAA By GRETA WEIDERMAN

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example, Swiss multinational pharmaceutical company Novartis uses the technology. iAssist provides electronic prior authorization, signatures and patient consent; instant access to patient eligibility information; customized electronic enrollment forms; and portable access from any computer or web-equipped device. “It basically gives the billing pharmacy all the information they need to fill the prescription,” said

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• Enables physicians to instantly prescribe specialty medications from any web-enabled device. • Assists in initiating most prior authorizations at site of care. • Provides a multifaceted approach to obtain patient’s HIPAA consent. • Provides access to patient eligibility information and customized electronic enrollment forms.

consents this year. Next year, legislation goes into effect in the state of New York requiring electronic prescriptions for all prescription medications. This regulation aims to improve and monitor prescription accuracy and misuse. iAssist offers a solution to comply with that regulation. Hensley and Spafford both have backgrounds in specialty pharmacy distribution and were part of the original management team at CuraScript Specialty Pharmacy, which was sold to pharmacy benefit manager Express Scripts. CuraScript is now called Accredo. Hensley and Spafford also created Advanced Care Scripts, which was sold to specialty pharmacy Omnicare.

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Understanding FIPA, continued from page 1 “Those in the healthcare space will be familiar with the term ‘covered entity’ but note that this provision covers every organization—beyond just healthcare—that acquires, maintains, stores, or uses personal information,” said Melnik. “The definition of personal information is quite broad and includes social security numbers, healthcare information, health insurance policy number, credit card numbers, and a user name or e-mail address, in combination with a password or security question and answer that would permit access to an online account.” Community Health Systems (NYSE: CYH), the nation’s largest hospital group by number of beds, received sharp criticism for not disclosing its massive data breach sooner. According to its filing with the SEC, the breach, which affected nearly 5 million patients, reportedly occurred in April or May, yet wasn’t made public until August. Exactly when the security breach was detected remains unclear. At least one proposed class action suit, in Alabama, has already been filed against CHS based on this breach. “Under Florida’s previous law, organizations were required to notify within 45 days,” Melnik pointed out. “Now, it’s ‘no later than 30 days after the determination of a breach or reason to believe a breach occurred’ unless there’s a law enforcement delay or ‘if, after an appropriate investigation and consultation with relevant federal, state, or local law enforcement

agencies, the covered entity reasonably determines that the breach has not and will not likely result in identity theft or any other financial harm to the individuals whose personal information has been accessed.’” Under FIPA, any breach involving 500 or more individuals requires notifying the Florida Department of Legal Affairs, who will require a full breach investigation report and evidence, along with copies of applicable policies and procedures. “This statute is a relatively sweeping change for Florida and raises the bar for other states,” said Melnik. “It applies to every business that handles ‘personal information’ of Florida residents and requires these businesses to take proactive ‘reasonable measures’ to secure data. “But, like many other data breach and data security statutes, FIPA fails to define what it means to take ‘reasonable measures.’ In general, this means that companies need to follow industry best practices. As a starting point, businesses should conduct a risk analysis to better gauge their risks.” (See sidebar.) FIPA also implements a records disposal requirement, said Melnik. “The law requires that each covered entity or third-party agent take all reasonable measures to dispose, or arrange for the disposal, of customer records containing personal information within its custody or control when the records are no longer to be retained,” explained Melnik.

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“Such disposal shall involve shredding, erasing, or otherwise modifying the personal information in the records to make it unreadable or undecipherable through any means.” This also means that “organizations need to understand the type of data they have on hand and implement a data disposal policy.” Given the increased liability brought about by this statute, Florida-based businesses that share data with other entities should review their contracts to ensure that data breach notification requirements are included together with appropriate cyberliability (data breach) insurance requirements, damages caps, and indemnification language, encouraged Melnik. “Non-Florida based businesses that handle ‘personal information’ of Florida residents should be aware that they too may be subject to the requirements and pulled into court under the Florida LongArm Statute,” she said. Interestingly, Melnik pointed out, the

Florida legislature addressed this possibility in the “Bill Analysis and Fiscal Impact Statement” as follows: “Although the bill doesn’t specifically provide that the covered entity must be conducting business in this state, the Florida Long-Arm statute may provide courts with the authority to assert personal jurisdiction over a nonresident covered entity. The statute enumerates a number of actions that a person or … representative may take that would submit that person to the jurisdiction of Florida courts. Those actions include, among other things, operating, conducting, engaging in, or carrying on a business venture in this state or having an office or agency in this state; committing a tortious act within this state; or breaching a contract in this state by failing to perform acts required by the contract to be performed in this state. A person may also become subject to the jurisdiction of a Florida court if the person is engaged in substantial and not isolated activity within Florida.”

Steps Healthcare Companies Should Take Now for FIPA Compliance Companies should consider taking a few proactive steps to gauge their risks and liabilities of FIPA, the Florida Information Protection Act of 2014, in light of the proactive requirement to take security measures, shortened deadline to provide data breach notification, and notification requirements for downstream entities, such as business associates, vendors, and contractors, suggested Tatiana Melnik, a Tampa healthcare attorney, focusing on healthcare information technology (HIT). Undertake a risk analysis to better assess potential risks and vulnerabilities to the confidentiality, integrity and availability of all personal information handled by the company. For a good risk analysis starting point, consider looking to the HIPAA materials and NIST (National Institute of Standards & Technology) guidance documents. Review existing privacy and security policies and procedures; update as needed. The policies should reflect what the organization actually does and not what it would do in an ideal world. Policies that are in place but aren’t followed may demonstrate willful negligence and emerge as the proverbial “smoking gun” in litigation. Develop an incident response plan, which should include a data breach notification plan. This plan should be called an “incident response plan” because not every incident is a breach. By calling something a “breach,” your team may be attributing a legal meaning to an event that is merely a potential security incident. Keep in mind, the term “breach” is defined in the statue. Any security incident is a stressful event. Having a plan in place, that at the very least contains important phone numbers for contacts who can assist you through the process, will ease the stress a bit. Your attorney should be the first call to make because you never know what you’re going to find during an investigation. Encrypt personal information to the fullest extent possible and definitely encrypt all mobile devices. The loss and theft of laptops is one of the leading causes of data breaches. Laptops should have hard drive encryption, as opposed to a separate drive that each employee should use to store personal information. If your company is using a Windows-based product, check to see if BitLocker is available on the version you’re using because it comes preinstalled in some Windows products and only needs to be enabled. Employee-owned mobile devices with access to “personal information” should be enrolled in a mobile device management system and the company should have written authorization from the employee to wipe the device, copy the device, and seize it in the event of litigation. Encryption is particularly important because it pulls the information out of the definition of “personal information” and therefore also pulls it out of the breach notification requirement. Identify all vendor and business relationship that impact “personal information” and review the existing contracts to ensure that your business will receive timely notification in the event of an incident, and also cooperation during the investigation. SOURCE: Tatiana Melnik, JD, Melnik Legal PLLC.

OCTOBER 2014

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PHOTOS COURTESY OF NHC

No Longer Last in Line The changing role of SNFs By CINDY SANDERS

Just as the notion of what’s considered ‘old’ has changed in today’s society … think ‘70 is the new 50’ … so too has the role and function of skilled nursing facilities. Gerald Coggin, senior vice president of Corporate Relations for National HealthCare Corporation, has witnessed transformative change in the long-term care industry during his more than four decades with NHC. With operations in 10 states, the publicly traded company based in Murfreesboro, Tenn. owns and/or operates 73 skilled nursing Gerald centers with 9,410 beds. Coggin NHC affiliates also operate 37 homecare programs, five residential living centers, 18 assisted living communities, plus offer additional services including long-term care pharmacies, memory care units, hospice care, and rehabilitative therapy. Coggin said the notion of a ‘nursing home’ as the last stop for seniors before they die is simply outdated. A little ironically, the industry has moved from being a residential model that looked like an old-fashioned, antiseptic medical facility … to a medical model that often looks like a well-appointed residence. As the model has changed, one of the most striking differences is in length of stay. Coggin noted that less than a decade ago, NHC’s average length of stay was 210 days. Today, the median length of stay is 26 days. In a number of facilities, such as NHC Farragut in Knoxville, Tenn., that time frame is even shorter. “We’re serving more patients than we’ve ever served, but the length of stay is much shorter than it’s ever been,” said Coggin. “Farragut is one of those facilities that is on the cusp of a new generation of long-term care. It’s all because of the emphasis on rehabilitation.” There are a number of reasons behind this change, but Coggin said cost and reimbursement … along with a culture shift … are among the primary drivers. The Omnibus Budget Reconciliation Act of 1987 signed into law by President Ronald Reagan fundamentally changed the way nursing homes operated … and simultaneously transformed society’s expectations of them. For long-term care facilities to receive Medicare and Medicaid funding in the post-OBRA world, they must provide services so that each resident might “attain and maintain her highest practicable physical, mental and psychosocial well-being.” “The emphasis was on making sure the right patient was at the right place. As a result, a new housing phenomena … assisted living … grew out of that,” Coggin explained. That ‘right patient, right place’ idea ta m pa b ay m e d i c a l n e w s

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Although NHC has adopted a medical model, the surroundings have an upscale residential feel.

endured and changed the concept of how a skilled nursing facility could align with hospitals in an evolving post-acute care role. “So much has been driven by reimbursement,” Coggin noted. He added hospitals could only keep patients, who were progressing as expected, for so long before Medicare would stop paying the inpatient rates associated with the higher acuity level of care. Yet, Coggin continued, these patients weren’t ready to go home, either. “That’s when we saw a shift in our patients … from a few Medicare patients who needed rehab to a lot of patients needing rehab,” he said. A tiered-down system was born from these hospital reimbursement constraints. At the same time, a cultural shift was happening. Longer lifespans and medical technology improvements meant more seniors could expect to live active lifestyles far beyond retirement age … and the senior segment of the population also began to increase dramatically. According to the Social Security Administration, there were approximately 9 million Americans age 65 and over in the year 1940. By 2000, that number had jumped to almost 35 million. By 2010, that number had grown yet again to just over 40 million. Increasingly, Coggin said, skilled nursing facilities “are the recovery centers where you go to rehab.” He added with a chuckle, “It’s not unusual at all to have patients come to us for services and then get a note a month later saying, ‘Thanks for the rehab. I just finished a round of golf.” He continued, “I’ve been in this business for 41 years, and we have clearly switched over in the last 15-20 years from a residential model to a patient care model … and it’s ramped up even greater over the last 3-5 years.” Once again, he pointed to cost and reimbursement as drivers of the most recent jump in the rehab population. Not only do many SNFs like NHC provide

a full range of occupational, speech and physical therapy services at a lower daily rate than hospitals, these post-acute facilities can also help hospitals avoid the monetary penalties associated with avoidable readmissions. Similarly, just as NHC accepts patients downstream from hospitals, the rehab facilities also look to move patients to a more appropriate care setting once

therapists have maximized their time with a patient … whether that is to assisted living or hospice or a return home. In fact, Coggin said, about 80 percent of NHC’s patients ultimately are discharged home. “It’s clearly a focus on transitions of care to make sure the patient receives the appropriate level of care for the appropriate amount of time and avoids unnecessary readmissions,” Coggin concluded of the new role SNFs play in the care continuum.

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Empowering Coalitions, continued from page 5

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BC1403868-0914

Step 6: Develop a Strategic Plan The coalition used research findings from each priority segment to make the marketing decisions that comprise an integrated strategic marketing plan. In this framework, the marketing plan included policy goals, policy targets, target values and concerns to be addressed, a causal model (price and other influential factors), positioning strategy, partners, competition, promotion, and success measures. “After acknowledging that corner store sales of healthy food items would be more difficult to promote than originally anticipated, the coalition decided to merge the corner store policy goal with ‘increasing access to healthy foods in governmental venues,’ because a pilot project of the Better Bites: Snack Strong initiative at community swimming pools had proven to be promising,” explained Bryant. “Moreover, it appeared that promoting healthful foods through government venues might be easier than originally expected. Once this decision was made, the coalition was able to reach consensus on the remaining components of an integrated marketing plan for promoting the blended policy goal: To make our city one of the first cities to ensure that all citizens have the opportunity to choose healthful foods wherever they live, work, or play.” Step 7: Monitor and Evaluate As part of the marketing plan, the coalition developed an evaluation method to use in monitoring progress, identifying the need for mid-course revisions to ensure strategic “on-message” direction, and assessing policy impact. Step 8: Are We Following the Plan? The marketing plan served as a blue-

print for the coalition’s advocacy activities. “When this coalition approached county council members about the introduction of a resolution to promote healthful food access—an initial step in its marketing plan—it was advised to demonstrate the feasibility of the Good Neighbor Store and Better Bites: Snack Strong initiatives through one or more pilot projects,” noted Bryant. “The Better Bites: Snack Strong initiative gained important traction as soon as the Parks and Recreation Department adopted it. Nutritionists on the coalition worked with park staff to design eight healthful food options to sell at public pools, capturing 10 percent of sales and significant media attention in the months immediately after introduction.” Sales data and interviews conducted with youth at participating pools were used to make menu adjustments. Sales increased the following summer (2012) to 19 percent of total concession sales, and then to 31 percent in 2013. Better Bites: Snack Strong had a steamrolling effect, with the adoption of its program by the local Class A professional minor league baseball team’s stadium concession stand, YMCA and other after-school programs, school concession stands, parent-teacher associations, summer camps, Little League fields, city-sponsored youth groups, and many restaurants. It gained further momentum when the State Department of Parks changed its food policy to adopt Better Bites: Snack Strong in all 17 state park restaurant locations. “This case study demonstrates how community partnerships have the potential to translate evidence on policy and environmental changes to improve public health,” said Bryant.

Reimbursement Revisit, continued from page 7 a pre-set annual spending target per patient. Unlike past payment experiments based on monthly capitated payments, the shared savings model combines existing fee-for-service payments with a reconciliation process at the end of the year. Providers then share in a percentage of the savings they generate. Best practices and quality metrics are a foundational element to ensure patients aren’t denied necessary care simply to save money. “The overall concept of the ACO is these providers are collectively accountable for the total cost and quality of care for populations of patients over time,” Lazerow stated. From Medicare Advantage plans to self-funded employers, the focus on population health has taken root across the country. While providers also seem to embrace the evidence-based concepts and focus on chronic disease management integral to population health, the financial realities of such programs have proven problematic in some cases. Lazerow noted that of the 32 original participants in the CMS Pioneer ACO program, nearly one-

third have left … with seven moving to Medicare shared savings programs, which have a lower risk profile for providers, and three dropping out altogether. “One challenge providers are facing is that sharing 50 cents on the dollar of volumes they are destroying might end up creating a negative financial outcome for the health system,” said Lazerow. “They’re not capturing enough of the savings they are generating.” The Bottom Line Lazerow noted he hears different sentiments from different providers as to which payment innovations they prefer. Some, he added, might like to stay in the traditional fee-for-service model, but that ultimately is unlikely given payer demands for more accountability, increased savings and improved efficiency. “Some providers right now, given their market dynamics, are in a watch and wait mode, but each year we see more and more payers and providers experimenting with accountable payment models,” Lazerow concluded. ta m pa b ay m e d i c a l n e w s

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GrandRounds Edward White Hospital Closure Announcement Dear Edward White Hospital Family and Friends: (On September 23) we announced the closure of Edward White Hospital effective November 24, 2014. I want to personally share with you how we reached this challenging decision. Despite the capital improvements we have made to the facility, the operational expense on our aging physical structure continues to increase. In this era where healthcare is migrating to the outpatient setting, we are seeing a significant rise in unoccupied licensed hospital beds throughout the region. The combination of these circumstances led us to determine that HCA West Florida’s resources would more effectively benefit the community by consolidating our services with those of our sister facilities in the area: Northside Hospital, Palms of Pasadena Hospital and St. Petersburg General Hospital. We have appreciated the support of our local community and our patients can be confident that they will receive the same outstanding level of quality patient care at other HCA West Florida Hospitals. Thank you for your dedication to Edward White Hospital and your support of our mission. Many of you have heard me say it is the people that make our hospital great. Please know I truly mean that and take pride in your accomplishments, your spirit and your extraordinary talents. I know many of your first thoughts at this news are for the many employees who are what make this hospital the wonderful place that it is. This has been my greatest concern and I am thankful that within our HCA West Florida affiliated family of hospitals there are many job openings available and we are hopeful that we will be able to find opportunities for more than 85% our employees. For more than 30 years the dedicated physicians and employees of Edward White Hospital have provided compassionate, quality care to their patients. Over the coming months, we will work closely with the medical staff to ensure continuity of care for all patients. We welcome and will assist any physician who is interested in transitioning their medical practice to other HCA hospitals, including, where possible, providing assistance in expediting the credentialing process. Edward White Hospital has a longstanding history in St. Petersburg and we value our relationships with our employees, medical staff and community. Thank you for being part of the Edward White Hospital family. It has been an honor and a privilege to serve you.

Moffitt Cancer Center Study Finds Few Physicians are Recommending HPV Vaccination for Boys Research from Moffitt Cancer Center shows family physicians and pediatricians are not always recommending vaccination against human papillomavirus (HPV) for young male patients. Approximately 6 million people are newly infected with HPV

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each year, a virus that can lead to the development of cancer. These observations helped scientists characterize the biology of HPV infection at each anatomic site and aid in the development of HPV prevention strategies, including the vaccines Cervarix® and Gardasil®. Cervarix and Gardasil are approved for HPV prevention in young females aged 9 to 26 years. Gardasil is also approved for young males aged 9 to 21 years. The Centers for Disease and Prevention’s Advisory Committee on Immunization Practices issued a permissive recommendation to vaccinate males aged 9 to 26 years against HPV in 2009. Under this recommendation, physicians may immunize males against HPV, but are not required to. Following the recommendation, a team of Moffitt researchers, including Vadaparampil, Anna R. Giuliano, Ph.D. and Teri L. Malo, Ph.D., M.P.H., conducted a survey of more than 600 family physicians and pediatricians to examine factors associated with physician recommendations for male HPV vaccination. The results helped to better understand physician beliefs and practices concerning HPV vaccination. The team discovered that physicians recommended HPV vaccination to less than 15 percent of their male patients aged 9 to 26 years. Pediatric specialists and doctors who support new vaccines were more likely

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to recommend the vaccine. They also found that physician HPV vaccine recommendations may also depend on insurance coverage. Many insurance companies choose not to cover vaccines when they are considered “optional” or “not required.” Moffitt’s Center for Infection Research in Cancer has partnered with U.S. Rep. Kathy Castor of Florida and other local healthcare organizations, to form the Tampa Bay HPV Vaccination Awareness Coalition to increase awareness of HPV-related cancer and its

prevention through vaccination. Florida has one of the lowest HPV vaccination rates, according to the Centers for Disease Control and Prevention. The state also has among the highest incidence of HPV-related cervical cancer in the country. The Advisory Committee on Immunization Practices now recommends routine HPV vaccination for both boys and girls. Most insurance companies cover the cost of the vaccination for children under the age of 18; the cost is also covered under the Affordable Care Act.

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GrandRounds Doctors Hospital of Sarasota Announces New Chief Medical Officer Doctors Hospital of Sarasota has appointed Thomas Trinchetto, MD as Chief Medical Officer. In his position as CMO, Dr. Trinchetto will provide leadership, medical oversight and expertise to ensure the delivery of high-quality healthcare. Dr. Trinchetto has served in numerous leadership roles including Chief of Staff and Chief of Medicine at Doctors Hospital of Sarasota, Medical Director of Emergency Services and Chief of Medicine at Fisherman’s Hospital in Marathon, Florida. Dr. Trinchetto received his medical degree from State University of New York, Downstate Medical Center College of Medicine and completed his internal medicine internship and residency at the former Baltimore City Hospital, since renamed the Johns Hopkins Bayview Medical Center. He is board certified in Emergency Medicine and Internal Medicine. His clinical experience includes thirty-four years in Emergency Care, four years inpatient Critical Care and four years Peer Review as a Physician Advisor for Maryland PRO.

Tampa General Hospital and USF Health Leaders Strengthen Collaboration Tampa General Hospital and the USF Health Morsani College of Medicine moved to further strengthen their relationship by giving the chief executives of both institutions a voice in each institution’s operational and strategic decision-making process.

Tampa General CEO Jim Burkhart, DSc, and Charles Lockwood, MD, dean of the Morsani College of Medicine and senior vice president of USF Health, will now participate in each other’s senior executive meetings. Each will receive an additional title to reflect the increased level of collaboration between the two institutions. In addition to president and CEO, Dr. Burkhart is now also the senior associate dean, Morsani College of Medicine at the University of South Florida. Dr. Lockwood has added the title of executive vice president, chief academic officer at Tampa General. The new titles reflect the desire to give each institution greater access into the decision-making process. Since it became a private, not-for-profit in October 1997, the hospital’s governing board has reserved a seat for the USF President or designee. The dean now will have a seat at meetings of the hospital’s senior executive team and medical executive committee. Dr. Lockwood will also work with the hospital’s leadership and medical staff to further develop academic programs and expand research capabilities. As senior associate dean, Dr. Burkhart will participate in the strategic planning activities of USF Health. He will work with vice deans to enhance clinical training for students, residents, and faculty. He also will participate in physician recruiting for the medical school and work with community leaders and health professionals to support the medical school and its mission.

Horizon Palliative Care Partners Opens in the Tampa Bay area Horizon Palliative Care Partners has begun operations in the Tampa Bay, Florida, area to give doctors and hospitals a way to provide medical support at home for patients suffering with serious, long term illness. The business was founded by Alexandra Owens, MD and Michelle León Salvat, MD, both Board Certified specialists in Hospice and Palliative Medicine with years of experience in clinical practice. Their mission is to enhance the quality of care and quality of life experienced by those facing serious illness in the Tampa Bay area. Horizon Palliative Care Partners will be based primarily in patients’ homes, which may include assisted living and long term care facilities. Palliative care is not curative, but rather supports seriously ill patients with medical care for ongoing symptoms and advance directive needs. The new organization is seeking alliances with hospitals, hospices, oncologists, primary care physicians, and other specialists. As these providers identify patient needs, Horizon Palliative Care partners will collaborate to achieve streamlined transitions to palliative care in the home or other long term residence.

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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