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Camp Proposal on Tax Reform Contains Many Changes and SurprisesOn February 26, 2014, House Ways and Means Chairman, Dave Camp (R-MI), released a 979-page “Tax Reform Act of 2014” discussion draft (Camp Proposal) ... 4

NASS Takes a Proactive Approach to Evidence-Based Coverage DecisionsIn an effort to improve patient access to appropriate, evidence-based care, the North American Spine Society (NASS) recently released detailed policy recommendations for coverage ... 5

By CINDy SANDERS

There’s no question healthcare delivery is in the middle of a transformational period highlighted by unprecedented consolidation. While there are a number of factors impacting alignment decisions, Paul Keckley, PhD, boiled the equation down to its simplest terms, “Economics drives behavior.”

Keckley, managing director for Navigant’s Center for Healthcare Re-search & Policy Analysis, said physicians are having to assess their practices in light of a new reality that requires efficiency, effectiveness and con-tracting clout to survive.

“If you’re of a view that the economics favors you being in-dependent for the rest of your practice, you go that route,”

he stated. However, the noted healthcare expert who has published three books and more than 250 articles on the

industry and health reform, said that practice model is becoming increasingly rare.

For many, Keckley said practice decisions take a step-wise progression. Option A finds two small practices within a specialty band-

ing together. Option B brings multiple special-ties together to form a large group. Option C has

physicians or practices joining forces with a hospital or payer under some type of employment, joint venture, or

managed services organization (MSO) agreement.

Partnering in a New Paradigm

(CONTINUED ON PAGE 10)

By LyNNE JETER

ORLANDO – In the Asthma & Allergy Foundation of America’s list of “2014 Asthma Capitals,” Orlando ranked No. 49, having slipped 13 spots from the previous year’s ranking of No. 62, and has consistently bounced around the 100 Most Challenging Places to Live with Asthma since the annual studies began in 2004.

However, the ranking may not be as dismal as it seems. This year, only tenths of a point sepa-rated Orlando from nearly a dozen major cities hovering around its total score of 74.08, calculated as a composite of all factors’ relative impact on ex-posure to asthma triggers, quality of life, costs and access to care. By comparison, Tampa ranks No.

Reducing the ‘Twitch’Orlando remains among nation’s most challenging places to live for asthmatics

“I cannot underscore enough the importance

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— Jason E. Lang, MD, MPH, Pediatric

Pulmonologist, Biomedical Researcher,

Nemours Children’s Health System,

and Associate Professor of Pediatrics, University

of Central Florida.

(CONTINUED ON PAGE 6)

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PhysicianSpotlight

By JEFF WEBB

LAKE MARY - When it comes to determination, Lori Grant comes by it honestly.

Growing up on a farm in rural south-west Georgia, Grant’s parents instilled ac-countability and independence at a very young age. Her mother Ann Addison is a Physician’s Assistance and Advanced Registered Nurse Practitioner who taught nursing, became director of the local health department, earned a PhD in healthcare management, became CEO of the nonprofit healthcare organization that serves underinsured and indigent patients and raised two children.

Grant said her earliest memories of medicine were accompanying mom to the local doctor’s office on Saturdays. “I ‘worked’ for her,” said Grant, “answer-ing phones, holding lights, any little thing a kid could do.” By age 10, she already knew she wanted to be a physician.

Grant said she’s always been “pretty proud of my mom” and how determined she was to continue her education and service to the public’s health. Yet, her mother never lobbied her to study medicine. “Actually she tried to talk me out of medicine. She tried to talk me into going into law … because she said I would argue with a wall,” said Grant, who was determined, like her mother, to blaze her own trail to success and service.

At the same time, Grant’s father, Toby Addison, was using his skills as a farmer in Colquitt, Ga., to teach his daughter a work ethic that has endured. “We grew peanuts and soybeans. … I loved peanut harvest season. My job (with mom) was to haul the trailers full of pea-nuts to the peanut mill, where they were dried, sold and shipped,” she said.

The Addisons raised pigs, too, and showing her pigs in competitions at county fairs taught Grant lifelong lessons about hard work and appreciating the value of a dollar, she said. “We saved our money and dad made us reinvest it” in their barn-yard enterprises, Grant said. She was de-termined to win more blue ribbons.

All the while, Grant honed her skills as an athlete. She started playing softball when she was 3 years old and evolved into a second baseman who batted well enough to earn a scholarship to play at Darton State College in Albany. But Grant turned it down so she could concentrate on using her merit scholarship to concentrate on academics at Georgia Southwestern State University. “My brother (Benji), who played college baseball, told me I would regret not taking the softball scholarship,” she said. But, once again, Grant was de-termined to do it her way.

After earning her degree in biol-ogy she took off a year “to decide what I wanted to do. … I had worked with some

podiatrists in Tallahassee and southwest Georgia and really kind of fell in love with the idea of being an expert in one field,” she said. “I only have 26 bones to deal with in the feet and ankles. … I always knew I wanted to do something with sports medi-cine or orthopedics, and (podiatry) kind of fit both. … I could do surgery, treat sports in-juries, save limbs and change people’s lives.”

So, Grant headed to the New York College of Podiatric Medicine. “I was told I would never make it and I would be back in Georgia within a year,” she recalled. That probably was the wrong thing to say to a person who specializes in determination, because four years later she was at Florida Hospital Orlando beginning her three-year residency in podiatric foot and ankle sur-gery, which she completed in 2009.

The first time Grant used a scalpel

was “very nerve-racking,” she said. “The attending (physician) handed me the scal-pel and said ‘here you go.’ It was almost like my hand wouldn’t work. I didn’t know if I could … I just took a big deep breath and said a little prayer under my breath and reminded myself that I’d been work-ing toward this for 8 years,” she recalled.

In 2009 Grant joined Physician As-sociates of Florida, an Orlando Health multi-specialty group where she and Robert Duggan, DPM, are the only podiatric sur-geons. She divides her time between offices in Lake Mary and Maitland, and Duggan staffs offices in Oviedo and Sand Lake.

Grant said she spends Monday-Thurs-day in clinic, where about 40 to 50 percent of her patients present with sports-related injuries. “I see a lot of runners and ath-letes,” she said, adding that about 10-15 percent of her patients are youngsters. “Everything from ingrown toenails to flat feet and sports injuries,” said Grant, who also takes emergency calls for foot and ankle fractures. But the majority of Grant’s schedule on Fridays, usually at South Sem-inole Hospital, are the bread-and-butter surgeries for bunions, hammer toes, tendon repairs and cyst removals, she said.

Grant said being part of a multi-spe-cialty group like Physician Associates is a definite plus. “They have taken me in and supported me from the beginning, I’ve been with them almost 5 years and it is amazing to have this big network of physi-cians as a referral base,” she said.

Grant also has a much smaller and much more personal physician network: She is married to anesthesiologist Timo-thy Grant, MD, whom she met in the OR at Florida Hospital Orlando. “I thought

he was married so I wasn’t giving him the time of day. It turned out I was completely wrong. He finally asked me out and I told him it was not a date, and that we were just going out as acquaintances. … Seven years later, here we are!” said Grant.

Being married to a fellow physician is a “huge advantage,” said 35-year-old Grant. “We understand each others’ life-styles. We get it and we never question it. … It’s nice having someone to come home to who understands the language and mentality of what we do.”

The Grants also share an understand-ing about their faith. “I grew up in the church. My grandfather was a preacher. I’m not going to say I’m religious, but I do believe in the power of prayer and I be-lieve we are all here for a purpose. I try to let that positivity come through to help put my patients at ease.” she said. “Surgery is a scary situation.”

Configuring her calendar with her husband’s can be a challenge, Grant said, so “when we have weekends when we are not on call, we use it to our advantage” by taking short trips and feeding an appetite for collecting art. “We make it work. We don’t have kids and, at the moment, we plan on not having kids because we just don’t know how we can fit a child into that mold right now,” she said.

In the meantime, Grant does have a list of leisure adventures to shoehorn into her busy life. As a runner who confesses she “has fallen off the wagon” with train-ing, Grant has set a goal to run a full mar-athon. She also has the lofty intentions of sky diving and piloting a plane.

Grant’s approach to those pursuits is still to be determined.

Lori A. Grant, DPMPhysician Associates, Orlando Health

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By STEPHEN R. LOONEy

On February 26, 2014, House Ways and Means Chairman, Dave Camp (R-MI), released a 979-page “Tax Reform Act of 2014” discussion draft (Camp Proposal). The Camp Proposal contains sweeping, sometimes surprising, and controversial changes to both individual and business taxation that will have a dramatic effect on many businesses, including professional service businesses such as medical prac-tices.

This article will briefly summarize select business and individual tax reform proposals contained in the Camp Proposal.

Individual Tax Proposals Tax RatesThe linchpin of the Camp Proposal is

the reduction of both individual and cor-porate tax rates. Although Representative Camp has stated that there are only two tax brackets for individuals under his proposal, plus an additional 10 percent “surtax,” the 10 percent surtax will likely be viewed by most people as a third tax bracket. The tax rate changes, as well as most of the other changes contained in the Camp Proposal would become effective 1/1/2015.

A 10 percent tax bracket would apply on adjusted gross income (AGI) up to $71,199, and the 25 percent tax bracket would apply to AGI from $71,200 up to $450,000 for married taxpayers filing jointly and up to $400,000 for other tax-payers. The new 35 percent tax bracket, or 10 percent “surtax” as Representative Camp prefers to refer to it, applies to a different tax base referred to as “Modi-fied Adjusted Gross Income” (MAGI), which is much broader than AGI, and in-cludes items such as tax-exempt interest, employer-sponsored health insurance pay-ments, self-employed health insurance de-ductions, pre-tax contributions to defined contribution retirement plans and medical savings account deductions. The 35 per-cent tax rate, which also works in conjunc-tion with the phase-out of the 10 percent tax bracket, applies to married taxpayers having MAGI of more than $450,000 and to other taxpayers having MAGI of more than $400,000.

Consequently, taxpayers who have MAGI greater than $450,000 (for mar-ried taxpayers filing jointly) or greater than $400,000 (for all other taxpayers) will be subject to a tax of 25 percent on their AGI up to those threshold amounts, and then subject to a 35 percent tax rate on MAGI in excess of such amounts. When compared to the current maximum mar-ginal rate of 39.5 percent, the maximum marginal individual tax rate of 35 percent, which applies to a broader base of income

than the current 39.5 percent, combined with the effect of the elimination of many deductions and credits, will result in many taxpayers, and in particular, physicians and other professionals, paying higher effective tax rates under the Camp Proposal than they do under current tax law.

Capital Gains and DividendsUnder current law, capital gains and

dividends are subject to a maximum mar-ginal tax rate of 20 percent. Under the Camp Proposal, 40 percent of capital gains and dividends generally will be excluded from a taxpayer’s income, with the remain-ing 60 percent subject to taxation at the or-dinary income tax rates of 10 percent, 25 percent and 35 percent.

Changes to Contribution Limit on Pre-Tax Contributions to Section 401(k) Plans

The Camp Proposal reduces by one-half the existing limits on employee pre-tax contributions to Section 401(k) plans, with the remaining one-half eligible to be contributed on an after-tax basis to a Roth account. The combination of in-cluding pre-tax contributions to 401(k) plans in MAGI subject to the 35 percent tax bracket and reducing the contribution limits available to employees on a pre-tax basis to Section 401(k) plans would seem to have a very negative impact on the ability of individuals to save for retirement, and will have a particularly harsh impact on physicians and other professionals.

Corporate Tax, Pass-Through Entity and Other Business Tax Reforms

Corporate Tax RatesThe Camp Proposal eliminates the

current tax brackets ranging from 15 per-cent to 35 percent for C corporations, in favor of a single 25 percent rate.

Although this reduction to a flat 25 per-cent rate might at first appear beneficial to personal service corporations such as physi-cian practices, if the “C” corporation medi-cal practice distributes earnings as dividends to its shareholder-physicians, the effective double tax rate on such earnings will be 42.85 percent and such earnings will also be subject to the Florida corporate income tax. Thus, it would still appear to be more tax efficient to operate a professional practice in a pass-through entity, such as an S corpora-tion, rather than in a C corporation.

Under the Camp Proposal, while large publicly-held and multi-national corpora-tions taxed as C corporations, will enjoy a flat tax rate of 25 percent, the majority of America’s small businesses which conduct their businesses through S corporations,

Camp Proposal on Tax Reform Contains Many Changes and Surprises

(CONTINUED ON PAGE 12)

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By CINDy SANDERS

In an effort to improve patient access to appropriate, evidence-based care, the North American Spine Society (NASS) recently released detailed policy recom-mendations for coverage of 13 common spine care treatments, procedures and di-agnostics.

The first-of-their-kind reference doc-uments outline when it is … and when it is not … appropriate to utilize each of the options based on an extensive review of current literature by a multidisciplinary team of experts.

William Watters, MD, president of NASS, said, “Maintaining patient access to high-quality, evidence-based and ethi-cal spine care is the single most important part of NASS’ mission. It is our hope that payers, spine specialists and their patients will use these evidence-based coverage recommendations as a reference to advo-cate for appropriate care for patients.”

Watters added the society was uniquely positioned to take the lead on such an extensive project because of the multispecialty nature of the organization, which includes the expertise of surgeons and allied health professionals. “We cover the full spectrum of spine care,” he noted.

Watters, who is a board certified or-thopaedic surgeon in private practice at the Bone & Joint Clinic of Houston and a clinical associate professor at both the University of Texas Medical Branch in Galveston and Baylor College of Medi-cine, said the society already had experi-ence weighing the evidence at the request of physicians, patients and payers. “NASS began a number of years ago becoming involved in third party payer coverage decisions,” he noted. However, he contin-ued, the turnaround time was often tight and the number of studies to consider ex-tensive.

“We decided to proactively create our own coverage decisions based on the best evidence available … and where evi-dence was lacking, based on the expertise in this group,” he explained. “We came up with what we feel is the most sound group of recommendations based on the best evidence available at this point and time.”

Watters continued, “One of the hopes that we have is that we bring a bit of uniformity to the whole process of spi-nal care.”

Christopher Kauffman, MD, health policy council director for NASS, con-curred. He said allowed treatments and diagnostics vary by state and by payer. These recommendations outline the scope and clinical indications for a therapeutic measure when a patient meets appropri-ate inclusion criteria. They also clearly state scenarios in which employing the measure is not indicated.

While not recommending payers re-imburse for every procedure under every

circumstance might be controversial among some providers, Kauffman said, “People who understand where medicine is going with outcome measures get it. So far, the re-sponse has been overwhelmingly positive.”

He added, “People may confuse cov-erage with medical appropriateness. The two are not equal. People assume pay-ment equals medical appropriateness. I can’t stress enough this isn’t true. Payment equals treatments where the literature has reached a certain bar of evidence.”

Kauffman, a board certified ortho-paedic surgeon in practice at Premier Orthopaedics in Nashville, said, “For everything we recommend, we think the evidence does reach the bar for coverage. This is what we think should be covered by any payer.”

However, he continued, it doesn’t mean other treatments being employed don’t have therapeutic benefits. “You can’t ever throw out the art of medicine.” Yet, Kauffman noted, “If you’re falling outside the clinical guidelines, you have to expect that you’re going to do a peer-to-peer review, or it might not be a covered service.” He added the recommendations would be routinely revisited to incorpo-rate new evidence.

In addition to the 13 coverage pol-icy recommendations published in May, Watters said NASS is already in process or planning to create documents for 14 additional diagnostic and therapeutic mo-dalities including annular repair, cervical

and lumbar radiofrequency neurotomy, cervical fusion, cervical laminectomy and laminoplasty, minimally invasive lumbar fusion, SI joint fusion and injec-tions, DNA-based scoliosis test and electri-cal stimulation for bone healing, among others. “The remainder will be released within a year,” he said.

“The plan is to reassess the literature at least every two years,” he continued, emphasizing the need to stay current as new studies are published and new treat-ment options become available. “This has to be a living document.”

He added it’s a nearly impossible task to ask physicians, surgeons, nurses, therapists and other providers to wade through all the literature required to prac-tice evidence-based, contemporary medi-cine. Having the committee go through the best, most soundly crafted studies to create each of the 5-30 page recommen-dations, which include supporting details behind the rationale and a thorough list of references, simplifies the process for prac-titioners and their patients. “These turned out to be remarkably educational docu-ments,” Watters stated.

Both Kauffman and Watters stressed at the end of the day, the coverage rec-ommendations are an effort to ensure patients have equal access to the best pos-sible treatments.

“It’s making sure that good spine care is available for patients across the U.S.,” Kauffman concluded.

NASS Takes a Proactive Approach to Evidence-Based Coverage Decisions

Coverage Policy RecommendationsTo access the documents for each of the procedures listed below, go online to www.spine.org and click on the “Policy & Practice” heading.

•Cervical artificial disk replacement

•Endoscopic discectomy

•Epidural cervical spinal injections

•Interspinous device without fusion

•Interspinous fixation with fusion

•Laser spine surgery

•Lumbar artificial dis replacement

•Lumbar discectomy

•Lumbar fusion

•Lumbar laminotomy

•Lumbar spinal injections

•Percutaneous thoracolumbar stabilization

•Recombinant human bone morphogenetic protein (rhBMP-2)

6 > AUGUST 2014 o r l a n d o m e d i c a l n e w s . c o m

50, with a total score of 73.49. Worse than average in Orlando: the

uninsured rate, and all four medical factors, including ER visits for asthma, use of quick relief meds and control meds, and number of specialists. The metro area ranked av-erage in self-reported asthma prevalence, public smoke-free laws, and poverty rate; and posted better than average results on estimated asthma prevalence, crude death rate, annual pollen score, air quality, and school inhaler access laws.

Medical News spoke with Jason E. Lang, MD, a Harvard fellowship-trained pediatric pulmonologist and biomedical re-searcher specializing in asthma at Nemours Children’s Health System in Orlando. Diagnosed with asthma as a child yet symptom-free for decades, Lang, 42, also associate professor of pediatrics at the Uni-versity of Central Florida, discussed local trends, challenges, and promising clinical trials that could improve the quality of life for asthmatics.

Why is the local asthma prevalence rate rising so rapidly?

Asthma is incredibly prevalent wher-ever you go. Central Florida is one of those places a little higher in prevalence. It’s been slowly creeping up over the last three or four decades and now it’s a common dis-ease. It’s not completely understood what’s causing asthma, though we’re testing a cou-ple of theories, such as the parallel between the rise in obesity and asthma prevalence.

Another theme: We still don’t have ef-fective treatments in many cases. There’s a real need for hospitals and medical centers to research the best treatments and to come up with new treatments that’ll work better.

Why is the rate for emergency room visits for asthma rising dramatically, and what needs to be done to lessen the frequency of those visits?

ER visits for asthma are incredibly common. Asthma is, year-in and year-out, one of the most common reasons for visits to the Emergency Department. That’s a reflection of how prevalent asthma is, and how serious it can get.

One area of improvement needed: Ac-cess for families to good quality primary care. We have many cases in the ER that could be prevented or seen by a primary care provider. Nemours is growing a high quality primary care network around Orlando to prevent asthma attacks and to manage them in the outpatient setting to avoid the ER.

Education is another area for improve-ment. In just five years since it was estab-lished, the Florida Asthma Program has done a great job of educating child care providers and school administrators on the disease. But it’s only a start. Understanding asthma can be really confusing to parents, and requires a lot of education. If families don’t have that education, it’s easy to want to resort to the ER, a place where they know they’ll get immediate, great care.

Overall as a health system, we need to provide better education about asthma to everyone in the community so that asthma can be diagnosed and managed by pedia-tricians and general practitioners. Also of

note: It’s my impression that asthmatics whose primary care doctors are in a prac-tice based on the Patient-Centered Medi-cal Home (PCMH) model – a model we’ve adopted at Nemours – are less frequent visi-tors to the ER.

Even with improved education and improved access to primary care, what challenges persist managing asthma?

For more than 20 years, the National Institutes of Health has had a set of guide-lines for diagnosing and managing asthma. Nemours is constantly trying to reinforce those guidelines to local primary care doc-tors, school nurses, and others in the com-munity who touch people with asthma. I cannot underscore enough the importance of good primary care.

That said, many cases don’t have the best treatments. I just saw a little boy with asthma, and the medication recommended in the national guidelines hasn’t worked very well for him. We need to continue a real push to find better treatments. With Nemours’ participation in various clinical trials aimed to produce better outcomes, which ones hold the most promise for the discovery of pivotal data?

We have an ongoing clinical trial in-volving children and young adults that looks at the role of omega-3 fatty acids in the development of asthma. We think it’s a nutritional component in the diet that may be too low, which may lead to severe asthma in children who are overweight or obese. (See sidebar on clinical trials.)

Another interesting study focuses on how exercise impacts asthmatics. My theory is that exercise helps asthma medicines work better and makes airways less twitchy. That’s

one of the parts of asthma that patients don’t like: twitchy airways. Especially in children, I think exercise really reduces it.

We’re always looking to offer people in the community an opportunity to par-ticipate in these studies. They often help tremendously.

Reducing the ‘Twitch’ continued from page 1

The Emergency Nurses Association (ENA) recently honored Nemours Chil-dren’s Health System with the presti-gious Lantern Award, and will recognize the Orlando-based healthcare organiza-tion as one of only 17 emergency de-partments nationwide at an awards gala Oct. 7-11, during the 2014 ENA Annual Conference in Indianapolis, Ind.

“These 17 emergency departments serve as true models of excellence for their commitment to quality care, safety, and presence of a healthy work envi-ronment,” said ENA president Deena Brecher, MSN, RN. “It’s important for us to recognize these hospitals are at the forefront of emergency care.” 

Nemours represents one of only two emergency departments in Florida – and the only one in Central Florida – to receive the Lantern Award, which rec-ognizes a department’s commitment to quality, safety, presence of a healthy work environment and accomplishment in incorporating evidence-based prac-tice, and innovation into exceptional emergency care.

Statistical evidence supporting the efficiency and effectiveness of Nemours’ Emergency Department model includes:

• In 2013, median time-to-provider was eight minutes; time-to-primary nurse was eight minutes; and time-to-room was four minutes. Once inside the ED, the model calls for an experienced, registered pediatric nurse to greet patients and their families – Nemours refers to them as pivot nurses – and immediately assess the needs of the patient, ushering them to the care required as quickly as possible.

• RN turnover is 13 percent, with a zero percent turnover rate for controllable resignations. • Nemours’ “Press Ganey Likelihood to Recommend” scores for 2013 were 91.4 percent, which is in the 99th percentile.“When we were designing Nemours Children’s Hospital, we set out to create a better emergency room experience for families,” said

Barbara Meeks, CNO at Nemours Children’s Hospital. “The Lantern Award from the Emergency Nurses Association is the gold standard for emergency care and provides further confirmation that Nemours is delivering on its goal to be the very best.”

Nemours Children’s Hospital Emergency Department receives prestigious Lantern Award

PHOTO: ©2012 JONATHAN HILLYER

PHOTO: JEFF LEIMBACH

Improving Asthma Outcomes via Clinical TrialsNemours’ collaboration with hospi-tals and medical centers nationwide on clinical trials at its Orlando and Jacksonville sites include:• Best African American Response to

Asthma Drugs (BARD)• Obesity and Asthma: Genetics and

Nutrigenetic Response to Omega-3 Fatty Acidsa

• Step Down Study/Use of Mobile Devices & the Internet to Stream-line an Asthma Clinical Trial

• Step-Up Yellow Zone Inhaled Cor-ticosteroids to Prevent Exacerba-tions (STICS)

• Steroids in Eosinophil Negative Asthma (SIENA)

• Therapy for Asthma in Toddlers and Acetaminophen vs. Ibuprofen in Children With Asthma

• Asthma Walk Study: Effect of low-impact walking on bronchial reactivity and steroid sensitivity in sedentary adolescents with inad-equately controlled asthma

• Vitamin D-related Oral Steroid Re-sponses in Children with Asthma

SOURCE: Nemours Children’s Health System.

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Providing High-Quality, Patient-Centered Asthma Care

U.S. Asthma Guidelines list six key steps for physicians with asthma patients:

• Assess asthma severity.

• Provide a written asthma action plan.

• Direct patients how to properly use inhaled corticosteroids (ICS).

• Show patients and their families how to control environmental triggers at home, work or school.

• Schedule follow-up visits.

• Assess and monitor asthma control care.

SOURCE: AAFA.

By LyNNE JETER

A thriving city rich in history, perched on the brow of the picturesque James River, has once again captured the uncov-eted title as the most challenging place to live with asthma.

For the second consecutive year, and four of the last five years, Richmond, Va., took the title perch, with worse than aver-age ratings for prevalence factors (crude death rate for asthma), risk factors (an-nual pollen score, poverty rate, the un-insured, and public smoking laws), and medical factors (emergency room visits for asthma).

Medical News markets located across the South and Midwest were represented in “Asthma Capitals 2014,” the 11th an-nual research project released by the Asthma & Allergy Foundation of America (AAFA). Boston Scientific Corporation (NYSE: BSX) sponsored this year’s report.

Medical News market rankings, with 2013 rankings in parentheses:

No. 2: Memphis, Tenn. (3)No. 6: Chattanooga, Tenn. (2)No. 22: New Orleans, La. (24)No. 26: St. Louis, Mo. (55)No. 27: Little Rock, Ark. (31)No. 38: Nashville, Tenn. (32)No. 41: Knoxville, Tenn. (10)No. 42: Jackson, Miss. (47)No. 48: Birmingham, Ala. (23)No. 49: Orlando, Fla. (62)No. 50: Tampa, Fla. (57)No. 55: Lakeland, Fla. (60)No. 64: Daytona Beach, Fla. (76)No. 65: Baton Rouge, La. (79)No. 75: Sarasota, Fla. (87)No. 81: Raleigh, NC (91)No. 87: Charlotte, NC (86)Most Metropolitan Statistical Areas

(MSAs) in Medical News markets im-proved over 2013, collectively dropping 45 spots. The St. Louis market showed the least improvement, moving up 29 spots among the most challenging places to live with asthma. The most improved MSAs for easier asthma living: Knoxville, Tenn., sliding down 31 spots, followed closely by Birmingham, Ala., which dropped 25 spots.

MethodologyAnalytical data from the 100 most-

populated MSAs in the United States de-termined the ranking system. Researchers and medical specialists focused on three primary areas – prevalence, risk, and medical factors – that include 13 unique factors, with non-equal weights applied to each data set in individual factor groups. Total scores were calculated as a compos-ite of all factors, reflecting each factor’s relative impact on exposure to asthma triggers, quality of life, costs and access to care.

Prevalence factors included the predicted population with asthma, self-reported population with asthma, and re-

corded death rates for adults and children from asthma. Risk factors included com-prehensive annual pollen measurements, average length of peak pollen seasons, out-door air quality, poverty and uninsured rates, state school inhaler access laws, and smoke-free public laws.

Medical factors included ER visits for asthma, rescue medication use, controller medication use, and the number per pa-tient of board-certified adult and pediatric allergists and immunologists, and pulmo-nologists.

ER visits represent a significant chunk of asthma care-related costs.

“Many ER visits are from people with severe asthma, but not all of them,” said Mario Castro, MD, professor of medicine and pediatrics at Washington University School of Medicine in St. Louis, discuss-ing the average of more than 2,300 visits to ERs for asthma in each U.S. city, with one in four admitted to a hospital. “Many people with less severe asthma show up to the ER, too. But much of this is avoidable with new treatments for severe patients and better prevention and care for those with less severe disease.”

Making StridesEarlier this year, the Supreme Court

upheld the U.S. Environmental Protection Agency’s (EPA) Cross-State Air Pollution Rule, which aims to reduce the amount of pollution drift from certain states into oth-ers, prompting health issues for residents in those states. The Supreme Court also

noted the rule is an effective way to con-trol emissions, and melds with the EPA’s mission under the Clean Air Act.

The AAFA is collaborating with state chapters to mandate or improve on the requirement of stocking epinephrine in schools for severe allergic reactions. For example, California is considering legisla-tion to strengthen its existing epinephrine-stocking law to require schools to stock the medication and train a volunteer to administer it. Illinois is considering legis-lation to require, rather than simply allow, schools to stock epinephrine. All states in Medical News markets have epinephrine-stocking school policies in place, with the exception of North Carolina, which at press time had pending legislation.

The AAFA has banded with other national health advocacy groups to sup-

port increased research funding, which in-cludes lobbying against proposed budget cuts for the National Institutes of Health, Centers for Disease Control and Preven-tion (CDC), Agency for Health Resources and Quality, and other agencies with research relevant to asthma and allergic diseases.

For example, the CDC’s National Asthma Control Program has helped decrease asthma mortality rates by more than 45 percent since its inception in 1999.

“There are many things that we can improve now to make life better for people with asthma,” says AAFA spokesperson and asthma patient, Talisa White. “Our Asthma Capitals report helps to shed light on the asthma burden in each city, but it also pro-vides a roadmap for improvements.”

Taking Your Breath Away How cities in the Southeast ranked in the new annual asthma report

8 > AUGUST 2014 o r l a n d o m e d i c a l n e w s . c o m

By LyNNE JETER

Florida’s not faring very well for people living with asthma, yet strides are being made to improve the environment.

In the “2014 Asthma Capitals” re-port, released by the Asthma & Allergy Foundation of America (AAFA), the Sun-shine State represents 9 percent of the list. Conditions have worsened since the 2013 list debuted, with “the most challenging places to live with asthma,” collectively dropping 117 spots.

A few startling Florida statistics:• From 2000 to 2010, lifetime asthma

prevalence among adults increased by 52 percent, and asthma-related hospitalizations statewide rose by more than 32 percent.

• Between 2006 and 2012, the lifetime asthma preva-lence among middle and high school stu-dents increased by 21 percent.

• In 2012, more than 2.6 mil-lion Florida adults and children had lifetime asthma, and approximately 1.6 million had current asthma. That statistic represents one of eight adults with lifetime asthma and one in 12 with current asthma; and one of five chil-dren with lifetime asthma, and one

in 10 with current asthma. “Asthma rates and

healthcare utilization for asthma have increased dramatically over the last 30 years in all populations in Flor-ida, and across the United States,” wrote

John H. Armstrong, MD, FACS, surgeon

general and Secretary of Health, in the Sept. 2013 re-

port, “Health: Burden of Asthma in Florida.”

“Asthma incurs high expenses, in terms of cost of care, lost workdays and productivity, and lower quality of life for per-sons with asthma and their families,” he noted. “Asthma is a leading cause of preventable emergency department visits and hospitaliza-tions.”

Before Florida be-came one of 36 states selected to receive funding and technical support from the Centers for Disease Control and Preven-tion’s (CDC) National Asthma Control Program, and established the Florida Asthma Program in 2009, the state had no systematic approach to state and local asthma surveillance, yet 15 percent of county health departments listed asthma as a priority health issue.

Now with the CDC’s support, the program has developed a comprehensive system for asthma data-gathering that provides easy, round-the-clock access to the latest county-specific asthma data, providing communities with information to better develop local Asthma Action Plans.

“One-on-one care between patients and doctors isn’t enough to really con-trol asthma,” said Julie Dudley, manager of the Florida Asthma Pro-gram. “Asthma requires coordinated care, and public health has the in-frastructure to create the connections and part-nerships needed to make that happen.”

Focusing on Children with Asthma

Among responses to asthma chal-lenges statewide, the Florida Asthma Program has launched its asthma control curriculum for child care providers and its Asthma-Friendly Childcare Award program. To receive an award, child care centers must participate in asthma control training and keep Asthma Action Plans on file. Within two years of its impetus, nearly 1,000 child care providers had completed the training, seven child care centers had achieved silver-level recogni-tion, and nine had achieved bronze-level recognition. As a result, a record number of child care centers across the state now have Asthma Action Plans on file.

The program’s partnership with the state chapter of the American Lung As-sociation has also infused asthma educa-tion in schools. By early 2013, more than 1,300 third, fourth and fifth graders had learned how to better control their asthma through the Open Airways for Schools program, and some 600 school faculty participated in the Asthma 101 program.

“Identify schoolchildren with asthma at the beginning of each school year,” urged Armstrong. “This will enable schools to track absenteeism, health room visits, 9-1-1 calls, and the number of times children leave school with asthma-related issues. This will enable school staff to identify and monitor students in need for additional asthma management support.”

Jason E. Lang, MD, a pediatric pul-monologist with Nemours Children’s Health System, said that measures taken by the Florida Asthma Program represent “a great step in the right direction to make it safe for children with asthma.”

Lack of Asthma Action PlansThe report also addresses another

startling statistic: Three of four adults in Florida with asthma (75.3 percent) report never having received an Asthma Action Plan from a doctor or other health profes-sional.

Shining a Light on Asthma ChallengesHow Florida cities ranked for asthmatics

Groundbreaking Change

On June 13, Gov. Rick Scott signed into law the most comprehensive epineph-rine-stocking legislation introduced to date in any U.S. state.

The Emergency Allergy Treatment Act, which will allow some public venues – Walt Disney World, restaurants, sports arenas – to stock epinephrine auto-in-jectors (epi-pens), improved upon previous legislation. It calls for trained person-nel, or non-trained personnel in an emergency with authorization from a medical provider, to administer epi-pens.

Florida had previously passed similar stock epinephrine legislation for schools. However, that legislation only allows schools to stock epi-pens; it doesn’t man-date them. Only four states – Maryland, Nebraska, Nevada, and Virginia – re-quire stocking epinephrine in schools. At press time, five states had pending legislation to require schools to stock epinephrine auto-injectors – California, Illinois, Massachusetts, New Jersey and North Carolina.

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In 2010, the Florida Asthma Program

convened the Florida Asthma Coalition with 48 members

representing 20 partner organizations. Within three

years, the coalition had grown to 150 members serving

approximately 100 organizations.

(CONTINUED ON PAGE 10)

Julie Dudley

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“It’s especially important for school-children to have easily understandable Asthma Action Plans because of the de-crease in the number of school nurses resulting from budgetary cutbacks,” said allergist-immunologist Thomas B. Ca-sale, MD, professor of internal medicine at the Ujniversity of South Florida’s Mor-sani College of Medicine in Tampa. “The acute management plan needs to be very simple so that patients or parents/school nurses can manage asthma to a better degree. Then they’ll know when to call a healthcare provider for an adjustment in medications versus when to go to the ER.”

The “Burden of Asthma” lists action

measures to prompt the development of these action plans:

For physicians and other primary care providers:

• Develop an Asthma Action Plan and review it with each patient to ensure the patient understands daily medications and proper usage techniques, how to avoid asthma triggers, and how to identify warn-ing signs that require quick-relief medications or additional medical interventions.

• Use data systems to track and moni-tor Asthma Action Plans and other components of asthma care.

For hospitals and emergency departments:

• Ensure patients have an Asthma Action Plan, provide or make refer-rals to self-management education, provide education and resources on managing environmental triggers in the home, and communicate with primary care and community care providers as needed.

For pharmacists:• Monitor your pharmacy’s asthma

medication order and refill inter-vals to identify patients with poorly controlled asthma. Contribute to the community’s asthma manage-ment team by alerting prescribers about patients whose asthma may be poorly controlled

For healthcare professional associations:

• Include a link to the National Asthma Control Initiative on your website and promote the six priority action messages for members:

1. Prescribe inhaled corticoste-roids as indicated by the guide-lines.

2. Use written Asthma Action Plans to guide patient self-man-agement.

3. Assess asthma severity at the initial visit to determine initial treatment.

4. Assess and monitor asthma control and adjust treatment if needed.

5. Schedule follow-up visits at pe-riodic intervals.

6. Act to control environmental exposures that worsen asthma.

“Large disparities related to race/ethnicity, gender, age, and income exist when reviewing the most severe outcomes of the disease,” noted Armstrong. “While

the prevalence of asthma in Florida is sim-ilar among all race/ethnicity groups, sub-stantial disparities exist in the rate of ED visits and hospitalizations, an indication of poorly controlled asthma.

“Improving asthma outcomes among disparate populations must be a priority for all partners involved in asthma man-agement.”

Shining a Light on Asthma Challenges, continued from page 8

“I think most doctors are past Option A. I think most doctors realize circling the wagons around a single specialty isn’t realistic,” said Keckley. “Two out of three primary care doctors have already cast their lot,” he con-tinued of aligning with hospitals, payers or very large groups.

“Frontline special-ists have already gone to bigger groups. Now they are moving to the next option … most look like they’re going to hospitals,” he added of orthopedists, ENTs and OB/GYNs. As for other specialists, he said the decision to remain independent, merge or consolidate is all over the board and is spe-cialty dependent.

Going forward, Keckley said, “I think we’re going to end up with a very few pri-vate doctors in practice independently.” He predicts seeing a few more very large, multispecialty practices. “I think the ma-jority end up employed in the hospitals be-cause of these new payment mechanisms.”

In fact, he noted, “It’s been incentiv-ized for the hospitals to hire physicians.” Clinical integration, outcomes-based re-imbursement and bundled payments have created an environment where hospitals and doctors are increasingly co-dependent.

Although hospital administrators and clinicians have always had to work together, Keckley said this new closeness highlights areas that must be addressed to maximize effectiveness. Three key stressors are administrative decisions, clinical per-formance, and … of course … allocation of money.

“There’s always going to be tension around operations,” he said of administra-tive decisions. “Each presumes the other’s operating is simpler than it really is,” he continued of the chasm between blue suits

and white coats.With reimbursement tied to out-

comes, he said physicians and hospitals face tougher decisions around strategy. One issue is how to address physicians not prac-ticing effectively. “The hospital suits don’t do a very good job of changing the behav-ior of doctors. It takes peers,” he noted.

The biggest cause of tension is ex-pected to be around allotting payments to each of the partners in a vertically inte-grated delivery system. “And then you get down to money, and that’s where it gets ugly,” Keckley stated. However, he con-tinued, too often the perception among ad-ministrators is that it’s all about the money when it comes to physicians. “If it was just about money, there are a lot of better ways to make money … and easier, by the way. Most doctors don’t go into it to be wealthy. It’s hard work. The average medical career is 30 years, and it’s a hard 30 years.”

That said, he added physicians do want to be successful, have a sense of sat-isfaction around their career choice and be well compensated for their work. However, Keckley noted, “There’s such a differ-ence between the way doctors think things should be and the way they are.”

Keckley said too many physicians tend to dismiss data as unreliable or believe their patient is an outlier. Yet, he added, “The table stakes are you’ve got to have data. You can’t just have a bunch of opin-ions.” To bridge that gap, Keckley said he believes it is going to take physicians will-ing to step into the hot seat and take criti-cism from their colleagues as the profession adapts to new economic realities.

“I think physician leadership is prob-ably going to be a theme over the next 10 years,” Keckley said. “The medical profes-sion is well respected and well compensated … that doesn’t change … but how that pro-fession plays in the delivery system is very much a work in progress.”

Partnering, continued from page 1

Dr. Paul Keckley

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Florida Environmental Public Health Tracking (EPHT) Program is grant-funded, to identify and promote the use of nationally consistent data in partner-ship with the Centers for Disease Con-trol and Prevention and other grantee states: www.FloridaTracking.com.

2014 Asthma Capitals in Florida

No. 20: Jacksonville

No. 49: Orlando

No. 50 Tampa

No. 55: Lakeland

No. 58: Miami

No. 64: Daytona Beach

No. 75: Sarasota

No. 76: Palm Bay

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By SANGEETA PATI MD FACOG

The most common comments we hear from men on testosterone are, “I got my life back!”. “My energy is great!” “My sex drive is back.” “I’m building muscle.” “I got off of Lipitor.” “My dia-betes is under control.” After 10 years of prescribing testosterone to thousands of men, and witnessing the improvements, and quoting the studies supporting im-proved quality of life and protection from heart attacks; imagine my surprise when the headline news was to the contrary. In November 2013, Vigen et al published op-posing results from a retrospective study which followed 8,709 men. They reported testosterone therapy increased heart at-tacks by an absolute risk difference of 5.8percent (95 percent CI -1.4 percent to 13.1 percent). It made all the headlines and I recalled 2002 when the WHI study in women hit the media before we saw the results. Our phones started ringing. I got a hold of the study and started to examine it very carefully.

Fortunately, I was not the only one examining the study. By the time I finished reviewing the study, the word was out. It was not a valid study. The editor of JAMA received requests for a formal retraction of the study from 29 societies including Endocrinology and Andrology, 160 dis-tinguished researchers and clinicians, 8 emeritus professors, >60 full professors, 9 journal editors, and Dr. Abraham Mor-gantaler from Harvard Medical School. Their position was that there was “gross data mismanagement and contamina-tion” rendering the study “no longer cred-ible”. Some issues with this study included grossly sub-therapeutic testosterone levels, 40 percent loss to follow-up and a mis-taken inclusion of 9 percent women!

The second wave of media attention followed the PlosOne retrospective review of 55,000 charts (Finkle WD et al, 2014) reporting an increased non-fatal myocar-dial infarction (MI) risk within the first 90 days of therapy, with a higher risk in men with a history of cardiovascular disease.

The pre-treatment MI rate was 3.48/1000 person-years. The post-treatment MI rate was 4.75/1000 person-years, an increase of 1.27/1000 person-years. Dr. Morganta-ler reported limitations including no con-trol group, unverified events (13 percent) and an apple-to-oranges comparison with a group on Viagra. In addition, data avail-able beyond 90 days, remains unreported without explanation. His conclusion was that the “study was non-informative”.

These flawed studies in the media re-mind us of the once predominant thought that “Cancer of the prostate is activated by testosterone injections.” That conclu-sion was based on a single patient.

A large body of literature from past decades supports testosterone’s positive effects on blood sugar, body fat, choles-terol, Alzheimer’s, bone density, arthritis and acute angina. In December of 2013, a review of over 100 articles in JAHA concluded that low levels of testosterone are associated with higher rates of mortal-ity and cardiovascular- related mortality, higher rates of obesity and diabetes. Ad-ditionally, the severity of disease correlates with the degree of testosterone deficiency.

Shores MM et al reported testoster-one therapy reduced mortality rate from 20.7 percent to 10.3 percent (p< .0001) over 4 years in 1,031 men over the age of 40 with initial testosterone levels below 250 ng/dL. Muraleedharan, V. et al re-ported that testosterone therapy reduced mortality in 581 male diabetics from 19.2 percent to 8.4 percent over 5.8 years. Eng-lish et al reported a statistically significant increase in time to ischemia on a treadmill test in 46 men randomized to testosterone gel or placebo. Caminiti, G. et al reported that testosterone improved functional ca-pacity in men with congestive heart fail-ure. Amory JK et al reported a 10 percent increase in bone density with testosterone over 40 months compared to placebo. And the data goes on.

At age 50, testosterone levels have de-clined by approximately 50 percent. This decline is accompanied by symptoms and disease. Most compelling is a study of over 11,000 men ages 40-70, which reported that a testosterone level over 564 ng/dL was associated with a 41 percent de-crease in all-cause mortality over 7 years. When men are restored to these optimal levels, energy, sexual function, stamina, joint pain, mental clarity, muscle mass and mood are significantly improved. Although, a well-designed randomized controlled trial is needed; a review of the current literature on disease and quality of life supports the most common statement we hear, “I got my life back!”

Sangeeta Pati, MD, is the Medical Director of The Institute For Restorative & Regenerative Medicine in Orlando. She is the recognized international medical authority and physician educator on bio-identical hormones. She is presenting a CME/CEU Workshop on Hormone Restorative Therapy for Men & Women-Science & Case Applications on September 27th in Orlando.

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partnerships, LLCs and sole proprietor-ships, will be subject to the three bracket system to which individuals are subject, and as such, will be subject to a top marginal tax rate of 35 percent. Combined with the elimination of many business deductions and credits by the Camp Proposal, this could have a crippling effect on America’s small businesses, including medical prac-tices, and have a substantial adverse effect on the economy.

Use of Cash Method of Accounting

Under current law, S corporations, partnerships (without C corporation part-ners), and qualified personal service corpo-rations are allowed to use the cash method of accounting as opposed to the more com-plicated accrual method of accounting. Under the Camp Proposal, although busi-nesses with average annual gross receipts of $10 million or less could continue to use the cash method of accounting, businesses, including pass-through entities, with more than $10 million of gross receipts would be required to use the accrual method of ac-counting. This will include many larger personal service corporations, including medical practices.

Social Security TaxesThe Camp Proposal includes a shock-

ing change which imposes the self-em-ployment tax (SECA) on S corporation shareholders (and partners of a partnership)

who materially participate in their busi-nesses within the meaning of Section 469. The Camp Proposal generally subjects 70 percent of the combined compensation and the distributive share of an S corporation’s (or partnership’s) combined and distributive share of the entity’s income as net earnings from self-employment subject to FICA or SECA, as applicable. Under present law, S corporations are required to pay “reasonable compensation” to their shareholder-employ-ees, which is subject to FICA, but neither the income that passes through to the sharehold-ers or dividend distributions made by an S corporation to its shareholders is subject to FICA or SECA (or the new 3.8 percent tax imposed on net investment income under Section 1411 provided that the S corpora-tion shareholder materially participates in the trade or business conducted by the S cor-poration). Consequently, under current law, the profits of an S corporation which are dis-tributed to its shareholders as dividends are not subject to FICA or SECA taxes provided that the S corporation is paying reasonable compensation to its shareholder-employees for the services they are actually rendering to the S corporation.

The author believes that Representa-tive Camp’s Social Security tax proposal would have a substantial adverse effect on many small businesses as well as medical and other professional service businesses which utilize pass-through entities.

ConclusionWhile the Camp Proposal does contain

a number of provisions favorable to taxpay-ers, and appears to simplify the tax code by eliminating a multitude of individual and business deductions/credits currently avail-able to individuals and businesses, it would appear that the overall impact of the Camp Proposal would favor large publicly-traded C corporations, but would likely have a very detrimental effect on individuals and pass-through entities through which most medical and other professional practices, as well as a majority of America’s small busi-nesses, are operated.

Camp Proposal, continued frompage 4

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After 40 years practicing Internal Medicine I remain perplexed by the chal-lenges of really bringing help to a patient that is consistent with the commitment: First do no harm. Easier said than done. Why? The most conscientious among us has been responsible for a medical com-plication such as an adverse drug event.

Not surprising given the variation in human beings, the mayhem of packed schedules, paperwork and documentation, tightening protocols, safety nets and stan-dards of care notwithstanding.

Personalizing care remains out of reach as witnessed by the annual surging rate of adverse drug events.

Yet there is a bright spot. The genet-ics of human disease and treatment is now a reality.

But bringing clinical genetics into everyday practice is difficult for reasons well known to doctors. Clinical integra-tion of the genetics of disease has not been robustly integrated into medical training. Obtaining a reasonable comfort level is just a lot of work.

In most cases, the first and best ge-netic test is a good family history, a rou-tine part of every comprehensive patient evaluation, but hey, who has time for that when the average patient encounter is measured in minutes.

Indeed, when I was responsible for the Genetic Cancer Center at Florida Hospital Cancer Institute we could spend days to weeks tracking down important family history to support a diagnosis or identify a risk dwelling deep within a fam-ily’s DNA.

Here are a few important ideas.• Disease risk genetic testing (DNA se-

quencing) is not generally diagnostic, only predictive (relative risk). This applies to both germ line (inherit-able) and somatic (non-inheritable mutations) and includes both single gene and polygenic disorders. Mito-chondrial disorders are part of this.

• Pharmaco-genetics is a sequencing analysis that does provide a definite (non-relative risk) base of informa-tion on how a given individual will react to a variety of drugs (Black Box warnings).

• Genetic science is providing a vari-ety of non-sequencing diagnostic and therapeutic opportunities based on gene expression such as HER2 and estrogen/progesterone (found on the actual tumor and not in nuclear DNA) status in breast cancer for ex-ample.

• In addition chromosomal analysis for problems like Down and Turner Syn-drome is readily available.

What is relative risk? Simply a num-ber compared to the baseline risk that exists in large patient populations largely determined by epidemiology. For exam-ple if the lifetime risk of prostate cancer is 16 percent that is a relative risk of 1. If a group of prostate cancer relevant gene loci are interrogated and various Single Nucleotide Polymorphisms are found that double the relative risk to 2, the lifetime risk of prostate cancer is now 32 percent. That gets my attention justifying more aggressive prostate assessments. Prostate cancer is polygenic.

• One of the concerns about this type of testing for “common diseases” as a component of personalized medicine is that common diseases are as above often polygenic and the result of mul-tiple minor genetic variants as well as a witch’s brew of environmental, nu-tritional and social issues. This is very different from the impact of a potent inheritable autosomal dominant gene like BRCA which when present as a heterozygote increases breast cancer risk by over 40 percent. If a homo-zygote mutation is present, risk goes up to over 80 percent (a 7 -8 fold in-crease).

• Personalized care can be guided by informed relative risk assessment but the truth is the biggest benefit accrues to a small percentage of cancer pa-tients such as the victims of aggres-sive inherited germ line mutations such as BRCA and the Lynch Syn-drome (colorectal cancer) amounting to 10 percent or less of cancer victims. These familial disease families are

able to be helped by genetic counsel-ing more than are those with common every day issues that are the result of a large number of non-inherited in-teracting minor gene variants and the patient environment. (This would in-clude non-BRCA breast cancer)

• After being immersed in relative risk issues as director of a large cancer institute’s genetic cancer center, I believe the real promise of clinical genetics for personalized medicine resides in pharmaco-genetics and the ability to predict adverse drug events.Your +/- 40,000 genes are fairly

stable except for the mostly unimportant somatic mutations that accumulate as we age and are part of the wear and tear on our DNA. But I said mostly, since virtually all cancers result from a tedious process of mutation accumulation spanning years in most cases and nudged along by lifestyle choices such as smoking. That said, the body’s ability to metabolize drugs tends to be defined very early and remains fairly stable unless one destroys their liver with drugs and alcohol.

• So while some mutations are inher-itable and some are not, the fact is we’re born with or slowly accumulate our troubling mutations. How they are expressed is another long story. A prudent alert physician can change the course of a patient’s life by provid-ing patients with personal knowledge of their liver’s ability to metabolize drugs through pharmaco-genetics. With countless adverse drug events

and over 100,000 deaths annually from ADEs, it is a problem that physicians

should attack. Reviewing our prescribing habits is a good start. But if we want to practice personalized medicine we have some amazing tools to help us with the ADE problem. We have pharmaco-ge-netics to provide patients with protection never before available!

Pharmaco-genetics studies the metab-olism of the enzyme systems that manage drugs. Simply put it is a drug effect test.

If one does not detoxify a drug or me-tabolize it normally a standard dose can result in an over dose. If one metabolizes a drug faster than usual the intended and desired effect may never be realized. Some drugs need conversion from one form to another e.g. codeine’s conversion to mor-phine to relieve pain.

The use of pharmaco-genetics as part of a personalized medicine practice provides patients a life-long safety net for future treatments. Established labs that provide physicians and patients clinically relevant information should do your phar-maco-genetics. Such information should be in the EHR just as allergies are noted. Pharmaco-genetics can truly help us real-ize the promise of personalized medicine.

John G. Langdon, M.D., FACP is the chief medical strategist for New Wave Biosciences, Inc. For over 40 years he has held leadership positions in clinical (Internal Medicine), academic and socioeconomic medical institutions. New Wave Biosciences is a medical device support team that partners with innovative developers of new medical technologies that have the potential to be major assets in healthcare and the practice of medicine. Dr. Langdon’s e-mail is jlangdon@newwavebio.com

To learn more, visit healthcare.goarmy.com/y941 or call 1-888-550-ARMY.

Personalized Medicine: What’s in your DNA?

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SunTrust Foundation Brings Much Needed Assistance to Children in Central Florida

Recently, the SunTrust Foundation helped the fight against child abuse in Central Florida take a major step forward, providing an important $25,000 contribu-tion to the cause. The SunTrust Foundation made its donation to Kids House Wayne Densch Children’s Advocacy Center (CAC), a one-stop headquarters for police and sheriff led investigation, medical treatment, financial and legal advocacy and mental health counseling for children and families who have endured child abuse in Seminole County, Florida.

Kids House is now in its 15th year serv-ing as a model statewide and nationally, for its “integrated” (i.e. all aspects from inves-tigation to healing) approach to fighting child abuse.

Hospitals Welcome New VP of Support Services

Central Florida Health Alliance (CFHA) welcomes its new Vice President of Sup-port Services – Alex Chang, FACHE, who has served as the Chief Operating Officer of HCA Fawcett Memorial Hospital/Engle-wood Community Hospital in Port Char-lotte since 2008.

During his eight years with HCA, Chang had oversight in many projects in-cluding the initiation of a Teleneurology program, transfer center and several waste

management programs. In his previous po-sition, he oversaw the construction projects for additional open heart and ortho/spine rooms.

Chang’s new role at CFHA will include overseeing the following departments: Materials Management/Supply Chain, En-vironmental Services, Food & Nutrition, Facilities/Plant Operations, Bio Med, Con-struction and Security. Chang is a Fellow of the American College of Healthcare Execu-tives with all of his healthcare experience in the state of Florida. He holds a Master of Health Sciences Administration from The George Washington University and a Bach-elor of Arts, Biology from The University of Chicago.

Funds Earmarked for New LRMC Observation Wing

The Leesburg Regional Medical Cen-ter Foundation presented a check in the amount of $600,000 to the Leesburg Re-gional Medical Center during a Board of Directors meeting on July 1.

The funds are earmarked for the Capi-tal Campaign for the LRMC Emergency De-partment’s new observation wing. This area will consist of twenty-four private rooms where patients who have already been processed through the Emergency Depart-ment may wait in comfort prior to full hos-pital admittance, a cessation of symptoms before discharge or an evaluation as to the next step in their ongoing medical care, ac-cording to Ted Williams, President of the LRMC Foundation.

The unit will be run by emergency-trained staff that will carefully monitor each patient.

By providing focused, rapid medical evaluations, observation units can help re-duce hospital readmission rates, save pa-tients an extended first hospital admission and improve patient outcomes.

The Foundation's Capital Campaign "Now Never Waits" continues to seek the public's help in raising $5 Million dollars as part of the $10 Million dollar project to renovate nearly 22,000 square feet of space of the hospital's first floor and enhance the healing process with the new observation wing.

Bert Fish Medical Center Recognized as an American Heart Association Fit-Friendly Worksite

Bert Fish Medical Center has been recognized as a Platinum-Level Fit-Friendly Worksite by the American Heart Associa-tion for helping employees eat better and move more.

Bert Fish Medical Center implemented an employee wellness program called “Fit For Life Rewards” in 2012. The program re-wards employees for adopting healthy life-styles including exercise, diet, brain training and healthy lifestyles modification. Operat-ing on a quarterly calendar, employees earn points for various healthy activities which are then tallied and a cash payment award-ed to the employee based upon their level of participation.

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