Orlando Medical News March 2016

Terry Su, MD, DDS

PAGE 3

PHYSICIAN SPOTLIGHT

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By LyNNE JETEr

The nation’s second-largest hospital network and second largest university have collaborated to signifi cantly boost the number of residency slots in hospitals across the Sunshine State, particularly in Orlando, Gainesville and Ocala.

In 2013, Hospital Corporation of America (NYSE: HCA) and the University of Central Florida (UCF) College of Medicine established an internal medicine residency program with the Orlando VA and Osceola Regional medical centers. Last fall, the two institutions announced a major expansion of their partnership to create new residencies – initially internal medicine, fam-ily medicine, OB/GYN – that will help alleviate the physician shortage in Florida.

“We simply don’t have enough residency slots nationwide for the number of medical school graduates each year,” said Deborah German, MD, UCF’s vice president for medical affairs and founding dean of the College of Medicine. “Even though 97 percent of UCF’s medical school grad-uates fi nd residencies, many qualifi ed students do

UCF Adds New Medical ResidenciesPartnership with HCA to Alleviate Doctor Shortage in Florida

By LyNNE JETEr

WINTER PARK – Florida Accountable Care Services (FACS) and United-Healthcare, a division of UnitedHealth Group (NYSE: UNH), are launching an accountable care program to improve people’s health and satisfaction with their healthcare experience.

The joint venture goes live April 1, and will focus largely on dedicating more resources to care coordination and making it easier to share important health infor-mation so that every doctor involved in a patient’s care is on the same page with the treatment plan.

FACS and UnitedHealthcare Launch ACOJoint Venture Goes Live April 1

(CONTINUED ON PAGE 12)

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Advancing TelehealthProponents Caution Lawmakers Of the two telemedicine bills moving through the Florida Legislature this year, only one seems poised to have a chance to become law: Senate Bill (SB) 1686, which authorizes healthcare practitioners to use telehealth and also creates a Telehealth Task Force under Agency for Health Care Administration (AHCA) to analyze and provide recommendations concerning telehealth operations ... 6

Diversifi cation and Consolidation Efforts Can Be CriminalAs consolidation occurs in the healthcare industry, diversifi cation follows. Consolidation and diversifi cation have a yin and yang effect. Consolidation of similar types of services and providers simply adds numbers, more of the same, and perhaps greater market share within the same service line ... 11

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U.S. Sen. Bill Nelson (Florida)

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announcement of the new partnership

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Services and UnitedHealthcare

on Monday, February 15,

2016.

PHOTO CREDIT: JULIE FLETCHER/UNITEDHEALTHCARE

Dr. Anneliese Beaubrun, (left), a second-year resident in UCF’s Internal Medicine Residency Program with Dr. Ejaz Ghaffar, Osceola Regional Medical Center Site Director of the residency program. The two are pictured working together at Osceola Regional.(CONTINUED ON PAGE 12)

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Head and Neck Surgeon Focuses on Cancer Treatment, ReconstructionEarly Biopsy for Lingering Mouth Sores Can be Life-saving

By LUCy SCHULTZE

Like a frequent marathoner who takes the miles in stride, head and neck surgeon Terry Su, MD, DDS, practices a rhythm of endurance and recovery.

In procedures that can take 10 to 14 hours, he works with a plastic surgeon to remove tumors of the mouth, jaw or neck, then perform reconstruction using skin and bone from the lower leg. The process includes microsurgical work to connect ar-teries and veins that integrate the grafted tissues.

“The next day, I’m completely ex-hausted,” Su said. “But at this point in our lives, we’re still relatively young. We can do a surgery like that on a Monday, and by the following Monday I’d be ready for a big surgery again.”

Su typically tackles only one or two such extensive procedures a month, as part of his practice with Osceola Plastics & Maxillofacial Cosmetic & Reconstruc-tive Surgery alongside plastic surgeon Luis Jaramillo, MD. Ordinarily, advanced re-constructive procedures are limited to aca-demic centers, Su said.

“When you have two or three resi-dents helping out, it makes both the pro-cedure itself and the rounding afterward easier to manage,” Su said. “Since these patients are usually in the hospital for a week or two, and we are also taking care of them during that time, we are limiting what we do right now.”

Still, Su said he has been glad to help address what he’s found to be a regional shortage of head and neck surgeons who do cancer surgery. He has been part of the Osceola Regional Medical Center affiliate practice for the past three years.

“Central Florida is very underserved in terms of head-and-neck cancer sur-geons,” he said. “We’ve seen patients being sent to Miami, Tampa or Jackson-ville. Even as this area continues to grow, there are not a lot of surgeons doing what I do. And a lot of primary physicians are not aware that there are surgeons avail-able locally to do these surgeries.”

A native of northern California, Su came to Florida for a fellowship in head and neck surgery and microvascular re-constructive surgery at the University of Florida College of Medicine-Jacksonville. He chose to stay in the state after his fel-lowship and accepted the position in Or-lando.

Su had initially pursued a career in dentistry. He completed dental school at New York University and returned to San Francisco to begin practicing. A few months in, however, he decided dentistry was not for him.

His choice to return to medical school

and focus on oral and maxillofacial sur-gery allowed him to redefine his career while still tapping his dental training.

“Many of our patients are referred from dentists, and my background helps me better relate to dentists,” Su said. “Dentists are important partners, because they are usually able to spot cancers pretty early. If you go for a dental cleaning twice a month, you should also be getting oral

cancer screening exams at each visit. Something that’s 1 cm in size is pretty ob-vious in the mouth.”

On the medical side, Su said, many primary care physicians do not have the same opportunity or awareness to catch mouth cancers early.

“I’ve had patients who have had ulcers on their tongue for six or seven months, who’ve been treated with mul-tiple rounds of antibiotics and steroids as the ulcers keep getting bigger,” he said. “It’s important for physicians to know that if there is any lesion in the mouth that doesn’t heal in two or three weeks, something is not right. It really needs to be biopsied.”

Su said that when such cancers are given six or seven months to grow, there’s a far greater chance that they will metas-tasize to the lymph nodes, reducing a pa-tient’s chance for survival.

“We know that if we are able to diag-nose and treat this cancer at Stage I, when it is relatively small and confined, the sur-vival rate approaches 90 percent,” he said. “However, a lot of times, when these pa-tients come to me at Stage III or IV, the five-year survival rate is only 35 percent.”

Because of the aggressive nature of malignant tumors and even many benign

tumors of the head and neck area, Su takes an aggressive surgical approach. In most cases, he removes not only the tumor but also surrounding normal tissue to en-sure the entire tumor is gone.

“Often, this leaves the patient with a big defect that can be very debilitating if it is not reconstructed properly,” he said. “For a tumor in the upper jaw, we may have to remove half of the jaw, so you have to put bone and soft tissue back. In getting bone and some skin from the lower leg, and connecting the arteries and veins under the microscope to reestablish blood flow to the flap, we are able to rebuild a jaw.”

Similarly, Su said, soft tissue flaps harvested from other parts of the body can be used for reconstruction after surgery to remove a cancer of the tongue.

“The goal is not only to restore form — aesthetically, you want to make it as comparable as you can — but also to re-store the function of the structures you re-move,” he said. “If someone has to have a tongue cancer removed, you want to re-build the tongue to make sure they’re still able to speak and to swallow.”

For Su, the reward in being able to provide such procedures includes both the

PhysicianSpotlight

(CONTINUED ON PAGE 13)

Dr. Terry Su


Jose Piovanetti, MD, is a physician with over thirty years of formal training and real-world expertise in the new medical specialty of clinical informatics. He has attained unique hands-on medical informatics knowledge and experience through completing medical informatics fellowship training as well as developing and managing electronic health records (EHR) since 1984.

He uses his acquired knowledge and expertise to assist hospitals, outpatient practices and other care facilities to expand and improve their informatics systems and operations. He can be reached at [email protected].

By JOSÉ E. PIOVANETTI, MD

U.S. healthcare professionals have been given the option of continuing to deliver care in a costly, unsustainable and inequitable system (which will even-tually disappear) or develop sustainable alternative(s) for the future, and continue leading. We have pockets that deliver ex-ceptional care, however, quality-care is not evenly distributed across regions or popula-tions. Even before 1991, when the Institute of Medicine published The Computer Based Patient Record: An Essential Technology for Health Care, there’s been a correlation between or-ganizations that have a real grip on their clinical data –which they manage electroni-cally to the extent possible – and those that provide exceptional care. Evidence suggests that electronically managing holistic health data improves healthcare as it has equiva-lently done for other sectors such as bank-ing, air travel and others; albeit, health data is far more complex than that of the ones managed by other sectors as well as how we use and process our data into information.

Before the 70’s pioneer-physicians saw that computers had uses in handling health data and began combining their medical expertise with available computer technol-ogy and created the field known as medical informatics (MI). The history of medical informatics doesn’t fit a short article, so I’ll refer you to a 1995 book by Morris F. Cohen, MD, called A History of Medical In-formatics in the United States: 1950 to 1990; he summarized early-day use of computers to manage clinical data to improve care, ad-here to evidence-based care, control costs and more. Consecutively Lawrence Weed, MD, was inventing in those early days the SOAP-format (i.e. subjective, objec-tive, assessment, plan) so physicians could keep their patient records organized while

computer technology evolved enough so patient records could be completely man-aged through these. By the early 1990’s, electronic records where showing promise by improving care coordination, adherence to evidence, while most where staring at the stars.

So medical informatics is a half a cen-tury multidisciplinary field that scientifically and methodically evaluates, designs, devel-ops and adopts, implements and applies computer-based tools to improve the four cornerstones of healthcare abbreviated by the acronym C.A.R.E.; meaning Clinical, Administrative, Research and Education. Another view is the convergence between distinct philosophies on how to manage data to improve health and care, including the body of knowledge of medicine, com-puter science, engineering, etc. Regardless of “definition,” the primary aim of MI is to make all attainable health-data and infor-mation available at the Point-of-Care with minimum impact on the provider-patient relationship alert about options and pre-ventable errors. Between the 1980’s and 90’s MI training was attained through one of a few National Institutes of Health (NIH) sponsored on-hands fellowships in a hand-ful of U.S. medical education institutions. By the end of 2011, the American Board of Medical Specialties (ABMS) approved Clinical Informatics as a medical sub-spe-cialty.

We can’t predict what the future of healthcare in the U.S. will look like, but one thing is unquestionable, data will be captured, maintained, managed and shared electronically. On the one side, MI’s decades-old track record, inevitable growth, influence and recent rec-ognition as a medical sub-specialty dictates that it will be an informatics-supported healthcare future. No matter that our entry into the electronic health data paradigm

has been less than stellar ever since the an-nouncement by President George W. Bush in 2004 of a U.S. Federal Government ini-tiative, “…whose aim was that the majority of Americans would have their health records managed electronically within ten (10) years…” the prob-lem has been the “solution (i.e. vendors) feeding frenzy” has taken over everyone’s practice and emotional stability.

Things posing as Electronic Health Records (EHR) have risen like cicadas but causing harm in the form of billions of dol-lars misspent, reduced productivity, ven-dor lock-in, amongst other nasty verrucae. Concurrently, the most dreaded and feared outcome also materialized and will con-tinue take deeper root unless physicians act fast; that is, “we’ve become slaves of new masters” as exemplified by the way EHR system vendors, to whom we’ve provided our data, hold us hostages to their systems. For example, once data is inserted into any EHR it cannot be migrated completely to another EHR in the very likely event that we need to change our “chosen” EHR.

Additionally, the U.S. federal govern-ment implemented an incentives program to honor providers who where using EHRs and demonstrated that they used them meaningfully with their patients – mean-ingful use. Now, the riddle of meaning-ful use, Medicare’s electronic prescribing, patient quality reporting system (PQRS), hospital inpatient and outpatient qual-ity reporting, health employer data infor-mation set (HEDIS) and other “metrics” have been conjoined into Medicare’s Value-Based Payments via the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA.) Accountable Care Organizations (ACO), merit-based incen-tive program (MIPS) and alternative pay-ment models (APM) all use “metrics” to demonstrate “quality” and “value”; am-

biguous terms that merit that I direct you to a NEJM article available at http://bit.ly/1PAjoNo.

Most providers, managers, admin-istrators or CEO’s have never heard the computer-technology sector practice that colloquially is referred to as “Wine, Dine and Sign”; I urge you pay close attention to this “offerings approach.” EHRs are here and the landscape will evolve rapidly and continuously; some systems will stay in the market, some will be absorbed and a sizeable number will disappear. In such a turbulent environment, physicians need to take back what they unknowingly gave-up, that is, full-access to the raw health data that we as physicians, not the EHR-vendors, are liable for, with no strings attached. Concurrently we also need to embrace health data exchange so we can reap the real benefit that com-puter technology promised for healthcare: the ability to construct more complete patient medical records at the Point-of-Care.

Those who’ve chosen medical, bio-medical or clinical informatics as a specialty, practice or career are specially trained to select and implement cost-effective Health Information Technology – of which EHR’s are just one part – as required by each or-ganization. Like pathologists and radiolo-gists, medical informaticists are healthcare professionals that at times may not have time for direct patient contact, but are still members of the workforce with knowledge to find actionable information in data and improve sustainable care – before non-healthcare-actors take the rest of healthcare away from healthcare professionals.

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By LyNNE JETEr

Of the two telemedicine bills moving through the Florida Legislature this year, only one seems poised to have a chance to become law: Senate Bill (SB) 1686, which authorizes healthcare practitioners to use telehealth and also creates a Telehealth Task Force under Agency for Health Care Administration (AHCA) to analyze and provide recommendations concern-ing telehealth operations.

“At least it would give us something substantial to build on,” said Lloyd Sir-mons, director of the Southeastern Tele-health Resource Center (SETRC), who has been leading a Florida Telehealth Workforce Group for the last two years to advance telehealth policy.

A companion bill, House Bill (HB) 7087, allows access to telehealth services by licensed healthcare professionals in Florida. If out-of-state healthcare profes-sionals register with the Department of Health or an applicable board, meet re-quirements, and pay a fee, they may also provide telehealth services to Floridians. However, they would be prohibited from opening a physical location and offering in-person services in the state. Otherwise, they would be able to practice within the relevant scope of practice established by Florida law and rule.

Both bills – SB 1686 and HB 7087 – passed committees the second week of February. However, bill-watchers are concerned that neither version will lead to telehealth policy law.

“In the 2015 Florida Legislative Ses-sion, the legislature avoided controver-sial telehealth coverage mandates and consensus-breaking details of more than 40 potential policy issues,” said Tamara Y. Demko, JD, MPH, author of Moving Telehealth Forward: The High Costs of Pay-ing Later, a report recently produced by Florida TaxWatch. “Instead, both the Florida House of Representatives and the Florida Senate focused on a set of narrow telehealth policy issues that nearly led to consensus and bill passage.”

Even though both bills advance tele-health in Florida to some degree, neither

provides a provision addressing reim-bursement of telehealth services. What is addressed are the fundamentals: defi ni-tions of telehealth, a broad list of eligible telehealth providers, standards of care, recordkeeping, and most aspects of pre-scription drugs.

Telehealth reimbursement struggles with many barriers, Demko pointed out, the fi rst of which is lack of telehealth pro-vider knowledge regarding billing and payment options.

“Florida providers need telehealth education, as some remain under the in-correct impression that Florida Medicaid provides no telehealth reimbursement,” she said. “Across six clinical delivery mod-els and nine business models for telehealth, standards of care and fraud and abuse concerns need to be addressed to provide assurances of comparative value for pay-ers and quality of patient care for state ac-tors. With a growing number of telehealth companies, certain companies have found ways to provide such assurance.”

While California, Texas, and New York have telehealth-friendly statutes and regulations, Florida does not, pointed out Dominic M. Calabro, president and CEO of Florida TaxWatch.

“In a healthcare environment where federal changes create uncertain fund-ing streams, telehealth provides a way for states to increase self-suffi ciency, contain costs, and improve access,” he said.

“While Florida currently has no telehealth mandates, Florida Medicaid does reimburse physicians for certain tele-medicine services,” said Demko, “and an unspecifi ed number of providers have successfully negotiated private payer re-imbursement arrangements.”

State prioritization of telehealth, re-gardless of federal funding discussions, is essential for one, little-discussed reason: statewide telehealth expansion can ulti-mately reduce reliance on non-secured federal healthcare funding and increase state self-suffi ciency, said Demko.

“Telehealth would allow Florida to reach its 19 million residents across 67 counties, regardless of location, age, infi r-mity, or transportation ability,” she said.

Speed of the advancement of tele-health in Florida would bode well in ad-dressing a troubling healthcare trend. By 2030, the 65 and older sector of Florid-ians is projected to reach 25 percent of the population.

“Before the silver tsunami strikes, and there’s a state of emergency, Florida can prepare for a healthcare crisis by having in place an established infrastructure,” said Demko. “Time wasted is money lost and, for Florida, the cost of waiting to act on telehealth is too high to ignore.”

Advancing TelehealthProponents Caution Lawmakers about the High Cost of Paying Later

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Sally was 73 years old. She was in the hospital for her third time in four months. Her cancer was spreading in spite of the treat-ments offered by her cancer spe-cialist. Her doctors sat down and reviewed the different options and the possible benefits and burdens of each of those options. When asked what she wanted to do, Sally said, “I want to go home, and I want chocolate ice cream.”

When one cares for peo-ple at end of life, and one hears “environ-ment,” the first thing one thinks about is home. When you ask people what they want at end of life, almost everyone indi-cates they would like to be at home. Home can mean different things to different peo-ple. It can be a private residence, a nursing facility, an assisted living facility, and so on, but it’s the place where the person now feels they belong.

Home, ideally, means a familiar en-vironment and, if at all possible, an en-vironment characterized by the presence of loved ones. The more years I spend working in hospice and palliative care, the more convinced I am that the single most

important environmental health factor for those with advanced illness is “home” and the loved ones that come with it. One of the reasons I am such a big advocate of hospice care is that it often enables people to remain in their homes at end of life. Hospice can provide the medical equip-ment (e.g. hospital bed, oxygen, wheel-chair, etc), the delivery of medications, the professional services, and the emotional/spiritual support to ensure high quality care wherever the patient considers home.

Even loving homes, however, can pose dangers to someone who is quite ill. Hospice personnel can do a home safety survey. Are there throw rugs that could ac-

cidentally cause a trip and fall? Is the bathroom close enough so there won’t be dashes and stumbles at night? Is there oxy-gen in the house and, if so, can we make sure there is no smok-ing or open flames nearby? Does the patient need some sort of wearable alert device so they can call for help if they fall and can’t get up? Is the lighting good enough where the patient keeps medications so he/she does not accidentally take the wrong tab-let? Hospice helps people stay home and helps make sure that home is safe.

Sometimes, as hard as we try, care at home may not be possible. Symptoms may be severe and require special kinds of treatment or the caregiver burden is too great for a spouse who might be in ill health him or herself. When a patient can’t be at home, a good environmental health plan is to make the new environ-ment as home-like as possible. If we can’t bring the patient home, let’s do our best to bring home to the patient. Having fa-miliar clothes, bedspreads, pictures, bed-side items, and people available can help in this regard. And, of course, we need to make sure this environment is safe too, as someone who is elderly and ill can become

disoriented in an unfamiliar environment making falls or accidents even more likely.

Our bodies interact with our envi-ronment through our five senses – sound, sight, touch, smell, and taste. Compas-sionate care of those at end of life requires a thorough understanding of each pa-tient’s sensory abilities – knowing which senses work well and which might be im-paired – and then developing a “sensory” plan of care. Our “environmental” ap-proach might include “aroma therapy,” or softly playing the patient’s favorite music, or offering gentle massage. For some, taste might be the best way to interact with the environment at end of life. Choosing foods that delight becomes more important than choosing foods according to their nutri-tional benefit.

With our cancer patient, Sally, there was ample time before this to push brus-sels sprouts over chocolate ice cream. Encouraging hospitalizations, diagnos-tic tests, and procedures may have made sense before, but those interventions will no longer serve to achieve her goals. Sally knows what she wants. If Sally wants to go home and Sally wants chocolate ice cream for breakfast, that’s exactly what this doc-tor will order. That will be my environ-mental health plan.

Environmental Health and End of Life Care

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By BrETT P. THOMAS, DO, fAAO

Many people feel that when they are injured in a motor vehicle accident (MVA), a fall or a sports injury, they are injured in the places that they were struck. Even a collision that has minimal damage can have negative ramifications that go beyond expectations.

• Trauma typically causes more global injuries rather than restricted to one region.

• The amount of force is a major contributor to the significance of the injuries

• Location of the force can also deter-mine if one area is affected or if it’s more global.

• Body position upon impact can determine which muscles and liga-ments will be compressed and which will become hyper-elongated.

• Direction of force will greatly influ-ence the type of injuries that occur such as compression, torque or an-gulated

• Acute vs. Chronic injuries definitely can affect the length of time that it may take to treat the area, restore vitality and limit its potential recov-ery.

• Healed vs. fully healed• Osteopathic manipulation can

make a huge impact in the healing

tissues from a traumatic injury. A traumatic injury affects the whole

body. If you jump in the air and land on your feet you feel the impact not only in your feet but also into your pelvis, shoul-ders, neck and maybe even into your head. Increase the force with a large ob-ject traveling at a high speed, or a child falling off of a monkey bar, and you can imagine the damage that occurs.

If you go back to physics in high school then you’ll remember that Force = mass x velocity. In non-physics terms, that mass is basically weight and velocity is speed. For example, it’s the difference between being hit in the head with a plas-tic hollow bat versus a wooden baseball bat.

Direction of the force of injury can also make a huge difference in what is injured and in what way. If someone gets hit in the head with a baseball bat, it makes a big difference whether it is from the front or back. If from the front, the anterior neck muscles and ligaments would be stretched beyond normal while the posterior neck muscles and ligaments would be compressed. If hit from behind, the reverse injuries would occur. Each set of injuries needs a different type of treat-ment

Body position at time of injury can also make a difference in the type of in-jury. If the patient is in a car crash and

hit from behind, the injuries would be different depending if they were look-ing forward or twisting looking at argu-ing children in the back seat. The twist of the body upon impact would typically be more damaging than if the body was straight upon impact. Thus, seemingly similar accidents may cause completely different injuries thus different treatments maybe needed.

A traumatic injury requires quick treatment. If there is too long a wait, the tissues themselves begin to change, caus-ing the need to re-educate the body’s tis-sues. The body’s healing process begins almost immediately. Within six weeks much of the healing cascade has ended or the body may maintain a prolonged inflammatory state. After time, muscle memory and tissue memory takes place and retraining those muscles and tissues is required during treatments. Also, over time some adhesion can form in the tis-sues or there can be long standing mus-cle spasms, which can be more difficult to heal or change. If the patient can be treated quickly, then that increases the chances of better outcome from injuries.

One of the things that are frequently misunderstood is that there is a difference between “healed” and “fully healed.” Just because someone has full range of motion and is without pain does not mean that they are completely healed. The bones

and tissue take about 1-2 years to fully heal and that is if there are no complica-tions. Many times people go to work or start exercising too quickly before their body has fully healed and they get rein-jured more quickly.

When people have traumatic injuries it is not always a simple question of where they have pain? The question should be followed by more questions such as: what was the direction of force on your body? What position was your body in when the accident occurred? For most traumatic injuries a region-by-region quantification of injuries should be made, otherwise the patient may just note the principle area of pain and not acknowledge other areas of lesser pain.

An osteopathic physician, uses osteo-pathic manipulation treatments (OMT) that are very good at helping the tissues heal properly. Various techniques are used depending on location of the inju-ries and which tissues are emphasized in treatments. Osteopathic manipulation techniques can involve the all areas of the body from the head to the feet. OMT will also treat ligaments, muscles, tendons, fascia, and position of the bones.

Traumatic Injuries are Not Simple Events

Brett P. Thomas, DO, FAAO, is clinical assistant professor of Osteopathic Principles and Practice at Lake Erie College of Osteopathic Medicine- Bradenton, Fla. campus. Visit www.drbrettthomas.com


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By ALAN rOCK

The three primary goals of any successful medical practice are main-taining a high appointment conver-sion rate, growing your new patient base, and retaining existing patients. If you’re marketing your practice, every time that phone rings, you have paid for that ring to occur. However, once that phone rings, and you ask a patient to hold, do you re-turn to the line to find that they’re no longer there? This is an area many practices struggle with or for that matter most businesses do.

On-Hold marketing is critical for every medical professional for attracting, converting, engaging and retaining both new prospective patients and existing ones. AT&T reports that the average business receives over 100 calls per day, and that 70 percent of callers are placed on hold. An even more staggering statistic is that more than 35 percent of callers who wait in si-lence or canned music hang-up in less than 45 seconds. Lost calls mean lost appoint-ments, lost opportunity and ultimately lost revenues.

When that phone rings are you doing everything possible to accomplish the 3 main goals? Once your staff has placed a caller on hold, what are they going to hear? Some practices play music or radio, giving you no control over the content. Do you re-

ally want to broadcast a competitor’s ad to your patient on hold? Many medical offices don’t take consideration into caller on hold time at all, and simply leave callers waiting in “dead-air limbo.” Patients would rather have a root canal, than wait in eternal si-lence. But, with custom branded On-Hold messaging, callers will wait up to four or more minutes, giving you the chance to serve them.

It’s been estimated that the average medical practice receives over 250 calls a month just from new prospective patients alone, (this doesn’t include the number of existing patient calls per month), and let’s say that new prospective patients represent approximately $500 each in revenue. As noted above, industry benchmarks indicate 175 of those callers will end up on hold, and that 62 of those callers will hang-up before

giving you the chance to serve them. When you do the math; 62 lost call-ers per month, times 12 months, equals 745 lost callers per year. And, if the average new patient represents $500 in revenue, then you’re losing a potential $372,500 per year in new patient revenue due to lost calls and appointments.

You have two highly targeted audiences in which you can present your marketing message, thus On-Hold messaging is the most effective and efficient tool for your practice to enhance patient communication, in-

crease revenues, strengthen patient loyalty and improve in office efficiency as well as the customer experience.

Listed below are just a few of the many topics you can include in your music on hold recording.

• Qualifications of the doctors and staff

• Provide health tips• Introduce new patient specials• Promote add-on services/treatments • Hours and Location• Insurances and Financing Options• Ask for valuable referrals (or any re-

ferral programs)• Website and Social Media Channels• Convenient on-line appointment

scheduling• Encourage requests for online re-

views

On-Hold marketing is truly a unique, highly targeted and invaluable in-bound marketing opportunity for your practice, one that should not be over-looked. A sur-vey conducted by Call Center Technolo-gies showed that callers who are exposed to messages on hold, results in a 25 per-cent increase in offerings mentioned while on hold. This can mean some real added profit centers for your practice.

Additionally, when you implement custom On-Hold strategy at your prac-tice, you can improve efficiency of your office staff by helping to answer frequently asked questions such as hours and loca-tion which cause increased hold times. By answering these common questions, you help to reduce hold time, freeing up staff to handle other tasks.

Maxi-Marketing reports that 88 percent of callers prefer On-Hold mes-sages to the alternatives (dead-air, radio or canned music). So, the bottom line is, “what callers hear while on hold” with your practice can be the difference be-tween a great patient experience, or like having a root canal being performed on the phone while waiting for your staff to return to the line.

Are you using message On-Hold mar-keting at your practice? Why not?

Alan Rock is owner of HoldMasters, established in 1987, serving clients across the United States and Great Britain. They offer service in any language. He can be reached at [email protected].

Marketing Your Practice Effectively and Efficiently


By ANN BITTINGEr

As consolidation occurs in the health-care industry, diversification follows. Con-solidation and diversification have a yin and yang effect. Consolidation of similar types of services and providers simply adds numbers, more of the same, and perhaps greater market share within the same ser-vice line. Consolidation coupled with diver-sification, however, expands the business into new service lines, perhaps to capture more of the patient experience.

For example, surgeon owners of a sur-gery center may look to take control of the anesthesia service line at the center. An or-thopedic surgery group may consider em-ploying its own physical therapists or start selling braces and orthotics. This diversifi-cation can take the form of acquisition of current competitors. While this would be normal in the non-healthcare field, it can be criminal in healthcare.

Consolidation and diversification carry both great opportunities and great risks. No practice should look to diversify or consolidate without the advice of good health law counsel.

Failing to seek counsel could put you in the situation one of my new clients is in now – entering a guilty plea to violation of the federal Anti-Kickback Statute for the financial arrangement his practice entered into with a drug company. To him, it was a way to make drugs available to his patients. On the surface, it seemed like a legitimate arrangement. To the U.S. Attorney, it was a crime. He sought the advice of counsel too late. Now I’m advising him on possible ways to continue to maintain his Florida medical license.

The U.S. Attorney does not take kindly to an “I didn’t realize this was wrong” de-fense. Physicians and their practices are obligated to make sure their diversification and consolidation efforts are legal. The gov-ernment has issued a Special Fraud Alert on contractual joint ventures. The govern-ment has also issued an Advisory Opinion on ambulatory surgery centers specifically, but that may apply to other types of service line consolidation.

In that opinion, the surgery center wanted to take control of the anesthesia service line by forming its own subsidiary anesthesiology groups that bill and collect for the anesthesiology piece on the sur-geries that the surgeon-owners perform. The government said that the proposed arrangement may violate the criminal Anti-Kickback Statute. The fact that the surgeon owners of the surgery center were entering into a service line that they could not have done on their own was a key con-cern for the government.

Any time a practice seeks to diversity, healthcare counsel experienced in the Stark Law, the federal Anti-Kickback Statute, the False Claims Act and Medicare billing rules should be consulted so that the relationship is structured legally.

The government-issued Special Fraud Alert on contractual joint ventures provides

plain-speak guidance on what types of con-solidation and diversification arrangements the government suspects as fraudulent. The Alert included some examples of potentially problematic contracts:

A hospital establishes a subsidiary to provide durable medical equipment (DME). The new subsidiary enters into a contract with an existing DME company to operate the new subsidiary and to provide the new subsidiary with DME inventory. The existing DME company already pro-vides DME services comparable to those provided by the new hospital DME sub-sidiary and bills insurers and patients for them.

A DME company sells nebulizers to federal healthcare beneficiaries. A mail order pharmacy suggests that the DME company form its own mail order phar-macy to provide nebulizer drugs. Through a management agreement, the mail order pharmacy runs the DME company’s phar-macy, providing personnel, equipment, and space. The existing mail order pharmacy also sells all nebulizer drugs to the DME company’s pharmacy for its inventory.

A group of nephrologists establishes a wholly-owned company to provide home dialysis supplies to their dialysis patients. The new company contracts with an ex-isting supplier of home dialysis supplies to operate the new company and provide all goods and services to the new company.

The Alert goes on to characterize the following common diversification elements as problematic:

The owner expands into a related line of business, which is dependent on referrals from, or other business generated by, the owner’s existing business.

The owner neither operates the new business itself nor commits substantial fi-nancial, capital, or human resources to the venture. Instead, it contracts out substan-tially all the operations of the new busi-ness.

Third, the other company is an es-tablished provider of the same services as the owner’s new line of business. In other words, absent the contractual arrangement, the other company would be a competitor of the new line of business, providing items and services in its own right, billing insurers and patients in its own name, and collecting reimbursement.

Fourth, the parties share in the eco-nomic benefit of the owner’s new business.

Fifth, aggregate payments to the other company typically vary with the value or volume of business generated for the new business by the owner.

If you are contemplating a consolida-tion or diversification transaction that has some of these elements in its structure, seek advice of counsel for clarification and guid-ance on whether a restructuring is required.

Diversification and Consolidation Efforts Can Be Criminal

Ann Bittinger, an attorney and owner of The Bittinger Law Firm, specializes in representing physician practices in their healthcare regulatory and transactional matters. She can be reached at [email protected].

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not, simply because there aren’t enough spots.”

After last year’s residency match, more than 600 U.S. medical school se-niors were left without residency positions, and unable to practice medicine after graduating with their medical degrees.

“We know that where a resident completes his or her pro-gram is usually where they decide to stay and work,” German said. “We’re eager to partner with hospitals across our community and state to attract and retain more excellent doctors for Florida residents.”

UCF President John C. Hitt pointed out the school’s agreement with HCA “shows how our students, com-munity and state benefit from the power of partnerships. Together, we’ll produce more well-trained physicians who will care for patients in Central Florida and throughout our state.”

Michael Joyce, FACHE, president of HCA’s North Florida Division, agreed. “As part of the nation’s largest hospital network, HCA’s North Florida Division brings significant resources and a dedi-cated commitment to meeting Florida’s critical need for physicians by expanding access to medical residency programs,” he pointed out. “We’re honored to partner with UCF to provide outstanding training and mentorship that will prepare the next generation of physicians to deliver the highest quality of patient care.”

The first step in the new effort will involve operating four existing HCA resi-dencies under the consortium and seek-ing any necessary re-accreditation from the national Accreditation Council for Graduate Medical Education (ACGME). The agreement won’t change any existing HCA or UCF partnerships. UCF cur-rently operates the Osceola Regional resi-dency in partnership with HCA and the

Orlando VA Medical Center. The two parties have pledged to con-

tinue working together to bring more resi-dencies to Florida, and plan to establish new residency and fellowship training pro-grams over the next five years that could bring total enrollment to nearly 600 resi-dents and fellows and graduate up to 150 physicians a year. This move marks HCA North Florida’s largest academic partner-ship.

The number of residencies hasn’t kept pace with Florida’s growing popula-tion and its increasing number of medical schools. In a nationwide comparison, Flor-ida ranks 42 of 50 states in the availability of residents per 100,000 people.

Last year, state lawmakers reviewed a study that showed an anticipated shortage of 7,000 specialists over the next decade in Florida, primarily in psychiatry, general surgery, thoracic surgery and rheumatol-ogy. They created 422 new residency slots

under the Governor’s State Medicaid Residency Program and the legislature’s new Graduate Medical Education Startup Bonus Program, increasing the number of residency slots in Florida to nearly 4,400. The bonus program provides participat-ing hospitals a one-time $100,000 bonus for each new residency slot created in spe-cialty areas with a shortage.

The HCA-UCF partnership may later add residency spots in psychiatry, emergency medicine, general surgery, and anesthesiology specialties.

Orlando Health CEO David Strong said innovative partnerships can help Florida create more residencies, especially those in high demand specialties.

“We’re excited about the common work we do to make Florida and our re-gion a national leader in graduate medical education,” he said. “Orlando Health has been and will continue to be an advocate and leader in graduate medical educa-

tion.” Former Florida Hospital CEO Lars

Houmann said that since its inception, one of the most important goals of the UCF College of Medicine has been to increase the number of physicians in the state.

“Residencies are a vital part of the formula of training and retaining high-quality physicians,” he said, noting that Adventist Health, parent of Florida Hos-pital, “is pleased to see progress toward that objective.”

Tim Liezert, director of the Orlando VA Medical Center, said his hospital’s two-year-old internal medicine residency with the medical school and HCA’s Osceola Regional Medical Center has provided great benefits to physicians-in-training and patients.

“We’re eager to create more collabo-rations like these for our veterans and the community at large,” he emphasized.

UCF Adds New Medical Residencies, continued from page 1

Dr. Deborah German

Of UnitedHealthcare’s nearly 3.4 million participants in Florida, some 20,000 enrolled in the insurer’s individual and employer-sponsored health plans are eligible to benefit from this collaboration.

Independent physicians, primary care doctors and specialists, now number-ing nearly 400, created FACS four years ago to help Florida doctors manage and operate Accountable Care Organizations (ACOs). After increasing physician aware-ness of the ACO model in Florida through partnerships with the Florida Medical As-sociation and the Florida Osteopathic Medical Association, the FACS team turned to the Medicare Shared Savings Program and Commercial Accountable Care Models.

“Our primary goal now is to assist the independent physicians in Florida in the management and operations of ACOs and provide them with the tools, services,

and technical expertise they’ll need to suc-ceed in the shifting landscape of health re-form,” said Sandeep Bajaj, MD, founder and CEO of FACS. “Our team is led and governed by Florida physicians for Florida physicians. Together, we’ve secured key partnerships with state and nationwide commercial insurance providers, and vari-ous Managed Care Organizations. Florida ACOs (have) the highest standards to en-sure that all platforms it delivers are best in class, quality, and value.”

Bajaj said FACS physicians are enthu-siastic about partnering with UnitedHealth-care “to apply our expertise in healthcare innovation and patient-centered programs to improve the health of their plan partici-pants and advance toward overall popula-tion health management.”

“Together, we expect to achieve even better health outcomes and improve pa-tient satisfaction, while reducing the over-

all cost of care,” he said.To mark the establishment of the

ACO, FACS and UnitedHealthcare offi-cials participated in a ribbon cutting cel-ebrating the opening of the new Florida Emergent Care Center at FACS’ Winter Park campus. The new center provides patients with a convenient, lower cost al-ternative to the emergency room for many of their healthcare needs. This new col-laboration helps avoid duplicate tests or uncoordinated care by using shared tech-nology, real-time data and information about emergency room visits and hospital admissions, and services designed to help patients manage their chronic health con-ditions and encourage healthy lifestyles.

UnitedHealthcare will supplement FACS’ data to help support overall popu-lation health, giving the entire care team clear, actionable data about individual patients’ health needs, potential gaps in care, and proactive identification of high-risk patients. Patient navigators may also facilitate and support community-based care coordination, such as aiding with planning after a patient is discharged from the hospital, and scheduling follow-up ap-pointments.

“With this new accountable care program, we can help ensure that people receive more personalized and better con-nected care,” said David Lewis, CEO of UnitedHealthcare of Central and North Florida. “Putting more resources into how their care is coordinated, and paying their care providers based on the quality of care and health outcomes, will significantly enhance people’s ability to live healthier lives.”

Care providers nationwide are show-ing strong interest in the shift to value-based care. UnitedHealthcare’s total payments to physicians and hospitals that are tied to value-based arrangements have tripled in the last three years to $45 billion. By the end of 2018, UnitedHealthcare ex-pects that figure to reach $65 billion.

FACS and UnitedHealthcare Launch ACO, continued from page 1


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Transcranial Magnetic Stimulation Therapy uses pulses of magnetic fi elds to stimulate nerve cells in the area of the brain that controls mood. TMS Therapy is an outpatient procedure that consists of 36 treatments, 5 days per week. Each treatment is approximately 37 minutes.

Transcranial Magnetic Stimulation Therapy

• Involves no surgery, anesthesia or sedation. The patient is awake and alert during the treatment.

• The patients can continue with their activities of daily living without any period of recovery between treatments.

• FDA cleared for patients who have depression and did not benefi t from any antidepressants.

Services O� ered:• Psychiatric Evaluations • Medication Management • Counseling • Group Therapy• Parenting Skills Training • TMS Therapy• Hypnotherapy

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TMS

By TIM TAyLOr Mobile device are proliferating in

medical practices today. Laptops, tablets, even cell phones are now used to access PHI about patients. If you use any of these devices, your data can be more at risk than using regular PCs that do not leave your desk.

Mobile devices can be very conve-nient when it comes to looking up patient information, but you need to take extra precaution with them to protect your patient’s medical information. There are some basic guidelines that you should fol-low when using your portable device.

First, are you using the device inside your office? Make sure that your device is connected to your office’s Wi-Fi network. This may sound simple, but a lot of Inter-net providers will provide free “hot spots” in your office if you get your Internet from them. This is convenient for your patients out in the waiting room, but you don’t want your device using it.

If you have taken the device out of the office and connected an Internet com-pany’s free Wi-Fi hotspots, it may try to automatically reconnect to it when you are in your office. These hot spots are not secure and you need to make sure that you don’t use one of them to access PHI.

Check with your company’s IT profes-sional to make sure you are using the “of-fice Wi-Fi” all the time when you are in the office.

If you are out of your office “down at the coffee shop” or any other place where you can get Internet access, fol-low these guidelines with your mobile device. First, only connect to your EMR via a VPN (Virtual Private Network) be-fore you bring up your software. If you don’t have a VPN set up on your mobile device, check with your IT company and have them install one on your device. A VPN encrypts the data between your de-vice and your office.

Alternatively, if your EMR is com-pletely cloud based (does not run on a server in your office), then your application should only run in a web browser using HTTPS:// or a secure connection. This is the type of connection that you would see when you hit your bank’s web site.

I strongly recommend that you don’t store ANY patient information actually on your device. If all data is accessed re-motely, and is never actually stored on your device, you don’t have to report it to anyone if it is stolen. Even a PDF of a patient’s lab results, stored on the device, makes that device “reportable” if it is lost or stolen.

If your EMR requires that you store ac-

tual patient information on the device, then the hard drive has to be encrypted. This usually only applies to laptops, as opposed to tablets or cell phones, because most don’t have the ability to store patient data.

Additional recommendations: Make sure you password protect your device and use a strong password. Change your pass-word often. Keep your device with you when you are in public and don’t let oth-ers see your screen when you are looking at patient information. Don’t share your device with anyone and be very careful of what APPS you install on your device.

Lastly, have your IT employee or provider install tracking software on your device. It has a much higher chance of being located, if it is lost or stolen, if a lo-cation tracking program is installed. Most tracking programs can also do “remote wipe” so all data/programs/everything can be wiped off if the device cannot be returned.

Mobile Devices and HIPAA Compliance

Tim Taylor is the Founder and president of TaylorWorks, Inc., a leading managed service provider in Central Florida. Since 1999, TaylorWorks has provided companies with proactive IT support and consulting. Tim successfully guided his company and team over the past 5 years through a 300 percent growth rate. In Tim’s career, he has been a programmer, a network engineer and IT company owner. He is originally from Memphis, Tennessee and has a business degree from the University of Memphis.

Head and Neck Surgeon, continued from page 3

surgical challenges they offer and the rela-tionships he forms with patients. He con-tinues to follow up with patients regularly even after they have completed radiation and chemotherapy.

“As long as they’re survivors, I still see them for routine cancer surveillance appointments,” he said. “Knowing the pa-tient for over a year, you really do develop a close relationship with them.”

Su’s areas of interest also include salivary gland pathology, microvascular reconstruction of complex deformities of

the bony and soft tissues of the face, and cranio-maxillofacial trauma.

He holds a medical degree from the University of California, San Francisco, and completed his oral and maxillofacial surgery residency, including a year of general surgery internship, at the Uni-versity of California San Francisco Medi-cal Center. He is board eligible with the American Board of Oral and Maxillo-facial Surgeons and is a member of the American Association of Oral and Maxil-lofacial Surgeons.


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Physician CME on Infectious Diseases in Orlando, June 27-28

The American Association of Physi-cian Specialists, Inc. (AAPS) will offer con-tinuing medical education (CME) on Up-dates in Infectious Disease, June 27 and 28, 2016, at the Wyndham Grand Orlando Resort Bonnet Creek.

The CME presentations will be held in conjunction with AAPS’s 64th House of Delegates & Annual Scientific Meeting and will include an emergency medicine breakout session. Presentation topics in-clude MRSA, mosquito-borne illnesses, infectious disease in travel, antibiotic re-sistance, and sepsis.

For more information, visit the AAPS website at www.aapsus.org or contact the AAPS Meetings Department at (813) 433-2277.

AAPS, headquartered in Tampa, is the governing body of the American Board of Physician Specialties (ABPS) which certifies and recertifies physicians in a variety of medical specialties. ABPS certifies both MDs and DOs.

Orlando Health Attorney George F. Indest III Selected to 2016 Florida Super Lawyers List

George F. Indest III, President and Managing Partner of The Health Law Firm, has been selected to the 2016

Florida Super Lawyers list. This honor is limited to no more than five percent of the lawyers within the state of Florida. Re-cipients undergo a rigorous multi phase selection process by the research team at Super Lawyers to receive this prestigious honor. Mr. Indest was chosen as a Super Lawyer in the field of Health Law.

Super Lawyers, is a rating service of distinguished attorneys from more than 70 various practice areas who have at-tained a high-degree of peer recognition and professional achievement. The Super Lawyers lists are published nationwide in Super Lawyers Magazines as well as in leading city and regional magazines and newspapers across the country..

In the past year, Mr. Indest has rep-resented a number of health care pro-fessionals, including physicians, dentists, pharmacists, nurse practitioners, and health facilities. Mr. Indest’s articles have been published in Florida Medical Busi-ness and on Kevin M.D. His recognition as a Super Lawyer is also accredited to maintaining the AV Preeminent Peer Re-view Rating of 5.0 out of 5.0 from Lexis-Nexis Martindale-Hubbel, which is the highest level attainable by an attorney.

He is Board Certified by The Florida Bar in the legal specialty of Health Law. He is a member of the executive counsel of The Health Law Section of The Florida Bar, as a well as a certified legal specialist by the U.S Navy in Health Law and Inter-national Law.

Nemours Expands in West Orange County

Families in West Orange County now have greater access to Nemours Chil-dren’s Health System through a new pe-diatrician in the area. Nemours Children’s Primary Care.

Dr. Christine Chan-Ragazzo, a board-certified pediatrician, provides primary medical care to children of all ages, from newborns to adolescents — includ-ing immunizations, school physicals and newborn care.

Nemours Children’s Primary Care, Horizon West is located in Wind-

ermere.The new office uses the same award-

winning electronic health record as the other locations within the Nemours Children’s Health System. And if a pa-tient needs to be treated by a pediatric specialist at Nemours Children’s Hospi-tal, that specialist will have access to the child’s medical history. Chan-Ragazzo is also able to review any additional af-ter-hours care provided to her patients at Nemours Children’s Urgent Care or through Nemours CareConnect, the new telehealth service that launched last fall.

Ribbon Cutting Ceremony Held for Mobile Health Unit

The Florida Department of Health in Seminole County (DOH-Seminole) host-ed a Mobile Health Unit Ribbon Cutting Ceremony on February 16, in Sanford.

Several dignitaries from Seminole County Government attended such as Chairman John Horan, Commissioner Carlton Henley, Commissioner Brenda Carey, and Commissioner Bob Dallari. Norton Bonaparte, City of Sanford Man-ager, was also in attendance.

The mobile health unit is oper-ated by DOH-Seminole, and funded by Seminole County Government, Orlando Health - South Seminole Hospital, True Health, WIC, and Healthy Start Coalition of Seminole County. During today’s cer-emony, each sponsor was recognized for their generous contributions.

DOH-Seminole’s mobile health unit provides health services to homeless, un-insured, and underinsured populations. Clients can obtain the following health services:

• Family Planning – Birth Control and Rechecks, Annual Physical, Preg-nancy Testing, Vasectomy Referrals and Free Condoms.

• Immunizations – Child and Adult, Flu and Pneumonia.

• Physicals - School and College En-try.

• Screenings – Diabetes, Hyperten-sion, Cholesterol, Heart Disease, Body Mass Index (BMI), and Blood Pressure.

• STD, HIV/AIDS, Hepatitis – Testing, Screening, and Education.

• Referrals – Follow-up Care, Smok-ing Cessation and more.

The mobile health unit is located at various homeless population sites, as well as other areas that have challenges with access to care. Locations include Reming-ton Inn & Suites (Altamonte Springs) and Rescue Outreach Mission (Sanford).

DOH-Seminole’s mobile health unit is staffed by an Advanced Registered Nurse Practitioner (ARNP) and Health Support Worker. The mobile health unit accepts Medicaid HMOs, offers insurance billing and payment options including VISA and MasterCard.

Mobile Health Unit services are provided as walk-in only. Specific dates, times, and locations are featured on www.seminolecohealth.com.

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Orlando Medical News March 2016