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The Journal of The Palm Beach County Medical Society

July - August 2011

Medical Education in Palm Beach County


Everyday Heroes… We’re going to need a lot more WOW! Remember that day? You can now be addressed as “Doctor.” After all those years of struggle… you finally graduated, your brain disbelieving that that day you had dreamed about had arrived! The physicians of Palm Beach County have quietly stepped up to compete with the “big boys” of the country in teaching. The University of Miami established programs that culminated in a four-year school of medicine then at FAU, graduating its first class in 2011, utilizing the phenomenal medical staffs at Bethesda and JFK for the third year clerkships, as well as an enormous participation of physicians from all over the county acting as preceptors for the first and second years. The U of M residency program has been very successful at JFK. Plans were being developed for additional programs in general surgery and OB/GYN. Psychiatry was being taught to third-year students at South County Mental Health. Osteopathic students from NOVA compete to be able to train at Bethesda. FAU is welcoming its first class of medical students this year. Wellington Regional has Osteopathic Residents, and St. Mary’s has students flying down from Vermont…and not just for the better weather in winter! The students that have come through the U of M regional campus in Palm Beach County have exceeded all expectations, and have scored above the national average on their exams. What’s the point? The point is that we do have phenomenal physicians and hospitals in Palm Beach County! We do not have to live under the shadow of any nationally recognized hospitals or Universities with regards to the quality of care we provide to our patients…whether they can pay us or not. We go to work every day providing the safety net that all the Government entities talk about, and even mandate. Yet we must constantly deal with “guidelines” from organizations such as JCAHO or the Feds, telling us how to do a job that I think we already do very well. Remember the survey that found Palm Beach County hospitals to have the best mortality rate in the country? Maybe we should export what we do? I am all for being open to new ideas or to ways to better myself. However, as we teach our students we are forced to be able to explain everything we do. And just saying that “I’ve always done it this way” doesn’t work. We are trained as physicians, which means we think and make our own decisions based upon the best evidence presented to us. Just because everyone else does it doesn’t fly either. We need to constantly re-evaluate all we do. Remember the study that crazed the country that childhood vaccines caused Autism? And then it seems the study was flawed after wreaking havoc?

As healthcare reforms pounce upon us, it is imperative that we don’t just jump on…or off… the bandwagon, that we join together to decide what is good for our community. We will be asked to provide the same excellent care to the people of Palm Beach County with less money. We will be asked to spend money smarter, regardless of the marketing from pharma, or even regardless of opinions from so called “authorities” from academia. It’s easy to sit in an office and make pronouncements. It’s another thing to go to work every day and worry if we are meeting the standards of others, which may not fit out community experience.

President’s Report

James J. Byrnes, M.D. I President, Palm Beach County Medical Society

“Dorothy…we’re not in Kansas anymore!” No, we’re in South Florida with our own challenges. Our delegation from the FMA to the AMA has valiantly worked on our behalf, and it is very difficult to explain to the docs in Iowa, Oregon or Kansas that one rule or policy does not fit all. And we can’t just click our ruby slippers and make it all better. Our Medical Society motto is “Looking Out For Physicians” and the Florida Medical Association has “Helping Physicians Practice Medicine” as a motto. The AMA speaks of “bettering public health.” We can serve patients…if we are strong and healthy as physicians. I am not ashamed to say I stand up the physicians first! Strong, quality physicians and hospitals translate into quality care…and good outcomes. This means working to educate not just medical students, but also the general population, our government officials and politicians. The Health Care District of Palm Beach County just appointed Ronald J. Wiewora, M.D., MPH as its chief executive officer! Was a fabulous move! A real physician in charge of delivering health care to the people of our county. On behalf of the Palm Beach County Medical Society, I am proud to congratulate Dr. Wiewora and offer him our support. I have spoken before about the Circus of Medicine and about waiting for the day to come when I can say “They DO know what we do.” I was at the AMA meeting in Chicago for only two days while some very dedicated local physicians took valuable, unpaid time out of their offices for seven days to represent us. And everyone else stayed here earning money every day. How much did they give up to represent our interests? The last weekend of July, our Society had about 20 Physicians who will represent our county, and South Florida, at the Annual FMA meeting in Orlando, again at each’s own expense. I am very proud that our own Dr. Alan Pillersdorf is now Speaker of the FMA House of Delegates, and has appointed me to chair the Reference Committee on Finance and Administration.

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OnCall July - August 2011

11 Feature I 11 I

Transformation: Medical Education in Palm Beach County

Articles I6I

Director’s Desk

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Emtala Issues Remain a Source of Confusion for Physicians

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AMA Update

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Facebook and Social Networking - Friend or Foe?

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Med Memo

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Groupon & Other Daily Deal Sites: Old Regulations and New Problems

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From Peg Boards to PDAs - How technology has evolved in doctors’ offices

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Circle of Friends / Classifieds

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Membership

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T.R. Reid - Best Selling Author (The Healing of America) Jeff Goldsmith, Ph.D. - Health Economist Peter Carmel, M.D. - President American Medical Association Madelyn Butler, M.D. - Past President, Florida Medical Assocation Alice G. Gosfield, J.D. - Physician Leadership Expert Cecil Wilson, M.D. - Past President, American Medical Association


Palm Beach County Medical Society Tenna Wiles I CEO, Palm Beach County Medical Society

“We could learn a lot from crayons: some are sharp, some are pretty, some are dull, while others are bright, some have weird names, but we have to learn to live in the same box.” - Anonymous This summer I have had the opportunity to attend the meetings of the American Medical Association and the Florida Medical Association. It is very clear that physicians around the nation, the state of Florida and in Palm Beach County have very diverse views on health policy issues and how organized medicine should address the challenges facing the medical profession.

Director’s Desk

We Could Learn...

The complexity of issues and diversity of views presents unique challenges for the physician leaders representing Palm Beach County. We are privileged to have strong leadership and representation at both organizations. Allan Pillersdorf, M.D., Jose Arrascue M.D., and Mark Rubenstein, M.D. represented Palm Beach County physicians at the highly spirited AMA Annual Meeting in June. Check out the “Meeting Highlights” on page 10. Under the leadership of President James Byrnes, M.D., 22 physicians served as delegates to the FMA Annual Meeting in Orlando. PBCMS worked with Dade and Broward County Medical Associations as members of the South Florida Caucus representing the best interests of the physicians of South Florida. Special recognition to Alan Pillersdorf, M.D. who served as Speaker of the House of Delegates and was elected as AMA Secretary. Mark Rubenstein M.D. was elected as Alternate Delegate. Our box of crayons has grown much brighter with the expansion of medical education in Palm Beach County. PBCMS member Michael Dennis, M.D. was recently named as Chairman of the Advisory Board of the Charles E. Schmidt College of Medicine at Florida Atlantic University.

The launch of the Charles E. Schmidt College of Medicine and expansion of medical education and residency programs are welcome additions to our community. I am honored to be working with Richard Greenwald, M.D., Chair of the PBCMS Council on Medical Education and Council Members Joan St. Onge, M.D., Brad Feuer D.O., Jeff Davis D.O., Jeffrey Bishop D.O., James Howell M.D., and Mariaelena P Caraballo, D.O. Residents and students representing all programs in Palm Beach County will join to together to create opportunities to support and nurture the future of the medical profession. Each program brings their own individuality but all bring a spirit of optimism and commitment. Their first program will be the 2011 Poster Symposium to be presented at the Future of Medicine Summit V to be held October 27-29 at the Convention Center. For information on the Poster Symposium and the Future of Medicine, go to www.pbcms.org. I invite each of you to consider how you can support medical education in Palm Beach County, whether it is teaching, mentoring or providing financial support to programs and scholarships. It is an investment that will yield great rewards.

2011 Board of Directors

James J. Byrnes, M.D.. . . . . . . . . . . President Jack Zeltzer, M.D.. . . . . . . . . . . . . . President-Elect K. Andrew Larson, M.D.. . . . . . . . . First Vice President Richard Raborn, M.D.. . . . . . . . . . Second Vice President Malcolm Dorman, M.D.. . . . . . . . . Secretary Ronald Zelnick, M.D.. . . . . . . . . . . Treasurer Lawrence Gorfine, M.D.. . . . . . . . . Immediate Past President Brandon Luskin, M.D. . . . . . . . . . . Member at Large Michael Lakow, M.D. . . . . . . . . . . . Member at Large Andrew Shapirio, M.D. . . . . . . . . . Chair, Council on Communications Brent Schillinger, M.D.. . . . . . . . . Chair, Council on Ethical & Judicial Affairs Richard Greenwald,, M.D.. . . . . . . Chair, Graduate Medical Education Daniel R. Higgins, M.D.. . . . . . . . . Chair, Health Information Technology Larry Gorfine, M.D.. . . . . . . . . . . . . Chair, Council on Legislation and Council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on Medical/Legal Affairs Daniel Kapp, M.D.. . . . . . . . . . . . . . Co-Chair, Council on Legislation and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Council on Medical/Legal Affairs David Soria, M.D. . . . . . . . . . . . . . . Chair, Council on Public Health & . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency Medicine K. Andrew Larson, M.D.. . . . . . . . . Chair, Council on Membership William Adkins, M.D.. . . . . . . . . . . Chair, Retired Physicians Section Maureen Whelihan, M.D. . . . . . . . Chair, Women Physicians Section Hatem Abou-Sayed, M.D. . . . . . . Chair, Young Physicians Section Richard Shugarman, M.D. . . . . . . Chair, Specialty Section Harish Madhav, M.D.. . . . . . . . . . . Co-Chair, Ethnic/Minority Section Roger Duncan, M.D.. . . . . . . . . . . . Co-Chair, Ethnic/Minority Section Randy Gershwin, M.D.. . . . . . . . . . Chair, Hospital Relations Mark Rubenstein, M.D.. . . . . . . . . Chair, Bylaws Stephen Babic, M.D.. . . . . . . . . . . . Chair, MEDPAC Andrew Shapiro, M.D.. . . . . . . . . . West District Representative Shawn B. Baca, M.D.. . . . . . . . . . . . South District Representative Mark Brody, M.D. . . . . . . . . . . . . . . Central District Representative Alan B. Pillersdorf, M.D. . . . . . . . . AMA/ FMA Liaison Jose F. Arrascue, M.D. . . . . . . . . . . PBCMS Services Liaison Jacqueline Pevny, M.D.. . . . . . . . . Member at Large Joan St. Onge, M.D. . . . . . . . . . . . . Member at Large Dyani Loo. . . . . . . . . . . . . . . . . . . . . Medical Student Representative

Palm Beach County Medical Society 2011 Board of Trustees

Lawrence Gorfine, M.D. Maureen Whelihan, M.D. Daniel R. Higgins, M.D. Jose F. Arrascue, M.D. Alan B. Pillersdorf, M.D. Brent M. Schillinger. M.D.

Mark Rubenstein, M.D. Jack Zeltzer, M.D. K. Andrew Larson, M.D. James J. Byrnes, M.D. Richard Raborn, M.D.

Staff: Tenna Wiles, CEO Tara Auclair Ryan, Director of Marketing and Community Relations Yvonne Shapiro, Director of Communications Ashley Eckes, Director of Disaster Services Deanna Lessard, Director Member Services & Education Nicola Chung, Project Access Program Director John James, Project Access Senior Program Coordinator Mindi Tingler, Administrative Assistant Natalie Gonzalez, Receptionist Lauren Tomé, Receptionist

OnCALL Managing Editor: Tenna Wiles Advertising Assistant: Yvonne Shapiro Subscriptions to OnCALL are available for an annual rate of $50. For more information, please contact Yvonne Shapiro at (561) 433-3940. The opinions expressed in OnCALL are those of the individual authors and do not necessarily reflect official policies of the Palm Beach County Medical Society, unless so stated. Advertising in OnCALL does not constitute endorsement by the Palm Beach County Medical Society or its committees.

Last OnCall Issue

On CALL is owned and published (6) times per year by the Palm Beach County Medical Society, Inc. 3540 Forest Hill Blvd., West Palm Beach, FL 33406 (561) 433-3940 & (561) 276-3636. © Copyright 2011 Palm Beach County Medical Society, Inc.

Available online at pbcms.org I6I


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OnCall July - August 2011

Emtala Issues Remain a Source of Confusion for Physicians and Medical Staffs By: Jeffrey L. Cohen - The Florida Healthcare Law Firm

EMTALA (the Emergency Medical Treatment and Active Labor Act) was passed by Congress in 1986. The purpose behind the law was to ease the burden of public or so-called charity hospitals from having to treat indigent patients because other hospitals refused to treat such patients due to their inability to pay. EMTALA is a non-discrimination law rather than a law establishing standards of care. The scope of the law is very limited. A hospital’s obligation is to (1) provide an appropriate screening to determine whether an emergency condition exits and (2) if there is an emergency condition the facility cannot transfer a patient until the patient is stabilized or if other conditions of law are met. A physician’s obligation under EMTALA essentially compels a physician who is on call to go to the hospital’s emergency department and to examine and treat a patient as necessary to satisfy the hospital’s screen and stabilize duty. Contrary to what some hospitals claim (and what some medical staffs decide), there is no obligation under EMTALA to see or treat a patient in a physician’s office. A positive or negative outcome has no bearing on the issue of EMTALA compliance. The futility of providing treatment to screen and stabilize is no defense to an EMTALA violation claim. Physicians who fail to comply with EMTALA can expect an investigation from the Office of Inspector General (OIG) of HHS and can face a civil monetary penalty of up to $50,000. Physicians who are found not to comply with EMTALA often face regulatory action (licensing board) and medical malpractice suits. 1. Medical Screening Examination (MSE) Requirement 42 USC §1395dd (a) requires a hospital to provide for an appropriate screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The law proscribes the basic elements of an appropriate MSE, but does not go so far as to dictate the clinical particulars that must be implemented. 2. Stabilizing Treatment Requirement Subsection (b) provides in pertinent part:

the risk involved with the transfer and requests in writing transfer to another medical facility and a physician has a signed certification that based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual… The terms “to stabilize” and “stabilized” are defined in Subsection (e), but are subjective or situational in nature. The definition depends on the risks associated with the transfer and requires the transferring physician faced with an emergency to make a fast on-the-spot risk analysis. Federal Appeals courts have supported the position that “stabilize” for the purposes of transfer is a relative concept that depends on the situation. 3. The Transfer Under subsection (c) of the law, a patient who has not been stabilized cannot be transferred unless there is a signed certification based on the information available at the time of transfer, the medical benefits reasonably outweigh the risk to the individual from effecting the transfer and only if the receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. Only unstable patients require a certification and consent of the receiving hospital. A patient who has been stabilized in the emergency room of the transferring hospital may be transferred to a receiving hospital without a certification and without an express written agreement of the receiving hospital. Stabilized patients may be transferred without any such limitation. Conclusion Medical staffs must be completely aware of EMTALA’s provisions to (1) ensure their members comply, and (2) have meaningful dialogue with hospital administrations, whose business objectives may conflict to some extent with those of the medical staff members. Physicians who are accused of EMTALA violations, either at the medical staff level, or as a result of an OIG investigation, need prompt and thorough guidance.

…the hospital must provide either – A) within the staff and facilities available at the hospital, such further medical examination and such treatment as may be required to stabilize the medical condition, or B) for transfer of the individual to another medical facility in accordance with subsection (c). Under subsection (c) a patient who has not been stabilized may be transferred only if the individual (or his/her representative) understands

With over 20 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen’s practice immerses him in regulatory, contract, corporate, compliance and employment related matters. As founder of the Florida Healthcare Law Firm, he has distinguished himself and his firm for providing exceptional legal services with the right pricing, responsiveness and ethics.

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AMA Update

OnCall July - August 2011

Physicians from every state and specialty set policy that will shape the actions of the AMA on issues of most importance to the nation’s doctors and their patients. Jeremy A. Lazarus, M.D.,

Public health

was elected AMA president-elect. He was House speaker for four years.

AMA House members adopted policy recognizing bisphenol A (BPA) as an endocrine-disrupting agent and urging that BPA-containing products with the potential for human exposure be clearly identified. The new policy also supports ongoing industry actions to stop producing baby bottles and infant feeding cups that contain BPA and to support a ban on the sale of such products. Delegates also supported a national ban on synthetic drugs known as “bath salts.” The House also took aim at obesity by suggesting price parity on fast-food restaurant menus, and by urging corporate responsibility in the use of marketing incentives that promote healthy childhood behaviors.

Care for the uninsured

In a closely watched vote, the AMA House of Delegates reaffirmed policy supporting individual responsibility for citizens to buy health insurance, with assistance for those who cannot afford it. The House also urged the AMA to continue advocating for needed reforms of the Affordable Care Act, including repeal of the Independent Payment Advisory Board and enactment of comprehensive medical liability reform.

Ethics Guidelines for CME

Delegates approved new ethical guidelines for financial relationships with industry in continuing medical education (CME). An AMA council report urged transparency by CME providers on financial ties that might

Medical licensure issues

Alarm among delegates about new maintenance-of-licensure issues prompted the HOD to adopt new policies on the issue. They include calling for the AMA to encourage medical boards to accept participation in maintenance of certification and Osteopathic Continuous Certification as meeting maintenance-of-licensure requirements.

“Residents’ and Fellows’ Bill of Rights”

The “bill of rights” adopted by the HOD outlines the rights of residents and fellows in a number of areas, including duty hours, education, supervision and safe workplace

influence educational activities.

Looking at new membership models

PBCMS Delegates to the AMA

Alan B. Pillersdorf, M.D.

Delegates heard that the AMA Board will report at the Interim Meeting on a new membership concept that will provide for both direct membership (of individuals and groups) and for society memberships.

Jose F. Arrascue, M.D.

Mark Rubensein, M.D. I 10 I


Tranformation: Medical Education

Anthony Silvagni, D.O. Dean of Nova Southeastern University, College of Osteopathic Medicine

Jeffrey Bishop, D.O. Director of Medical Education Wellington Regional Hospital

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Micheal Friedland, M.D. VP of Joint Medical Education Program Charles E. Schmidt College of Medicine

Jeffrey Davis, D.O. Chief Medical Officer St. Mary’s Medical Center

Bradley S. Fever, D.O. Regional Director of Medical Education Columbia Hospital

Paschal Goldsmidt, M.D. Dean of University of Miami Miller School of Medicine


OnCall July - August 2011

in Palm Beach County

By Leon Fooksman

T

en years ago, few medical students and newly graduated doctors were drawn to Palm Beach County because of the low number of clinical clerkship rotations and residencies at hospitals and clinics. That resulted in the county of more than a million people heading toward a shortage of doctors, as not enough young doctors entered practice to replace veteran physicians who retired or left the profession. Today, newly created and expanded physician education programs have local healthcare leaders hopeful that a strain on local medicine, particularly in primary care, will be avoided in the years to come. “The trend in medical education is very favorable for the county,” said Dr. Richard Greenwald, chairman of Palm Beach County Medical Society’s Council of Medical Education. Dozens of medical students are now being trained in Palm Beach County-based schools and hospitals. And dozens more medical school graduates are in residency programs. “Doctors get attracted to going back to where they did their residencies,” said Dr. Joan St. Onge, a member of Palm Beach County Medical Society’s Council of Medical Education. “Through all these new programs, we’ll see many of them settle and work here.” The largest new initiative is the opening of Florida Atlantic University’s Charles E. Schmidt College of Medicine in Boca Raton. The first class of 64 students is starting this fall. The school will put students to work with physicians in the community during the first year as part of an innovative curriculum that focuses on community-based clinical experiences and problem solving. In the next four years, the school anticipates enrolling 256 students. That means, by the time of its first graduation, Charles E. Schmidt College of Medicine plans to secure up to 250 residencies at hospitals in Palm Beach and Broward counties. The residencies will be in specialties such as internal medicine, pediatrics, and surgery.

Other physician education programs in Palm Beach County are: • JFK Medical Center in Atlantis and Bethesda Memorial Hospital

in Boynton Beach offer clinical clerkships to University of Miam Miller School of Medicine Regional Campus students. JFK Medical Center and West Palm Beach Department of Veterans Affairs Medical Center also offer residencies.

• Wellington Regional Medical Center’s Family Practice Residency Program is affiliated with the Lake Erie College of Osteopathic Medicine. • St. Mary’s Medical Center in West Palm Beach provides clinical clerkships to University of Vermont College of Medicine students. • Palm Beach Centre for Graduate Medical Education offers residencies at Palms West Hospital in Loxahatchee, Columbia Hospital in West Palm Beach, and JFK Medical Center. • Lakeside Medical Center runs the Family Medicine Residency Program as well as Palm Beach County Preventive Medicine/ Public Health Residency Program, which is a collaborative program between the Palm Beach County Health Department and the Nova Southeastern University College of Osteopathic Medicine. • Bethesda Memorial Hospital offers a clinical rotation to Nova Southeastern University College of Osteopathic Medicine. Another local medical college also is being planned. Palm Beach Medical College in West Palm Beach, a wholly owned subsidiary of Palm Beach Medical Education Corporation, was granted provisional licensure by the Florida Department of Education Commission for Independent Education in January. The forprofit college is now moving ahead with the development of the curriculum. These programs have eased concerns among healthcare advocates, hospital administrators, and business leaders about emergency rooms being pushed to capacity and long waiting times at physicians’ offices. But they stress that more clinical clerkship rotation and residency programs are needed as an already-crowded healthcare system prepares to absorb thousands of new people once President Obama’s main healthcare reforms go into effect in 2014. All this comes amid the possibility of drastic cuts to the Medicare subsidy for postgraduate medical education at the nation’s teaching hospitals. The bipartisan National Commission on Fiscal Responsibility and Reform has recommended as much as $5.8 billion in cuts to help reduce federal spending. The potential for a doctor shortage is real, mainly because physicians are aging. Other reasons for leaving medicine: high cost of liability insurance and poor reimbursement rates.

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Save the Date for the

Annual Gala December 3, 2011


OnCall July - August 2011

Facebook and Social Networking – Friend or Foe?

By Joseph Putz, LHRM Risk Management Consultant First Professionals Insurance Company

S

ocial networking and blogging are increasingly popular forums in our society. Facebook© currently has over 600 million active users, a phenomenal number considering the fact that it was launched just seven years ago. Other social networking services have experienced similar growth. All of these services are increasingly becoming an integral part of the lifestyle of our society. Along with the growth and popularity of social networking sites comes the issue of the risks associated with their usage. The sites offer individuals the ability to share information and communications with family and friends. Privacy issues thus become a key concern, centering on the placement of personal information on the site and the ability to view and share this information by others. Communications intended for a limited audience can be seen by “friends” who might take a comment out of context or draw the incorrect conclusion based on that comment. Once something is posted, it never can be totally removed or eliminated. Physicians and other healthcare providers have an even more unique dilemma. Should they participate in networking, and should they “friend” patients? The answer to these questions is not an easy one, since there are both benefits and risks associated with networking. The most obvious benefit involves increased communications between doctors and patients, which can enhance the physician-patient relationship. The risks include the previously mentioned issue of privacy, and the potential for confidential information to be posted (or the perception of confidential information). Sachin H. Jain M.D., MBA recently wrote an article for the New England Journal of Medicine, “Practicing Medicine in the Age of Facebook©.” In this article, Dr. Jain tells the story of a caregiver who posted her experience involving her interaction with a difficult (unnamed) patient, forgetting the fact that one of the patient’s family members had been a recent addition to the caregiver’s network of “friends.”

Throughout their medical education, doctors are taught the importance of maintaining a professional relationship with their patients. This implies the need to maintain a professional distance between themselves and their patients. The posting of comments and pictures to a social networking site can blur these lines and may expose personally held opinions and beliefs to the general public. Additionally, pictures and comments posted to a social network, which previously were private, can subsequently be utilized in ways that could be to the doctor’s detriment. Just as employers may search social networking sites for information on prospective employees, prospective patients may take the same approach when selecting a physician. Social networking can be a useful tool for certain activities and efforts. However, its usage in a professional setting should be carefully considered and very specific guidelines should be developed should the decision be made to participate in these activities. Remember, the only way to completely avoid liability for comments or postings on networking sites is to not use those vehicles at all. First Professionals Insurance Company is a leading medical professional liability insurance carrier. For more than 35 years, FPIC has been dedicated to providing the highest quality products and services to protect healthcare providers. To request more information regarding our risk management program, please call (800) 741-3742, ext. 3016 or send an e-mail to rm@fpic.com.

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President’s Report - Continued from pg 2 As we are facing some very uncertain times over the next few years, it is imperative that we stay together, that we unite as if in that union we’re not allowed to have, that we budget funds from our offices for dues to the PBCMS and the FMA to represent us, that we badger fellow physicians to join us in this quest, that we take credit for our ability to provide a quality education to our young medical students, who still have high ideals about what being a physician means. The Medical Society has formed an advocacy group with our County’s hospitals, and I must ask the medical staffs of every hospital in the County to ask their hospital administrations to financially support this effort, following the leads of the administrations of Bethesda and JFK hospitals who have already done so, but can’t do it alone. We have had significant contributions from Physicians, but we need the hospitals pocket books to be opened, too. Working quietly, without lots of fanfare, the U of M Regional Campus attracted some very qualified medical students who took a major gamble that the Physicians and hospitals of Palm Beach County could provide them with a world class education. And we did! We have to take credit for this treasure, and recognize the ability we have to make a difference. We have included medical students and residents on the Board of the PBCMS, in an effort to stay in touch with each other, to keep up with the progress of medical education in Palm Beach County, and to keep the students and residents involved with our physicians. Our Future

of Medicine summit this fall promises to be ever better, and we will have a Poster Symposium for students and residents, too. We must continue to support our future colleagues as they progress in their education. We have to join together to be strong so we can make sure we can continue to share our knowledge with our students, and be recognized for the genuine quality care we deliver every day.


Med Memo

OnCall July - August 2011

July - August 2011

SUMMER SCHOOL FOR PHYSICIANS August 24. 6:00 – 7:30 PM “How Physicians and Chiropractors Can Work Together, Share Revenues and the Legal Issues Involved” Location: The Florida Healthcare Law Firm, 909 SE 5th Avenue, #200, Delray Beach Summer School Programs for Physicians are free for members. Light refreshments will be served. To RSVP and for additional information call 561-433-3940 or contact deannal@pbcms.org

Office Manager’s Institute Series 2011-2012 Office Manager Institute Series – Delray Beach Golf & CC Attention Practice Administrators, Managers & Physicians!

EDUCATIONAL OPPORTUNITIES November 4-5. “Thirtieth Annual Echodardiography Symposium” Doral Marriott Resort. 11 Cat. 1 CME Credit. For additional information call 786-596-1667 or contact juliez@baptisthealth.net November 12-13. “Third Annual Coronary CTA in the ED: A Hands-on Workshop” Fontainbleau Hotel, Miami Beach. 16.5 Cat. 1 CME Credit. For additional information contact juliez@baptisthealth.net November 13-16. “Eleventh Annual Emergency Radiology Symposium” Fontainbleau Hotel, Miami Beach. 18.5 Cat. 1 CME Credit. For additional information contact juliez@baptisthealth.net Twenty-Six Annual Sanford H. Cole, M.D., Memorial OB/GYN Symposium January 27, 2012. Miami Marriott Dadeland. For additional information contact maidap@baptisthealth.net or call 786-596-1667

Navigating Health Care Reform

We are excited to be expanding our OMI series to Delray Beach this season. We have lined up some great presentations. We are offering four sessions (October, January, March & May) and they will be held at the Delray Beach Golf Club 2200 Highland Avenue, Delray Beach on the third Wednesday of each month from 11:30 – 1:00 There is a $25 charge for each lunch program for PBCMS members and their staff and $35 for non-members & staff. Register online at www. pbcms.org for the entire series by October 3rd and save $10 - $90 Members and $130 for non-members. Topics and dates are as follows: • October 19th - Minimizing the Risk of Embezzlement in the Medical Office • January 18th - Healthcare Reform 101 • March 21st - ICD-10 Coding Tips to Avoid Denials • May 16th - Accountability – People do Exactly What We Let Them Do

2011-2012 Office Manager Institute Series – Hilton- PB Airport Attention Practice Administrators, Managers & Physicians! We have lined up informative educational programs and speakers for 2011 – 2012. Sessions are scheduled October 2011 thru June 2012 and will be held at the Airport Hilton 150 Australian Avenue, WPB on the first Wednesday (with the exception of January 2012 luncheon) of each month from 11:30 – 1:00 There is a $25 charge (includes lunch) per program for PBCMS members and their staff and $35 for non-members & staff. Members can save money by purchasing the entire series of 9 programs now for only $200 ($25 savings) if you register by October 3rd. Non-members $290 Topics and dates are as follows: • October 5th - Turning Good Employees into Great Employees • November 2nd - How to Develop & Implement a Practice Analysis • December 7th - Mobile Medical Computing - Changing the Medical Community • January 11th - Coding & Compliance 2012 (11:30 – 2:00) • February 1st - Google Plus • March 7th - How to Handle Difficult Employment Situations • April 4th - Stark & Anti Kick Back Laws & Other Hot Legal Issues • May 2nd - Managed Care Contracting – It’s More Than Just the Rate • June 6th - Managing Your Denials

Register on line at www.pbcms.org Series enrollment deadline is October 3, 2011

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Groupon & Other Daily Deal Sites:

Old Regulations and New Problems By: Jeffrey Segal, M.D., J.D. and Michael J. Sacopulos, J.D.

L

ast week, I receive a Groupon alert for a local restaurant I like. For those of you living under a rock, Groupon is a social networking group discount program.

Here’s how it works. A local merchant, like a restaurant or hair salon, offers a discount - often 50% off or more. This gets a lot of attention. But, the discount isn’t activated until a critical mass of Groupon subscribers ‘tip” the deal. Enough people must commit to “paying” for the discount. That’s how Groupon gets paid. For the restaurant, the deal was $60 off. But, you had to pay Groupon $30 for the $60 off coupon. If you’re good at math, you recognize the deal is really $30 off – still a nice discount. The deal didn’t activate until it tipped with 20 people. Over 1,100 people ultimately took advantage of the deal. You now see the power of a rip-roaring discount. The restaurant will have to deliver. For all I know, they might “eat it” on this deal. But, if the restaurant’s goal was to turn on a large number of people to their restaurant to try it out – and potentially become repeat customers, this Groupon deal might be a smashing success. Onward to health care. Some physicians and dentists have jumped in – offering Groupon discounts to subscribers for services. Their goal is the same as the restaurants. Think of the discount as a loss leader. Introduce the patient to the office. If they are happy with the service and care provided, perhaps they will become loyal, long-term paying patients. Some doctors are already reporting eye-popping results. Over 900 new patients for a cosmetic procedure in California. Over a hundred new patients for dental work. Are these doctors losing money on the heavily discounted procedures? Difficult to tell. Will these people become longterm patients? Who knows? Here’s what we do know. Most medical and dental licensing boards

have updated long-established policies that might create headaches for doctors embracing Groupon and other online daily deal discount websites as a marketing tool. A scant few are tackling the issues. Most are sitting on the sidelines. More on that in a minute. Most licensing boards, if not all, have strict policies prohibiting feesplitting. Fee splitting occurs when a patient is “induced’ to visit a provider and the doctor “kicks back” a referral fee to the referrer. There are safe harbors which don’t trigger enforcement of fee-splitting penalties – such as when a doctor refers to another doctor in his multispecialty practice – and they are both employees in the same facility. If they split profits at the end of the year, then, in a sense, the referral has generated extra fees split by all. Fortunately, as a safe harbor, this does not trigger any action. But, if two unrelated doctors have a handshake agreement whereby referrals will be paid a cool $300 for every surgery – that’s likely against the law – and probably violates licensing board fee-splitting policies. On its face, doctors who sponsor Groupon discount deals are cutting Groupon in on their professional fees for the referrals And, since there is no safe harbor for Groupon deals, a doctor could be on the wrong side of a Board investigation. In the earlier example, it’s easy to see how a doctor abuses the trust of his patient by getting paid for referring to a surgeon and receiving cash for the referral. The cash taints the doctor’s judgment – and it puts the doctor’s financial interest above the patient’s interest. But, do payments to Groupon promote that same type of abuse? Doubtful. With Groupon, the prospective patient is being given information and a discount. The patient is free to make their own decision as to whether or not to accept the advertised discount. There is no pre-existing doctor-

Continued on pg 19 I 17 I


FROM PEG BOARDS TO PDAs

OnCall July - August 2011

How technology has evolved in doctors’ offices By Larry Mellgren - Thinsolutions

W

hen I started selling billing systems in 1987, I did some market research. I found that only about 15 percent of offices had computers for billing. Of those, most were larger practices with mini computers. Most of the other offices were using peg boards for billing. If you remember, the peg board system consisted of multiple NCR (no carbon required) forms so that you could write on one form and have the results transferred to another form, winding up on a ledger card that was used to record all patient financial activity. If you needed to do an insurance form, you completed it by hand or typed it and mailed it to the carrier. When you needed to send a statement, you simply copied the ledger card and mailed it to the patient. When payments were received, you used the peg board system to record the results. As you can imagine it was a very labor intensive operation and prone to errors. With the advent of the IBM PC AT in the late 1980s, there was finally enough power in an affordable computer to allow small to medium-size offices to do appointments, billing and accounts receivable electronically. The system would not only keep track of charges and payments, but also allow you to print forms and statements with a dot matrix printer. You could now also keep track of your accounts receivable and produce management reports easily. When a practice needed to have more than one person working on their date at the same time, they used technology such as a local area network, ZENIX or UNIX operating system. Now that the data was captured electronically, the next logical step was to transmit claims electronically; first to Medicare and Medicaid and then through clearing houses to private insurers. Electronic remittance and statements became available and would save offices time and money. On the clinical side, preliminary steps were taken to automate documentation of progress notes utilizing voice recognition. Early results were not that good due to lack of computer power and immaturity of the software. Electronic medical records were starting to show up in a few forward thinking practices; however, the cost and complexity of the early offerings kept most practices away.

Fast forward to today. The Electronic Medical Records of today, thanks to increased computer power and better software, are rapidly moving into doctors’ offices. Not only will they automate documentation utilizing voice recognition and templates, but they include E. prescribing, Computerized Patient Order Entry, labs, faxing, scanned images, referral letters and many other useful features that can allow an office to go paperless. Because the data is now electronic it can easily be shared and mined. It also lends itself to facilitating secure patient communications through patient portals. Patient portals will not only allow secure communications between providers and patients, but will also allow appointments to be requested, patient forms to be filled out on-line, patient education, practice marketing and even patient payments. Remote access is also facilitated with the new array of technology bursting forth on the market. You can now access your clinical data with a laptop, tablet, iPad, smart phone or PDA. Via the Internet, a provider can be almost any place on the earth and, with proper authority, have access to their data. This not only improves patient care but also reduces a large amount of stress and increases productivity. With all this wonderful technology does come more responsibility to make sure that it is purchased with your existing technology and work flow in mind. That it is implemented properly, supported properly, backed up properly and updated properly. If your billing system goes down you stack up your Super Bills and march on. When you have EMR’s partnering with a solid IT support company, having qualified personnel on staff is a must. You must have maximum up-time and 24/7 monitoring to make sure problems are caught before they become an emergency. So in a brief span of years we have gone from the peg board and the paper chart to the wonderful technology that is available today. The rate of change is ever increasing so who knows where we will be in future years. It will be an exciting ride.

Thinsolutions is a local IT services company that provides Managed Services, Hosting Services, Cloud Services, Web Design and optimization and Software Development. They also represent Microsoft Office based gloStream EMR and PM in South Florida. Larry can be reached at 954-585-9112 or lmellgren@thinsolutions.com. www.thinsolutions.com

I 18 I


New Doctor Education Programs Aim To Prevent Physician Shortages - Continued from pg 11 In Florida, about 64 percent of doctors were 46 or older in 2008, according to the state Department of Health’s 2008 Florida Physician Workforce Annual Report. Also, 13 percent of doctors planned to reduce significantly their scope of practice or leave medicine in the next five years. In addition, 11 percent of physicians who took emergency room calls said they reduced the number of hours they worked in a hospital emergency room. The Association of American Medical Colleges has warned of a physician deficiency of up to 125,000 doctors by 2025 across the United States. Locally, medical leaders say a lot has been accomplished in recent years to head off any shortages.

“We’re headed in the right direction,” said Dr. Greenwald, who is also professor of clinical biomedical science at Charles E. Schmidt College of Medicine. Dr. St. Onge, also assistant regional dean for clinical curriculum at University of Miami Miller School of Medicine Regional Campus, agreed. “We’re definitely addressing the physician shortage,” she said. Leon Fooksman is a journalist who writes for OnCall. You can reach him at fooksman17@gmail.com.

Groupon & Other Daily Deal Sites: Old Regulations and New Problems - Continued from pg 17 patient relationship whereby misplaced trust can result in a bad outcome. The Groupon model is consumerdirected health care in action. The federal government has laws on its books which also prevent “kickbacks.” The Office of Inspector General for U.S. Dept. Health and Human Services (“OIG”) issued an Advisory Opinion on an analogous program – pay-per-lead – or pay-per-call program. There, OIG concluded that a pay-per-lead program did indeed violate the plain language of the Anti-Kickback Statute. And, such a program did not qualify for any statutory safe harbor. That said, OIG concluded they would not enforce the statute against participants in those programs, because such programs did not promote the type of abuse the statute was meant to curtail. While helpful in giving a doctor comfort, a doctor making a decision whether or not to participate in Groupon must also pay attention to policies of their state professional licensing board. And, as noted, most licensing boards have explicit prohibitions against “fee splitting.”

I 19 I

The Oregon Board of Chiropractic Examiners (“OBCE”) appears to be the first out of the gate to tackle the issue. At a recent meeting, they formed a committee to draft language bringing their fee-splitting policy into the Internet age. Such language, if adopted, would narrowly allow doctor participation in Groupon-like programs without opening the floodgates for other practices which abuse the doctor-patient relationship for personal financial gain. It is unlikely professional licensing boards would take a strong stand against individual doctors for promoting Groupon deals. After all, the model voluntarily pushes down the cost of health care. But, Board investigations are often complaint-driven. So, if patients complain to the Board for any number of reasons, an investigation might broaden to include allegations fee-splitting. Doctors who want to test the waters with social networking group discount programs would be well advised to proactively lobby their licensing bodies to update their decades-old fee-splitting policies. If a Board takes action against a doctor for fee-splitting, you can be sure that any assessed penalty would not be at a Groupon discount rate.


PBCMS Circle of Friends

OnCall July - August 2011

The Palm Beach County Medical Society is most grateful to its Circle of Friends. Your support helps us provide services to physicians, healthcare providers, patients and our community. We couldn’t do what we do without you! Acevedo Consulting Coding & Compliance Specialists 561-278-9328 jacevedo@acevedoconsulting.com Alpern Rosenthal Accounting & Tax Consultants 561-689-7888 tclarke@alpernfl.com Anderson Moore Construction 561-753-7400 jschumacher@amcbuild.com Avisena Revenue Cycle Management 305-446-8599 bfoster@avisena.com Broad & Cassel Attorneys at Law 305-373-9430 msegal@broadandcassel.com Danna-Gracey Medical Malpractice & Workmen’s Compensation Insurance 561-276-3553 matt@dannagracey.com FPIC Medical Malpractice Carrier 800-741-3742 hakes@fpic.com

Gulfstream Business Bank 561-665-4212 jchen@gsbb.com

Shutts & Bowen, LLP 561-835-8500 tmonaghan@shutts.com

Interim Healthcare of the Treasure Coast 561-616-9500 sgriffin@interimhealthcare.com

Suntrust Bank 954-765-7194 elizabeth.breslin@suntrust.com

Ironstone Bank 561-253-8135 laura.king@ironstone.com

The Florida Healthcare Law Firm 561-455-7700 jcohen@floridahealthcarelawfirm.com

Managed Care Advisory Group (MCAG) 800-355-0466 jgadd@mcaginc.com

ThinSolutions Remote Control IT Management 941-741-4287 lmellgren@thinsolutions.com

Morgan Stanley Smith Barney 561-393-1535 patricia.c.corbett@mssb.com Northwestern Mutual 561-622-4699 david.coldwell@nmfn.com 561-962-2931 david.laser@nmfn.com

VNA of Florida Home Health Agency 1-800-318-0399 Windstream Communications 954-727-2121 barbara.burns@windstream.com

Proffitt Management Solutions Business Coach 561-582-6060 nancy@proffittmanagement.com

Classified Ads OFFICE BUILDING FOR SALE OR LEASE Free standing, Approximately 4000 square ft. building, 18 parking spaces, handicap accessible ramp. Perfect for a physician’s office, across from Bethesda Memorial Hospital. Options available to lease partial, all or purchase. To discuss options, please call Eric Luckman at 561-436-5414 or Joanne Luckman at 561-436-5411. 3652 S. Seacrest Blvd. Boynton Beach, FL 33435. SEEKING TO PURCHASE OFFICE-BASED PRACTICE Seeking to purchase office-based practice from someone interested in retiring after December 2011. Call Marian: 941-256-8886 or 407-855-1121 MEDICAL OFFICE FOR SALE OR LEASE Near Palm Beach Gardens Medical Center, X-ray ready, move-in ready. Call 561-627-4000 ext. 4 or email jcb@jcbills.com for more information.

PRIMARY CARE PHYSICIANS We’re seeking an Associate for our growing outpatient practice in Boynton Beach. Generous salary, benefits and growth prospects. Send resume to resumes@primus-fl.com

Follow us on and to keep abreast of the latest news and activities from PBCMS I 20 I


Palm Beach County Medical Society Membership Applicants Richard A. Daigle, D.O. PO Box 1407, Boca Raton, FL 33429 Phone: 561-955-0357 Specialty: Anesthesiology Medical School: University of Nebraska Medical Center 2000 Internship: NJ University of Medicine & Dentistry 2001 Residency: Fletcher Allen Healthcare 2001-2004 Hospital Affiliations: Orange Park Medical Center (Jacksonville) Date of Birth: 1/15/1971 Nikerson Geneve, D.O. 941 SE 1st Street, Belle Glade, FL 33430 Phone: 561-992-9477 Specialty: Family Practice Medical School: Nova Southeastern University 2006 Internship: Wellington Regional Medical Center 2006-2007 Residency: Wellington Regional Medical Center 2007-2009 Board Certification: American Osteopathic Board of Family Practice Hospital Affiliations: Lakeside Medical Center Date of Birth: 4/11/1978 Sol V. Guerrero, M.D. 11135 Jog Road, Suite 5, Boynton Beach, FL 33437 Phone: 561-374-8969 Fax: 561-374-8929 Specialty: Endocrinology, Diabetes and Metabolism Medical School: St. Christopher College of Medicine 2005 Internship & Residency: Medical College of Georgia 2006-2009 Board Certification: American Board of Internal Medicine Hospital Affiliations: Boca Community Hospital Date of Birth: 8/23/1968

I 21 I

Scott R. Meisel, D.O. 1397 Medical Park Blvd., Suite 100, Wellington, FL 33414 Phone: 561-964-2211 Fax: 561-641-7171 Specialty: General Surgery Medical School: New York Institute of Technology 1991 Internship: Beth Israel Medical Center 2000-2001 Residency: Nassau University Medical Center 2001-2006 Fellowship: Nassau University Medical Center 2006-2007 Fellowship: University of Virginia 2007-2008 Fellowship: Stony Brook University Medical Center 2009-2010 Board Certification: American Board of Surgery Hospital Affiliations: Wellington Regional Medical Center Date of Birth: 3/28/1973 Joan E. St. Onge, M.D. 160 JFK Drive, Suite 205, Atlanits, FL 33462 Phone: 561-548-1548 Fax: 561-548-1552 Specialty: Internal Medicine Medical School: Georgetown University 1986 Internship: Georgetown University 1986-1989 Residency: Georgetown University 1989-1990 Board Certification: American Board of Internal Medicine Hospital Affiliations: JFK Medical Center Date of Birth: 7/10/1958


PRSRT STD US POSTAGE

PAID WEST PALM BEACH, FL PERMIT NO. 515

3540 Forest Hill Blvd., Suite 101, West Palm Beach, FL 33406 RETURN SERVICE REQUESTED

The Future

When the government made money available to help doctors make the move to electronic health records (EHR), they entrusted just a few organizations with the funding and training to help doctors make that transition.

The Team

South Florida Regional Extension Center is the local organization that has been selected to help you transition to EHR and use it in a meaningful way to improve patient care and safety. That’s why the Palm Beach County Medical Society (PBCMS) has partnered with and supports the REC. Our highly trained specialists will help you ask the right questions to select the best EHR solution for your practice and help you reach the government standards for EHR meaningful use.

The Cost

SIGN UP TODAY www.pbcms.org pbcms@pbcms.org 3540 Forest Hill Blvd., Suite 101 West Palm Beach, FL 33406 561-433-3940

For the first 2,500 priority primary care physicians who sign up with the South Florida REC, this critical service is 100% FREE. There is no need to hire expensive consultants or search through a multitude of vendors. The South Florida REC will save you time and money in your transition to EHR. Not only that, The South Florida REC will help speed your journey toward meaningful use and the government incentives that go along with reaching that goal.

The Incentive

Practices that accept Medicaid are eligible to receive up to $63,000 in incentive money once they reach the government standards for meaningful use. Practices that accept Medicare are eligible to receive up to $44,000 in incentive money once they reach the government standards for meaningful use.

The Regional Extension Center

Because the REC is funded, trained and approved by the Office of National Coordinator, we are the recognized experts on EHR selection and implementation and the government’s standards for meaningful use.

SOUTH FLORIDA

REGIONAL EXTENSION CENTER®

The Journal of Palm Beach County Medical Society (July-August 2011)  

In this issue: pg. 2 . - Presidents Page pg. 8. - Emala Issues Remain a Source of Confusion for Physicians and Medical Staffs pg. 10 - AMA...

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