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OnCALL

THE OFFICIAL PUBLICATION OF THE PALM BEACH COUNTY MEDICAL SOCIETY

2021 Q2

ADVOCACY MATTERS


David Drossner, MD Director, Outpatient Cardiology

Sarah Fuchs, MD Fetal and Pediatric Cardiology

Proudly Welcome

Himanshu Adlakha, MD Fetal and Pediatric Cardiology

To discuss the needs of a prospective patient, or to schedule an appointment in Northern Broward, Palm Beach or Martin counties, please call the Nicklaus Children’s Heart Institute at 561-514-7390. We are also available to consult with other healthcare providers at any time of the day or night via our 24/7 on-call cell phone number at 561-203-1026.

Nicklaus Children’s Pediatric Specialists at Coral Springs 9750 NW 33rd Street, Suite 109, Coral Springs, FL 33065 nicklauschildrens.org/CoralSprings

Nicklaus Children’s Boynton Beach Care Center 10383 Hagen Ranch Rd., Suite 200, Boynton Beach, FL 33437 nicklauschildrens.org/BoyntonBeach

Nicklaus-2121 PBCMS OnCall Quarterly NCPS-Heart Quarter 2_FINAL.indd 1

Nicklaus Children’s Palm Beach Gardens Outpatient Center 11310 Legacy Ave., Legacy Place, Palm Beach Gardens, FL 33410 nicklauschildrens.org/PalmBeach

Nicklaus Children’s Pediatric Specialists at Palm City 3228 SW Martin Downs Blvd., Suite 33, Palm City, FL 34990 nicklauschildrens.org/PalmCity

4/8/2021 5:03:51 PM


AFTER THE STORM, WHEN DAWN ARRIVES

WE CAN’T LET OUR GUARD DOWN!

By Roger Duncan, MD 2021 PBCMS President

A lot has changed since I wrote my inauguratory article laying out my vision and desired accomplishments for the upcoming year. Over the last several months, I have witnessed progress, and the demonstrated importance of health care providers and science to the health of a community and economy. COVID-19 vaccinations are in full swing, with approximately 84 million persons fully vaccinated, which represents about 30% of the United States population, and schools, amusement parks and bars re-opening. And, while this is good news, the Centers for Disease Control and Prevention reports that Florida is the first State to surpass 3,000 cases of the variants from the United Kingdom, South Africa and Brazil. So, while we have seen progress, we can’t let our guards down. We have to stay vigilant and for the sake of our colleagues, patients and community continue to be the leaders on one of the biggest challenges Palm Beach is encountering. So, how has the Palm Beach County Medical Society been leading, under my tenure, for the last several months? We have educated patients about the importance of COVID-19 testing and receiving early Monoclonal Antibody therapy, as well as, advocated for patients to receive COVID-19 vaccinations in physician offices. We have conducted very informative Town Hall discussions with the Florida Surgeon General, Dr. Scott Rivkees, regarding the logistics, statistics, and outcomes of Gov. Ron Desantis’ COVID-19 response. I’ve personally expressed to him that we, as a medical society, and individual physicians stand ready, and have signed up to be vaccine providers to our patients and the public. Physicians are often the best and right persons to lead on the issue of convincing, encouraging and educating our COVID-19 vaccine hesitant populations. Studies have long shown, for example, that many patients in AfricanAmerican, Hispanic, rural and other underserved communities distrust the medical community. While

they often express distrust of institutions and studies, they do express trust in their own personal physicians and that is the reason why our Physician Leadership Academy has also undertaken novel efforts to encourage and educate on the importance of vaccines. We have also been working collaboratively with other medical societies to reach all citizens within our community. We continue our very active drive of Advocacy and Legislative affairs. In February, we held a virtual town hall with more than half a dozen state legislators who met with several dozen physicians and engaged in frank discussions regarding the standard of care which should be provided to patients and the need for physicians to be involved in the management of patient care. They heard and acknowledged our issues and will bear these facts in mind as they participate in a very active and consequential Legislative season unfolding in Tallahassee. While we wholeheartedly respect the work of mid-level providers, we have to continue to defend from further encroachment in the scope of our practice. We look forward to once again having in-person visits to our Senate and House legislators both in Tallahassee and their local offices. We have worked to find novel and unique ways to reimagine our traditional events and continue to provide many overworked physicians and medical professionals the opportunity to continue to engage and interact as a group. We hosted 50 physicians to a sold-out virtual wine tasting event with a world renowned and Master Sommelier, Virginia Philip, the 11th woman in the world to earn this accreditation, where we enjoyed excellent wine and learned about wines from many regions. Residents, fellows, and other physician scholars will be able to virtually showcase their research projects and President’s Message continued on page 5 2021.Q2 

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TABLE of CONTENTS

BOARD OF DIRECTORS

DEPARTMENTS

2 4

President’s Report Welcome New Members

FEATURES Chief Executive Officer of Palm Beach County Medical Society By Kelly Skidmore, CEO PBCMS

6 7

Celebrating Doctors Day with a Toast Document! Document! Document! By June Conner COC and Karen Green CPB, CPC

8 11

18th Annual Heroes in Medicine – May 20th How SBIRT Toolkit Can Help Tackle Drug Overdose Epidemic In Palm Beach County And Beyond By Leon Fooksman

14

BEFORE COVID-19, Outlier Medical Malpractice Verdicts Were Rising—What’s Next? Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company, and Leader of the TDC Group of Companies

16

2021 Renewal Success

Barry Levi, Founder and President Jeremy Cohen, Senior Group Benefits Agent

18

Medical Real Estate Buzzword Alert: “MedTail” Lesley Sheinberg

20

2021 James J. Byrnes Poster Virtual Showcase

Gauri Agarwal, MD & Lisa Martinez, MD

21

ABOUT THE COVER Florida State Capitol photo is courtesy of Wikimedia Commons, the free media repository, user :DXR, Daniel Vorndran. July 2016 Old Florida State Capitol, Tallahassee, East view 20160711 1.jpg https://commons.wikimedia.org/wiki/File:Old_Florida_ State_Capitol,_Tallahassee,_East_view_20160711_1.jpg creativecommons.org/licenses commons.wikimedia.org

Subscriptions to OnCall are available for an annual rate of $50. For more information contact PBCMS at (561) 433-3940. The opinions expressed in OnCall are those of the individual authors and do not necessarily reflect official policies of Palm Beach County Medical Society or its committees. OnCall is owned and published four (4) times per year by Palm Beach County Medical Society, Inc., 3540 Forest Hill Blvd., #101, West Palm Beach, FL 33406. (561) 433-3940. ©Copyright 2019 Palm Beach County Medical Society, Inc. OnCall Journal is designed and edited by Mad 4 Marketing. Visit us on the web at mad4marketing.com 954.485.5448

3 Q2.2021 

Roger Duncan, MD – President Claudia Mason, MD – President-Elect Dawn Davanzo, MD – First Vice-President Martha Rodriguez, MD – Secretary Andrew Berkman, MD –Treasurer Larry Bush, MD – Immediate Past President Ayesha Abid James Heron, MD Rena Amro, MD Marc Hirsh, MD Jose Arrascue, MD Krishna Kishor, MD Stephen Babic, MD Ekaterina Kostioukhina, MD Shawn B. Baca, MD Catherine Lowe, MD Colette Brown-Graham, MD Harish Madhav, MD Ramon L. Cuevas-Trisan, MD Alan B. Pillersdorf, MD Kleper de Almeida, MD David Shulan, MD Micheal Dennis, MD Ali Syed, MD James Goldenberg, MD Charles Szuchan Gregg Goldin, MD Justin Williams, DO Faustino Gonzalez, MD Jack Zelter, MD Henry M. Haire, MD

BOARD OF TRUSTEES Brandon Luskin, MD Marc J. Hirsh, MD Larry Bush, MD Alan Pillersdorf, MD Mark Rubenstein, MD Jack Zeltzer, MD Jose F. Arrascue, MD Chair Roger Duncan, MD Claudia Mason, MD Dawn Davanzo, MD Martha Rodriguez, MD

BOARD OF DIRECTORS Ivy Faske, MD – President Matt Gracey – Vice President Stuart Miro, MD – Secretary Don Chester – Treasurer Michael T.B. Dennis, MD – President Emeritus

Jean Acevedo Elaine Alvarez Jose F. Arrascue, MD Brenda Atkins Steven Borzak, MD Madelyn Christopher Ljubica “Jibby” Ciric Patti Corbett Bobbi Horwich Barbara James Andrew Larson, MD

Gary Lesser, Esq Roshan Massoumi Alan B. Pillersdorf, MD Brent M. Schillinger, MD Mollie Shulan, MD Ben Starling III Patricia Thomas Maureen Whelihan, MD Paul Wieseneck Jack Zeltzer, MD

STAFF

Kelly Skidmore – CEO Deanna Lessard - Director of Member Services and Physician Wellness Karen Harwood – Director of Community Programs Mindy Gonzalez – Director of Finance & Administration Mindi Tingler – Director of Communications Katherine Zuber - Director of Membership Development & Events John James - Director of Public Health & Disaster Services


PALM BEACH COUNTY MEDICAL SOCIETY WELCOME NEW MEMBERS Anthony Campo, MD Specialty: Psychiatry and Addiction Rui P. Cerejo, DO Specialty: Internal Medicine and Rheumatology Lee Fox, MD Specialty: Radiology Deborah A. Loney, MD Specialty: Otolaryngology (Pediatric and Adult) Zachary McVicker MD (Active Practicing 1st Year) Specialty: Orthopedics Sports Medicine Mark Meyer, MD (Dual Member) Paul David Mendoza, MD Specialty: Internal Medicine and Rheumatology Maricarmen Quintero, MD Specialty: Internal Medicine and Rheumatology Christina Rankin, MD Specialty: Anesthesia Curtis E. Scott, MD Specialty: Gastroenterology Bruce Jeffery Stratt, MD (Semi-Retired) Specialty: Diagnostic Radiology Arnold Charles Winkelman, MD (Retired) Carlos Villalba, MD Specialty: Internal Medicine (Hospice Palliative Care)

MEDICAL STUDENTS Claire Hoang (Kansas City University) Sarah Shareef (Kansas City University) Harrison C. Stubbs (Kansas City University)

For membership information contact Deanna Lessard at deannal@pbcms.org or 561-433-3940 x105.

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President’s Message By Roger Duncan, MD Continued from page 2

compete for prizes at the 2021 James J. Byrnes MD Poster Showcase. We also look forward to having a fabulous virtual HEROES IN MEDICINE event on May 20th where we will spotlight those individuals and organizations providing outstanding service in Palm Beach County.

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Key to leading on issues of importance to us, is increasing our voice and influence through membership growth and participation. We are increasing new memberships through a couple of dynamic and strategic efforts. We now offer a new dual membership opportunity for new members who hold current membership in an adjacent county or other specialty medical society. The membership committee is working to forge new alliances and welcome new voices and perspectives with diverse groups of physicians. To that end, we held a Medical Inclusiveness Town Hall event with special guest, Yvette Miley, NBC and MSNBC Senior Executive, who also happens to be a Palm Beach County native and Suncoast High School graduate. She spoke on how diversity in teams and perspectives leads to stronger organizations and better patient care, compliance and healthcare outcomes. COVID-19 has presented us with a unique opportunity to lead our community out of a crisis. Each one of us has a role to play from simple acts such as, being an example to others when we get vaccinated, to encouraging and educating the community about the importance of getting vaccinated. We also need your help to protect the practice of medicine in Palm Beach County. We have to lead on the educational standards which should fundamentally be required in order to be allowed to practice independently. Help us by reaching out to your elected representatives and educating your friends and neighbors about these issues, as well as making donations to our PAC so that our voices can be heard. There is strength in numbers so encourage membership and get involved. Collectively, we can impactfully lead and successfully advocate to maintain the highest quality of medicine and healthcare for our patients and community. I applaud the members of our Palm Beach County Medical Society and all the physicians within our community for their fortitude and resilience in these incredibly challenging times.

5 Q2.2021 

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CHIEF EXECUTIVE OFFICER OF

PALM BEACH COUNTY MEDICAL SOCIETY By Kelly Skidmore CEO PBCMS

For the past several years there were leaders in the Florida Legislature who had an agenda that unfortunately undermined medicine with the issuance of an onslaught of scope of practice expansion measures aimed at a variety of non-physician health care professionals. During the 2021 Legislative Session, once again bills that transfer specific aspects of the practice of medicine to lesser trained individuals continued to be filed, however, many were able to be amended or stopped from passing. The Optometry bill was back again as CS/HB 631 and SB 876 and would have allowed the Board of Optometry (not the Board of Medicine) to approve which ophthalmic procedures an optometrist could perform, including laser and non-laser procedures and therapies and removal of superficial foreign bodies. The bill would have allowed the Board of Optometry to set the criteria, such as content, grading, and passing score, for someone to become a “certified optometrist,” eligible to perform the expanded scope practices. The bill also set the prescribing authority of optometrists to include ocular pharmaceutical agents and controlled substances. HB 111/SB 424 proposed the autonomous practice of advanced practice registered nurses to no longer be limited to primary care/family medicine, general pediatrics, general internal medicine, and midwifery but include much more. There was a bill to exempt retired physicians who provide pro bono services from continuing education requirements and created licensure criteria for Canadian applicants. Requiring the Board of Psychology to certify psychologists to exercise prescriptive authority as well as three separate bills related to physician assistants were other bills moving through the legislative process. In their original form, the physician assistant bills would have eliminated the limitation on the number of physician assistants a physician can supervise at one time, changed the requirements for physician assistant

continuing education related to prescribing controlled substance medications, and required the Board of Medicine and the Board of Osteopathic Medicine to register physician assistants as autonomous physician assistants if they met specified criteria, among other things. Additionally, four positive measures related to improving telehealth were introduced, along with bills to address prior authorization, retroactive denial, step therapy protocols, and Personal Injury Protection (PIP). The major win for the Session was the passage of the bill enacting civil liability protections related to COVID-19 for health care professionals. That bill was signed into law by the Governor. There were still more bills related to medicine that were filed. Members of the Legislature continue to find it necessary to “practice medicine” through introducing a host of policy decisions that impact doctors and their ability to treat their patients appropriately and efficiently. This makes it imperative for the physician community to remain alert and vigilant while the Legislature is in Session. Advocacy for or against a measure must be able to happen quickly and be sustained as bills make their way through the House and Senate committee process, to the respective chamber, and ultimately to the Governor for his signature or veto. Although COVID19 made it difficult, if not impossible, for many physicians to advocate in person, the imperative to speak with lawmakers about what actually happens in doctor’s offices every day was not lessened. Your voices are needed, your experiences are important, and your challenges need solutions. Thank you to everyone who stepped up and spoke out. It made all the difference.

For more information contact Kelly Skidmore by email kellys@pbcms.or or call 561-433-3940. 2021.Q2 

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CELEBRATING DOCTORS DAY

WITH A TOAST Master Sommelier Virginia Philip, only the 11th woman in the world to earn this prestigious accreditation, led a virtual wine tasting hosted by Palm Beach County Medical Society on May 30th. The Doctor’s Day Virtual Wine Tasting was held to toast doctors for their extraordinary service to the Society and their patients. THE EVENT WAS MADE POSSIBLE BY THE GENEROUS SUPPORT OF THESE SPONSORS:

Receiving the Master Sommelier certification in 2002, Philip remains only one of 26 women in the world who have earned this international proficiency. She holds an honorary doctorate in oenology from her alma mater Johnson & Wales and received the title of “Best Sommelier of the U.S.” from the American Sommelier Association five years in a row, 2002-2006. “What an honor it was to enjoy a wine tasting led by a world renowned Sommelier and celebrate with so many of my esteemed colleagues,” said PBCMS President Roger Duncan, MD, who was among 40 members, friends and doctors attending the event.

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DOCUMENT! DOCUMENT!

DOCUMENT!

!

By June Conner COC and Karen Green CPB, CPC

Evaluation and management services are now either based on time OR the provider’s medical decision making. Always remember to be descriptive - ADJECTIVES are our friends! Bullet points are easy but do not show the provider’s thought process. While the History and ROS are not counted as points they are considered in the decision-making process.

COMPLEXITY OF DIAGNOSIS:

Describe the problem in detail. Remember to use those adjectives! Multiple low risk problems can create a higher risk due to interaction. Document the length of the illness. Is the problem acute, chronic, straight forward, stable or exacerbated? The statement, “The history of ___” does not indicate that the patient is currently being treated for that diagnosis on that day. It could be used in the provider’s decision making but does not count as a diagnosis when coding today’s visit. You should also document the patient’s symptoms, pain level and prognosis.

DATA:

Was data reviewed, ordered, or interpreted? Document the records reviewed from any outside source, each test that is interpreted or reviewed and indicate the time spent. If you performed the test, the interpretation is included and not counted when coding. Did you speak with another qualified healthcare professional regarding today’s visit? If yes, document whom you spoke with and time spent (to easily document have a data macro added to your EMR. Remember this could bump up your E&M level if coding based on time, especially when you do not meet a higher level of E&M with diagnosis or risk.)

RISK:

There are a lot of topics that fall under risk, for example, drug management. Drug management is not just prescribing medication. Documenting the reason a patient should NOT be taking a medication, explaining why OTC medicine would be beneficial, and taking into consideration the other diagnoses when prescribing a new medicine ALL fall

under drug management. Remember toxicity monitoring of certain drug therapy could contribute to bumping you to a level five visit. Please refer to the list posted by Palmetto GBA. Decision making also falls under risk. The risk is considered differently depending on the type of procedure/surgery ordered and whether it is major or minor. Document the decision for hospitalization or emergency care and why it is necessary. The decision to not escalate care or resuscitate the patient should also be documented along with poor prognosis. Indicate the time

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it took to discuss these options with the patient and/or family at today’s visit.

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Providers, help your coders by documenting the patient’s story for the diagnoses being treated and considered in the decision making for TODAY’s visit. Document your thought process in the assessment and Plan. Why were tests ordered? Why was the patient sent to the hospital or having surgery? Why were symptoms taken into consideration when prescribing medication or ordering tests? Symptoms may not be considered as a risk but are definitely a part of the provider’s decision making. It is not recommended to copy from previous notes. Rather, use macros set up in your EMR to help guide through today’s visit.

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Joining the Project Access Volunteer Network (PAVN) means supporting a healthier Palm Beach County.

We are honored to celebrate the past 20 years of medicine in Palm Beach County and we look forward to the future.

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MAKE AN IMPACT

This group of volunteers enables patients to receive care through our collaboration with safety-net clinics and specialty providers. As a physician volunteer with Project Access, you receive: • Sovereign Immunity for services provided through the Florida Department of Health’s Volunteer Health Care Provider Program. • Up to five CME credits, every two years. • Complete discretion in the number of patients treated – the number of donated services is up to you! • The opportunity to be part of a seamless experience for you and the patients because all care and services are managed through the Direct Care program. • The satisfaction of knowing your participation in Project Access helps reduce inappropriate ER admissions.

Contact Angelica Cervantes at angelac@pbcms.org for more information.


There’s really no reason NOT to switch to AmTrust! With the new Workers’ Comp Insurance rate decrease that took effect on January 1, 2021, there is no better time than now to switch to AmTrust There is no better time to move your coverage. Rates have dropped as of January 1, 2021, and should you decide to switch, you have nothing but upsides: • Take advantage of the NEW decreased rate • NO penalty should you decide to switch coverage • You can carve out coverage from your PEO • Pay-As-You-Owe workers’ comp premium automated payment solutions through AmTrust • Potential dividend of up to 30% of your premium AmTrust North America has been a true partner to the PBCMS and Danna-Gracey for many years, and now, with the resources of AmTrust - rated “A” (Excellent) by A.M. Best - we are able to provide this exclusive enhanced dividend program that is like no other for Florida physicians and medical practices.To date, these programs have given back over $9 million in dividends to Florida medical society members insured through these programs.

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Certified Financial Planner Board of Standards Inc. owns the certification mark CFP®, ChFC® is a registered trademark owned by The American College of Financial Services and Investments & Wealth Institute is the owner of the certification marks CPWA®. J.P. Morgan Wealth Management is a business of JPMorgan Chase & Co., which offers investment products and services through J.P. Morgan Securities LLC (JPMS), a registered broker-dealer and investment advisor, member FINRA and SIPC. Annuities are made available through Chase Insurance Agency, Inc. (CIA), a licensed insurance agency, doing business as Chase Insurance Agency Services, Inc. in Florida. Certain custody and other services are provided by JPMorgan Chase Bank, N.A. (JPMCB). JPMS, CIA and JPMCB are affiliated companies under the common control of JPMorgan Chase & Co. Products not available in all states. INVESTMENT AND INSURANCE PRODUCTS: • NOT A DEPOSIT • NOT FDIC INSURED • NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY • NO BANK GUARANTEE • MAY LOSE VALUE © 2021 JPMorgan Chase & Co. All rights reserved.


HEROES 

MEDICINE

Congratulations

PALM BEACH COUNTY MEDICAL SOCIETY & SERVICES

2021 HEROES IN MEDICINE HOST COMMITTEE

FOUNDING BENEFACTOR: Rendina Healthcare Real Estate CHAIRS: John Dalton & Martha Rodriguez, MD HONARY CHAIR: Alan Pillersdorf, MD Frank Adderley Cheryl Anders Shawn Baca, MD Nancy Brinker Larry Bush, MD Carol Carnevale Robert Chait, MD Sally Chester, RN Jibby Ciric, PsyD

Gregory Cotes, MHA Peter Cruise, PhD

Marissa Hayes

Melissa Nash

Genevieve Smith

Linda Culbertson

Kim Hillard

Emanuel Newmark, MD

Marnique Sparago

Michelle Howell-Phillips

Pamela Payne

Sarah Steele, MBA

Mario Jacomino, MD

Henry Pevsner, MD

Mark Stein, MD

Barbara James

Laura Pierson

James Sugarman

Gordon Johnson, MD

Alan Pillersdorf, MD

David Summers, RN

Fred King

Viki Regan

Rebecca Weiss

Alicia Lewis

Claudia Rodney

Kelly Wilson

Shannon Materio

Sharon Rose

Jack Zeltzer, MD

Shenetria Moore

Mark Rubenstein, MD

Judy Dunn, RN Trish Ernst Jennifer Ferriol Mark Goldstein Faustino Gonzalez, MD Henry Haire, MD Carol Hakemian-Felt

THANK YOU TO OUR SPONSORS

Contributions benefit Palm Beach County Medical Society Services, Inc., a not-for-profit, tax-exempt organization. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES AT www.FloridaConsumerHelp.com OR BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. Registration #CH12678.


18th Annual Heroes Ankush Bansal, MD

Alicia Rootes, MBA Kenneth Scheppke, MD

Alina Alonso, MD

Verdenia Baker

Lisa Clayton, DO

Darcy Davis

Joseph Ouslander, MD

Florida Kidney Physicians

Clinics Can Help

Malcolm Dorman, MD

PHYSICIAN HERO

HEALTH CARE PROVIDER HERO

BRUCE RENDINA HERO

TULISA LAROCCA, MD LEADERSHIP HERO

Ankush Bansal, MD Cleveland Clinic Martin Health Alicia Rootes, MBA Charles E. Schmidt College of Medicine, FAU

COMMUNITY HERO

Kenneth Scheppke, MD Medical Director, Palm Beach County Fire Rescue

(Non-Physician) Clinics Can Help

Alina Alonso, MD Verdenia Baker Darcy Davis

PROJECT ACCESS HERO

HEALTH CARE EDUCATOR HERO Lisa Clayton, DO FAU Emergency Medicine at Bethesda Health

Florida Kidney Physicians Dr. Jose Arrascue Dr. Marco Farias Dr. Jhon Guzman-Rivera Dr. Hitesh Kapupara Dr. Wayne Kotzker Dr. Osvaldo Valenzuela

HEALTH CARE INNOVATION HERO

LIFETIME ACHIEVEMENT AWARD

Joseph Ouslander, MD Charles E. Schmidt College of Medicine, FAU

(Posthumously) Malcolm Dorman, MD

HEROES IN MEDICINE FINALISTS Bianca Biglione

Jemelle Mayugba, MD

Jennifer Caceres, MD

Olayemi Osiyemi, MD

Sankaranarayana Chandramohan, PhD

Palm Health Foundation’s Healthier Together Initiative

Kitonga Kiminyo, MD

Luis Javier Peña-Hernández, MD

Bob Kropa

Madonna Stotsenburg


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HOW SBIRT TOOLKIT CAN HELP TACKLE DRUG OVERDOSE EPIDEMIC IN

PALM BEACH COUNTY AND BEYOND

By Leon Fooksman

The numbers are heartbreaking: More than 20 million people in the United States have a substance use disorder (SUD). The rate of prescription overdose deaths has increased five-fold since 1999. And more than two-thirds of people who misused prescription opioids obtained them through prescriptions filled at a pharmacy for either themselves or a friend or family member. One of the most-discussed approaches in medicine in addressing this problem is using a tool called Screening, Brief Intervention, and Referral to Treatment (SBIRT). It’s been developed and used, for close to a decade, at primary care offices, emergency departments, workers’ compensation clinics, hospitals, criminal justice centers, and schools. Covered by most insurance, SBIRT is an evidence-based approach to identify people who use alcohol or other drugs in unhealthy ways but who do not necessarily have a substance use disorder (i.e., abuse, dependence). The screening is a brief conversation between a clinician and patient using motivational interviewing techniques. Patients determined to have more severe symptoms may be referred to behavioral health treatment. Sounds good, right? But like so much in medicine, there are challenges. One is how to get physicians and medical providers to use SBIRT more frequently in their practices and clinical settings. The other is what to do when patients are found to have a “positive” response – in other words, how do providers get patients the help they need to overcome their substance disorder. As part of the Palm Beach County Medical Society (PBCMS)’s Opioid Health Care Initiative, PBCMS asked

John Hulick -- senior program manager for substance abuse at Palm Beach County Community Services Department -- for his thoughts on finding solutions. “Palm Beach County has re-thought and focused its behavioral health system of care toward being more person-centered and recovery-oriented,” he said. “SBIRT represents a similar paradigm shift in substance use interventions in that, traditionally, these have focused on individuals who have severe substance use or those who meet criteria for substance use disorder.” Hulick added: “My hope is to have a truly integrated and collaborative approach between the primary and behavioral sectors in order to address these concerns. SBIRT provides one path toward achieving this through implementing this effective strategy for earlier interventions before the need develops for more extensive or specialized treatment.”    As for encouraging more providers to use the SBIRT program model, he said: “I certainly recognize how busy doctor’s and their offices are.  My hope is, as emphasis remains on caring for a patient’s health, that we continue to educate the profession that unhealthy alcohol and other drug use are among the most common causes of preventable morbidity and mortality.”  Since SBIRT is available through commercial and public insurance, that should, he said, “hopefully mitigate some cost concern in order to allow doctors and their staff  to provide universal screening, early intervention, and timely referral to treatment for people who have SUDs.” For another perspective on using SBIRT, PBCMS members Brent Schillinger, MD and Abby Strauss, MD spoke with Bertha Madras, MD, in a podcast called “Drug Use Screening SBIRT”  in November 2020. (Dr. Madras,

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a professor of psychobiology at Harvard Medical School, was deputy director for demand reduction in the White House Office of National Drug Control Policy.) Asked how physicians should respond to positive screening using SBIRT, she said: “If you are going to screen, you have to be equipped to know what to do if you get a positive screen.” She added that providers either refer the patient to a treatment center or be “capable of handling the intervention and treatment yourself. But you cannot screen, get a positive and then do very little after that.” One of the main reasons physicians are worried about the screening, Dr. Madras said, is they “don’t know what to do. There’s no medical education.” She added: “Physicians have been trained on tobacco screening, but few have been trained on how to give motivational interviewing and how to intervene.” She also said that medical schools and residency programs need to “mainstream this kind of training.”

Dr. Madras said studies as far back as the 1960s and 1970s showed that by physicians asking simple questions -common now as part of the SBIRT toolkit -- they “changed behavior, even without an intervention, even without motivational form of interviewing.” She added: “So raising the question is important for many points of view.”

Dr. Madras will conduct a virtual presentation on SBIRT during an Opioid Educational Seminar for Physicians and Healthcare Providers on Friday, May 21st from 12-1pm; for more information go to www.pbcms.org.

HERE IS THE LINK:

pbcms.org/opioid-addiction-treatment-resources.

YOU’LL FIND:

• Recommendations on screening approaches for alcohol and other drug use. • Steps for referring patients to substance use specialty care. • Suggested brief intervention script.

Don’t miss your shot... to join the festivities of Sunfest, Fourth on Flagler, Oktoberfest and all of the fun Palm Beach County has to offer!

GET

YOUR COVID-19

SHOT! 15 Q2.2021 


BEFORE COVID-19, OUTLIER MEDICAL MALPRACTICE VERDICTS WERE RISING—

WHAT’S NEXT?

Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company, and Leader of the TDC Group of Companies

Severity—the average cost of a medical malpractice claim—continues its relentless increase. Though severity has been rising since at least the 1970s, in recent years we have seen a sharp increase in outlier verdicts, which exceed common policy limits and often set records for their venues: From 2014 to 2018, the number of verdicts in excess of $25 million more than tripled1. Similarly, from 2010 to 2019, the average of the top 100 jury awards for medical malpractice cases rose by almost half2. This disturbing trend threatens the viability of smaller medical malpractice insurers, who may not have the resources

related malpractice cases may be less likely to result in large plaintiffs’ awards. Nevertheless, outsized awards to plaintiffs are part of an ongoing long-term trend. Clinicians may well ask why severity is increasing at the same time the medical community has made important strides in patient safety and the overall frequency of claims has dropped. At The Doctors Company, we’ve seen a drop from a high of 17 claims per 100 physicians in 2000 to fewer than seven claims per 100 physicians today.

SOCIAL MEDIA IS A POTENT FACILITATOR OF BATCH CLAIMS. A PATIENT WITH AN UNEXPECTED ADVERSE OUTCOME FROM A PARTICULAR OPERATION MAY POST, “DR. X BOTCHED MY SURGERY.” to cover such large verdicts, and portends medical malpractice rate increases while adding to burgeoning healthcare costs. Before the pandemic, nearly all states had seen these extraordinarily large awards, but whether the pace of these awards will be affected by the pandemic is unknown. Some U.S. states have adopted limited liability protections for physicians during COVID-19, but those protections may be tested in the courts. Alternately, because physicians may be seen as heroes, pandemic-

The consolidation of healthcare is one driver of high verdicts. Large corporate defendants, almost always with very high policy limits, make attractive deep pockets in the eyes of sympathetic juries. Monetary desensitization is another important factor. Our national debt exceeds $22 trillion, our annual budget is over $4 trillion, companies with no profits have valuations in the billions, and top athletes commonly sign contracts worth hundreds of millions of dollars. Though paid indemnities in average malpractice claims average many 2021.Q2 

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hundreds of thousands of dollars, and typically cover 100 percent of economic losses, these numbers may appear less impressive in an era where nine- and 13-digit numbers are commonly used. A.M. Best, which rates insurance companies, has expressed concerns about the impact of monetary desensitization, also known as social inflation, on severity3. Batch claims, lawsuits in which plaintiffs bring multiple claims against one defendant based on the same behavior, are another contributor. Examples include the claims brought against compounding pharmacies alleging that breaches in sterile technique affected many individual patients. Social media is a potent facilitator of batch claims. A patient with an unexpected adverse outcome from a particular operation may post, “Dr. X botched my surgery.” Others who believe they have had a similar experience respond, and an attorney gathers them all into a batch claim. Claims of this kind were distinctly unusual in the past, but are now an annual occurrence. States lacking caps on noneconomic damages are particularly vulnerable to these factors. Without caps, awards for pain and suffering are unlimited and are almost always present in outlier cases.

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The increase in severity adds to the costs of healthcare, which already account for 18 percent of our gross national product4. At The Doctors Company, we saw a 55 percent increase in severity—the cost of the average claim—from 2000 to 2018. This drives increases in insurance rates: The average payment for a closed medical malpractice case has been growing well beyond the pace of inflation since 2014—and this spike in claims losses necessarily drives the rate increases that insurers are implementing in 20205. (Such increases are sometimes falsely attributed to COVID-19 which is too recent to have driven claims costs.) Ultimately, added costs are passed down to patients in their bills for healthcare. The rise in severity negatively affects us all, but unless jurors’ attitudes change, batch claims decrease, and caps on noneconomic damages are protected, outlier verdicts will continue to become more commonplace.

1.) Burns B. MedPL market updates. Oral presentation at: PLUS Symposium Series, Healthcare and Medical PL; March 12, 2019; Chicago, IL. 2.) Strategic Study Series Insurance Research. 2020: Medical professional liability insurance—years of plenty, years of famine. Hartford, CT: Conning;2019:22. 3.) A.M. Best Company. U S medical professional liability market remains in flux. Best’s Market Segment Report. Published April 29, 2020. Accessed December 8, 2020. http://news.ambest.com/newscontent. aspx?refnum=224903 4.) Centers for Medicare and Medicaid Services. National health expenditure data. Published December 11, 2018. Accessed November 23, 2020. https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. 5.) Karls C. Paid indemnity severity, countrywide by closed year. In oral presentation: What is that light at the end of the tunnel? At: MPL Association CEO/COO Workshop; March 11-14, 2020; Scottsdale, AZ.


2021

RENEWAL SUCCESS

Barry Levi, Founder and President Jeremy Cohen, Senior Group Benefits Agent

Palm Beach County Medical Society (PBCMS) offers an exclusive, association-type health insurance opportunity and additional benefits to physician practices in Palm Beach County. The plans provide affordable health insurance and other lines to member EMPLOYER-physicians, their fulltime employees, and their families. It offers comprehensive plans and a range of benefit levels. With consideration of multiple factors, most practices experienced a 0% rate increase, effective March 1st, 2021. Over the past several years, Palm Beach County pricing has outperformed the standard market by more than 10%. Rolled out in 2020, the PBCMS members completed their first year with Unum, providing dental, vision, life insurance and disability insurance. For 2021, the entire group received a 0% increase across all lines.

The Trust Plans have both traditional plans and High Deductible Health Plans (HDHP), which use Health Savings Accounts (HSA). Most plans are BCBS Blue Options Network plans (Their all-encompassing national/international network). Two new HMO plans have become available, to enhance the overall offering. The Palm Beach County Medical Society, Inc. rolled out another member exclusive ancillary benefit program effective March 1st, 2020 with Unum. Members of PBCMS, Inc. will have the opportunity to offer their employees a wide variety of large-group ancillary insurance options through UNUM. Those benefits are dental insurance, vision insurance, life insurance, as well as short and long term disability.

The Trust Plans are a Co-Op/Association type plan, where the members merge assets together to create a larger group. For over 30 years, federal laws and regulations allow for employers and “groups of employers in the same profession” to form a “NOT FOR PROFIT” Trust for employee benefits. This is best known as a “Co-Op,” according to the Florida Bar Association. The MCMS, Inc. Insurance Trust Fund was created in 1981 as such a Co-Op, but only for Physicians (and their employees) in Private Practice. Under the Co-Op’s agreement with Florida Blue, physicians have no risk for excessive claims, and they share in underwriting surplus profits. At a time when many doctors are concerned about rising operational costs – including employee health coverage – Co-Op participants are reaping the benefits of a group insurance plan that rewards the physicians and their families, as well as practice employees and their covered dependents. Medical practices in 10 Florida counties have shared in a profit of more than $2.3 million since joining with members of other local medical societies to form a single, large group insurance plan with Florida Blue. Through this thriving health insurance Co-Op, participating physicians are sharing major profits, saving money and offsetting future rate increases.

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19 Q2.2021 


MEDICAL REAL ESTATE BUZZWORD

ALERT: “MEDTAIL”

By Lesley Sheinberg Managing Director NAI/Merin Hunter Codman medical commercial real estate specialist

We are now a year past the pandemic outbreak. Vaccines are being rolled out, new case rates are declining, and people are starting to venture out again. If you haven’t noticed, I challenge you on your next trip to your local retail strip or larger shopping center to look for new, non-traditional retail tenants. Perhaps next to your trusty dry-cleaner or favorite specialty food store you will notice that bright and shiny new healthcare clinic?

THIS TREND IS REFERRE D TO AS “MEDTAIL”, MEDICAL TENANTS FOUND IN TRADITIONALLY RETAIL C E NT ER S .

This trend is referred to as “MedTail”, medical tenants found in traditionally retail centers. Even prior to the pandemic, medical providers were starting to offer services in non-traditional office space locations and the conveniences of shorter wait and drive times made patients happy to use them. The pandemic kicked this trend into overdrive. “COVID-19 has sped up the inevitability that preventative wellness is no longer a choice,” said Willie Hoag, principal at Tether Advisors, in their recently issued 2021 Retail Healthcare Outlook study. “The retail space is overbuilt, mediocre and redundant…It’s exciting that a new group of players is filling former retail spots while providing access and convenience to consumers.”

Retail property investors and landlords realize many medical tenants offer strong credit and desire longterm leases. They are happy to negotiate creative terms to medical users in order to fill vacant space left by traditional retailers who did not survive or downsized during lock-downs. Creative terms aren’t just offered to medical clinics, increased retail space use is also projected for primary care, counseling and mental health, many of which offer both telehealth and a convenient physical location with patient-friendly amenities like a great parking spot and their favorite cup of Joe. If your practice is looking for a high-visibility location in a high-traffic center or if you are entertaining the idea of investing in a retail plaza, perhaps offering multiple medical services, I can help.

Feel free to contact me, Lesley Sheinberg, Managing Director, NAI/Merin Hunter Codman, 561-254-7810 or lsheinberg@mhcreal.com.

About NAI/Merin Hunter Codman NAI/Merin Hunter Codman, www.mhcreal.com, is one of South Florida’s leading commercial real estate firms with over three decades of experience advising clients on strategic acquisitions and dispositions and providing landlord representation, tenant representation, property management and construction management services. The firm has expertise in all commercial property sectors including office, retail, industrial, multifamily, hotels and land. NAI/Merin Hunter Codman’s client base includes some of the nation’s most prestigious institutional and private equity investors. Operating as part of the NAI Global network, NAI/Merin Hunter Codman can facilitate property transactions around the nation and the world, serving as a single point of contact for its clients’ counsel and execution. NAI/Merin Hunter Codman is headquartered in West Palm Beach, Florida with regional offices in Boca Raton, Fort Lauderdale, Palm Beach Gardens and Wellington.

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2021 JAMES J. BYRNES

POSTER VIRTUAL SHOWCASE Gauri Agarwal, MD & Lisa Martinez, MD Poster Virtual Showcase Co-chairs

PBCMS hosted the 2021 James J. Byrnes Poster Virtual Showcase April 19 - April 26, 2021. The objective of the poster presentations is to offer students, residents, fellows, and other physician scholars the opportunity to share significant research and interesting clinical vignettes with their fellow clinicians.

A very special thank you to Gauri Agarwal, MD & Lisa Martinez, MD for co-chairing the showcase PBCMS received 80 outstanding applications from Palm Beach County Medical Students and Residents and 1 International Medical Student.

MOST FOLLOWED POSTER

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INTERNATIONAL POSTER

MOST FOLLOWED RESEARCH ABSTRACTS

MOST FOLLOWED CLINICAL VIGNETTES

2021.Q2 

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PRST 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

Cheers to

100 Years!

PALM BEACH COUNTY MEDICAL SOCIETY SERVICES PRESENTS

Celebrating a Century of Medical Excellence

OPIOID SERIES

Opioid Educational Seminars for Physicians & Healthcare Providers FRIDAY MAY 21, 2021 12:00-1:00 PM Online Event

Featuring BERTHA MADRAS, PHD

Bertha Madras, PhD SBIRT: Helping Your Practice Cut the Toll of the Opioid Epidemic

Screening, Brief Intervention and Referral to Treatment services, better known by the acronym SBIRT, is a powerful physician tool for fighting the ever present opioid epidemic. In fact John Hulick, Palm Beach County’s “drug czar” thinks SBIRT may be one of the most effective strategies that medical doctors can implement in their daily practices within the opioid use disorder arena. Join renowned Harvard psychobiologist Bertha Madras, PhD for an informative discussion on the entire SBIRT process. Dr. Madras has been such a strong advocate of the SBIRT approach that she was the person instrumental in leading the effort to obtain CPT billing codes so that physicians can get paid by Medicare, Medicaid and private insurers for these screening services. She also is noted for generating the first publication that documented the effectiveness of SBIRT.

REGISTER NOW

https://attendee.gototraining.com/r/4196816506373499394 Listen to her Podcast here: https://interviewlibrary.info/expertsspeak/BERTHA_MADRAS_MD_ DRUG_USE_SCREENING_SBIRT_NOV2020.mp3

Training ID: 522-232-540 JOINT PROVIDERSHIP CME ACTIVITY 1 hour AMA PRA Category 1 Credit TM provided by VA Medical Center

WWW.PBCMS.ORG

Profile for Palm Beach County Medical Society & Services

2021 Q2 On Call  

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