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PHYSICIAN SPOTLIGHT PAGE 3
Harinath Sheela, MD ON ROUNDS
Overcoming Challenges UCF REC provides valuable PCMH services ... 7
Three Issues That Could Significantly Impact Physician Reimbursement in Florida ... 8
New ER Care Headquarters Doubling EMLRC is important step in addressing emergency provider barriers By LyNNE JETER
Expansion is underway to double the size of Central Florida’s Emergency Medicine Learning and Resource Center (EMLRC), a non-profit organization advancing emergency care through advocacy and education by providing assistance to more than 5,000 emergency providers annually. Groundbreaking for the new two-story complex being built on South Conway Road in Orlando took place April 30. With a target opening date in November, the 9,400-squarefoot complex will replace the current facility
shared by the Florida College of Emergency Physicians and the Florida Emergency Medicine Foundation. “It’s about time,” said Vidor Friedman, MD, managing partner and vice president of governmental affairs of Maitland-based Florida Emergency Physicians (FEP), ACEP Board of Directors member, past president of the Florida College of Emergency Physicians
(FCEP), and former director of emergency services for Florida Hospital-Celebration Health. “We’ve been in the current location since 1990, and the facility we purchased had served in another function. The building itself isn’t in very good shape.” The EMLRC has also housed the offices of the Florida College of Emergency (CONTINUED ON PAGE 4)
Starting Fresh Weiss Pediatric Care on target to become Sarasota County’s first Pediatric Medical Home By LyNNE JETER
SARASOTA—On their 40th wedding anniversary, Rob and Diane Weiss could’ve been celebrating retirement from a bucket list of travel spots. Instead, the Weiss family marked the turning point by opening Weiss Pediatric Care in Sarasota, one of 14 participants in a rigorous statewide demonstration project that has the practice squarely on the path to become Sarasota County’s first Pediatric Patient-Centered Medical Home (PCMH). “When you get to this stage in your professional career, (CONTINUED ON PAGE 6)
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PhysicianSpotlight
Harinath Sheela, MD Digestive and Liver Center of Florida By JEFF WEBB
ORLANDO - Harinath Sheela’s father and mother told him to dream a goal, go after it, never give up and he could not fail. “So far they have proved to be correct,” said Sheela. The 42-year-old is one-third of a team of gastroenterologists at the Digestive and Liver Center of Orlando. where he is in a family practice, so to speak, with his brothers, Srinivas Seela and Seela Ramesh. Asked about the differences in their names, it is evident Sheela has told the story many times: “It was lost in translation. When we moved here (from India) the immigration passport people mixed them up,” he said. You think the Department of Motor Vehicles is frightening? Try the immigration office! It is a lifechanging experience. You have no rights when you go there,” said Sheela. Of course, the brothers could have changed their names to set the record straight, but they found it oddly convenient as they enrolled in various training programs, universities and now in their medical practice. The differences in their names has provided distinction and eliminated confusion, he said. That explanation is even easier to understand when you learn the brothers have been together since childhood in Hyderabad, India, and throughout their professional training, first as civil engineers and then as physicians. Sheela, the youngest of the brothers, explained they “grew up in frustration because we knew we could do much better” than in India, where the economy was closed and career options were very limited. That is why, after earning undergraduate degrees, they set their sights on the U.S., “the land of opportunity, liberty and freedom,” he said. All three scored very high on a test to enroll in a masters program in civil engineering at Cleveland State University, which he said he completed in just 9 months. He went back to India and worked for three years to build water systems, roads, dams, and irrigation “because there was so little infrastructure back home and we wanted to do something great,” he said. “But then we saw that we were helping in general, but wanted to have an impact on (individuals) and that medicine was the only true way to do that on a dayto-day basis,” he said. “With medicine, we wouldn’t have to wait 5, 10 or 15 years to see results. We could see results immediately. We could touch people’s lives every day. It’s immediate gratification to see a person in pain, find the problem, treat them and (eliminate) the pain.” He attended medical school at Spartan Health Sciences University in St. Lucia, and then completed his internal medicine and gastroenterology residency orlandomedicalnews
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at the University of Connecticut in Farmington. A three-year fellowship followed at Yale University School of Medicine in New Haven before he began private practice in Orlando. Being together as a family during their training in Connecticut helped ease “the rigors of advanced medical training, said Sheela. “There are advantages to having family at the same place … we could talk and study together. We could share books,” he said. But it also added some pressure in terms of expectations. “We had to work hard and prove that we were there for a reason and not to play games. We had to prove that we were going to be better than others. People thought we would go separate ways, but we said “this is our goal and our agenda and this is what we are going to do,” said Sheela. “Residencies and fellowships are really, really draining and that’s when lots of people have really bad (personal and family) experiences. We did not because we stuck together as a family,” he said. And the family has grown since then. Brother Srinivas has three children, brother Seela has one child, and Sheela and his wife Stephanie have two toddlers, a boy and a girl. (The doctors have a youngster sister in Cincinnati who is a software developer married to an endodontist.) Sheela said traveling with his family
and extended family members as a group is one of his favorite pastimes. “We make memories with nephews and nieces and parents and learn how to enhance someone’s life,” he said. Sheela said he and his brothers “take turns” traveling to India where they are working with state and local governments to provide access to healthcare in remote villages. “We built a 30,000-squarefoot healthcare center where we have a walk-in clinic, and emergency room with acute care,” he said. “We have fellows and med students man the center 24/7, but because it is 100 miles from the main city and no one wants to live there, they go for three-month rotations, said Sheela. “We raise money and connect (the students) with teaching hospitals. We created that model with the professors. We get the manpower, so the (doctors and nurses in training) aren’t working for free, they are learning. Our goal is to be self-funded (charity) run by private groups (paid) and self- sustain,” he said. Sheela’s work in Orlando is what
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makes that charitable work possible. At the Digestive and Liver Center he treats many medical conditions, including inflammatory bowel diseases, irritable bowel syndrome, hepatitis B and C, metabolic and other liver disorders. But he said he is the go-to guy for unexplained abdominal pain. “Next to chest pain, it is the most common reason for hospitalization,” he said. “Patients usually have gone through a couple of doctors and tests, but can’t get a definite diagnosis. They come to me to put together the pieces of the puzzle,” explained Sheela, who also is chairman of Florida Hospital’s Department of Gastroenterology. “Medicine is a fascinating thing. Common things are common, but rare things are rare. But the rare things are the ones that cause problems, so I put on my thinking cap and solve them,” he said. But what he likes most about his work is “seeing how people feel after we find the problem and cure it. You see the relief on their faces and their family’s faces. You do all this training and you put it to use.”
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New ER Care HQ, continued from page 1 Physicians (FCEP). “Over the years, the center has required more staff as we’ve increased more and different kinds of programming both for the public and ER providers,” said Friedman. “We needed better and more office space to meet those demands.” The EMLRC provides continuing medical education (CME) locally for providers who choose not to travel, and the center’s educational offerings have moved from bringing people to Orlando for a meeting or conference at a hotel to more online education. “The current facility has been an asset to the community of emergency care providers for a long time, but it was built at a time when the education and training was a lot different than it is today,” said FCEP executive director Beth Brunner. “It’s served the community well, but going into the future, we need flexible space for providing simulation education and meetings.” The new headquarters will provide enough space to accommodate an increasing number of conference meetings, onsite educational courses, and visitations from high school and college groups from around the state. “This is good news, and will help us raise the level of emergency care in Florida,” said Friedman, referencing “America’s Emergency Care Environment: A State-by-State Report Card – 2014,” in which the state received an overall C-, ranking 27th overall in the 2014 American College of Emergency Physicians’ comparison report card on America’s emergency care environment. In 2009, America earned an overall mediocre grade of C- on the Report Card. This year, the country received a near-failing grade of D+. “The trifecta of per capita physician shortages, insufficient hospital capacity and inadequate health insurance coverage are straining our emergency care system to the breaking point,” said Michael Lozano, MD, president of the Florida College of Emergency Physicians (FCEP). “Florida has few psychiatric care beds, which contributes to long wait times for emergency patients. People are waiting on average more than 5 hours in Florida’s emergency departments. These factors contribute to a situation where many - even those with health insurance are experiencing issues in accessing appropriate emergency care services.” Room for Improvement According to the Report Card, Florida faces severe shortages of emergency physicians and other specialists – neurosurgeons, orthopedists and hand surgeons, for example – needed to care for emergency patients. Full implementation of the Affordable Care Act without a Medicaid expansion in the state is expected to severely limit access to primary care physicians, already in short supply. In individual categories, Florida’s worst grade was an F in Access to Emergency Care, ranking it 49th in the nation. Florida received a D+ in Public Health and Injury Prevention, partly because of a lack of safe driving laws that resulted in the nation’s highest rate of pedestrian fatalities
HCA Focuses on Emergency Department Growth in Metro Orlando Increased access to emergency care is a driving force behind Hospital Corporation of America (NYSE: HCA) healthcare construction projects taking place in Central Florida. This summer, the Nashville, Tenn.-based company plans to open a $10 million freestanding emergency department in Hunter’s Creek in south Orlando. The 10,600-squarefoot facility will staff four emergency doctors, and provide pediatric and adult services round-the-clock.
and a rate of bicyclist fatalities more than twice the national average. In the category of Medical Liability Environment, Florida received a mediocre C, due to the paucity of insurers offering liability coverage and a lack of pretrial screening panels. In the categories of Quality and Patient Safety Environment and Disaster Preparedness, the state earned C+ marks. Of specific mention: Florida’s strengths in the former include a funded state EMS medical director and triage and destination policies for both stroke and heart attack patients. The state, impacted annually by hurricane activity, has implemented various policies and procedures to help first responders cope quickly with a disaster. These include application of a statewide high-tech solution for electronic patient tracking and mandatory disaster drills, and exercises for long-term care facilities and nursing homes. These issues are vitally important considering the state’s soaring senior population. Special Considerations “Emergency medicine is very unique,” said Friedman, whose physician-owned practice staffs 10 Emergency Departments in Metro Orlando, managing a total volume of more than 500,000 patients a year. “In most states, about 25 percent of the population is seen in an ER department. In Florida, because of our high number of visitors, one-third is seen in a given year. Also, we have probably the highest percentage of Medicare recipients per capita of any state in the country. That puts an additional strain on not just the ER system, but also the entire healthcare system.” A recently released Rand Corporation study, “The Evolving Role of Emergency Departments in the United States,” found that while admissions to U.S. hospitals grew more slowly than the nation’s overall population from 2003 and 2009, most of that growth was prompted by a 17 percent increase in unscheduled admissions made from emergency departments. That growth more than offset a 10 percent drop in admission from doctors’ office and other outpatient settings. “Some say half of all hospital admissions come from the ER,” said Friedman. “Actually, that number is closer to 75 percent. If you’re not scheduled for surgery or outpatient chemotherapy or something similar, the only way into a hospital is through the emergency department. As Floridians age, they’ll need more access to EDs.
“Following the recent expansion at Osceola Regional Medical Center, this facility will provide additional quality health services that are needed in our community,” said Robert Krieger, CEO of Osceola Regional Medical Center, which recently opened a new bed tower. HCA recently opened its freestanding emergency department in Oviedo and is seeking to expand its Emergency Room at Central Florida Regional Hospital.
“An important aspect about the center is that part of mission of the FCEP and the center is to educate the public about what emergency medicine is and does. The expanded facility will allow us to do that much better than we can now.” Collaborative Issues “Florida needs to become a destination of choice for healthcare professionals,” said Lozano. “We need to promote systems and situations where we attract, train and retain all types of medical providers — especially those who work in our emergency departments. One way to do that would be to improve our medical liability environment. Florida has a national reputation as a physician-unfriendly state when it comes to litigation. We need to promote a medical legal environment where skilled and competent physicians feel that they can act in their patient’s best interests, and not be constantly second guessing themselves.” Lozano was quick to point out the Report Card evaluates conditions under which emergency care is being delivered, not the quality of care provided by hospitals and emergency providers. Five categories comprise 136 measures: access to emergency care (30 percent of the grade), quality and patient safety (20 percent), medical liability environment (20 percent), public health and injury prevention (15 percent) and disaster preparedness (15 percent). The Florida Department of Health (Bureau of EMS), Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), and the Florida Board of Nursing and the Accreditation Council for Continuing Medical Education (ACCME) have accredited the EMLRC to sponsor continuing medical education for paramedics, EMTs, nurses and physicians.
SAVE-THE-DATE: On June 27-29, the 6th annual Symposium on Critical Care will take place at the Ed Rosen Shingle Creek Resort in Orlando. Michael Winters, MD, a senior editor of the ACEPendorsed book, “Emergency Department Resuscitation of the Critically Ill,” is slated to speak, along with Amal Mattu, MD, author of a dozen books pertaining to high-risk topics in emergency medicine, and a frequent national and international speaker. Critical care scenarios will be presented and discussed to challenge and educate participants. For more information about this CME course and an upcoming one in September, visit http://www.floridaep.com/#!symposia/cmxs.
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Starting Fresh, continued from page 1 Ramping Up Pediatric Medical Homes
Round 1 Practices (past):
For a state well-known for managing challenges inherent of caring for a soaring senior population, Florida has perhaps surprisingly become a front-runner concerning promising initiatives that focus on the smallest population segment: children. The Florida Pediatric Medical Home Demonstration Project will soon wrap up its third full year of implementation. The first round of 20 participant teams began their work in August 2011; it was completed in April 2012. Of this group, 16 practice teams elected to continue with the second phase of the project, which took place from May to December 2012. The project was replicated such that a second round of 14 practice teams joined and began their work in August 2013. Of this Round 2 group, a dozen practice teams will continue onto a second phase of the project, which will end in December. In one of few such pacts, Florida and Illinois share an $11.3 million, five-year grant that will end in 2015. The two states are testing collection and reporting of recommended and selected supplemental measures of children’s health quality, using existing data sources and improved data sharing. The two states are also working to ensure that ongoing statewide health information exchange and health information technology efforts support the achievement of child health quality objectives and to enhance the development of provider-based systems of care that incorporate practice redesign and strong referral and coordination networks, particularly for children with special needs. Florida and Illinois are also supporting collaborative quality improvement projects to improve birth outcomes across the two states. For the CHIPRA Cycle II grants that Florida was among 23 states to receive to fund aggressive initiatives that reach a large quantity of eligible children, priority areas include using technology to facilitate enrollment and renewal, and engaging schools in outreach, enrollment and renewal activities. For example, the University of South Florida (USF) in Tampa received $1 million in CHIPRA funds to engage school districts in outreach and enrollment activities. Rural school districts receive special attention, and also school districts with large populations of limited English proficient (LEP) students. A multi-media teen marketing campaign and curriculum target uninsured adolescents in high schools. USF is also working with the Florida Association of Children’s Hospitals to increase the number of school professionals trained to identify and assist eligible families with applications.
• All Children’s General Pediatrics, St. Petersburg • Altamonte Pediatric Associates, Altamonte Springs • Atlantic Coast Pediatrics, Merritt Island • Brevard Health Alliance Monroe Center, Cocoa • Children’s Health of Ocala, Ocala • Gentle Medicine Associates, Boynton Beach • Jacksonville Beach Pediatric Care Center, South Jacksonville Beach • Longleaf Pediatrics PA, Orange City • Martin Memorial Pediatrics, Stuart • Mirtha Cuevas MD Inc, Orlando • Orlando Health Pediatric Faculty Practice, Orlando • Pediatric Associates–Miami Beach, Miami Beach • Pediatric Clinic, Memorial Primary Care Center, Hollywood • Pediatric Partners, Palm Beach Gardens • Rozalyn Hester Paschal MD, PA, Miami • St. Vincent’s Family Medicine Center, Jacksonville • Tallahassee Pediatrics, Tallahassee • The Chronic Complex Clinic at St. Joseph’s Children’s Hospital, Tampa • University Pediatrics, University Park • USF Pediatrics South Tampa Center for Advanced Healthcare, Tampa
Round 2 Practices (present): • A to Z Pediatrics, New Port Richey • Angel Kids Pediatrics, Jacksonville • Bloomingdale Pediatric Associates PA, Valrico • Caladium Pediatrics, North Lake Placid • Halifax Keech Health Center, Daytona Beach • Lee Physician Group Pediatrics, Lehigh Acres • Martin Memorial Pediatrics, Port St. Lucie • Miami Children’s Hospital Pediatric Care Center, Miami • Pediatric & Adolescent Medicine of Seminole, Longwood • Premier Pediatrics, Ocala • UF Health Pediatrics—San Jose, Jacksonville • Weiss Pediatric Care, Sarasota • The Wolff Center for Child & Adolescent Health, Pensacola • Wolfson Center for the Medically Complex Child, Jacksonville SOURCE: Agency for Health Care Administration.
people start thinking about retirement or at least slowing down,” said pediatrician Rob Weiss, MD, FAAP, who celebrated a birthday by sharing his story. “We had a choice to do that. Dianne likes to say, ‘We could be going to Paris; instead, we opened an office.’ We felt if we were going to do this, now is the time in our lives professionally … while we’re still young enough and passionate enough to give it the time to make it successful.” Teamwork bodes well for the Weisses, parents of three children ages 27 to 35. In the practice, Diane Weiss, MS, serves as practice manager, parenting and child development specialist, and lead team member for the Medical Home Demonstration Project. “We wanted a model that looked at the family and child as an entire package rather than sporadic visits,” said Rob Weiss. “We became aware of the PatientCentered Medical Home, which dovetailed nicely with our goal.” This is a whole new world, said Rob Weiss, who marks 36 years of practicing medicine this month. “I cut my teeth and have grown up on the model of coordinated practice between multiple doctors, larger groups and coverage groups,” he said. “There’s always been a dance making a decision on individual changes when approaching patient care in a collaborative effort between multiple physicians. Often, the roadblocks (CONTINUED ON PAGE 7)
A Labyrinth Plan The American Academy of Pediatrics (AAP) spurred development
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of the Florida Child Health Insurance Program Reauthorization Act (CHIPRA) quality demonstration grant, with the assistance of the Agency for Health Care Administration and the Florida Department of Health. CHIPRA funding is being used to strengthen medical homes’ capacity to provide high quality, family-centered care through the Florida Children’s Medical Services Network for CYSHCN. The project focuses on quality improvement in practices and is being administered and implemented via the AAP Quality Improvement Innovation
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Starting Fresh, continued from page 6
Overcoming Challenges
to making significant choices are enormous. You’ll find that many times, it’s daunting to make a change among multiple providers. What’s exciting about this concept is that it’s a limited group with a coordinated effort to produce a product that keeps with this model.” The Florida Pediatric Medical Home Demonstration Project, initially launched in 2010 with 20 pediatric practices, is designed to provide physicians and their staff with strategies, tools, and resources necessary to strengthen medical homes’ capacity to provide high quality, familycentered care for all children and youth, including those with special healthcare needs. Weiss Pediatric Care is among select practices statewide to participate in a phase slated for completion this year. The 14 pediatric practices are assessing the effectiveness of the systems of care they provide and implementing tests of change with the aid of tools, strategies and measures to improve these systems. “It takes time to gather important data,” said Rob Weiss. “Our practice isn’t designed for families who want to rush in and out.” The greatest challenge internally has been accomplishing required tasks without making the workload unbearable. “It means longer days for Dianne and me, but it’s exciting … that’s surprised me,” he said. For example, the daily huddles to discuss each patient’s condition and treatment plan have become a vital earlymorning routine. “It starts the day on a different kind of note,” he emphasized. “Before we even see the patients, we ask them to complete a questionnaire addressing developmental
UCF REC provides valuable PCMH services
The ‘Unseen’ Medical Home A medical home is not a building, house, hospital, or home care service, but rather a model of primary care delivery developed by the American Academy of Pediatrics (AAP). According to the AAP, characteristics that define a medical home include care that’s accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. The medical home is community-based, interdisciplinary, and uses a team approach to provide preventative, acute and chronic care. The medical home concept promotes seven key principles: 1. Personalized medicine. 2. Physician-directed medical care. 3. Whole person orientation. 4. Coordinated care. 5. Evidence-based medicine (EBM), benchmarked and measured. 6. Enhanced access to care. 7. Added value. SOURCE: American Academy of Pediatrics.
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and behavioral issues, and general concerns parents may have before the doctor even comes into the room. This checklist helps us maximize the communication opportunity with the family. When they leave, we review the information on the discharge summaries with the parents.” The practice has established a computerized tracking system to follow patients who have been referred for specialty care, measure outcomes and determine priority areas for interventions. “We know what roles everyone will play, and we put this all together in a care plan package so that it’s a more coordinated effort,” he said. Weiss Pediatric Care also began offering Saturday office hours to make care more accessible for established patients; and, rather than delegate after-hours calls to a back-up group, the team fields all calls and questions that can’t wait till the next business day. “With ours, I can access information at home on my cloud to better help my patients after hours,” said Weiss. “It sounds very daunting time-wise, but people have been very respectful … once you learn the dance steps, it becomes quite doable.” As Weiss Pediatric Care celebrates its one-year anniversary, Diane Weiss raved about the improvements made across the board. “It’s been one of the most challenging endeavors of our professional lives, but what a difference it makes,” she said. “It truly transforms the way you provide care by better anticipating and addressing the needs of families, particularly those who have children with special needs.”
By LYNNE JETER
Finding a structured, sustainable process; understanding quality measurements; and lacking resource availability—financial, staffing, technology – are major barriers to independent practices seeking to pursue medical home designation. That’s why the UCF Regional Extension Center launched its Patient Centered Medical Home (PCMH) recognition and transformation support services last fall. “The PCMH model has the potential to change how we think of primary care,” said Josue Rodas, executive director of the UCF REC, one of 62 RECs established nationwide to help primary care providers adopt, implement and reach meaningful use of electronic health records. “We support the evolving healthcare delivery models, and the PCMH initiative with our PCMH-certified content specialists spearheading the team. Our customized approach guides providers through the process with best practices that follow National Committee for Quality Assurance (NCQA) requirements.” Jordon Schagrin, MHCI, PCMH CCE, project manager of PCMH Recognition Services/ Central Florida HIT Initiative for the UCF REC, focuses on helping private, independent doctors in small practice settings. “Florida is not a national leader in the PCMH movement,” said Schagrin. “It’s positive to see the state provide support because what it takes to become a PCMH is very challenging, very resource-intensive, and also very timely.”
Under the PCMH model, prevention and care management is the emphasis. The UCF REC, established by the UCF College of Medicine in 2009, provides organizational readiness assessments, assists practices with PCMH recognition requirements through an accrediting agency, and supports practices through long-term transformation. For the Florida Pediatric Medical Home Demonstration Project, Schagrin helped some pediatric practices determine if they would benefit from applying for a spot on the short list of providers selected for the pilot project. “The state was very selective in their criteria,” he said. “The providers who saw the opportunity to participate in the pilot project are innovators. I advised one forward-thinking provider not to apply because he wasn’t ready to do it. Those who applied were the right people to apply.” Shagrin pointed out the medical home concept is “very positive in many ways, but still limited in its scope.” For example, the overall goal of the PCMH implementation, Shagrin emphasized, is to build a sustainable medical home model. “One of the biggest complaints about Patient-Centered Medical Homes nationwide is that just because a practice is recognized as such, there’s no assurance that practices are operating under the model past a demonstration project period,” he said. “We’ll continue our work to keep these medical homes sustainable.”
Celebrate Medicine with the Florida Medical Association
What:
FMA Annual Meeting
When: July 25-27 Where: The Hilton Orlando Bonnet Creek Why:
• Up to 16 hours of CME • Physician networking • High-profile speakers • Family fun near Walt Disney World To learn more and join the FMA today, visit www.FLmedical.org.
Join the FMA today.
FLORIDA MEDICAL ASSOCIATION
JUNE 2014
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Three Issues That Could Significantly Impact Physician Reimbursement in Florida
By JARROD FOWLER, MHA
Changes to Medicaid reimbursement Since 2013, qualifying physicians who provide certain primary care services to Medicaid recipients have been eligible to receive Medicare-level reimbursement rates because of the Patient Protection and Affordable Care Act (PPACA). Unfortunately, this provision of the law is set to expire at the end of this calendar year unless Congress extends funding for the program. The expiration of these increased payments is likely to have a significant impact on thousands of Florida physicians. According to a presentation by the Agency for Health Administration (AHCA) at a Florida Senate committee in November, more than 11,500 Florida physicians had
taken the steps to receive these increased payments. Another change that could affect physician reimbursement is Florida’s new Statewide Medicaid Managed Care (SMMC) program, which will shift around 85 percent of Florida’s roughly 3.4 million Medicaid recipients into managed care plans throughout this year. Under this program, physicians and Medicaid managed care plans will negotiate reimbursement rates. However, there is also a new performance standard that plans can meet only by paying physicians at or above Medicare rates for similar services. Plans that don’t meet this performance standard after two years of continuous operation may be fined by AHCA. Because of this new performance standard, physicians who haven’t already negotiated rates that meet or exceed Medicare rates may see their Medicaid reimbursements increase once the SMMC plans in their regions have been operating continuously for two years. Ongoing efforts to replace the
sustainable growth rate and reform Medicare reimbursement As most physicians are aware, the sustainable growth rate (SGR) is the flawed formula currently used to calculate physician reimbursement rates under Medicare. Originally enacted through the Balanced Budget Act of 1997, the SGR has effectively been overridden by Congress every year since 2002 to prevent increasingly large Medicare payment cuts from affecting physicians. Had the SGR lapsed this year, Medicare reimbursement for physicians would have dropped by roughly 24 percent. Payment cuts of that magnitude could seriously threaten the financial viability of physician practices and reduce access to care for Medicare beneficiaries. Recently, Congress attempted to repeal the SGR indefinitely and replace it with a new method of calculating physician reimbursement that would eliminate the need to revisit the issue every year. However, despite strong bipartisan, bicameral support, proposals to repeal the SGR ultimately failed because of a lack of agreement on funding. However, there
are a few takeaways from the congressional debate that physicians should be aware of. First, if recent proposals to repeal the SGR are any indication, pay-for-performance under Medicare fee-for-service is here to stay. That is, physicians shouldn’t expect that the pay incentives tied to meaningful use, PQRS and the new valuebased modifier that is gradually being implemented will disappear if the SGR is ultimately replaced with something else. Instead, these programs would more than likely be modified and consolidated into a composite score that will be used to calculate penalties and bonuses. Further, any SGR replacement is likely to heavily incentivize participation in accountable care organizations (ACOs) and other types of so-called alternative payment models (APMs). The proposal that Congress nearly moved forward with would have provided larger annual payment increases for physicians who derive a substantial proportion of their revenue through APMs. So whether the SGR is ul(CONTINUED ON PAGE 10)
Tr a i n i n g · E d u c a t i o n · I n n o v a t i o n · C o m m u n i c a t i o n
Multidisciplinary Conference and Trade Show for the Healthcare Sector! Improving Training and Education to Enhance Safety and Performance 22-24 August 2014 | Rosen Shingle Creek Resort | Orlando, Florida, USA
Keynote Speaker! For further information, please visit
John Armstrong, MD, FACS, Florida’s State Surgeon General will speak at this year’s Healthcare Education Assessment Training & Technology (HEATT) Conference and Trade Show.
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The Impact of Healthcare Reform on Physician Practices By JAMES PERRY, Benefits Consultant, Corporate Synergies
Physician practices today face enormous hurdles as they attempt to navigate through the changing landscape of healthcare reform. From growing regulatory burdens to health insurance confusion, practices are constantly figuring out ways to control costs. Healthcare reform’s widespread impact ripples through all aspects of healthcare – and physician practices see all sides as payers, providers and patients. The swarm of activity taking place in Central Florida’s Lake Nona and Medical City has shifted some attention from the area’s burgeoning hospitality sector to its growing medical sector where well-managed healthcare for employees is just as important for patients. But, there are just some challenges to overcome. According to the Medicare Payment Advisory Commission, Medicare spending is projected to grow at a slower rate than in the past 10 years (3.3 percent annually compared with 6.1 percent annually). The lower projections for growth in spending per beneficiary are due in part to reduced updates of fee-for-service Medicare and lower payments to managed care plans
and in part to the recent slowdown in use of services. As a result, costs are being pushed to third parties for reimbursement. Healthcare reform has added additional taxes that insurers must pay, which translates to higher premiums on fully insured plans. The tax portion between patient-centered outcomes research (PCOR) fees, transitional reinsurance fees and the insurer fees add roughly 3 to 5 percent on top of the normal “trend” increase. The Patient Protection and Affordable Care Act (PPACA) mandated the maximum in out-of-pocket costs. Also, co-pays, which previously did not apply to the out-ofpocket costs, now do apply. Ultimately, this makes any benefit plan slightly or possibly significantly “richer.” Depending on the current benefit design, we have seen insurers add anywhere from 2 to 7 percent to the premium cost to account for the richer benefit. That adds up to anywhere from a 5.5 to 11 percent increase in costs before any claims or trends are taken into account. Insurance companies are highly motivated to control costs, which creates a difficult road ahead for physician groups. That’s why it’s critical for physician practices to consider alternative funding ar-
rangements. Most carriers (CIGNA, UnitedHealthcare, Aetna) are moving forms of alternative funding arrangements down to small groups, which would typically be community rated. These arrangements reduce the premium tax burden, provide composite rates for a group that would have agebased or tiered rates, and provide actionable data to bring real ROI on wellness programs. One thing to do now is to automate benefits administration. Not only is this great for the employer, it’s great for employees. User-friendly tools engage and educate staff about benefits through an easy-to-use navigation portal. Now, a wealth of information is just a click away. Open enrollment and life event processing can be confusing and challenging for anyone. With an automated system, employees can learn, view and then elect benefits specific to their eligibility. All transactions can be seamlessly transmitted to payroll, ensuring accurate payroll deductions. Physician groups should set aside time to educate employees to make them bet-
ter consumers of healthcare. A well-designed campaign puts the responsibility of health and cost control in the employee’s hands. If an employee understands that premiums and the organization’s overall insurance rates are based on utilization and claims experience, there is more of an incentive to get engaged. Who is better to educate their employees about healthcare than physicians? Effective wellness programs actually help shift the responsibility to the employee and reduce the employer’s healthcare costs overtime. Proactive disease management and prevention, including health risk assessments, biometric screenings and employee education, should be a standard practice for physician groups. Employees simply need to be smarter about their health decisions and physicians are perfectly aligned to be great educators. Just as physicians see time and time again with patients in the exam room, lifestyle choices also impact employees in (CONTINUED ON PAGE 13)
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Physician Reimbursement, continued from page 8 timately repealed or not, the recent congressional discussion of this issue served as one of the clearest signals yet that pay-forperformance programs under Medicare are likely to remain in place or expand over time. The 90-day grace period Because of a little-known provision of the PPACA, physicians may not receive reimbursement for some of the services they render if patients who sign up for coverage on the exchange fail to pay their premiums. Patients who sign up for coverage on the exchange and receive subsidies will enter into a 90-day grace period if they fall behind on paying their premiums. During this 90-day grace period, the patient will remain insured so long as he or she catches up on premiums before the grace period expires. However, if the patient does not catch up on his or her premiums by the end of the grace period, coverage will be retroactively terminated. The potential problem for physicians is that if a patient’s coverage were to be terminated under these conditions, the insurer would only be required to pay for covered services that were rendered during the first 30 days of the grace period. The patient’s insurer would not, however, be required to pay for any services rendered during the final 60 days of the grace period. This could substantially increase
the risk of bad debt for physicians seeing patients who have signed up for coverage through the exchange. The statewide impact of the 90-day grace period could be significant as close to 1 million Floridians have enrolled for coverage through the exchange. Of those, the Department of Health and Human Services claims that around 91 percent received a subsidy and could therefore potentially enter into the 90-day grace period if they fall behind on their premiums. So while it is impossible to predict the rate at which this problem will actually occur, the sheer number of patients that the grace period could apply to suggests it is hardly implausible. State legislation that would have addressed this issue by prohibiting retroactive denials in instances where insurance coverage is verified by the patient’s provider prior to the delivery of care failed to pass this year. However, similar legislation aimed at addressing the problem is expected to be reintroduced next year. Jarrod Fowler, MHA, is Director of Payment Advocacy for the Florida Medical Association and serves FMA member physicians by directly answering their questions about payment issues, healthcare policy and other issues affecting physicians. To learn more, call the FMA at (850) 224-6496.
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The Unknown Headache By BRiAN D. FuSELiER, DDS AND BARRy A. LOugHNER, DDS, MS, PHD
dura mater.” Moreover, “The meningeal branch of the mandibular nerve enters the skull through the foramen spinosum with the middle meningeal artery. It divides into two branches (in the middle cranial fossa), which accompany the anterior and posterior divisions of the artery and supply the dura mater. The anterior branch communicates with the meningeal branch of the maxillary nerve.” Interestingly, “the posterior branch sends filaments to the mucous membrane of the mastoid cells.”
The unknown headache is the “lowerhalf” headache. Another name for “lowerhalf” headache is “facial migraine.” Neil Raskin, MD, headache neurologist, in his book Headache (1988) cited the vascular characteristics of chronic recurring facial pain that “should not deter the diagnosis of a migraine variant.” Dr. Raskin wrote that such observations were “innovative and important,” but largely overlooked as representing a Diagnostic Schema primary headache disorder. How does a clinician Clearly, Dr. Raskin diagnos “lower-half” headconcluded that migrainache? The answer is ous pain can occur in simple: Ask the patient Lower-half headache centered in the jaw the maxillary and man- associated with vascular elements, also the same questions regudibular dermatomes of called facial migraine larly asked to diagnose the trigeminal nerve. Enmigraine elsewhere. Ask: closed in these lower facial dermatomes are “When the lower face pain is most severe anatomical structures not commonly underand at its greatest intensity, do you have stood to be involved in migraine pathophysinausea, light sensitivity or sound sensitivology. These structures include the muscles ity? Is there a family history of headache?” of mastication, TMJ and teeth. In addition, Herein, these questions point to the most the mucous membranes of the nasal sinuses, common associated features of migraine: and air cells of the mastoid processes are innausea (88 percent), photophobia (83 pernervates by the maxillary and mancent) and phonophobia (76 percent). dibular divisions of the CNV, In addition, 90 percent of mirespectively. graine patients have a familial Confirmation of the history of headache. neuroanatomical basis of Watch out - the patient “lower-half” headache or can fool you! If the patient facial migraine is found tells you that the extreme fain Gray’s Anatomy: cial pain was so bad that the “The middle meninpain itself “made me nauseated geal nerve is given off (in or made me throw-up,” be skepthe middle cranial fossa) tical. Worse pains than migraine, from the maxillary nerve directly after its origin Maxillary and mandibular dermatomes of from the trigeminal ganglion; CNV cover the lower half of face as well as the temporal fossa. The mandibular it accompanies the middle mennerve innervates the mastoid air cells. ingeal artery and supplies the
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such as tic pain, are not commonly associated with nausea, vomiting, photophobia or phonophobia. Alternatively, the patient may blame the nausea and/or vomiting on medications that she/he is taking for the extremely severe facial pain. This may be true, but unlikely, if other common associated features are present. Obviously, one must rule out other conditions of the lower half of the face: sinus headache, trigeminal neuralgia, carotid system arteritis, TMJ dysfunction, and dental pathology. Comorbidity of migraine with any of these conditions complicates pattern-recognition of the pain presentation. Comorbidity increases the chances of making a Type 2 error: believing that a pattern is not real when it is. Another complication of diagnosing lower-half headache is that seen in common migraine located elsewhere, i. e., the severe migrainous attack may have no associated features. Pathophysiology of “Lower-half headache” Given that branches of the maxillary and mandibular divisions of CNV innervate the dura mater, how does the extra-cranial anatomy of the lower face receive sensory input from the intra-cranial vasculature imbedded in the meninges? The illness of “lower-half” headache is a story of trigeminal nociception that is centrally-mediated based on the neurological concept of viscera-somatic convergence. Peripherally, the viscera is intra-cranial representing the meninges, and the soma is extra-cranial representing the maxillae and mandibular structures forming the carriage of the lower face. Importantly, neuronal innervations of the visceral meninges are the first, second or third divisions of CNV. Whereas, the neuronal innervations of the somatic facial anatomy are the second or third divisions of CNV. Gray’s Anatomy documents that all three divisions of CNV innervate the me-
Viscero-somatic Convergence: Peripheral visceral meningeal nociceptor of the mandibular nerve originating from the middle cranial fossa sends a branch to synapse with a somatic 2nd order pain transmission neuron that of a tooth. When active, the meningeal nerve turns on the dental nerve, and patient feels migraine in the teeth.
ninges. The meningeal nerve of the maxillary nerve innervates the meninges of the anterior wall of the middle cranial fossa. The meningeal branch of the mandibular nerve, also known as the nervus spinosum, innervates the remaining meninges of the middle cranial fossa. The largest population of meningeal neurons are nociceptors. The somatosensory innervations of the maxillo-mandibular complex that subserve pain are nociceptors whose first central synapse is in the superficial lamina of the medullary dorsal horn. Within the superficial lamina are cell bodies of second-order pain transmission neurons that normally transmit signals from maxilla-mandibular nociceptors via the trigemino-thalamic tact to rostral perception areas that are discriminative for pain of the lower face. Importantly, the first central synapse of some visceral nociceptors of the meninges converge on the secondorder somatic trigemino-thalamic neurons. Thus, the identical central target of the peripheral meningeal nociceptors and the lower face nociceptors represent viscerasomatic convergence. (CONTINUED ON PAGE 14)
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Choosing a Retirement Plan for Your Business
PROViDED By RACHEL WRigHT, FiNANCiAL ADViSOR, MORgAN STANLEy
If you own a business, you understand the importance of attracting and retaining key employees. One of the most vital steps you can take to take care of those you hire is to create an appealing benefits package. A great component of any benefits program is a retirement plan. There are many options available to you. In choosing a retirement plan you should consider, among other things, your company’s size, financial situation, and ability to comply with regulatory oversight and administrative responsibilities. Here is a summary of many of the options potentially available to you. IRA-Based Plans • SEP IRAs A Simplified Employee Pension IRAbased plan (SEP IRA) may be ideal for a one-person business or a business with just a few employees. It is relatively inexpensive and easy to start and administer. The employer -- not the employees -- contributes to a SEP IRA maintained by each
plan participant. Employees are immediately vested, and each employee decides how his or her money is to be invested. Although there are some exceptions, in general, a SEP IRA must cover any employee who is 21 or older, earned at least a certain amount from the business for the year ($550 for 2013), and has worked there during at least three of the preceding five years. In 2013, the annual contribution limit for each employee is 25% of compensation or $51,000, whichever is less (special rules apply for self-employed individuals). SEP IRAs also offer small-business owners flexibility regarding both the amount and timing of contributions. As a result, a SEP IRA may make sense for a business with profits that tend to fluctuate from year to year. • SIMPLE IRAs The Savings Incentive Match Plan for Employees IRA-based plan (SIMPLE IRA) is also valued for its ease of administration and is generally available to businesses with 100 or fewer employees. A “matching” SIMPLE IRA plan allows employees to contribute up to $12,000 of salary in 2013 (plus $2,500 in “catchup contributions” for employees age 50 and over, if permitted by the plan). The employer must then make a dollar-fordollar matching contribution on elective deferrals of up to 3% of each participant’s annual compensation, but the employer has the right to match as little as 1% in two out of any five consecutive years. The other method for funding a SIMPLE IRA requires the employer to make non-
To learn more, visit healthcare.goarmy.com/y941 or call 1-888-550-ARMY.
elective contributions equal to 2% of compensation for each worker who has earned at least $5,000 during the year, whether or not the worker has elected to contribute salary. For 2013, the maximum compensation amount that can be used to determine the non-elective contribution amount is $255,000. Defined Contribution Plans • 401(k) PLANS A 401(k) plan allows eligible employees to make pre-tax deferrals. Participants decide how much money to contribute to their individual accounts (up to applicable plan and legal limits) and usually how to manage their investments. The employer can have the option of making matching or profit sharing contributions. These employer contributions can vest immediately or over a graded or cliff schedule if it is a traditional 401(k) plan, but must vest immediately if it is a safe harbor 401(k) plan. A participant’s elective pre-tax deferrals are always 100% vested. Participants may contribute up to $17,500 for 2013 – those age 50 and over may be able to add another $5,500. In 2013, total contributions to an individual’s account cannot exceed $51,000 or 100% of compensation, whichever is less. Additionally, the plan may allow employee loans and hardship and other in-service withdrawals. • ROTH 401(k)s The difference between a Roth 401(k) and a traditional 401(k) is that the Roth version is funded with after-tax dollars
while the traditional 401(k) is funded with pre-tax dollars. An employer may decide to offer both types of accounts. As with a traditional 401(k), participants may contribute up to $17,500 for 2013 – those age 50 and over may be able to add another $5,500. In 2013, total contributions to an individual’s account cannot exceed $51,000 or 100% of compensation, whichever is less. Employers are permitted to make matching contributions on employees’ designated Roth contributions. However, employers’ contributions cannot receive the Roth tax treatment. The matching contributions made on account of designated Roth contributions must be allocated to a pre-tax account, just as matching contributions are in traditional 401(k)s. Profit-Sharing Plans A profit-sharing plan allows the business owner to decide (within limits) from year to year whether to contribute on behalf of participants. If contributions are made, the business owner needs to adhere to a set formula for determining how the contributions are allocated to participants. This money is accounted for separately for each participant. Contributions to the plan can be subject to a vesting schedule. Consider a profit-sharing plan if your income varies significantly from year to year and you don’t want to be committed to an annual contribution. Money Purchase Plans Money purchase plans are now subject to the same contribution limits as profit-sharing plans, but offer less flexibility. The percentage of each eligible employee’s compensation to be contributed is set when the plan is established and cannot be changed each year. You may want to consider a money purchase plan if your income is stable enough that you don’t mind committing to an annual contribution, but as money purchase plans entail more complex administrative responsibilities, and are now subject to the same contribution limits as profit-sharing plans, with less year to year flexibility, money purchase plans have generally fallen out of favor. Defined Benefit Plans • TRADITIONAL DEFINED BENEFIT PLANS A defined benefit plan is a type of plan where employee benefits are determined based on a formula using factors such as salary history and duration of employment. Actuaries use statistical analysis to calculate the cost of funding future benefits. The calculation takes into consideration employee life expectancy and normal retirement age, possible changes to interest rates, annual retirement benefit amounts, and the potential for employee turnover. Investment risk and portfolio management are usually entirely the re(CONTINUED ON PAGE 13)
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Choosing a Retirement Plan for Your Business, continued from page 12 sponsibility of the company. Employees are entitled to the vested accrued benefit earned to date upon the occurrence of certain events. If an employee leaves the company before retirement, the benefits earned so far may be frozen and held in the plan’s trust for the employee until he or she reaches retirement age. • CASH BALANCE PLANS An increasingly popular type of retirement plan is the cash balance plan, which combines aspects of both DB and DC plans. As in a DC plan, cash balance plan participants have their own separate account balances. Like a DB plan, however, the employer is generally responsible for the funding of accounts and bears the investment risk. The amount to be contributed by the employer each year is actuarially determined. The employer must make sure that the plan has enough money to pay out total contributions plus specified interest for each plan participant, regardless of the performance of plan investments. Loans and hardship and other in-service withdrawals are optional. Keep in mind that regardless of the type of qualified retirement plan a company decides to offer, the federal Employee Retirement Income Security Act (ERISA) stipulates that it must be established and managed in the best interests of its participants. So while it certainly makes sense to determine which option best addresses your company’s needs, the final decision must ultimately take into account the long-term needs of your workforce. Nonqualified Plans Many companies offer nonqualified plans to certain highly compensated employees. Such plans come in many shapes and sizes: for example, defined benefit excess plans, defined contribution excess plans, voluntary deferred compensation plans, and supplemental executive retirement plans (SERPs). Nonqualified plans are usually not subject to ERISA and therefore are more flexible. Nonqualified plans do have certain common features. Generally speaking, the contribution limits applicable to the qualified plans described above do not apply to nonqualified plans and thus contributions
can be significantly higher than for qualified plans. As with qualified plans, contributions to properly designed nonqualified plans are tax deferred; taxes are not paid until funds are distributed. Unlike vested contributions under qualified plans, however, contributions are not technically owned by plan participants until they are paid; plan liabilities -- including employee contributions -- represent an unsecured promise to pay on the part of the employer. This can present issues in the event of a change of control with the company or if it goes bankrupt. One popular funding mechanism is corporate-owned life insurance (COLI). In this arrangement, employers fund nonqualified plans with variable universal life insurance. Although COLI-funded plans can be complex, they offer tax-free growth, can be cost effective, and are attractive to sponsors seeking to match assets with the liabilities created by deferred compensation plans. Which type of retirement plan works best for your business will depend on a number of factors, including your staffing requirements and available funding. Let me work with you to identify the program that best suits your specific needs. Article by Wealth Management Systems, Inc. and provided courtesy of Morgan Stanley Financial Advisor. The author(s) are not employees of Morgan Stanley Smith Barney LLC (“Morgan Stanley”). The opinions expressed by the authors are solely their own and do not necessarily reflect those of Morgan Stanley. The information and data in the article or publication has been obtained from sources outside of Morgan Stanley and Morgan Stanley makes no representations or guarantees as to the accuracy or completeness of information or data from sources outside of Morgan Stanley. Neither the information provided nor any opinion expressed constitutes a solicitation by Morgan Stanley with respect to the purchase or sale of any security, investment, strategy or product that may be mentioned. Rachel Wright may only transact business in states where she is registered or excluded or exempted from registration. Transacting business, follow-up and individualized responses involving either effecting or attempting to effect transactions in securities, or the rendering of personalized investment advice for compensation, will not be made to persons in states where Rachel Wright is not registered or excluded or exempt from registration. Tax laws are complex and subject to change. Morgan Stanley Smith Barney LLC (“Morgan Stanley”), its affiliates and Morgan Stanley Financial Advisors and Private Wealth Advisors do not provide tax or legal advice and are not “fiduciaries” (under ERISA, the Internal Revenue Code or otherwise) with respect to the services or activities described herein except as otherwise agreed to in writing by Morgan Stanley. This material was not intended or written to be used for the purpose of avoiding tax penalties that may be imposed on the taxpayer. Individuals are encouraged to consult their tax and legal advisors (a) before establishing a retirement plan or account, and (b) regarding any potential tax, ERISA and related consequences of any investments made under such plan or account. Wright may be reached at Rachel.Wright@morganstanley.com
EMPLOYMENT OPPORTUNITIES MD’S, DO’S, ARNP’S, PA’S Physical medicine based urgent care with three locations throughout Greater Orlando is seeking a board certified or board eligible physician as well as a ARNP or PA to join this growing practice.
ABOUT THE PRACTICE
Presently we have multiple board certified MD’s who provide consultations for patients with soft tissue musculoskeletal based injuries. Treatment plans are then enacted which include physical therapy, diagnostics, pain management, and surgical intervention.
OPPORTUNITY
This group is growing due to the community’s rapid growth and development. The primary focus is on evidence-based medicine.
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• Board certified or board eligible in family practice, internal medicine, physiatry, or similar fields • Interest in physical medicine and rehabilitation
BENEFITS: • • • • •
Part Time or Full Time Salary with bonus potential Health Benefits and Vacation Days Professional Liability Insurance No Call Requirement Flexible hours with ability to see 10-25 patients/day
Contact Andrew Cremé, Director of Business Management Phone (321) 576-5331 Email acreme@mdpcinc.com
Florida Wound Care Doctors Taking wound care to wound healing
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The Impact on Physician Practices, continued from page 9 the workplace. Four behaviors identified by the Centers for Disease Control and Prevention (CDC)—inactivity, poor nutrition, tobacco use and frequent alcohol consumption—are primary causes of chronic disease in the United States. These behaviors lead to a higher prevalence of diabetes, heart disease, and chronic pulmonary conditions, according to the CDC. The cost-reduction potential is large for employers with well-established strategies around health and wellness, telemedicine, and benefits administration. Ultimately though, to impact healthcare inorlandomedicalnews
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surance premium costs, physician practices will have to look at managing their employees’ health risks like they would with workers’ compensation. In the end, this reduces controllable risks and provides the best way to reduce costs in the long run. Corporate Synergies Benefits Consultant Jim Perry specializes in reducing the employer’s employee benefit costs through in-depth market research, strategic plan design, claims data analysis and diligent negotiations. He directs the strategic benefits process, monitors the business plan and ensures the delivery of exceptional client service. He has extensive experience in the Florida market and serves clients from the firm’s regional office in Orlando.
Front row (L to R): Dr. Michael Cascio and Dr. Walter Conlan; Back row (L to R): Dr. Barry Cook, Patrice Muse, ARNP, Deborah Tedesco, ARNP, and Dr. Ricardo Ogando.
BUSINESS OFFICE: 295 W. PINE AVE., LONGWOOD, FL 32750 • 407.339.4499
www.floridawoundcaredoctors.com WOUND CARE CENTERS Wound Care & Hyperbaric Medicine Center at South Seminole Hospital 407.767.5843 Longwood, FL
Dr. P. Phillips Comprehensive Wound Care Center 321.842.7320 Orlando, FL
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Wound Healing Center at ORMC/ Lucerne Annex 321.841.5469 Orlando, FL
Wound Healing & Hyperbaric Medicine Center at Health Central 407.253.2780 Ocoee, FL
JUNE 2014
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The Unknown Headache, continued from page 11 Under normal conditions, the synapse of peripheral meningeal nociceptors onto central trigemino-thalamic neurons are silent. During an acute attack of migraine, these silent synapses become awake and active resulting in stimulation of the second-order neurons followed by propagation of pain signals rostrally that are ultimately perceived as severe pain attacks in the lower face. Moreover, the truth is that the extra-cranial peripheral dermatomes of CNV as seen in diagram 1 are different than the intra-cranial peripheral dermatomes of CNV. The consequence of this truth is related to lower-half headache. The tentorial branch of the ophthalmic division of CNV arises near the trigeminal ganglion and runs between the layers of the tentorium to which it is distributed. The tentorial branch of CNV innervates the entire tentorium that extends posteriorly all the way back to the internal occipital protuberance, as well as all of the meninges above the tentorium. Thus, migraine in the occipital area can be a trigeminal pain that has the potential to participate in the neurological mechanism viscera-somatic convergence resulting in pain perceived in the lower half of the face. Note with careful interTentorium of meninges is innervated by the first division of CNV as far posteriorly as the internal occipital protuberance.
Intracranial dermatomal map of CNV. Note the reception areas of the entire intracranial tentorium and the supratentorial occipital region. Note the extracranial mastoid process wherein lies air cells innervated by the mandibular nerve of CNV.
est the yellow circle behind the ear in diagram 5. Traditionally, the extra-cranial dermatome for this area is known to be C2, i. e., the lesser occipital nerve distribution. On the other hand, the sinus lining of the mastoid air cells deep to the skin is innervated by a small branch of the mandibular division of CNV. Based on pathophysiology of lower-half headache described above, meningeal migraine pain can refer lower-half pain to the back of the head behind the ear. Treatment Strategies for the treatment of “lower half headache” follow the same well-published and standard protocols of care for migraine anywhere else in the head. For example, abortive medications are recommended for severe attacks occurring less than 15 days per month. Whereas, more frequent attacks may require a daily preventative medication regiment. Botox can also be used in the muscles of mastication. Summary Recurrent severe jaw pain associated with vascular elements in the lower half of the head caused by migraine is called “lower-half” headache or facial migraine. Recognized as a
PUBLISHED BY: SouthComm, Inc. FLORIDA MARKET PUBLISHER John Kelly johnkelly@orlandomedicalnews.com
Viscero-somatic Convergence: Peripheral visceral meningeal nociceptor of the tentorial nerve sends branch to synapse with somatic 2nd order pain transmission neuron that subserves infraorbital nerve of the maxillae. When active, the tentorial nerve activates the 2nd order neuron, and patient feels migraine in the midface.
primary headache disorder, the severe pain is located in the maxillae and/or mandibular dermatomes of CNV. Associated features of “lower-half” headache are identical to common migraine – nausea, photophobia and/or phonophobia. Most patients fail to recognize these manifestations as associated features of migraine. In some cases, no associated features occur which makes diagnosis difficult. In addition, comorbidity of “lower-half” headache together with maxillo-mandibular pathologies makes diagnosis difficult. Therefore, a multidisciplinary approach is recommended. Brian D. Fuselier, DDS is a member of the International Association for the Study of Pain, and the American Pain Society. Barry A. Loughner, DDS, MS, PhD is a member of the International Association for the Study of Pain, the American Pain Society, the American Dental Association, and the Ethics Committee of the American Association for the Study of Headache. Dr. Fuselier and Dr. Loughner are actively practicing at Central Florida Oral and Maxillofacial Surgery. This practice is unique as they have both Oral Surgeons and Facial Pain Specialists practicing together. For more information visit www.cforalsurgery.com
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Chief Executive Officer Chris Ferrell Chief Financial Officer Patrick Min Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Chief Operating Officer/ Group Publisher Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content/Online Development Patrick Rains Orlando Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2014 Medical News Communications.All rights reserved. Reproduction in whole or in part without written permission is prohibited. Medical News will assume no responsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.
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GrandRounds FREE EMR SOFTWARE New Ophthalmology Practice Opens In Orlando Orlando Eye Specialists held a grand opening ceremony in May for its new medical office nestled in the heart of East Orange County. The multi-specialty ophthalmology practice offers routine eye exams as well as screenings for diabetic retinopathy, macular degeneration, glaucoma, cataracts, and various other eye conditions. The grand opening was commemorated with a special ribbon cutting ceremony to formally welcome Javier Perez, Medical Director and owner of Orlando Eye Specialists, to the community. Ana Bello of the Hispanic Chamber of Commerce joined Dr. Javier Perez and his friends and family for this special occasion. The event gave locals an opportunity to get to know Dr. Perez and the services his ophthalmology practice will offer.
Nemours Children’s Health System Expands in Lake and Seminole Counties Families in Lake and Seminole counties will now have greater access to the Nemours Children’s Health System through two new primary care offices. Nemours Children’s Primary Care, Clermont and Nemours Children’s Primary Care, Oviedo both opened their doors to patients and families this month. The physicians at each location are now providing a variety of pediatric services; from checkups and immunizations to sick visits and physicals. Patient families will be more connected to Nemours’ team of world-class pediatric specialists as the primary care locations share an electronic health record with Nemours Children’s Hospital and Nemours Children’s Specialty Care locations. This integration provides every member of the care team - including the patient families - with a complete picture of a child’s care history. Dr. Odette Stanley-Brown is the physician who will treat kids at Nemours Children’s Primary Care, Clermont. She is a board-certified pediatrician and fellow of the American Academy of Pediatrics who has provided health care to Florida families for more than 25 years and she’s been a pediatric practitioner in the hospital as well as the urgent care environment. Dr. Andrea Burns, a native Floridian and Oviedo resident, will lead Nemours Children’s Primary Care, Oviedo. Dr. Burns also helps with community-based educational workshops on adolescent health and obesity prevention and volunteers with two Central Florida service organizations. In addition to the nine Nemours Children’s Primary Care locations, the network in Central Florida includes Nemours Children’s Hospital with a fullservice, pediatrics-only Emergency Department in Orlando’s Lake Nona Medical City, three Nemours Specialty Care locations, and five Nemours Children’s
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Urgent Care locations. These locations will also share the electronic health record with the other components of the Nemours Children’s Health System.
Disney Gives $3 Million to Emergency Care Efforts At Arnold Palmer Hospital for Children The Walt Disney Company has presented a $3 million gift to Arnold Palmer Hospital for Children to help fulfill a critical need in the treatment of young patients at the hospital’s Bert Martin’s Champions for Children Emergency Department & Trauma Center. The gift will enable the purchase and installation of a new 3T MRI machine that will serve as a critical first step in the treatment of children in need of emergency and trauma care in addition to supporting other key pediatric programs at Arnold Palmer Hospital. Currently, Arnold Palmer Hospital has one Flash CT scanner and one 1.5T MRI machine within its Imaging Center. A growing patient population and the expansion of key pediatric specialty programs have significantly increased the demand for the existing MRI machine. The new 3T MRI machine ensures patients receive the highest level of care by providing more detailed images faster than ever. It also improves patient safety by providing a radiation-free imaging option. Also, by adding a new machine, the patient experience will be enhanced for both child and family. Providing quality pediatric care with the latest technology is critical for Central Florida and its dynamic community of local residents and millions of visitors from around the world who come here to visit theme parks and attractions. Orlando Health values its longstanding relationship with The Walt Disney Company, who proudly supports children’s hospitals across the country and is focused on improving the quality of life of children and families.
Hospital is First in Region, Fourth in Nation, to Install Newest Minimally Invasive Surgery System Another first in healthcare has been announced by Central Florida Health Alliance (CFHA) which has finalized plans to bring the newest, leading-edge, surgical system to Central Florida. In May CFHA installed the new da Vinci Xi Surgical System at The Villages Regional Hospital (TVRH) and will become the first hospital system in the region, and only the fourth in the nation, to do so. Don Henderson, President and CEO said introducing this new technology is part of the organization’s ongoing commitment to ensure its patients have access to world-class care in their own community. The new robotic assisted surgery system is a fourth generation system developed by Intuitive Surgical, based on more than two decades of learning, research and real-world application of
previous da Vinci models. The da Vinci Xi delivers real-time 3D-HD video, and utilizes smaller, thinner robotic arms with a greater range of motion than previous versions. This creates a more natural extension of the surgeon’s eyes and hands. The goal is to further reduce the size of surgical incisions, and decrease the amount of tissue damage during surgery. TVRH has surgeons on staff who are already experienced with previous generations of the da Vinci system. Operating Room staff are also being thoroughly trained in the use of the new equipment.
Osceola Regional Medical Center Names Two New Officers Osceola Regional Medical Center has named Rick R. Naegler Chief Nursing Officer and Bryan Lee as Chief Operating Officer. .Naegler most recently served as the Chief Nursing Officer at HCA’s Lake City Medical Center in Lake City Florida. Naegler was previously Assistant Chief Nursing Officer and Director of Critical Care at HCA’s Capital Regional Medical Center in Tallahassee. Before joining the HCA system, Naegler held Director of Nursing positions at Archbold Medical Center in Thomasville, Georgia; and St. John’s Health System in Springfield, Missouri. He had also served as Director of the Post Anesthesia Care Unit at St. John’s Health System and was the Vice President of Operations at Total Healthcare Services, also in Springfield. A member of the American College of Healthcare Executives, Naegler is also an active member of Rotary International. Bryan Lee most recently served as the Chief Operating Officer at Eliza Coffee Memorial Hospital, a 358-bed facility in Florence, Alabama. In October 2013, Lee was named one of Alabama’s top “Young Movers and Shapers under 35” by Business Alabama magazine. Before joining RegionalCare Hospital Partners, Lee was Division Vice President for Select Medical, managing 10 longterm acute care hospitals across the Southeast. He also served as Chief Executive Officer at Select Specialty Hospitals in Pensacola, Florida, and Nashville, Tennessee. In 2008, Lee was selected as a “Top 15 Leader” from among the 21,000 employees at Select Medical. He was also named a “Rising Star” by the Independent News in 2008. Lee received his bachelor’s degree in healthcare management from the University of Alabama in 2001. He later received a Master’s degree in Business Administration (MBA) and his Master’s in Health Administration, both from the University of Alabama at Birmingham. In 2008, he was recognized as a Fellow in the American College of Healthcare Executives. In addition to his professional responsibilities, Lee has been involved with the American Heart Association Heart Walk and Heart Ball; the Relay for Life; Rotary International; and Trinity Episcopal Church.
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