Page 1

PROUDLY SERVING HILLSBOROUGH, PINELLAS & PASCO

August 2013 December 2009 >> >> $5 $5

PHYSICIAN SPOTLIGHT

HMA Loses Florida Corporate Roots

Adewale Troutman, MD

Nashville-based Community Health Systems acquires Naples-based hospital operator in historic deal

PAGE 3

ON ROUNDS

Stacking the Deck FSU channels novel approach to retain medical graduates in Florida ... 4

Plan B IASIS Health sells trio of local hospitals to HCA ... 8

Social Media Revolution in Healthcare AMA Tampa Bay shares Mayo Clinic story at September event; forerunner events focus on networking, fun ... 9

ONLINE: TAMPABAY MEDICAL NEWS.COM

By LyNNE JETER

NAPLES – The honeymoon wasn’t over for Bayfront Medical Center, a century-old independent hospital located in downtown St. Petersburg. And only 35 days had passed since the Southeast Volusia Hospital District Board of Commissioners, after years of vacillating between suitors, had started exclusive negotiations toward a lease agreement for the 112-bed Bert Fish Medical Center in New Smyrna Beach. For both hospitals, plus the three rural (CONTINUED ON PAGE 5)

The Tide is Turning for Geriatrics Ken Brummel-Smith, MD, discusses decade of change in high demand specialty By LyNNE JETER

TALLAHASSEE—History was made in 2003 at Florida State University (FSU) when Ken Brummel-Smith, MD, joined the College of Medicine (COM). To move geriatrics to a priority area in the college’s mission, FSU became the nation’s first allopathic school to be created with a Department of Geriatrics, with Brummel-Smith, past president of the American Geriatrics Society, as founding chair. “Other medical schools added departments later, transitioning from a division

within internal or family medicine, or a freestanding center, or an institute into a department,” said Brummel-Smith, noting that nine allopathic medical schools in the U.S. now have a Department of Geriatrics. At FSU, it’s one of five academic departments in the College of Medicine. Ironically, Brummel-Smith almost bypassed specializing in geriatrics because of the lack of educational opportunities at medical schools during the early 1970s, when he attended, and the lack of geriatric residency slots nationwide. Instead, it was a chance encounter that sculpted his career path.

“My first job after fellowship was teaching a family medicine residency, and my director told me about the Society of Teachers of Family Medicine having a conference on teaching geriatrics in the family medicine residency program, and said it was going to be a big deal someday. When asked if I’d go and see what I could find out about it, my first thought was, wow! A free trip to Boston! I really didn’t have much knowledge about geriatrics then,” said Brummel-Smith. “After getting enthused at the conference and involved in developing educational programs, I switched from fam(CONTINUED ON PAGE 6)

BE PART OF THE CONVERSATION BLOG TONIGHT www.tampabaymedicalnews.com Click on Blog and Contribute Healthcare Solutions PRINTED ON RECYCLED PAPER

PRSRT STD U.S. POSTAGE PAID FRANKLIN, TN PERMIT NO.357


New Hope For Your Patients With Non-Healing Wounds If your patients have a wound that will not heal, The Centers for Wound Care at Edward White Hospital, Largo Medical Center and St. Petersburg General Hospital can help. We provide treatment that will help heal your patients’ wounds quickly and effectively so they can get back to the healthy lifestyle they deserve!

The Centers provide:

The Centers Treat Acute and Chronic Wounds:

• Hyperbaric Medicine

• Pressure Ulcers

• Traumatic Wounds

• Diabetic Ulcers

• Burns

• Advanced Wound Care Techniques

• Neuropathic Ulcers

• Established and Proven Clinical Practice Guidelines

• Ischemic Ulcers

• Other Chronic Non-Healing Wounds

(Provided at Edward White Hospital & Largo Medical Center)

• Venous Insufficiency

• Educational Community Seminars

To learn more about the Centers for Wound Care, call:

1-855-422-2228 www.EdwardWhiteHospital.com www.LargoMedical.com www.StPeteGeneral.com

2

>

AUGUST 2013

medicalnews

.com


PhysicianSpotlight

Adewale Troutman, MD Executive Director, Public Health Leadership and Practice, USF By JEFF WEBB

TAMPA - He is nearing the end of his term as president of the American Public Health Association, but Adewale Troutman is nowhere near the end of his quest to create health equity in America and around the globe. “My work for the past 15 years or so has focused around eliminating the unacceptable differences in the health status among populations based on race, ethnicity, socio-economic status and, more recently, an awareness of differences based on sexual orientation and disability status. Those are the driving forces for me, both in my local work and with national organizations,” said Troutman, professor and executive director of Public Health Leadership and Practice at the University of South Florida College of Public Health. Troutman’s leadership position with the 140-year-old organization is a threeyear commitment, one year as incoming president, one as president, and one as immediate past president. “We set a standard of pillars each year. During my term the three are: creating health equity, assuring the right to health and healthcare, building public health capacity and infrastructure,” Troutman said. His role as president of the APHA has kept him on the road quite a bit. “Minimally, there are 17 separate visits to 17 different states in a year, and that doesn’t include special invitations,” he said. For instance, this year he is going to Ottawa to represent the APHA at a Canadian Health Association conference, and to Cape Town, South Africa. His travels are a point of pride and possibilities for Troutman’s boss at USF, Donna Petersen, ScD, and dean of the College of Public Health. “We couldn’t be more delighted to have a USF Health voice at the highest levels of policy deliberation and advocacy,” Petersen said when Troutman became president of the APHA. “It is incredibly exciting to have someone of (his) caliber and expertise leading the nation’s largest public health organization. The fact that he is also a leader at USF Health helps make the connection between his vision and ours – that health is about a lot more than healthcare; it is about improving lives through community engagement and deliberate preventive action,” she said. Troutman’s international reputation raises USF’s profile, said Petersen, who got to know him when they were on the National Board of Public Health Examiners. She said she helped recruit him to USF because “we need people with high energy, creativity and passion and he certainly has all of those in abundance.” Troutman “is a marvelous public speaker,” said Petersen, who shared that she often hears feedback from colleagues in her field who say they

medicalnews

.com

saw Dr. Troutman at a conference and he was singing the praises of USF. Being an ambassador for USF is a pleasure, said Troutman, and it is becoming easier all the time. “I do think that people are taking notice. USF is building a reputation for its innovation around educational advances ... As I travel I see there is an increasing awareness of how fine of an institution USF is,” he said. Notably, he hears a lot about CAMLS, the one-of-a-kind Center for Advanced Medical Learning and Simulation in downtown Tampa. “It’s one of the most exciting things in medical education that I’ve ever seen,” he said. Troutman said he receives positive reviews about “our online learning and the quality of our graduate programs” for Masters of Public Health degrees, which is under his direction. “We are the office of Public Health Leadership and Practice and to a large degree what we do is work with people who are in the practice field. Many of them take an online MPH. Many take an executive program where they come in once a month for several days and then at the end of the year they come in for this seminar. We also have two federal grants, one from the Health Resource and Services Administration, which is for workforce development, and one from the Centers for Disease Control, which is about building community coalitions. Both of those are under my direction,” he explained.

Troutman said he hasn’t “done clinical medicine in quite some time. I occasionally am in the classroom doing guest lectures for other professors. I do a Capstone seminar, which is an accumulation of all the principles (students) learned in their 2 years of MPH learning, a kind of 5-week intensive review and examination period of special projects,” he said. One of the reasons he is not lecturing on a full-time basis is because of his responsibilities with the APHA, he said. “It would not be possible for me to run a course with as much traveling as I do. But when my term on the APHA is up, I anticipate teaching more courses.” When he is not fulfilling his administrative responsibilities at USF and the APHA, Troutman also is active with the organization 100 Black Men of America. “I have been involved for quite some time,” he said. “It was founded primarily as a mentoring organization, but it has expanded now,” said Troutman. “We have 110 chapters in the U.S. and over 10,000 members. Health and wellness is one of the group’s four pillars.” Troutman is currently chair of the International Health and Wellness Committee, which helps develop health screening and education programs, he said. This realm of volunteerism has added perspective for Troutman because of some sobering childhood memories growing up in the Bronx, he said. “I got a copy of Jet magazine and the cover photo was of 14-year-

old Emmett Till in his coffin,” Troutman recalled. Till had been murdered in 1955 by racists in Mississippi for speaking to a white woman in a store. “I was very frightened,” Troutman said. “As a terrorist event, it certainly worked with me because I was terrified. I was concerned that it could happen to me, and I developed this fear of the South,” he said. “I was amazed that there were such differences about what blacks could or could not do in different parts of the country.” In the same magazine, Troutman said, there was a story about Miami. Every face in the photos was white and “it made another statement to me that there are places in this country where (black people) just can’t go. It affected me,” he said. And, as he has strived to establish equity in healthcare, those memories “have been a background theme in terms of my work all of my adult life.”

BREAST SURGERY NOW AT ST. JOSEPH’S HOSPITAL - NORTH New hours! Dr. Claudia Lago Toro has added office hours at our location in St. Joseph’s Hospital - North. To make an appointment, please call Monday through Friday at

(813) 264-6490

4211 Van Dyke Road, Suite 200 Lutz, Florida 33558-8005

Claudia Lago Toro, MD

Claudia Lago Toro, MD is Board Certified in General Surgery. As a Breast Surgical Oncologist, she specializes in the medical and surgical treatment of the below conditions for adults: w Breast Diseases (Male and

w Procedures Including:

Female) Including:

- Ultrasound Guided Cyst

- Malignancies

- Aspirations

- Cysts

- Excisional Biopsy

- Breast Masses/Lumps

- Lumpectomy

w Abnormal Breast Imaging

- Mastectomy

w High Risk Evaluation

- Genetic Testing for BRCA1/2 Mutations

We accept most commercial insurance.

Doctor of Medicine: University of Puerto Rico San Juan, Puerto Rico Surgical Residency: Baystate Medical Center Springfield, Massachusetts Breast Surgical Oncology Fellowship: Bryn Mawr Hospital Bryn Mawr, Pennsylvania Member: American Society of Breast Surgeons Society of Surgical Oncology American Society of Clinical Oncology FLUENT IN SPANISH

HealthPointMedicalGroup.com

AUGUST 2013

>

3


Stacking the Deck FSU channels novel approach to retain medical graduates in Florida

‘‘

By LYNNE JETER

ORLANDO – When leaders at the Florida State University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine instate, even if they completed residencies elsewhere. “We were concerned it was a fluke and hoped the trend kept up,” said Michael Muszynski, MD, dean of the FSU COM Orlando regional campus, and associate dean of clinical research. “Five years later, it’s holding steady between 60 and 64 percent.” State lawmakers approved the opening of the FSU COM in 2000, after the Board of Regents denied requests in the late 1990s, stating more doctors weren’t needed. The charter class graduated in 2005. As of May, 82 of 135 FSU COM graduates who have completed residencies are practicing medicine in Florida (61 percent). Of those, 70 percent (57) are in-state primary care providers (PCPs) and 16 percent (13) are practicing in rural, medically underserved areas of the state. “The reasons why our statistics are much better than the standard 30/60 percent split – that is, 30 percent of graduates from traditional-based medical schools typically return to the state after completing residency and 60 percent stay where they did their residency – is because of the foundation we laid with our mission statement, which was created by us from the very start,” said Muszynski. “We wanted the foundation firmly established so that whoever inherited the program from the pioneers who started the school wouldn’t be able to vary from the mission.” First, FSU COM stacks the deck on the front end through a holistic application approach, focusing on applicants who want to live and practice medicine in Florida. Second, the college follows a community-based medical school model during students’ clinical years, where they connect one-on-one with physicians in the community. And third, medical school faculty makes it fun and interesting to be a community-based doctor with a mentoring system that maintains contact with students during school and afterward. “We didn’t take a willy-nilly approach,” said Muszynski. “We put a great deal of thought into how our approach might work. We knew we had to make an impression on medical students when they were making choices about their careers. And it’s working. The only thing that surprised us was how well it’s worked. We would’ve been happy with a 40 to 50 percent return, but 60 to 65 percent is astounding.” During the formulation of their ap4

>

AUGUST 2013

We put a great deal of thought into how our approach might work. We knew we had to make an impression on medical students when they were making choices about their careers. And it’s working. The only thing that surprised us was how well it’s worked. We would’ve been happy with a 40 to 50 percent return, but 60 to 65 percent is astounding.

’’

– Michael Muszynski, MD, Dean, Orlando Regional Campus, FSU College of Medicine.

proach, FSU medical school leaders noted behavioral changes before, during and after medical school. “What you thought you wanted to do for a career when you were in high school was probably different than when you were in college,” he explained. “It changes quickly during those years as you become exposed to more influences. Medical students’ thinking typically isn’t solidified at that point about what they want to focus on in life. They’re still experiencing and sampling. Their choice maturity is young.” Also, during residency, medical graduates begin to get involved in the community, marry, start families, buy their first home, and/or begin receiving local job offers, making it an easy choice to remain at the residency location. “We thought graduates usually make their choices during residency because they picked a specialty,” said Muszynski. “Traditional medical school models aren’t so much about a connection where students are from, but where they are. We wondered about the lack of that connection. I thought back to my Ohio State University days after medical school. My loyalties weren’t to Central Ohio; my warm-and-fuzzies were at Ohio State. We asked the question: How can we change that? We had to make an impression on medical students when they were making choices about their careers. So we embarked on a grand experiment to change the 30/60 ratio with FSU medical school graduates by attacking it on all three fronts.”

Deck Stacking

Rather than reviewing only grades and scholastic ability, the FSU COM application review board selects students with attributes that mirror the school’s mission. “We quickly discovered that students who stated upfront their agreement with our mission had experience supporting

that mission alignment,” said Muszynski. “For example, we noted that many applicants from smaller towns and smaller high schools were involved in a meaningful way with their community and seemed more likely to maintain that mission. We made no apologies for those identifying descriptors.” For several years, FSU COM only accepted in-state applicants. Now, approximately 5 percent of approved applicants hail from out of state. Still, the board remains very selective. “If we have an applicant from New York, for example, whose goal is to return to that city, we would be more reluctant to accept that applicant,” he said. “We hope applicants are being honest, at least at that time, so we can have better predictive measures.” All factors considered equal between two applicants – one from a rural area and an urban applicant – the rural applicant may be get a slot above the urban applicant, said Muszynski. “A student from a rural area is more likely to align with our mission just because of their setting,” he explained. “But the rural applicant who didn’t do much extracurricular-wise, where the urban applicant worked with the underserved, then it’s different. That’s part of the holistic approach.”

Middle Ground

To keep the in-state return mindset strong, the FSU COM uses a communitybased curriculum to place third and fourth year medical students in the field. “Community-based curriculums have been talked down by some schools, particularly the Ivy League types, with objections that they don’t turn out significant researchers,” said Muszynski. “We contend its equal worthiness, and we produce researchers that we support whole-heartedly. We focus on producing physicians who can care for patients in community settings, and a community-based curricu-

lum is central to the process.” For example, FSU COM has a unique apprenticeship model. Students aren’t assigned to hospitals, wards or residency teams. Instead, they’re assigned to a physician practicing in the community who has been trained to be an educator. That physician typically receives $2,000 a month on a contract basis. As a result of this model, the FSU COM has no fulltime faculty for years 3 and 4, with the exception of the campus dean. “You might find some medical schools in Florida that do a little of this here and there, but nobody to the magnitude we do,” said Muszynski, noting that 19 alumni practicing in Central Florida are educators on the Orlando and Daytona campuses. “Most medical schools assign students to a place, not a particular physician dedicated to a block of time for the student. That strongly connects students to the local community.” The approach also includes a geriatric rotation component to spark interest in caring for older patients. “They all like their geriatric experience and can relate to it with their grandparents,” said Muszynski. “Older patients are so appreciative of a physician’s time and that resonates with medical students at an impressionable time.” Also during the clinical years, medical students typically become “fiercely loyal” to the community, he said. FSU COM has also established a strong student advisor network. Each student is assigned to a community advisor on an 8-to-1 ratio. Students are counseled not only about their careers, but also life in general, volunteerism, and the delicate yet very important work/life balance that perplexes many physicians. Advisors are overseen by a dean or associate dean, depending on the campus, on a 20-to-1 (students-to-dean) ratio. “That low of a ratio in the U.S. rarely exists,” emphasized Muszynski. (CONTINUED ON PAGE 5)

medicalnews

.com


HMA Loses Florida Corporate Roots, continued from page 1 Shands Healthcare facilities that had been acquired for $21.5 million in 2010, it made plenty of sense to tie the knot with Health Management Associates Inc. (NYSE: HMA), a Naples-based hospital operator that had been on a spending spree acquiring struggling hospitals. In late March, Fortune magazine had named HMA among the World’s Most Admired companies in Health Care: Medical Facilities for the second consecutive year and fifth time in seven years. HMA had also been named the leading company for two subcategories in 2012: Use of Corporate Assets and Social Responsibility. Yet soon after HMA CEO Gary Newsome announced plans in May to retire to instead preside over a Uruguay mission with the Church of Jesus Christ of Latterday Saints, rumblings swept through Wall Street that fiscally struggling HMA might be the target of a takeover. In a May 31 note to investors, Chris Rigg, an analyst with Susquehanna Financial Group, was cautiously optimistic that Community Health Svystems (Nasdaq: CYH) might be pursuing HMA, estimating the Franklin, Tenn.-based hospital operator could acquire the company for $18.50 a share, a premium to HMA’s shares that had recently traded near $14. “We would be surprised if a transaction were announced in the very near-term,” he noted. “We don’t believe CEO Gary Newsome would be leaving the company in July if a formal auction process, which we expect HMA would conduct, were currently underway. That being said, we believe Community is the best-positioned name in the hospital group to operate HMA rural focused hospital assets.”

The Engagement

On July 30, in a power play reminiscent of the 1987 blockbuster movie, “Wall Street,” the news became official: Com-

munity Health Systems (CHS) announced plans to acquire HMA for $3.9 billion in a deal valued at $7.6 billion that would create the nation’s largest for-profit hospital chains in terms of number of facilities. “This is the second biggest hospital deal announced this summer,” said healthcare industry consultant George Paul, antitrust partner with White & Case. In June, Dallas-based Tenet Healthcare Corp. (NYSE: THC) announced its acquisition of Nashville, Tenn.-based Vanguard Health Systems (NYSE: VHS) in a pact valued at $4.3 billion. “This deal is part of a growing wave of hospital consolidation, as hospitals seek ways to diversify and lower costs in anticipation of a sea change occurring in the healthcare industry with the implementation of the Affordable Care Act, uncertainty over how states will handle Medicaid George Paul coverage and reimbursement, and Medicare changes,” he said. Paul emphasized that under Obamacare, scale will matter greatly as hospitals seek to cope with reimbursement changes and as consumers become increasingly price sensitive. “Insurers will pressure hospitals to become more efficient than ever, and as a result, it’s not surprising to see these two companies merge,” he added. With a similar focus on non-urban locations, CHS leases, owns or operates 135 hospitals around the country. With HMA’s 71 hospitals, CHS would have 206 acute-care hospitals, with a much larger footprint in Florida. The antitrust review will focus on highly localized markets, Paul pointed out. “While the two parties overlap in 29 states, it doesn’t appear that they have substantial overlaps on a localized level,” he explained. “The Federal Trade Commission (FTC) will focus on how many pa-

Stacking the Deck, continued from page 4 Stage 3

To further strengthen community ties and the job placement network, Florida Hospital recently provided a $2 million gift to establish the Florida Hospital Endowed Fund for Medical Education to help the FSU COM support its educational mission. “Our mission aligns strongly with Florida Hospital’s except that we’re not a faith-based school; we’re public,” said Muszynski. “These students are highly sought after, and relationships end up being life-long. We have 16 graduates already practicing in Central Florida. You might think: only 16? But it’s impressive when you consider the number of graduates during our ramp-up years between 2005 and 2010, and those who are just finishing 5-year residencies. We’ve now created a number of scholarships to enmedicalnews

.com

courage students to return to Central Florida.” Fittingly, said Muszynski, the scholarship application requires students to write an essay explaining why they want to return to the area. Maintaining connectivity with graduates throughout their residency is also a driving force to “having them come home,” said Muszynski. “I follow them through the last two years of development and know them pretty well by the time they graduate,” he said. “Then we all (advisors) keep connected to the students after they graduate, tuning in to changes in their lives and what they want to pursue, and then working with our strong alumni network to find opportunities for them to return home.”

tients in an area would likely view the two operators as substitutes for each other in terms of location, quality and specialties. Where the two are close substitutes, the FTC could seek divestitures if it were to find that patient choice may be limited.” The new CHS would be rivaled only by its across-town neighbor, Hospital Corporation of America (HCA), which has fewer hospitals (162), yet reports higher revenue. Last year, HCA raked in $33 billion; CHS and HMA had a combined $18.9 billion. “This compelling transaction provides a strategic opportunity to form a larger company with a diverse portfolio of hospitals that is well-positioned to realize the benefits of healthcare reform and to address the changing dynamics of our industry,” said CHS CEO Wayne Smith. “Our complementary markets and the ability to form networks in key states, along with the synergies that will be available to us, can create value for the shareholders of our companies, the communities we serve, our employees and medical staffs.” Both companies’ boards of directors unanimously approved the definitive merger agreement, with CHS paying HMA $3.9 billion in cash and stock and assuming $3.7 billion of debt. The deal would give HMA shareholders a 16 percent stake in the new company. Before the market opened on July 30, HMA shares fell 6.9 percent to $13.89; CHS stock rose 2.4 percent to $48.35.

net revenue to $146 billion, attributing the discouraging fiscal picture to low admissions, increases in observation stays, higher bad debt, a reduction in surgeries, and the federal government’s sequestration. Same-hospital admissions were predicted to fall 6.7 percent, compared to the second quarter of 2012. In its first-quarter financial filing, HMA reported it had received a subpoena from the U.S. Securities and Exchange Commission (SEC) for documents involving accounts receivable, billing writedowns, contractual adjustments, reserves for doubtful accounts, and revenue. In May and June, HMA received three more subpoenas from the HHS’s Office of Inspector General related to the process by which the company admits people from its emergency department. The new subpoenas supplemented ones the company received in 2011. Another subpoena was issued on physician relationships. In December, a CBS “60 Minutes” segment focused on HMA’s aggressive policies aimed at increasing admissions and “disgruntled former employees.” No stranger to the federal pressure-cooker, CHS recently received a new subpoena for similar allegations from the Department of Justice. Competing hospital chains and medical schools in Florida, including the Florida Medical Association, declined to comment on the July 30 CHS-HMA announcement.

The Unraveling

The relationship between HMA and its largest shareholder (14.6 percent), Glenview Capital Management, a hedge fund managed by billionaire Larry Robbins, had soured in recent months. Glenview, a private investment management firm established in 2000 with more than $6 billion in assets, also owns nearly 10 percent of CHS. Robbins had been critical of HMA’s sluggish financial results and “unconstructive” executive behavior, pointing to HMA CFO Kelly Curry. Glenview had tried to replace HMA’s entire board of directors with eight candidates in a Fresh Alternative campaign to revitalize the company. In June, Glenview had written HMA about “significant room for improvement,” which it said had fallen short in its financial performance for more than a decade. “Under the supervision of the sitting board, HMA lacks the financial acumen to deliver on its projections,” Glenview released in a July 30 statement. “Unfortunately, this continues to be the case.” Another Nashville, Tenn.-based hospital group, LifePoint Hospitals (NASDAQ: LPNT), had also expressed interest in acquiring HMA.

The Next Step

Until the merger is completed – the target deadline is March 31 – John Starcher Jr., president of HMA’s Eastern Group with 23 hospitals in seven states, will step up as HMA interim CEO. HMA’s projected second-quarter earnings show a drop of .05 percent in AUGUST 2013

>

5


The Tide is Turning, continued from page 1 ily medicine to geriatric medicine.” Since then, the field of geriatrics has exploded. As baby boomers have aged, the need for geriatricians grows. Currently, 38,000 geriatricians are projected to meet the country’s needs. “We’re nowhere near that,” said Brummel-Smith. “We’re at 7,000 now. The main problem is we don’t have enough applicants. When I started in 1980, hardly anyone believed it was worth talking about. Now, there’s interest from the general public, but not enough interest from medical students. Lack of money and prestige are two reasons why.” To address the shortage in Florida, Brummel-Smith routinely encourages high school groups pursuing medical paths to strongly consider geriatrics. “I always give them data that says: if you look at the top income to the lowest income, geriatricians are at the bottom of the scale,” he said. “We actually make less money with a specialty in geriatrics than we would in our primary specialty of family medicine or internal medicine. But interestingly, you can line up the reverse in job satisfaction. Geriatrics has the highest; neurosurgeons, among the highest paid, have the lowest. We tell them to think about paying your bills and your loans, but don’t think you need to sacrifice your life to do it. Choose a specialty you love rather than one that pays well. And you’ll be happy the rest of your life.” Brummel-Smith also ensures that all FSU-COM medical students have rotations in geriatric medicine in the school’s community-based curriculum model. “Otherwise, if you took 1,000 people in a community, 700 would have a reason for thinking about their health during that month,” he explained, referencing the well-known study, “The Ecology of Care,” which first appeared in the New England Journal of Medicine in 1961, and was recently revisited with similar results. “About 300 would have contact with the healthcare system in some way. About 100 would be admitted to a hospital, and one would go to an academic teaching medical center. So the population of patients who are taken care of, and the doctors taking care of them in an academic medical setting, is almost completely unreal realty. Then medical graduates after residency go into practice where the real situation is. For family medicine physicians, 30 percent will be geriatric patients. For internists, it’s 40 to 50 percent. And they’re just not prepared for it. So during medical school and residency, students get a negative view of geriatrics because you’re not seeing that many older patients in academic medical centers, and they hardly ever see geriatricians as role models. Combined with the negative financial incentives, and the negative emotional incentives that a lot of academic doctors put on geriatrics, it doesn’t surprise me that few people choose geriatrics.” The tide is slowly turning in favor of geriatric medicine. CMS has elevated geriatrics to primary care status, paying $38,500 per resident annually, a 10 per6

>

AUGUST 2013

‘‘

If you look at the top income to the lowest income, geriatricians are at the bottom of the scale. But interestingly, you can line up the reverse in job satisfaction. Geriatrics has the highest; neurosurgeons, among the highest paid, have the lowest. Choose a specialty you love rather than one that pays well. And you’ll be happy the rest of your life.

’’

- Ken Brummel-Smith, MD, Founding Chair, Department of Geriatrics, Florida State University College of Medicine.

cent payment bonus from $35,000. The shift from production- to value-based medicine will also make a difference. South Carolina has adopted a student loan repayment program as an incentive for geriatricians, a move Brummel-Smith hopes Florida and other states will emulate. “In general, there’ll never be enough geriatricians to take care of all people over the age of 65,” he said. “Pediatricians have it somewhat easy, even though they fudge the line. They see 18 as the end of the timeline, even though in special cases, patients with disabilities will stay with them into their twenties because it’s hard to find physicians who know their problems.” Even though baby steps are helpful, it remains problematic for geriatricians, who don’t fit the standard productivity model of many medical groups. “Geriatric patients don’t fit into the 15-minute visit model,” he explained. “Older patients have more medical needs and take longer for each appointment. Also, the way our healthcare system is working right now and the way of reimbursement, you’re not being paid to make a patient well. You’re paid to provide certain services. And many things that need to be done aren’t strictly medical. There’s coordination with long term services and supports and social issues and all sorts of things.” For example, on a recent clinic day, Brummel-Smith spent an hour with the wife and daughter of a geriatric patient who was too demented to understand his condition. “We wanted time to have an in-depth discussion about care planning,” he said. “I couldn’t bill for that because under Medicare rules, you can only bill for the patient’s care if the patient is there. But we were doing deep patient care planning that was very emotionally difficult, and it’s going to lead not only to a very good outcome as he nears the end of his life, but also it’ll help save CMS a lot of money for unnecessary care he wouldn’t want in the first place. There’s no way I could bill for that.” The PACE Elderplace Program in

Oregon, which Brummel-Smith led before relocating to Florida, used a globalcapitated model he calls “the ultimate model for reimbursement.” “If the capitation is fair – and that doesn’t mean exorbitant or skimpy -- then you can appropriately care for the patients, and let the geriatric team and the patient decide the right treatment rather than having insurance companies make the decisions,” he said. “We were free from all billing constraints, and we knew we had a certain amount of money to care for all our participants. We had quality measures to meet -- some were patientgenerated -- so we were doing things they wanted, not just what we thought was good for them. It really was the perfect way to practice medicine.” Overall, there’s an upside to the gap of supply and demand of geriatricians. Even though geriatrics is labeled for patients over the age of 65, most seniors up to age 74 are relatively healthy and don’t need a geriatrician, Brummel-Smith said. “The perfect patients for a geriatrician are those above age 75, and especially those with multiple chronic conditions and long-term care needs, such as dementia, and the kinds of problems that are very difficult for internists and family physicians to take care of in a standard 15-minute visit,” he said, pointing out the American Geriatric Society considers the specialty both a primary care and consultation model. “We manage primary care for that population of complex and frail elders, and consultations to other physicians for the ‘younger’ old people,” he explained, “and for older people who are generally receiving good care from their primary care provider.” Even though only two graduates of FSU have completed geriatric fellowships, which reflects the average national percentage, Brummel-Smith is optimistic that more will follow as geriatric fellowships are being developed around the state. “We’re unhappy it’s not higher, but that wasn’t our primary goal,” he said. “Ours was to make sure every physician who graduates is good at taking care of

older people regardless of the specialty they choose. We have good evidence that they do, and anecdotal feedback from residency directors that they really like having our students because they’re not intimidated by caring for older patients, and they’re very good at interview skills.” When funding is available, BrummelSmith plans to pursue a study for a closer look into alums’ medical offices and their care for the older population, including quality measures and comparisons to graduates who attended medical schools without a concentrated geriatrics focus.

The 4-1-1 on Ken Brummel-Smith, MD Ken Brummel-Smith, MD, founding chair of the Florida State University (FSU) College of Medicine’s Department of Geriatrics, graduated cum laude from Loyola University in 1971, the University of Southern California School of Medicine in 1975, followed by an internship and family practice residency at Glendale Adventist Medical Center in California. In 1980, he completed a family practice fellowship in faculty development at the University of Southern California School of Medicine’s Department of Medical Education. Before relocating to Florida in 2003, Brummel-Smith served as medical director to the PACE Elderplace Program in Portland, Ore., and as Bain Chair of the Providence Center on Aging and professor of family medicine at the Oregon Health Sciences University. In Oregon, he served on the Governor’s Task Force on the Future of Care of Seniors and People with Disabilities and co-chaired the Health and Prevention Subcommittee. Past president of the American Geriatrics Society, Brummel-Smith was selected by his peers 11 times among the Best Doctors in America, and chaired the Association of Directors of Geriatric Academic Programs. During his first year at FSU, Brummel-Smith chaired the Florida AtRisk Driver’s Council. In 2009, he served on the Tallahassee Senior Center Foundation Board. He holds the Charlotte Edwards Maguire chair and professorship at FSU – Maguire made a gift to endow his chair as part of the school’s strong emphasis on geriatrics and helped recruit Brummel-Smith to Florida – and continues to serve as a state and national advocate for geriatrics training.

medicalnews

.com


Adding Value

HMA rebrands 7 hospitals as Bayfront Health

MANAGE YOUR MEDICAL WORLD BY VOICE Dragon Medical Practice Edition is 99% accurate “out of the box” and includes a complete range of medical vocabularies.

Kathryn Gillette

Tampa Bay Times By JEFF WEBB

Like so many other for-profit hospital companies in the U.S., Health Management Associates is jockeying for market position to be a winner in an evolving and uncertain era in the history of healthcare delivery. The Naples-based company’s recent decision to rebrand seven of its hospitals on Florida’s Gulf Coast as “Bayfront Health” is evidence of that strategy. But the initiative, which was spawned in St. Petersburg and includes HMA’s hospitals from Hernando County to the north to Charlotte County to the south, remains focused more on patients than profit, according to Kathryn Gillette, marketing president and CEO of Bayfront Health. “We’re here to make sure that we add value to healthcare at the local level first,” said Gillette, who was hired in April to oversee the regional network from its flagship facility in St. Petersburg, formerly the nonprofit Bayfront Medical Center. The six other hospitals comprising Bayfront Health, which span a 150-mile corridor roughly aligned with Interstate 75: • Brooksville (formerly Brooksville Regional Hospital) • Dade City (formerly Pasco Regional Medical Center) • Spring Hill (formerly Spring Hill Regional Hospital) • Port Charlotte (formerly Peace River Regional Medical Center) • Punta Gorda (formerly Charlotte Regional Medical Center) Venice Regional Medical Center (retaining its core name, but adding “an affiliate of Bayfront Health” to its title. Gillette said her vision is to integrate resources at Bayfront Health St. Petersburg with each hospital in the network. “These hospitals are really excited to have the name Bayfront Health and that will be meaningful in their communities. We are going to add value to them,” she said, “but we are not going to overstep our bounds.” The hospitals’ management teams will remain intact, Gillette said, as will the relationships they have with residents, employees, local governments and the business community. “We don’t intend to interfere.” medicalnews

.com

From a practical, patient-centered perspective, Gillette said, Bayfront Health will benefit both patients and HMA. On a corporate level, it offers the opportunity to operate as a unified system in a geographic region, creating more cost efficiencies and capabilities. For patients, it provides options and depth in terms of treatments and locations. According to a statement released by Bayfront Health in announcing the rebranding, “As Bayfront Health becomes a truly integrated system, our patients will have the benefit of choosing the facility and physician that best meets their medical needs. There will be seamless transitions, from meeting with a specialist to the hospital stay, improving the overall experience for both doctor and patient.” That would include sharing medical records, transfer agreements in certain medical specialties, clinical protocols and technology, as well as about 6,000 healthcare professionals. HMA also predicted the new Bayfront Health network will account for a combined 66,000 inpatients, 200,000 emergency room visits, 56,000 surgeries and a half-million outpatient visits each year. Gillette said establishing the Bayfront Health system will enhance HMA’s teaching and research relationship with the University of Florida Health and Shands Hospital. “We are very proud of the fact that UF and Shands are part of the this relationship. We’ve had a number of meetings about ways that UF can enhance deliveries of their healthcare system, first in the St. Pete market,” she said. “Also, we are immensely proud of the fact that this medical corridor of All Children’s and the University of Florida St. Petersburg is right down the street from us. So, we’re looking for ways to build on that ... There is an awful lot that can be enhanced in the delivery of healthcare when you come together with partners who bring things to the table that you might not have at your fingertips. The University of Florida is one of those that I’m very excited about. They are well known in this community. People understand them, and they have a very strong affiliation and feeling about the university. It’s a first-class program.” Earning buy-in from leaders in each (CONTINUED ON PAGE 11)

The software allows clinicians to dictate in their own words, generating “once and done” documentation, which they can then review.

Call for Florida Tax Rebate on Medical Software* Dictate faster and more accurately than ever before. Dictate anywhere in your EHR and accelerate adoption. Save clinicians 30 minutes or more a day Spend more time with patients Dictate in clinician’s own words. Support higher level or reimbursement.

Sales, Training and Customization of Dragon Medical Practice Edition

Call Bonnie 877-272-8280 or Polly 866-977-3324 Visit our website 1st-Dragon.com *Not to be combined with any other discounts

AUGUST 2013

>

7


Plan B

IASIS Health sells trio of local hospitals to HCA By LYNNE JETER

Last April, IASIS Healthcare LLC (IASIS) CEO Carl Whitmer emphatically said the Franklin, Tenn.-based company wasn’t for sale. Whitmer’s statement came on the heels of fiscal quarter results showing that IASIS, the nation’s largest privately held hospital company, had adopted accounting guidance resulting in the classification of bad debts as a revenue deduction rather than an operating expense. He attributed the decline in net patient revenue per adjusted admission to Medicaid rate reductions implemented by certain states, and also an increase in the provision for bad debts resulting from growth in the volume of uninsured patients in certain markets, such as Arizona. Whitmer had also taken heat for his annual compensation – among the highest industry-wide – of $1.85 million annually. Well-connected globally, Whitmer instead said IASIS was mulling growth plans after Bloomberg Businessweek reported that IASIS’ parent company, Fort Worth, Texas-based TPG Capital, was exploring the sale of the healthcare company. The private equity firm had acquired IASIS in 2004. “We’re seeing a very strong, active pipeline of potential opportunities,” Whitmer told the

Nashville Business Journal in early 2012. Last August, IASIS announced a joint venture partnership with Aurora Health Care to pursue healthcare acquisitions, new construction, management of facilities and development of clinical services. Aurora is one of the nation’s largest integrated not-for-profit systems. Now IASIS competitive neighbor, Nashville, Tenn.-based HCA Holdings (NYSE: HCA), established in 1968 as one of the nation’s first hospital companies, will acquire at least part of the 18 acute-care hospital system in seven states with 4,365 beds that also includes a behavioral hospital facility. HCA declined to disclose how much they’re paying to acquire the Tampa-area IASIS hospitals that reported $242 million in revenue last year. The deal, expected to close by the end of the year, includes 691 beds in Hillsborough and Pinellas counties – the 307-bed Palms of Pasadena Hospital, 183-bed Memorial Hospital of Tampa and 201-bed Town & Country Hospital – that IASIS acquired in 1999. IASIS was established in 1998. The trio of hospitals is expected to become part of HCA West Florida, bringing the total of HCA facilities in central and west Florida to 19 hospitals and 16 ambulatory surgery centers. In its most recent annual report, com-

pany officials said the Florida market “can be more challenging than other markets in which we operate:” because of its large Medicare population, high managed-care concentration and the state’s certificate-ofneed program. After the second quarter results were announced in May, Whitmer explained: “During the second quarter, we experienced an anticipated increase in expenses due to the timing of strategic investments we’ve been making to expand service lines and access points, to open our new 48bed hospital in the Heights community of Houston, to renew Health Choice’s contract in Arizona and continue its expansion, and to fund physician integration plans and related start-up costs. Additionally, we experienced many of the same industry dynamics as other hospital companies, to which we have reacted by implementing additional cost savings initiatives within our hospitals, physician operations and corporate infrastructure. As a result, this quarter’s operating results reflect a convergence of some long-range business investments in what turned out to be a time of softer volumes across the country, especially in March; however, we believe the strategic efforts we have undertaken will bring about growth in new revenues and that the cost initiatives implemented in March and April

will generate additional savings as the year plays out.” After the acquisition of IASIS Tampaarea hospitals was made public, Whitmer added almost as a footnote that IASIS continues to consider acquiring physician practices, a play made possible by improved cash flow. “This transaction is an example of how ongoing changes in the healthcare industry are creating a variety of opportunities for health systems across the country to evolve their care delivery models,” said Whitmer. “And as such, recent assessments of our strategic growth plans in new and existing markets coupled with HCA’s scale and complementary capabilities in Florida make this the appropriate time to change ownership of these three important community hospitals.” HCA West Florida President Peter Marmerstein, FACHE, said the trio of hospitals has “strong traditions of caring for their communities for many years.” “These hospitals Peter will enhance our abil- Marmerstein ity to serve patients throughout the Tampa Bay and St. Petersburg area,” he said, “and we look forward to welcoming them to HCA West Florida.”

20415 medical news AUGUST.indd 1

8

>

AUGUST 2013

medicalnews

.com


Social Media Revolution in Healthcare AMA Tampa Bay shares Mayo Clinic story at September event; forerunner events focus on networking, fun By LyNNE JETER

The fastest-growing American Marketing Association chapter in the United States has several exciting upcoming events in August and September for all healthcare and marketing professionals, capped by a Breakfast for Champions presentation by Lee Aase on Friday, Sept. 27, from 7:30 to 9:30 a.m. at Centre Club in Tampa. Aase, hospital social media pioneer and director of the Mayo Clinic Center for Social Media, will share “The Mayo Clinic Story: Bringing the Social Media Revolution to Healthcare,” about how the world renowned clinic, established more than 100 years ago by William Worrall Mayo, MD, and his physician sons, William and Charles Mayo, progressed naturally from traditional media relations to direct-toconsumer news delivery to giving patients a platform for their stories. “The social media revolution is the defining communications trend of the third millennium,” said Greg Millman, 2012-13 president of AMA Tampa Bay, and vice president of marketing and communications for Eagle Asset Management in Tampa. “From blogs to Facebook to Twitter to YouTube, the power of worldwide broadcasting

and publishing is now available to anyone. Have you considered how these techniques are likely to affect your organization? Are you proactively exploring how you can use these tools creatively to accomplish organizational objectives?” Aase will describe the steps taken, safeguards developed, and concrete results achieved. He’ll also share Mayo Clinic’s vision to move social media use beyond marketing by applying revolutionary tools to improve health and healthcare for all. The event, open to all healthcare and marketing professionals, will begin with a

full, hot breakfast buffet and networking. The presentation will begin at 8 a.m., followed by a Q&A session at 9 a.m. The limited seating event costs $30 for members, $40 for non-members, and $25 for students. Centre Club is located on the eighth floor of 123 South Westshore Boulevard. Before Aase’s late September presentation, the Tampa Bay chapter of the AMA (AMA Tampa Bay), AVI-SPL, the (CONTINUED ON PAGE 12)

The Intersection of Wisdom and Inspiration The American Marketing Association, established in 1937, now with more than 40,000 members worldwide, remains relevant by consistently innovating and evolving. The national organization’s annual conference, “Where Wisdom and Inspiration Collide,” will take place Sept. 9-11 at the Sheraton New Orleans on Canal Street in New Orleans. Four power players will give keynote presentations: Mary Garrett, vice president of marketing and communications for IBM Global Sales and Distribution, will present “Big Data and

the CMO - the new BFFs.” Jonah Berger, marketing professor at the Wharton School at the University of Pennsylvania, and the author of Contagious: Why Things Catch, will discuss “Crafting Contagious Content.” He’ll discuss the six key steps to driving social transmission and show how to leverage those concepts to craft contagious content. Rebecca Messina, vice president of global marketing capability and integration for The Coca-Cola Company, will discuss “Marketing from the Inside Out,” about what the shift in

the external marketing landscape means to the evolution of the internal marketing discipline. Mark Viken, vice president of brand marketing for Sharp, will discuss “The Power of Brand Integration,” and share how integrating branding and messaging in owned and within channel distribution partners are doing more with less. For more information about the AMA’s upcoming annual conference, visit http://www. marketingpower.com/Calendar/Documents/ AMC%20Full%20Program%207.8.13.pdf.

Recovery is possible. But only if you call. One of the few hospital-based, medically supervised detox programs in the state. Our unique Addiction Recovery Center allows a person to safely and comfortably detox even with the most severe addictions. Our center takes the utmost care with regard to privacy and comfort, including private rooms and entry, laundry facilities, group therapy rooms and staff offices, all located in the same area. We also have the ability to help after detox with free aftercare meetings twice weekly and a full intensive Outpatient Program that is covered by most insurers. We accept calls and admit patients 24 hours a day, 7 days a week. So if you or a loved one needs help, please consider calling right now.

1-866-WE-DETOX (933-3869)

6001 Webb Road, Tampa, FL 33615 townandcountryhospital.com

6/28/2013 10:49:21 AM medicalnews

.com

AUGUST 2013

>

9


For quality, safe and compassionate care... Florida Hospital Carrollwood Bariatric Weight Loss Surgery Program Designated as a Center of Excellence in Metabolicand Bariatric Surgery™ by the Surgical Review Corporation. SRC sets a global standard for excellence for surgical specialties.

PHYSICIANS: SEND YOUR PATIENTS TO OUR FREE BARIATRIC WEIGHT LOSS SURGERY SEMINAR

Tuesday, June 25, 2013 | 6:30 p.m. Florida Hospital Carrollwood Auditorium

7171 N. Dale Mabry Highway Tampa, Florida 33614 FHCarrollwood.org | 813.932.2222

10

>

AUGUST 2013

medicalnews

.com


ICD-10: Are You Ready? By BILL HEFLEy, MD

With the rapidly approaching ICD-10 ‘go live’ date of October 1, 2014, medical practices should be well on their way in preparing for the transition. With implementation of ICD-10, physician offices accustomed to the 13,000 ICD-9 codes must be prepared to transition seamlessly to a new set of 68,000 codes. More specifically, a physician or billing clerk currently using ICD-9 to properly code the diagnosis of ‘patella fracture’ must choose between two possible codes; when utilizing ICD-10 that number explodes to 480 codes. Yes. Get ready. In 1992 the World Health Organization (WHO) published the International Classification of Diseases, Tenth Revision. The U.S. made modifications to the WHO ICD-10 creating the ICD-10-CM (Clinical Modification) which is the diagnosis code set that will replace ICD-9-CM Volumes 1 and 2. The Department of Health and Human Services (HHS) published a regulation requiring the replacement of ICD-9 with ICD10 and later pushed back the compliance date one year to October 1, 2014. Farzad Mostashari, MD, the National Coordinator for Healthcare Information Technology, asserted last month that there would be no extension of the deadline. While many physicians see the transition to ICD-10 as an unnecessary burden, other physicians and industry stakeholders believe that the ICD-9 code sets are obsolete and inadequate. ICD-10 codes have more characters and a greater number of alpha characters creating space for new codes and flexibility for future medical advances. ICD-10 has increased specificity that will improve the ability to identify diagnosis trends, public health needs, epidemic outbreaks, and bioterrorism events. In addition, ICD-10 will improve claims processing, quality management and benchmarking data. A successful ICD-10 transition requires exhaustive preparation by medi-

ICD-9

ICD-10

~ 13000 Codes 3-5 Characters 1St Digit May Be Alpha (E Or V) 2-5 Are Numeric Limited Space For Adding New Codes § Lacks Detail & Laterality

§ § § § § § §

§ § § § §

~ 68000 codes 3-7 characters 1st digit alpha 2nd & 3rd digit numeric 4th– 7th digits alpha or numeric Flexible for adding new codes Very specific & utilizes laterality

MYTHS ASSOCIATED WITH ICD-10 The Go-Live date will most likely get delayed again The only staff members affected will be coders and billing specialists My EMR and PM vendor will be automatically compliant General Equivalence Mappings are a good solution to coding an individual clinical chart After October 1, 2014 payers and clearinghouses will aid practices by automatically crosswalking submitted 9 codes to 10 codes

cal practices. Yet recent research by the Medical Group Management Association indicates that only 4.7 percent of practices reported that they have “made significant progress” when rating their “overall readiness level for ICD-10 implementation.” The research was derived from respondents in 1,200 medical practices in which more than 55,000 physicians practice. Preparing to practice medicine in the world of ICD-10 is no small undertaking. It will require time and money. Having an experienced billing clerk “coder” in the practice will no longer be sufficient to generate accurate codes. Simply converting the practice’s ICD-9 superbill to ICD10 is problematic. Many industry experts don’t see the superbill being preserved at all. The American Academy of Professional Coders (AAPC) recently issued a two page ICD-9 superbill which when crosswalked to ICD-10 became nine pages long. Another industry consultant sites an example of a

two page ICD-9 superbill translating into a 48-page ICD-10 superbill. Preparation for the medical practice begins with internal training and testing of all parties involved in producing proper coding. Administrators must establish a training and implementation schedule; set deadlines; create a project team; identify training resources; perform documentation gap analysis; evaluate and modify the practice’s forms; budget for transition expenses; communicate with practice management (PM) software and EHR vendors; assess hardware and software update requirements; and arrange testing with clinical and billing staff, PM and EHR vendors, clearinghouses and major health plans. Providers must be trained on the changes in clinical concepts and the level of detail in ICD-10, so that their documentation supports the ability to code to the highest level of detail. For many specialties, it is highly recommended that physicians take anat-

Adding Value, continued from page 7 community’s hospital is key, said Kanika Tomalin, vice president of external affairs for Bayfront Health. “As we talked with the boards of directors of all these hospitals about our strategy, all made up of business leaders in each of these communities, they have answered the strategy with great enthusiasm because they have such immense pride in their local hospitals. But they absolutely want to know that their hospitals are sustainable and buoyed by a larger platform that allows them to be viable in the future. They recognize this strategy will (help them) for many years,” Tomalin said. “A big part of the Bayfront Health network is having a community presence and setting the standard for healthcare as it will be delivered in each of these communities. HMA delivers healthcare in 23 hospitals across the state and we are looking for ways we can use this same model of medicalnews

.com

leveraging resources to the benefit of our patients. Finding ways to enhance what each of us do very well individually and creating an aggregate impact across multiple delivery spots,” Tomalin said. Still, there is uncertainty about how “leveraging resources” may manifest itself when it comes to HMA. National news reports have speculated that HMA may be the target of a takeover by HCA, the world’s largest for-profit healthcare company, which already owns many hospitals in the same market. That possibility does not faze Gillette. “It has been talked about, but as a seasoned healthcare executive, it has not changed my approach from day-to-day because I recognize that these business dealings are going to happen at the corporate level. In any system of hospitals that might be being talked about, the job is being on

the ground and giving good patient care. It has not affected me, and I say that with the greatest amount of sincerity,” she said. While acknowledging that there has been some need for rumor control among employees, Gillette said “I remind people that our (responsibility) is to the patients.” Tomalin shed light on the climate of today’s healthcare industry. “Anyone with any familiarity of the industry knows this is an ongoing conversation and developing consideration for every provider of healthcare in this entire nation. Everybody is talking to everybody about how they can find a way to deliver better care to more people at a lower cost ... That means looking at ownership structure,” she said. “We are very fortunate and proud to have an educated body at Bayfront that really understands the impetus of these changes in healthcare, said Tomalin.

omy and physiology refresher courses. Billing staff must increase their knowledge of anatomy and physiology, learn and adopt a completely different coding system and be able to code to the greatest level of detail. Training options include sending staff for offsite training, hiring an outside trainer to come to the practice, online training, webinar training and book-based training. Frequent testing and trial coding for all staff is also highly recommended in the months leading up to the ICD-10 ‘go live’ date. In addition to internal preparation, medical practices must also arrange testing with their PM vendor, EHR vendor, clearinghouse and major health plans. Many PM vendors and EHR vendors will not be ready to meet the October 1, 2014 ICD-10 compliance date. Practices must communicate with their vendors months in advance to schedule software upgrades and testing to assure readiness. If the practice’s PM or EHR vendor is not going to be prepared for the ICD-10 launch, the practice will need to make plans to switch in time for the transition date. Many practices with in-house billing departments will weigh the benefits of outsourcing the practice’s revenue cycle management. Costs associated with the preparation for the ICD-10 transition are not insignificant. Industry experts suggest budgeting $200,000 to $280,000 for an eight-physician practice. Expenses include training, testing, hardware upgrades and PM/EMR software upgrades. In addition to the onetime costs associated with implementation, many practices will experience ongoing, recurring costs related to the need for increased coding staff, consulting services, subscriptions to print and software-based coding aids and reduced productivity as a result of increase need for documentation and coding complexity. The ICD-10 transition will undoubtedly eclipse Y2K and the HIPAA 4010 to 5010 transition in terms of the impact on the healthcare industry. Unprepared practices will face painful disruptions in cash flow and a chaotic scramble to regain practice productivity. Even well-prepared practices that execute ICD-10 implementation flawlessly will likely experience some disruption in cash flow. Remember, a successful revenue cycle requires every entity in the claims processing chain to be fully prepared for ICD-10. The PM system, EMR system, clearinghouse and payer must all communicate properly electronically and adjudicate ICD-10 claims correctly. Some bugs are inevitable. Practices should have in place a line of credit sufficient to cover three months operating expenses prior to ‘go live.’ Preparation will take considerable planning, time and money and should begin immediately. October 1, 2014 is just around the corner. Bill Hefley, MD, is President and CEO of MedEvolve, offering a full range of highly evolved application software, interoperability interfaces, and revenue management services focused on practice profitability and efficiency. Visit the website at www.medevolve.com

AUGUST 2013

>

11


M&A Trends Reshape How Hospitals Handle Risk and Patient Safety By JOSEPH WILSON, MD

Healthcare is experiencing a broad trend toward consolidation, with the overall number of mergers and acquisitions across all sectors at the highest level in a decade. Hospitals and health systems are buying group practices at a rapid pace – and many physicians are looking to sell. This scenario may not be for everyone, as physicians wish to remain independent for a variety of reasons. But for many, the prospect of relinquishing administrative and operational responsibilities is compelling, A survey by management consulting firm Accenture finds that as of 2013, only about one-third of physicians are independent (that is, own a practice) compared to 57 percent in 2000. And the movement shows no sign of slowing down. There are complex and compelling reasons motivating both physicians and hospitals to consolidate, including rising medical costs, the burden of compliance and federal healthcare reform. And even good change can be hard work. Acquiring physicians brings with it a host of challenges, from on-boarding new employees to integrating them into the culture, adjusting workflow processes, aligning doctors with the organization’s financial and quality improvement goals—down to making sure you have the right professional liability insurance that provides the best coverage for all risk levels.

What Hospitals and Providers Want

CMS regulation, rising EHR costs, and electronic processing of claims are driving costs and, therefore, the move toward consolidation. Decentralization of providers into small or solo practices has been cited as a reason the healthcare market is inefficient, with patients seeing duplicate providers who may prescribe overlapping treatments or deliver widely divergent, uncoordinated care. Physicians are increasingly faced with a tough business decision on top of the difficult clinical challenges they address every day: Whether or not to remain independent. The recession has played a hand by making it harder to run a small business, with fewer patients coming in for care and greater numbers unable to pay. Younger doctors don’t want the long hours and administrative headaches that come with private practice – billing, claims processing and negotiating fee schedules with insurers – not to mention a significant IT investment. According to its 2010 final rule, CMS said the average EHR implementation costs as much as $54,000 per physician on top of annual maintenance costs that run about $20,000 per doctor. Many providers are willing to become an employee in exchange for a regular salary with a productivity bonus and a stable schedule that focuses on patient care, not office management.

GUARANTEED

CLICUGKHS

THRO

Get verified results (impressions and/or clicks) for (LOCAL) online advertising.

Increase web traffic Powerful branding opportunity Any metro market in the U.S. Preferred, certified brand-safe networks only Retargeting, landing pages, SEM services available

DIGITAL@SOUTHCOMM.COM 12

>

AUGUST 2013

For hospitals, healthcare payment reform, compliance and a looming physician shortage is driving consolidation. To enable care coordination, health systems need doctors in the fold – and they need to have adequate staff to meet the influx of millions of Americans projected to gain insurance through regulated health exchanges. By acquiring physician practices, hospitals bolster coordination of services, increase market share, receive a steady stream of referrals and are entitled to incentive payments for providing more efficient, integrated care. While these new alignments come with a host of benefits, they also carry some uncertainty. Hospitals must integrate and manage physician practices. And beyond operational challenges, clinical and business reputations are at stake. Hospitals need to be cognizant of how the acquisition of physicians can affect the organization’s exposure and risk profile both in the community and among insurance entities that provide professional liability (PL).

Rethinking Professional Liability

Hospitals approach providing coverage in a number of advantageous ways. Some hospitals incentivize employment by providing basic coverage, allowing physicians to go above and beyond at their own discretion. In other situations, the employer negotiates premium rates on the provider’s behalf. While there are many ways to provide coverage and many types of insurers, hospitals need a medical professional liability company that goes beyond claims processing and provides value through risk assessment, analytics, patient safety education and defense counsel. Insurance is not a one-size fits all proposition. Different roles carry different levels of risk. Turning to a company that can provide effective, collaborative risk management for all levels of exposures that hospital staff present—from specialists to primary care physicians to nurses, to administrative employees—enables the hospital and its physicians to improve quality and compliance, enhance decision-making and decrease financial loss to the benefit of all stakeholders. A PL company that uses analytics has the ability to deliver actionable information. Physician- and specialty-specific reports and loss analyses, along with risk management expertise, can help hospitals identify claim trends of its physicians. This information can help hospitals find more ways to improve procedures and systems, thus lowering risk within the organization. The liability environment is changing and hospitals are starting to see the frequency of insurance claims rise, making it imperative to have better control of claims and settlements. Having experts on hand to negotiate and keep those costs low across every medical specialty is essential to a successful operation. Moreover, the insurance

company collects and analyzes professional liability claim data, providing hospitals with detailed tracking reports on everything from claims losses to defense costs and legal expenses. It will also provide reporting to data banks as well as state and federal regulators, so that hospital administrators can report data accurately and measure results and expenses separately from hospital-wide trends. A hospital that turns to professional liability experts for its employed physicians makes better use of the facility’s resources with specialized knowledge, risk management, legal counsel and a coordinated defense that strengthens the collaborative bond between the physician and hospital. The insurance company can provide immediate access to counsel on urgent matters, as well as advise on HIPAA compliance, how to deal with a difficult patient, and manage adverse outcomes to defuse potentially risky encounters and minimize exposure – all of which improves communication, encourages teamwork and reduces claims. Joseph S. Wilson, MD, is Chairman and CEO of MagMutual Insurance Company, the Southeast’s largest mutual professional liability insurer. Dr. Wilson has served on MagMutual’s Board since 1999, is Board Certified in cardiology and interventional cardiology, and is a Fellow of the American College of Cardiology. He can be reached at jwilson@ magmutual.com

Social Media, continued from page 9

world’s leading video communications provider, in conjunction with Meeting Professionals International (MPI) Tampa Bay, will host the August “After 5” event, “Be Cool! Technology Expo,” for the third consecutive year. On Aug. 14, from 5 to 7 p.m., participants will enjoy food offered in a “Taste of Tampa Bay” atmosphere while technology buffs experience “extra cool” hands-on demonstration at interactive stations, featuring the newest advances in communications and collaborative meeting room solutions. The event is free for Tampa Bay AMA members and guests. On Thursday, Sept. 12, Outback Steakhouse CMO Kappitt will share how the 25-year-old Australian-themed restaurant brand stays relevant, contemporary and innovative while also maintaining its brand ethos, or trustworthiness. Outback Steakhouse, a subsidiary of Tampa-based Blooming Brands Inc., will provide lunch. The event will start at 11:30 a.m. at A La Carte Event Pavilion on Dana Shores Drive in Tampa, and costs $50 for non-members, $30 for members, and $25 for students. With more than 400 members, AMA Tampa Bay represents healthcare marketing professionals from Tampa, St. Petersburg, Clearwater and Sarasota metro areas.

medicalnews

.com


Ten Ways to Avoid and Fight a Lawsuit Against Your Assisted Living Facility By JOHN W. HEILMAN, Esq.

For administrators of assisted living facilities (ALFs), helping residents stay active and healthy while maintaining a high quality of life can be daunting. Many residents are at high risk for injury, irrespective of supervision and assistance levels, and the risk of lawsuits against ALFs is, unfortunately, a constant concern. The best way to fight lawsuits is to avoid them in the first place. Steps can be taken in this regard. However, if the facility does encounter legal issues, there are also strategies for successfully fighting them. Below are ten ways to avoid and fight lawsuits.

Avoiding a lawsuit

• Focus on the basics The best way to avoid a lawsuit is to have a passion for excellence in operating the facility, fostered in a heart of love. Love is critical for success in this industry – love for the wellbeing of the residents and their families, toward the staff, toward the greater community, and a personal passion for the healthcare field. Focusing this passion on the fundamentals of running an ALF will help the facility exceed the standards of Chapter 429, Chapter 58A-5, and Florida law concerning negligence, helping to keep the ALF out of legal trouble. • Keep 1823s current The cornerstone of the physicianALF relationship is of course the Resident Health Assessment, AHCA Form 1823. Be sure that each 1823 is properly and fully completed, signed and dated. Remember, too, that an administrator of an ALF must determine that each resident is appropriate for admission and for continued residency. The 1823 must be updated every three years or after a significant change as defined by Rule 58A-5.0131, Florida Administrative Code, whichever comes first. • Assist with obtaining third party services (and document) An administrator or his or her designee should coordinate and facilitate third party services to residents. Because physicians and third party providers often have delays unrelated to the ALF’s efforts, it is important, and required by Rule 58A5.016(8), to document attempts to coordinate third party services. • Aggressively monitor staffing numbers and transparency Be sure to comply with hours requirements weekly. Calculations should exclude those persons who cannot count toward the total figures. Make sure daily work schedules for direct care staff are available on request. Further, time sheets and work schedules should be maintained as required by Rules 58A-5.019 and 58A5.024. • Maintain records specifically

medicalnews

.com

listed in Rules Rule 58A-5.024 clearly lists records which must be kept regarding 1) the facility, 2) staff, 3) and residents. Precise record keeping helps administrators focus on the basics. For example, we occasionally see charting of medication observation on a day when a resident was at the hospital or deceased. Proactively advise staff that plaintiffs’ lawyers will aggressively point out such errors. • Create internal incident reports In addition to AHCA incident reports, internal incident reports should be created as a standard practice. Each facility should have a blank form incident report that any employee can fill out if there is an incident with injury, or alleged injury. Internal incident reports should be kept separately from AHCA incident reports in a central and confidential location.

Fighting a Lawsuit

• Notify your insurance company immediately If the ALF is served with a lawsuit, or receives a statutory presuit notice of intent letter, administrators should immediately put the facility’s insurance company on notice. Every presuit notice and lawsuit has the potential to be an existential threat to an ALF, to the economic security of staff members, and the tranquility of residents. The best way to fight it is to immediately involve a lawyer, as appointed by the ALF’s insurer. As a general rule,

after the facility has notified the carrier, administrators should do nothing unless instructed to, or “green-lighted,” by the lawyer. • Question your lawyer, and ensure he or she practices in longterm care A litigator is someone who spends much of his or her time resolving bitter disputes, being persuasive, and answering difficult and complicated questions. If the lawyer repeatedly cannot answer questions in a manner that instills confidence, administrators need to advise the carrier of their concerns. Communications with the carrier should be in writing, and preferably via fax and mail. It is also imperative, of course, that the lawyer practice in long-term care – as it is a very specialized area of practice. • Help your lawyer Assuming the lawyer can answer questions consistently, it is critical for administrators to provide assistance. The defense of a lawsuit is a team effort, and it will fail if the client does not play the proper role on the team. This means respecting and generally going along with well-reasoned recommendations. It also means diligently searching for documents and information, and asking questions of the staff. Additionally, administrators should be accessible via fax, phone and email, sometimes on short notice. • Maintain sufficient insurance Inadvertently letting your policy lapse

or not carrying enough insurance can destroy an ALF. Even in cases where administrators had thought they were doing everything right, jury verdicts have been rendered in the $1 million to $5 million range, and even higher. In addition to carrying the proper amount of insurance, administrators should make sure that applicable officers, directors, partners, members and owners are named as additional insureds on the insurance coverage as appropriate. Diligence and organized record-keeping with adherence to State-mandated obligations are the best risk management techniques an ALF can employ. The areas discussed above are where ALF operators may sometimes fall short. Turning attention to these on a recurring basis can fight lawsuits the best way – by avoiding them altogether. When claims do arise, ensure that your insurance company is immediately “put in the loop,” and that you have a sufficient rapport with your long-term care defense lawyer to fight relentlessly. Such a fight may be needed to protect the good name and viability of your facility. John W. Heilman, JD, MBA, is an attorney in the Tampa office of Marshall Dennehey Warner Coleman & Goggin, a civil defense litigation firm with more than 450 attorneys in six states. He has defended matters for many of the largest U.S. long-term care and insurance companies throughout Florida and the Southeast. He also practices in general liability defense. He can be reached at jwheilman@mdwcg.com.

Maximize Your

Company’s ROI with

2

Retargeting

SouthComm Digital’s Retargeting Solution Offers Superior Results through:

Search retargeting drives new qualified traffic to your site based on recent keyword searches including competitor keywords.

• Segmented Campaigns – run two campaigns simultaneously

STEP 1: Prospect searches

• Includes Facebook Exchange inventory

STEP 2: Prospect clicks on a search result – either organic or paid, directing them to a site

• Frequency cap on impressions to offer superior reach

STEP 3: After a prospect leaves, we advertise to the user around the web

• Comprehensive Retargeting strategy

STEP 4: User clicks thru to your website and converts or purchases

PROSPECT COMES BACK TO YOUR SITE

PROSPECT VISITS YOUR WEBSITE

“Users are 70% more likely to convert on their second visit to your site” PROSPECT SEES YOUR AD ON OTHER SITES ACROSS THE WEB

Prospect leaves without converting or buying

medicalnewsinc.com

SouthComm Digital has combined Site and Search Retargeting to give your business phenomenal overall lift in site visitation & conversions!

FOR MORE INFORMATION, CONTACT sales@olandomedicalnews.com sales@tampabaymedicalnews.com

AUGUST 2013

>

13


GrandRounds HealthPoint Medical Group Welcomes General Surgeon Stephen M. Butler, MD is Board Certified in General Surgery. He received his Bachelor of Arts degree in Biology and his Doctor of Medicine from the University Dr. Stephen of Missouri in Kansas City. M. Butler He continued there, completing a 5 year Surgical Residency and served as Chief Resident through St. Luke’s Hospital. He completed a Fellowship in Endoscopy and Laparoscopy at Mt. Sinai Hospital of the Case Western Reserve University in Cleveland, Ohio. Dr. Butler has over 20 years of experience in general surgery. He is the former Chief of Medical Staff and Chairman of the Department of Surgery at South Florida Baptist Hospital (SFBH), where he was also instrumental in the development of their GI Endoscopy Center, Laparoscopic Bariatric Surgery programs, and the design of the current SFBH operating rooms. Dr. Butler’s clinical interests include breast, gastrointestinal and thyroid surgery. He has extensive experience in endoscopic and laparoscopic procedures, as well as vascular procedures including carotid endarterectomies, endovascular abdominal aortic aneurysms, and abovethe-knee femoral popliteal bypass. He is a Fellow of the American College of Surgeons, and a member of the Florida Medical Association.

Tampa ACO’s Launch Data Solution With ServData ServData Inc, a Miami based medical software developer, announced the release of the ACO Solution, a software application designed to assist in the utilization and quality measurements of beneficiaries enrolled in Accountable Care Organizations (ACO’s). The web based portal was launched today for Florida Medical Clinic and Reliance Health Network, providing secure, broad organizational access to their Centers for Medicare and Medicaid Services (CMS) data. Quality measures, benchmark performance and provider accountability are among the top data analysis tools in the application that uses claims data from CMS to produce graphs and reports by beneficiary. Additional provider network and beneficiary assignments can be identified with integrated ACO data. To participate in Shared Savings Plans, ACO’s are faced not only with managing the cost of the assigned beneficiaries’ healthcare, but also meeting specific benchmarks and Quality Performance Measures. The ACO Solution uses claim line item detail to determine whether those benchmarks and quality measures have been met, according to Dario Boza, company President. Miami based ServData, Inc. is a leading developer of medical office software products specializing in integrated payer

14

>

AUGUST 2013

PUBLISHED BY: SouthComm, Inc. PUBLISHER Jackson Vahaly jvahaly@southcomm.com FLORIDA MARKET PUBLISHER John Kelly johnkelly@orlandomedicalnews.com

TGH Among Health Care’s Most Wired Tampa General Hospital is one of the nation’s Most Wired Hospitals, according to Hospitals & Health Networks, the flagship publication of the American Hospital Association. It was the only Bay area hospital named in the publication’s 2013 rankings, joining nine other hospitals in Florida and just 288 other hospitals in the country – out of a potential of 5810 hospitals and health care systems. The publication sponsors the annual Most Wired Survey, which is an industrystandard benchmark study. The survey measures the level of IT adoption in U.S. hospitals and health systems, and is a tool for hospital and health system leadership in developing IT strategic plans. TGH has advanced into technologies data analysis tools and practice management solutions designed for the healthcare provider. Florida Medical Clinic (FMC) ACO is a multi-specialty provider clinic participating in the CMS Medicare Shared Saving Plan. FMC ACO serves Medicare beneficiaries throughout Hillsborough and Pasco counties –www.floridamedicalclinic.com Reliance Health Network is a diverse network of primary care providers and specialists chosen as one of the select few ACOs funded by the CMS Innovation Center’s Advanced Payment Model ACO – www.reliancehms.com

BayCare Health System Announces Breast Milk Supply Program for its NICUs BayCare Health System has announced a partnership with Prolacta Bioscience to ensure a safe, standardized, and steady supply of pasteurized donor breast milk to meet the feeding requirements of their hospitalized premature infant population. Under the partnership, Prolacta will manage the breast milk donor qualification process by conducting health screenings, blood testing, and the milk collection process for BayCare Health System’s newly established BayCare Donor Milk Program. Prolacta also will conduct safety and quality testing before pasteurizing the human milk products for in-hospital use. To facilitate this partnership, BayCare’s Donor Milk Program will work to increase awareness regarding the fact that moms with a surplus of breast milk can donate their extra milk, as opposed to pouring

that focus on patient safety and quality, such as using technology to avoid medication errors, said Balaji Ramadoss, chief technology officer. Physicians can use smart phone technology to care for their patients from anywhere in the world. The award recognizes TGH for having a wide range of advanced technologies, from allowing patients to review their records and interact with their care givers on-line, all the way to the use of advanced robotics for surgeries. Health Forum, an American Hospital Association information company, distributes, collects and analyzes the Most Wired data and develops benchmarks that are becoming the industry standard for measuring IT adoption for operational, financial and clinical performance in health care delivery systems. their “liquid gold” down the drain, as many mothers do without knowledge of other options. This call to action in the community is essential since growing demand of human donor milk has resulted in supply shortages, causing some hospitals to continue the use of cow milk-based nutritional and formula supplementation. The breast milk donations from BayCare’s own community allow participating hospitals the opportunity to become self-sustaining. The hospital will be guaranteed a supply of donor breast milk based on the needs of their premature infant population, in part supported by the volume of milk donated by nursing mothers from within the greater Tampa Bay Area community. The milk donor process is being made surprisingly easy and convenient by BayCare’s Donor Milk Program. Moms will be able to donate without ever having to leave the comfort of their own homes, and the family doesn’t incur any out-of-pocket expenses. The initial screening is done online, certified phlebotomists come to the mother’s home, and all of the storage and shipping supplies are sent directly to the mom. Shipment pick-up is then arranged so that the donating mother and her baby won’t be burdened by having to drive the shipment coolers anywhere. For many moms this will come as a welcome option, since many struggle with what to do with their extra breast milk, and they will now be able to support premature infants in their greater Tampa Bay Area community, through a process made easy and convenient by Prolacta. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

ADVERTISING John Kelly 407-701-7424 Jkelly@tampabaymedicalnews.com Nick Mazeika 727-254-8165 nmazeika@tampabaymedicalnews.com NATIONAL EDITOR Pepper Jeter editor@medicalnewsinc.com LOCAL EDITOR Lynne Jeter lynne@medicalnewsinc.com CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com GRAPHIC DESIGNERS Katy Barrett-Alley, Amy Gomoljak Christie Passarello ACCOUNTANT Kim Stangenberg kstangenberg@southcomm.com CIRCULATION subscriptions@southcomm.com CONTRIBUTING WRITERS Lynne Jeter, Cindy Sanders, Jeff Webb —— All editorial submissions and press releases should be emailed to: editor@medicalnewsinc.com —— Subscription requests or address changes should be mailed to: Medical News, Inc. 210 12th Ave S. • Suite 100 Nashville, TN 37203 615.244.7989 • (FAX) 615.244.8578 or e-mailed to: subscriptions@southcomm.com Subscriptions: One year $48 • Two years $78

SOUTHCOMM Chief Executive Officer Chris Ferrell Chief Financial Officer Patrick Min Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Business Manager Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content/Online Development Patrick Rains

Tampa Bay Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2012 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.

tampabaymedicalnews.com

medicalnews

.com


medicalnews

.com

AUGUST 2013

>

15


World Class Medicine. Hometown Care.

Recognized nationally. tRusted locally. Caring for patients in 16 Greater Tampa Bay Area communities Tampa Bay Area Physicians Jorge Ayub, MD

Larry Gandle, MD

Janelle Park, MD

Jose Alemar, MD

Christopher B. George, MD

Y. K. Peter Park, MD

Rand W. Altemose, MD

Vivian Griffin, MD

Hitesh Patel, MD

Jennifer L. Ball, DO

Andrew E. Hano, DO

J. Andrew Peterson, MD

Gregoire Bergier, MD

Vu Tran Ho, MD

Raju V. Rao, MD

Sawsan G. Bishay, MD

Nuruddin Jooma, MD, MPH

V. Upender Rao, MD, FACP

Rafael W. Blanco, MD

Craig S. Kitchens, MD

Mark S. Robbins, MD

Kerry E. Chamberlain, DO

Richard A. Knipe, MD

Joseph Sennabaum, MD

Hafeez T. Chatoor, MD

Gajanan A. Kulkarni, MD

Ramesh K. Shah, MD, PA

Marion T. Chirayath, MD

K. S. Kumar, MD, FACP

Shalin R. Shah, DO

Mamta T. Choksi, MD

Julio Lautersztain, MD

Gerald H. Sokol, MD, MSc, FCP

Julia Cogburn, MD

Don D. Luong, MD

R. Waide Weaver, MD

Michael Diaz, MD

Joseph R. Mace, MD

David Wenk, MD

Robert L. Drapkin, MD

Idelfia A. Marte, MD

David D. Wright, MD

Ramana Dutt, MD

Arthur J. Matzkowitz, MD

Gail Wright, MD, FACP, FCCP

Matthew A. Fink, MD

Edgar G. Miranda, MD

Lane D. Ziegler, DO

Gustavo Fonseca, MD

Magda Melchert, MD

Sunil Gandhi, MD, FACP

Jeffrey L. Paonessa, MD

855.550.LIFE (5433)

Tampa Bay locations Additional FCS locations

•

FLCancer.com

Tampa Bay Medical News August 2013  

Tampa Bay Medical News August 2013

Read more
Read more
Similar to
Popular now
Just for you