Summer 2018 Newsletter
Dear FLAAEM members,
Welcome to the summer 2018 edition of the Florida AAEM newsletter. We at FLAAEM are working hard to represent our members’ interests. Let us know any issues you are experiencing practicing emergency medicine in the state of Florida so we can bring light to the situation. Email the board at firstname.lastname@example.org with any questions or concerns.
Michael Dalley, DO FAAEM
Program Director Mount Sinai Medical Center Miami Beach EM Residency
Board of Directors FLAAEM
Communication Committee Co-Chair
In this Issue
Summer is here and the next group of medical students is stepping into their new roles as residents. Florida programs had a very successful emergency medicine match this year with 14 programs matching 140 new residents. Many of these new trainees rank programs highly based on the leadership, faculty and location of the residency. However, I am sure they do not know to look closely at the employer of the faculty working there. What am I talking about? Why is this an issue?
In the last few years there has been a recent surge in new residency programs in this state, especially at sites run by contract management groups (CMGs). CMGs are primarily owned by capital venture, private equity and various financially driven enterprises. Not by the physicians themselves or any academically focused entities. In my opinion, with shareholders' interest in mind, the driving factor of these corporate groups is financial. More patients, more procedures and more RVUs translate to profit. The consequence is a push to work more quickly with metrics dictating patient care. In residency, however, the focus should be on education – practicing good and responsible medicine. There should not be pressure to see all patients and place orders within 5 minutes of their arrival. There should not be pressure to discharge patients within an hour. Those times are unrealistic for a trainee who is trying to learn the ropes of emergency medicine. Speed and efficiency are things that come later. As attending physicians, we have mastered this juggling act of seeing and dispositioning patients in a timely manner.
I worry that residents in training programs managed by CMGs are getting pressured to work the “CMG way”. I don’t think this message is overt. I doubt any resident is being sat down to go over their RVUs per patient or their time to discharge. But they see their faculty being scrutinized for these things. This also inevitably limits the attending’s ability to teach. In my opinion, only residencies with strong leadership can resist these corporate forces. However, fledgling programs unaware of this issue need to shelter their trainees so that education can be the main goal of the residency.
AAEM is aware of this growing issue and put out a statement regarding CMG oversight and management of residencies in 2017:
AAEM opposes the oversight and management of emergency medicine residency programs by contract management groups with lay ownership. AAEM is concerned that this arrangement raises significant conflicts of interests between a residency program's educational mission and the contract management group's fiduciary duty to its shareholders.
I care about the future of our specialty and I want to ensure that all of us protect the education and training of emergency medicine residents. I understand that this topic is controversial for some of you but we need to open a dialogue about these issues and consider them in order to confront threats to our specialty.
Vicki Norton, MD FAAEM
President, Florida Chapter Division of AAEM
Lawrence Isaacs, MD FAAEM FACEP
Director, Neuroscience Institute LeeHealth
Medical Director, Emergency Department
Gulf Coast Medical Center, Ft. Myers, FL
Board of Director, Florida Chapter Division of AAEM
Stroke care is arguably the fastest moving science in emergency medicine these days. For those of us old enough to remember when we couldn’t do anything except for admit and administer an aspirin there has become a huge paradigm shift in treatment. It’s obviously become a time-critical, maybe-we-can-make-a-difference condition. I was fortunate to have attended the International Stroke Conference and I’m going to give an emergency physician friendly synopsis of where we are in stroke care in 2018.
Thrombolytics are still the first line treatment for all non-hemorrhagic strokes whose last known well (LKW) is under 4.5 hours (tPA must be administered by the 4.5 hour mark). The updated (2018) guidelines have loosened the restrictions/ relative contraindications (especially in the “second tier” timeframe- 3-4.5hr window). Endovascular thrombectomy (EVT) has solidified itself as the most effective treatment for a large vessel occlusion (LVO).
Before the 2018 updates, this procedure was only seen as beneficial up to 6 hrs last known well (LKW), the recent updates has changed this dramatically. Patients with a suspected LVO whose LKW is under 4.5 hrs should still receive tPA (if there are no contraindications), and go to the endovascular suite for EVT as quickly as possible.
Concerning thrombolytics, as I stated above, the restrictions, especially in the 3-4.5 hr range has been loosened. The “bombshell” study, the announcement few seemed to be expected was a New England Journal of Medicine study that showed Tenecteplase (TNK) had superior functional outcome and reperfusion before EVT than tPA. TNK is also easier to administer and less expensive than tPA. So, I’m sure you’re wondering why stroke systems are not switching to TNK. I can’t give you a great answer except that the study only had 202 patients and it was a single study. I suspect one more well-powered study showing similar results would change our practice.
Concerning EVT, the big news was the extension of the time window for certain patients who may benefit from EVT. Two studies, the DAWN (NEJM 2017) and Defuse-3 (NEJM 2018) together extended the window for LVO strokes up to 24hrs LKW. This would obviously include many “wake-up” strokes. To determine if your patient is eligible for EVT, they will need to be a LVO and receive a CTA (usually head and neck) and a CT perfusion. The CTA will confirm LVO and the CTP will need to show a large mismatch between core infarct (dead brain) and penumbra (brain at risk). In other words, lots of brain still alive and at risk of dying with a small core infarct. In most systems it’s not the emergency physician to determine eligibility (Defuse-3 criteria is up to 16 hrs LKW and 24 hrs for patients that meet DAWN criteria), but we should be aware that these wake-up strokes/late presenters do have a chance for treatment. It’s all about if they’re an LVO and how much brain is at risk.
DAWN, Defuse-3 is moving stroke care to “imaging guided” treatment. So, radiology will be playing an increasingly important role in stroke care. One facet of this, which my Neurointerventionalists are very excited about, but is probably not ready yet (but maybe soon) is multi-phase CTA in determining candidates for late EVT. Multi-phase CTA is a “regular” CTA of the head, but then, usually 6 seconds later, the pt gets another CT, then 6 seconds later another. The number of CTA’s is usually 3-4. What this does is shows the collateral circulation in the brain/ penumbra. More collaterals, better perfusion, more likely to do well. That’s the thought, at least….
Joshua Elliott Novy, MBA MS
MS4, University of Miami Miller School of Medicine
FLAAEM Student Member Representative
There exists debate within the emergency medicine community over the relative merits and disadvantages of the freestanding emergency department (FSED) as a model for delivery of care for acute illness and injury. It is important to note that the operation of FSEDs is tied very closely to their regulation, which varies greatly from state to state. This is exemplified by the fact that FSEDs are not permitted to operate in California, and Texas boasts the most FSEDs for any state in the U.S. Florida is home to 43 FSEDs as of the submission of this article, each regulated by certificate of need (CON) requirements such that they may only operate under the license of an existing hospital with an on-site ED. The most recent publicly available data for visits to Florida’s FSEDs reflects those from 2016: 540,190 visits to FSEDs operating under the licenses of 28 distinct hospital entities, with $2.19B billed for services provided. Services billed to Medicare & Medicaid as the primary payer group totaled $927.3M (42.3% of total billing) for 242,170 visits (44.8% of FSED visits in 2016). Billing to Medicare and Medicaid in 2015 reflected approximately 43% of total billing from FSEDs in Florida; it can thus be reasonably surmised that Medicare and Medicaid represent a significant source of income for these facilities, and with the growing presence of FSEDs in Florida, may even be the lifeblood of their financial viability for the hospital systems that operate them.
However, a slowdown may be on the horizon for the proliferation of FSEDs in Florida and the rest of the U.S. In March, the Medicare Payment Advisory Commission (MedPAC) recommended to Congress that CMS payments to these facilities be reduced by 30% for those FSEDs within 6 miles of a hospital with an onsite ED. As of 2016, Florida is home to over 4.16M Medicare beneficiaries, roughly 20% of our state population. It is important to consider the financial impact of the proposed changes for Florida’s FSEDs and the parent hospitals under which these facilities are licensed to operate. Likewise it is worthwhile to consider which communities may be affected by the MedPAC recommendation. To address these questions, publicly available data on hospitals and FSEDs in Florida was retrieved from the Agency for Healthcare Administration (AHCA) and the ED Query tool. The physical plant (street address) for each of the 43 FSEDs in Florida was retrieved; using Google Maps supported software, a 6 mile radius was created with each FSED address as an epicenter, and the zip codes within the radii were obtained. These zip codes were then referenced against an index of all 216 hospital facilities in FL with an on-site ED. For those hospitals with an on-site ED located in a zip code found within the 6-mile radius of a FSED, the straight-line distance between the two facilities was determined using Google Maps supported software. Thirty-five of Florida’s 43 FSEDs are located within 6 miles of a hospital with an on-site ED; under the MedPAC recommendations, only 8 FSEDs would be unaffected. The latest publicly available billing data for Florida FSEDs reflects the 2016 fiscal year; of the 35 FSEDs that will be affected by the proposed CMS payment reduction, 28 FSEDs were in operation in 2016 under 21 distinct hospital licenses to which billing data could be identified. In 2016, 392,604 visits were seen in these 28 FSEDs, 173,744 (44.25%) of which listed Medicare/Medicaid as the primary payer group. Billing to Medicare/Medicaid represented $702M (42.1%) of total charges assessed by these facilities for all visits in 2016. This preliminary analysis demonstrates that reimbursement from CMS is indeed a significant source of the income generated by FSEDs for the parent hospitals who operate these facilities. At 42.1%, a 30% reduction in payments for eligible Medicare/Medicaid visits would result in an approximate 12.6% reduction in total billing.
The FSED model was first conceived in the 1970’s in the interest of improving access to emergency care in geographically disadvantaged locations. Given the laxity of CON requirements in Florida, we have seen these facilities emerge in more densely populated areas. The changes proposed by MedPAC will likely limit further entry into the FSED market by hospitals. However, it is difficult to predict whether a 1/8th detriment to revenue generated by FSEDs will deter continued operation of existing facilities, especially with the knowledge that FSEDs confer an additional revenue stream for hospital systems rather than serve as the core revenue itself. Hospital systems that have achieved scale with several FSED locations may be immune to the impact these changes will have on their bottom-line, while those systems with single FSEDs may consider a repurposing of their already built facilities if a 1/8th reduction in reimbursement from CMS is too detrimental to sustain operation as a FSED given their respective payer mix. Hospitals and hospital systems are not the only ones who stand to be affected greatly by this policy, however. Though the so-called “6-mile rule” spares geographically disadvantaged regions serviced by FSEDs, we have very recently seen major urban centers such as the Houston metropolitan area ravaged by natural disasters. The recommendation made by MedPAC has been met by a backlash from hospital systems and the American Hospital Association (AHA). The recommendation has been critiqued on the basis that it is supported by limited data sets that do not incorporate analyses of Medicare beneficiaries, Medicare costs or payments. Joanna Hiatt Kim, VP of Payment Policy at the AHA has cited the threat of this policy to “vulnerable communities following a year in which hospital EDs responded to record setting natural disasters and flu infections.”
Florida – a paradise amidst meteorologic chaos - is no stranger to natural disasters. AAEM’s very own Dr. Bobby Kapur has shed insight to emergency department operations in the setting of natural disasters, borrowing lessons from his own experiences internationally and in Florida. "Access to acute care services such as those provided by Florida’s FSEDs help to satisfy a need in communities which may not have the resources or demand to support a full-scale hospital." As our industry continually strives towards the triple aim of quality, cost reduction, and health improvement, we must not ignore the important axis of access.
Robert Farrow, DO
Resident Member FLAAEM at Large BOD
Several exciting things are happening in the FLAAEM community. Over the course of the last several years, multiple emergency medicine residencies have opened their doors to new classes of residents and have joined the ranks of other strong emergency medicine programs in the state.
The national AAEM president, Dr. David Farcy, is from our home state and is also the Department Chair for Mount Sinai.
The annual FLAAEM Scientific Assembly continues to grow and this year included a Sim Wars competition, Ultrasound course and research submissions from across the state. While we look for the Assembly to continue to grow this year, FLAAEM is planning to also have a FLAAEM Fall Social for residents and students. Look out for email notifications as the date and location will be set soon! If you have any ideas for FLAAEM or questions about how to get involved please email the resident board member, Rob Farrow (PGY-4, Mt. Sinai) at email@example.com . We are looking forward to a great year for FLAAEM!
Mount Sinai Hospital, Miami Beach
FLAAEM Membership. Below is a summary of the recent happenings at Mount Sinai Miami Beach
- Dr. Newberry (Ultrasound Director) led a successful ultrasound workshop for residents and faculty at Mt. Sinai in July. This is the second annual course designed to give exposure to common ultrasound utilities in the emergency department. The workshop was supported and attended by interns and faculty from Aventura Medical Center, Kendall Regional Medical center and US educators from around the state of Florida
- Seniors Rob Farrow, Jackie Farrow and Justin Burkholder presented their research (Trigger Point Injections for Musculoskeletal Neck and Back Pain in the ED) at SAEM’s national conference in Indianapolis, IN.
- Congratulations to our graduating seniors and their future pursuits:
- Jackie Farrow – Cleveland Clinic, Weston, FL
- David Kinas – Ultrasound Fellowship, Mt. Sinai / St Lukes - New York, NY
- Burr Fong - Sibley Memorial Hospital, John Hopkins Medicine, Washington DC
- Haley Watsky – Bayfront Medical Center, St. Petersburg, FL
- Joe Sherer – Nashville General Hospital, Nashville, TN
- As we say goodbye to our graduating seniors, we look forward to an exciting academic year. Positions for the 2018-2019 academic year are as follows:
- Chiefs: Rob Farrow (PGY-4), Adam Memon (PGY-3) and Mike Dicenso (PGY-3). If you would like to collaborate with our program or need to reach them please email firstname.lastname@example.org
- Student Coordinators: Aldo Manresa (PGY-3) and Chandelle Raza (PGY-2)
- Finally, we would like to introduce our new class of residents: Nick Boyko, Stephanie Fernandez, Fenil Patel, Rahul Paul, Kevin Siegler, Jenna Varner, and Ethan Zimmerman
Robert Farrow, DO
Mount Sinai Medical Center, Miami Beach
FLAAEM Resident Member at Large BOD
University of Miami/Jackson Memorial Hospital
Greetings from Miami!
After a wonderful and busy interview season, we were thrilled for Match Day and to finally find out who our new 15 EM residents would be. We are excited to welcome an extremely talented and diverse group of new residents who come of many different backgrounds from all over the country! We have planned a fun-filled orientation month packed with many social events including a Marlins baseball game and a barbecue as well as many learning opportunities such as an airway workshop, central venous line training, ATLS, ACLS, BLS and PALS. We are ecstatic to finally have the full complement of residents in our 3-year EM program.
As our current second years rise to their final year in residency, we are also elated to have our first ever group of chief residents: Dr. Natalia Alvarez, Dr. Emily Cooper, and Dr. Michael Roberds. They were selected by their peers and mentors and are ready to jump into this rewarding and exciting inaugural role.
Finally, we also wanted to congratulate some of our residents for their involvement and academic achievements. Dr. Emily Ball and Dr. Anwar Ferdinand presented their abstract “Opt-out Emergency Department Screening of HIV and HCV in a Large Urban Academic Center” at AAEM and received the runner up award for the Western Journal of Emergency Medicine Population Health Abstract Competition. Dr. Henry Zeng also presented a very interesting case of cerebral toxoplasmosis at AAEM, and Dr. Ariana Weber will be attending Dr. Richard Levitan’s advanced airway course this summer.
We look forward to a sunny summer and soon it will be interview season all over again. Time flies when you’re having fun!
Chris Freeman, MD
St Lucie Medical Center
Summer 2018 is finally here and we at St. Lucie Medical Center are ready for some fun in the sun! As we move into July and August in Florida, we experience the bittersweet departure of our graduating senior residents, the joy of welcoming our incoming class, and look forward to this year’s coming events.
We send our warmest St. Lucie bear hug to the incoming class of 2021! To Drs. Drew Brooks, Jerome Daniel, Michael Dreschler, Shelby Guile, Abby Reagan and Ashkahn Zomorrodi: We welcome you with open arms and we are more than thrilled to bring you into our family. You all have what it takes to be outstanding EM physicians and we will work hard to help you to achieve success along the way.
We wish our graduating class of 2018 a warm farewell. Dr. Alexa Yager is headed to Washington State, Dr. Thomas Caraballo will be working in the Chicago area, Dr. Brittany Nobilette is headed home to San Diego, Dr. Hicham El Alami will return to the San Francisco Bay Area. We are exceedingly proud of your accomplishments and we wish you all the best on your journey to the other side of the mountain. We cherished our time with all of you, as you all helped to brighten our lives and the lives of your patients. You will all be missed!
This past year, we participated in several wellness events. All of the PBCGME participated in the FAU ropes course which was a thought provoking, team building event. We also ran the Classics by the Sea 5K, and soaked in some rays by the pool for our annual Residents Day out. This year, we look forward to adding simulation to our curriculum in partnership with the FAU simulation center.
We at St. Lucie wish all of you a wonderful and safe summer of 2018 and we look forward to seeing you all at the next conference.
Thomas Adams, DO
St. Lucie Medical Center
FOMA - Discounted Rate of $25 for Prescribing Controlled Substances Course
The Florida Osteopathic Medical Association (FOMA) is providing FLAAEM members a $25 rate (regularly $75) for their two (2) hour online “Prescribing Controlled Substances” course. Fulfills the opioid prescribing requirement for all Florida physicians. Log-in to your member account to retrieve the discount code.
Free Annual Scientific Assembly - 8th Annual Scientific Assembly: May 10-12, 2019
Registration opens January 2019
Dress A Med - 20% Discount on scrubs/uniforms
FLAAEM is pleased to announce our latest partner in our member discount program. Dress A Med provides quality scrubs and medical uniforms. FLAAEM members receive a 20% discount sitewide.
Advanced Medical Certification - 35% Discount on online ACLS & PALS
FLAAEM has aligned with Advanced Medical Certification (AMC), the premier online certification and recertification course provider for health care professionals offering 100% online courses for certification and recertification in ACLS, PALS, BLS and CPR.
American Seminar Institute - 15% Discount on custom travel CME
American Seminar Institute (ASI) offers portable and accredited continuing education courses. You can take your individual course at home or anywhere in the world. Complete your continuing education when it fits into your schedule. Multiple specialty areas and topics are available.
FLAAEM Advocacy and Legislation reform
Free Western Journal of Emergency Medicine (WestJEM) subscription
A new position “Director of the FLAAEM Scientific Assembly Planning Committee” was unanimously approved by the FLAAEM Board of Directors. The position will go into effect once the AAEM Board of Directors’ approves the new position.
Overall FLAAEM membership has improved year over year. The FLAAEM board will continue recruiting efforts to appeal for more members and continue to grow.
Plans were discussed to hold a fall FLAAEM membership get-together in Orlando. Details to Follow.
The FLAAEM Board of Directors agreed to return to the Fontainebleau Miami Beach for the 8th Annual FLAAEM Scientific Assembly in late spring 2019.
Government Affairs Committee Update
Dr. Cruz reported a continued concern about due process and balanced billing in Florida, especially with the increasing number of corporate management companies in the state.
Insurance companies are increasingly denying claims from the emergency department, citing the claim is not “an emergency medicine (EM) claim.” An example is “chest pain” as a patient complaint, with GERD as a diagnosis, not being approved because GERD is not considered an “EM” claim by some insurance companies.
FLAAEM Board of Directors inquired about the possibility of forming a FLAAEM PAC to continue to advocate for the EM physician.
2018 Upcoming Board Meeting
- Tuesday, October 9, 2018, 3:00pm ET – conference call.
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- How Do You FEEL about Echo in Cardiac Arrest
- TPA in under 20 minutes is Recklessness
- Mosquito trial may hold an answer to the spread of Dengue and Zika
- Liability Reform changes the way Physicians approach Coronary Artery Disease