Physician Spotlight with Dr. Alice Hoyt

Health Law Talk Presented by Chehardy Sherman Williams

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Intro (00:01):
Welcome to Health Law Talk, presented by Chehardy, Sherman Williams health Law. Broken down through expert discussion, real client issues and real life experiences, breaking barriers to understanding complex healthcare issues is our job.

Conrad Meyer (00:24):
And good morning everyone. This is another edition of Health Law Talk here at the Chehardy Sherman Law Firm Conrad Meyer, Rory Bellina to well versed healthcare attorneys here. And also today a special guest in the studio, Dr. Alice Hoyt. Hi, doctor.

Dr. Alice Hoyt (00:42):
Good morning, Conrad. How are you? Good morning,

Conrad Meyer (00:44):
Roy. It’s morning. Good to have you in. And, and I think today is, it’s a special day that you’re here. We, we really thank you for coming into the studio with us this morning. and we thought today would be all about, all about you and sort of figuring out who, what is what, what sort of doctor are you, what’s going on in your personal, private practice, and and a little bit more about your advocacy background. So, Absolutely. So, so to start off with, give us, give the listeners an idea, you know, what is, you said, you, you told me earlier you’re, you’re a pediatric food allergist

Dr. Alice Hoyt (01:20):
And adult

Conrad Meyer (01:21):
And adult and adults. So correct me. Thank you. Yes. So tell me a little bit about your practice and your background. Absolutely. And so the listeners can know.

Dr. Alice Hoyt (01:29):
So, I am a Louisiana girl, born and raised in South Louisiana. and I’m a board certified allergist immunologist, also board certified in internal medicine and in pediatrics. And I focus my clinical practice on food allergy. I’ve been doing this for years now. prior to opening my practice here in Metairie, I was at the Cleveland Clinic, and prior to that I was at Vanderbilt University. So have, have really been blessed to work at amazing, amazing institutions and was just so excited to come back down to my home state, very close to my hometown, and open up a practice where I felt I could best serve patients.

Conrad Meyer (02:07):
That’s great. I mean, I, I, you got some good background. I mean, Cleveland Clinic, I mean, very well recognized mm-hmm. background. And, and so when you talk about food allergy, I mean, I remember growing up, I mean, and I even asked you this question, I remember growing up, nobody in, when I was my age talked about food allergy, you know, and I’m, I’m, I’m, I’m not young anymore, but I don’t remember, you know, everyone freaking out or saying, No, we can’t cook this or can’t bring that ever. So, so tell me, how did this develop?

Dr. Alice Hoyt (02:36):
Well, it wasn’t talked about then, because it wasn’t being diagnosed then is one thing, but also it, it was not occurring then. I mean, anal access, meaning an immediate onset of hive swelling, trouble breathing, vomiting, that’s anal access. Mm-hmm. that’s hard to miss. And so I don’t think that it’s, we just were missing the diagnosis. It is that it was not happening as much. And it is happening much, much more now. Why? We don’t know. Right. We don’t know why more and more, especially children are developing food allergies.

Conrad Meyer (03:10):
That’s interesting. Cuz I, I, I know I used to think to myself, Is this just helicopter parents? Is this just over anxious children or even adults? I mean, do we, is there something wrong or there, Is there really such a thing as a food allergy

Dr. Alice Hoyt (03:25):
There? There absolutely is. and I do remember our, our journey on this road, Conrad, cuz you’ve been helping my nonprofit organization for years now. And it’s been interesting. I don’t think I’ve ever told you this, but I think it’s been interesting to watch your your level of knowledge and specifically regarding food allergy and policy that really grow and expand. And I remember one day I was on the phone with you and you’re like, What? Like, this is really happening about, it was something about stock epinephrine, which I know we’ll get to, right. but it, it’s just yes, it, it is happening more and more. what is interesting is called the hygiene hypothesis. And, and that’s the whole concept that we’re all mm-hmm. too, too hygienic. Sure. and what’s interesting about food allergy is that the, the allergic antibodies that participate in allergic reactions, they’re also used to help keep us safe from parasite infections. Mm-hmm. , I say that because in third world countries where they don’t really have food allergy, but they have parasite infections, it’s sort of the same immune mechanisms that are associated with food allergy. Whereas here we don’t really have parasite infections. We have plenty of food allergy. So just food for thought.

Conrad Meyer (04:38):
So what, what mean, I guess the most common one that, I mean you and I have even discussed at peanuts mm-hmm. , is that, would you say that that is probably the most common food allergy? Or do you think maybe a top, I don’t know, top three? I don’t know.

Dr. Alice Hoyt (04:52):
So now we have a top nine.

Conrad Meyer (04:54):
You have top nine.

Dr. Alice Hoyt (04:54):
Top nine. Wow. Wow. Sesame, sesame seed is really coming in there with a strong se

Conrad Meyer (04:59):
Sesame seed. Oh,

Dr. Alice Hoyt (05:01):
Yes,

Conrad Meyer (05:01):
Yes. Wait, like raw sesame or like roasted sesame, or does it matter?

Dr. Alice Hoyt (05:05):
Excellent question. Studies have shown that in peanuts in particular, and that was done at work here, sa hala, Malachi, that roasting peanuts actually makes them more allergenic. We think it has to do with the way the, these sugars in the proteins

Conrad Meyer (05:21):
Become right down. And, and then they, the oils come out when you roast it. I mean, is it,

Dr. Alice Hoyt (05:25):
So it, it’s called a mailer defect. It’s that nice to, like, when you put toasts in, you put bread in in the, in the toaster, it makes toast. It’s nice and brown and warm and like yummy smelling. I like that. That’s called the mailer effect. And something about that makes the protein more allergenic. clinical pearl number one here, what you’re allergic to if you’re allergic to a food is actually the protein. So foods are, foods are made of carbohydrate. Right. Protein, fat or alcohol. Right. The allergen is a protein. And so clinical pearl number two, Conrad, you mentioned oils. Most people who have a food allergy, they can actually eat at Chick-fil-A. That fries in highly refined peanut oil because highly refined peanut oil is highly refined. Meaning there’s no peanut protein in it. It’s just oil. And oil is not the allergen.

Conrad Meyer (06:14):
Interesting. Mm-hmm. , I had, I really had no idea. Did you

Rory Bellina (06:17):
Know that Rory? I did not. No. And I want to get back to, to the peanut part cuz I was just having this conversation with another parent the other day at, at our kid’s school and, and the topic of it’s a peanut free school and the peanut allergies that topic was what we were discussing. What’s your kind of, can you go through what’s the history of that? Because I, I honestly didn’t know, and when I, when I talked to it with, with older people or my parents or my in-laws, you know, they, they’ll say, Oh, well we didn’t have that kid’s day peanuts. They were, they were fine. But like you mentioned, there seems to have been this big shift to where, you know, now most schools I think are, are peanut free. Kind of where did that come from and kind of what are your thoughts on, on that? Cause I’m curious about that just on a personal basis.

Dr. Alice Hoyt (06:56):
Absolutely. So first let me clarify for our audience, the top nine food allergens, peanut tree nuts, egg milk, wheat, soy, thin fish crus station, shellfish, and now sesame seed. So in 20 thir 2023, you’re gonna begin seeing sesame seed on your nutrition labels if it’s an allergen. Mm-hmm. highlighting that it’s an allergen regarding peanut-free schools, that is a very, very hot button issue. And the Journal of Allergy Clinical Immunology published an article at the end of 2021. And my colleague and I actually wrote a response to the article. And that was also published in the Journal of Allergy and Clinical Immunology. And it was all about food allergy reaction prevention and management in schools and early learning centers. They reviewed all of the evidence that we have from how to manage food allergy effectively in schools and in early learning centers like daycare’s, preschools, and all of their recommendations.

(07:55):
They ended up all being conditional recommendations for a few reasons. Meaning we don’t have a whole lot of evidence as to whether or not to make this particular policy regarding food allergy in school. and the evidence we do have is all kind of like, eh, not great. So our response to the article was like, this is a fantastic article, but one thing that they really didn’t highlight was the importance of having an allergist, a board certified allergist involved with schools to help schools make evidence-based informed policies that meet the school’s culture. So for a preschool, you’re gonna have different policies in place regarding food than you would for a high school. Right. But if you’re trying to take a, a sort of a cookie cutter approach of, well, we all have to do this fill in the blank XYZ policy, that is not you’re doing a disservice really to the students as

Rory Bellina (08:48):
Well. And, and that’s what I’ve seen and we were discussing the conversation I was having with the other parent was that it’s a archdiocese policy or whatever district you’re in, it’s, it’s just their policy. So, you know, instead of going on a school by school basis, I think they just made it a blanket policy for, for all of their schools. And it, it might, may or end not affect the individual schools, but, but now every child in the whole district, ias, whatever it is, it, it affects them.

Conrad Meyer (09:14):
I wanna know one thing. I mean, I wanna know how many, how many of the art, whether it’s the archdiocese here in New Orleans or the schools themselves, how many of them have a board certified allergist actually advising them? I would fair, I, I would fair to say none. I mean, honestly, I mean, I, I don’t, I don’t see that happening. I mean, in your, in your practice Dr. Hoyt, when you meet with schools or you talk to the administrators, do you find that it’s more non-clinical people who are making these policies, do they even get the advice of physicians and if they do get the advice of physicians is are they really physicians that should be giving that advice? That,

Dr. Alice Hoyt (09:51):
That’s an excellent point. and Roy, let me go back to your question too about lots

Conrad Meyer (09:56):
Of questions here,

Dr. Alice Hoyt (09:57):
. cuz I didn’t answer your question about the thought of peanut free schools, there’s actually not evidence that peanut free schools actually prevent allergic reactions. it’s sort of a false sense of security to be quite honest. but what there is a little bit of evidence for maybe is if you have targeted allergy zones that are very much age appropriate. And that comes back to my point about having policies that are appropriate for a child’s age. pre-k is gonna be different than a high school. So should schools be peanut free, we don’t have evidence that says that that’s helpful.

Rory Bellina (10:35):
And is it harmful if they are peanut free? Is there any harm to not exposing your kids to, I mean, I think what’s happened to me personally, I have three kids all at the same school and they can’t have peanuts at all in the school. So, and, and they typically don’t choose to eat it on the weekends. So essentially they’re not eating peanuts or they’re not eating certain types of food. Are there any harm

Conrad Meyer (10:56):
To that? You can’t even, like from the school standpoint, and at least in my kid’s school, you can’t even bring stuff to school that was baked, cooked, put together where there was peanuts even around.

Rory Bellina (11:08):
Yeah. Yeah. I mean, I know at the beginning of the year, I think most of us get that, that form of, you know, check your labels and if it’s in a factory where peanuts were mixed, I mean,

Conrad Meyer (11:16):
Can’t bring in Yeah.

Rory Bellina (11:17):
It’s, I mean, are there, what are the harms to that? I see you’re smiling. No one can see

Dr. Alice Hoyt (11:21):
That. So it’s so interesting that you’re bringing up, like made in a factory, there’s very limited there are very specific regulations regarding how to label foods and regarding allergens food need to, food allergens need to be labeled one of two ways. The allergen needs to be highlighted within the ingredients list or right below that where it says, it will say contains and it’ll list one of the aller if, if the peanut, if peanut’s in there, it’ll list peanut. So that, that makes it easier for us to see what’s actually in the food label or the nutrition fax label. but all these other things like made in a factory or whatever, like, none of that’s regulated. That’s all whatever a company wants to put on their label to you know, I mean cover their behinds.

Rory Bellina (12:08):
Now are there any downfalls to not exposing kids to peanuts or Essentially that again, goes back to my thing my kids don’t eat peanuts. cuz they’re not eating at school and they, so they don’t, we don’t, they don’t request a peanut butter and jelly on the weekends, so they’re really not getting it, I guess. Are there any, we’re limiting that. So if they grow up and, you know, hopefully go off to college and they eat a peanut butter and jelly sandwich, you know, what, what are the effects of, of something like that, of not being exposed to a certain food or ingredient or, or allergen protein, as you mentioned, for essentially until most, I think most high schools have the prohibition as well, and then you go off to college and you have a peanut butter and jelly sandwich. Are there any,

Dr. Alice Hoyt (12:49):
So we know that exposure develops tolerance, and what that means is that your immune system will see a food and recognize it as like, okay, this is fine, this is totally cool. clinical pearl number three, do not order food allergy testing online because it’s just gonna be silly IgG testing, which is not allergic antibody testing. IgG is an antibody that simply says that your body’s been exposed to something. It, it doesn’t necessarily say much more than that. It doesn’t say much more than that regarding food allergy. so the concept of having children avoid foods, we know that that can promote the development of allergy, or what I really should say, the loss of tolerance.

Rory Bellina (13:29):
Okay. Okay. So if, when they do have that be put and jelly sandwich, if they would’ve had a reaction at 3, 4, 5 and, and maybe would’ve, you know, had to come see you or need some sort of treatment mm-hmm. or some sort of, you know, protocol when they have it now at 16, 17, 18, that they could have a much bigger reaction or response to

Dr. Alice Hoyt (13:50):
It. That we, we do know that our teenagers are, adolescents are young twenties, they are at risk for worse outcomes. And there are a few different reasons for that. One, some people say that, Oh, well they, they have worse decision making skills risky behaviors also clinical, I don’t know, number four, alcohol will actually lower your threshold to have an allergic reaction. so that’s something that’s really important to talk to your, your college aged kids about who have food allergy is, you know, if you’re at a party and you’re drinking and your, your decision making is being further impaired, then you’re at risk of accidentally ingestion, ingesting your allergen. And then because you’re ingesting it with alcohol, you could potentially have a worse reaction or more likely to have a reaction. also if you look at the immune system of an adolescent, I mean, there’s a reason like going back into biblical times that those were the people that were fighting and they think they’re invincible.

(14:48):
Right. And their immune system does too. The immune system is a boss at that, at that time of life. And unfortunately what’s happening when someone’s having anaphylaxis, that is that their immune system is going rogue. It’s seeing something and it is attacking it thinking that it is, it is trying to, to fight this bad guy, basically. But it really is the immune system going rogue. And so that is why, another reason that I do think that, or that is a risk factor that I like to consider when I’m thinking about risk for our adolescents and our young twenties kids. Now the concept of you avoid a food, you’re at risk of developing a food allergy. And I’ll come back to that. and then is your reaction gonna be worse later on? We think it would, it could be worse just because you’re, you’re no longer a little kid with a immature immune system. You’re an adolescent with that boss immune system that I talked about.

Rory Bellina (15:43):
So I’m sure it’s hard to make a recommendation, a broad recommendation. It it’s probably more case by case or child by child specific. But what’s your kind of general rule, you know, should children, should, should you allow your children to eat these when they’re home or, you know, kind of under your supervision? Should you, you know, encourage them to eat the allergens, like you said, the crustaceans or the peanuts, you know? No, I can

Dr. Alice Hoyt (16:07):
Absolutely make very strong recommendations.

Rory Bellina (16:08):
Okay. That’s what I want, .

Dr. Alice Hoyt (16:10):
Absolutely. So we do know, based on evidence, based on studies that children under the age of one who have egg allergy and or severe eczema, they are at risk of developing peanut allergy. So there are some risk factors to developing a food allergy. How, you know, a four month old has an egg allergy. We, we could, we could get into the details of the recommendations, but their recommendations are very good because of, or of, of the guidelines and of the evidence because they do help us identify children who are at risk of developing a food allergy. I had a, a kiddo the other day who had never had peanut before, is a baby has some pretty rough ex eczema. mom was concerned about a different food. I was concerned about peanut because I knew that having severe eczema puts a child at risk of having peanut allergy did the blood work and very, very strongly suggests peanut allergy.

(17:10):
So if you listen to my podcast, then you’ll hear, oh, Dr. Hoyt, you always say you have to do a food challenge to really confirm they’re allergic and, and don’t just go on the blood work. That is very true. However, we are getting better and better with our testing and allergy testing in the hands of a skilled board certified allergist can be very, very helpful for your child. and so we know there are a few very specific tests that we can order to help us determine whether or not we think your kiddo actually is allergic specifically to peanut, so that then we can make an informed recommendation such as str, avoid peanut, and also consider what’s called oral immunotherapy, which is when we teach the immune system to grow that tolerance.

Conrad Meyer (17:55):
See, So let me ask you this. So you, you mentioned this just a moment ago about what you do, what the plan is, and, and I’d like to to get to segue into that. So you recently opened up a new practice in, in old Met in me mm-hmm. , is that right? Yes. Can you tell us and the listeners about your practice and, and, and the name of it and, and how that came to be and, and go into a little bit, I’d like you to, to tell everyone why is it that your practice is, is different.

Dr. Alice Hoyt (18:24):
Absolutely. so the name of the practice is Hoit Institute of Food Allergy, and we provide evidence-based, family focused information about food allergy to our families. why I think we’re different is because of the people who work at our institute. not so much including me, I, what I do is I provide you the most UpToDate evidence based approach to understanding what’s going on with your child’s food allergy, making a a, making a diagnosis. So many people are walking around with a misdiagnosis. So I clarify the diagnosis, what food you really are allergic to. So many people think they’re allergic to all tree nuts. Most people are not allergic to all tree nuts. In fact, a lot of things that are labeled tree nuts are not even technically tree nuts. Again, I could go on a tangent about that, Roy, but I will get you a diagnosis.

(19:17):
Right. And then provide you a treatment plan. Typically the treatment plan for a food allergy is to avoid the food. That’s always a great plan. But we can also do what’s called oral immunotherapy, which is when we teach the immune system to tolerate the food. but I mean, other allergist can do that and they do it and they do it very well. Many of them do. But what’s really unique about my practice is that I have on board an excellent, excellent, excellent therapist who helps our families identify stressors provide strategies for overcoming those stressors. Because food allergy, it’s, it’s a 24 7. It’s a 24 7 problem where you’re sending your kiddo to school. And in addition to all the other things you worry about when you send your child to school, you’re worried that they’re not gonna come home cuz they accidentally ingested, they’re allergen. Right? I mean, like, my child does not have food allergy, thank the lord. And I, I just, I I worry about so many things with her. I can’t imagine having to worry about that too. Right. and so having Melissa on board, she is, she’s just fantastic. And I mean, she helps with things like bath time, making that less stressful so that your oral immunotherapy dosing, you’re less likely to just all of these things.

Conrad Meyer (20:32):
And so Melissa, she’s, she is a licensed social worker. Mm-hmm. therapist. Mm-hmm. that works. So you have a multidisciplinary team. Yes. And you take this multidisciplinary approach that, that I I don’t think I’ve seen any other allergi do that before. So, so that’s very, very unique. And so she, she walks with, excuse me, She works with you to sort of, you do the clinical aspect on the allergy side mm-hmm. . And she manages the therapy side for the families.

Dr. Alice Hoyt (21:02):
Right. Because I could be recommending a treatment plan. Right. But if that treatment plan has particular stressors in it for the family, we’re not gonna have success. And so I need that other component, that social emotional support component mm-hmm. to help the family have the outcome, achieve the goals that the family wants to achieve. The other person I have to mention is Alexis, who’s our comprehensive care navigator. I don’t know if y’all have ever tried to call your doctor, but it, it can be very difficult to get in touch with your physician at Hoit Institute when you make that phone call. You are talking to Alexis. Alexis is our care navigator. She and I are in constant communication. I’m shocked she hasn’t texted me during this podcast. But she will help with your whole experience making sure we get records. If in all of that, like when people call us, we, we take you in as part of our family.

Rory Bellina (21:54):
And I’d love to know more, more, a little bit more about your practice as well. Cause I’m, I’m thinking of it for personal reasons for one of my children, but, you know, typically who are the patients that, that come to see you? What are the issues that they come and they say, Dr. Hoyt, here’s what’s been going on and, and kind of what’s that, that patient population for you look like?

Dr. Alice Hoyt (22:10):
A lot of it is younger families who have children who are, are younger age who have food allergies. They’ve been told like, Oh, well there’s, there’s nothing really to do. You just have to avoid the food. Yet they go online and read reputable resources and find, oh, well what’s this thing called oral immunotherapy? And, and why can’t my child do that? And and that’s what I do. That’s what I specialize in. when I was at Cleveland Clinic, I helped build the Food Allergy Center of Excellence up there. And so this is what I do. it, it’s hard if, if you’re a board certified allergist who also does all these other very important disease processes to also do the type of food allergy management, this very detailed type of practice that I described mm-hmm. that I think is really important for a family to, to have the comprehensive experience and care that they need.

(23:01):
And so it’s a lot of younger families who, who want to do something about their child’s food allergy. We also have some kids who, who are about to go off to college and their families are, are kind of like, you know what we’re, we’re concerned. Cuz we, we do hear these, these stories. We work with a group in Ohio whose daughter passed away at College of Anaphylaxis. Mm-hmm. . and, and so it’s really families who are informed food allergy families are so informed. They’re informed. They know, they know there’s potentially a treatment out there for their child and they want to know more about it.

Rory Bellina (23:31):
Okay. And when, when these families come in, is it, it’s typically a sit down conversation and then, you know, or where do things go from there? From, from testing? Or can, can you kind of go into Yeah, absolutely. What happens after that or during that initial consult?

Dr. Alice Hoyt (23:44):
Yeah. So my initial consultation is actually two parts. And so when you call to schedule an appointment, Alexis gonna, is gonna schedule you for the first day and then a week or two later the, the follow up to it. the most important thing is I sit down and talk with you. I sit down and talk with you. Alexis is right there with me. She does helps a lot with documentation so that I’m not, I mean, who likes to be sitting there talking to their doctor and their doctors literally like typing it into a computer. I hate that. And so I don’t do that . I sit down and I talk to my patients. That’s also where I’m able to, to, to see their cues. And, and I can see when a mom is stressed about something and a dad is, or a dad is stressed about something and the dynamic that’s going on there, because all of that goes into how successful could oral immunotherapy be or what is really going on?

(24:31):
What is that anxiety level? Because then I’ll talk to Melissa about it. Melissa will pick up on that so that we can really help the family. But we do the initial discussion, What, what has happened with your child? What symptoms, how long after all, all of the clinical questions, I’ll do skin testing. if that hasn’t already been done, a lot of allergist are referring their patients to me. and so if, if we need to do skin testing, we’ll do that. If I need to order specialized blood testing, which many times I do, then we’ll order that at that visit. And that’s why they come back a couple weeks later so that we have, we have all of the information. Then when they come back to make a decision about what do I really think is going on, do we need to do an ingestion challenge? Meaning your, you and your kiddo will come back and we’ll do incrementally increasing amounts of the food to determine whether or not we think you’re allergic. depending on what your testing is and what your history shows. Or do we need to decide on the avoidance pathway or the oral immunotherapy pathway.

Rory Bellina (25:32):
Okay. I mean, No, I mean, that, that sounds great. I was, I was curious, you know, kind of where that, that trans transgression went. as far as your practice, I know we want to jump over into your non-profit and everything on, on that side as far as your practice goes. are you taking insurance? Are you private pay? Kind of, Cause I know our listeners, especially the local ones are gonna have questions about that. You know, how are you set up for

Dr. Alice Hoyt (25:56):
That? So we’re direct pay. Okay. We we will help families submit a what’s called a super bill, which is a horrible name. but we’ll provide itemized overview of, of services and fees. But ultimately I answer to my patients Sure. If I’m getting paid by an insurance company, and this is just my own personal approach to it, and not all physicians can, can practice this way, but I set up Weight Institute. So I’m gonna practice the way I feel that I, I am called to practice. I am gonna answer to the family. So it’s the family who at the end of the day is going to be writing the check to the

Rory Bellina (26:32):
Institute. Sure. And I think Con and I are are starting to see that I know we, one of our more recent podcasts, direct pay Proma care shifting to that model. And it seems it’s so exciting and impressive and, you know, as the, as the cost of insurance just continues to, to skyrocket, you know, just on your, your premiums and then your deductibles or even higher in copays. I mean, it, it’s really becoming a question of is it, is it absent a car accident or or traumatic type of surgery that we need? Do, do we really need these huge insurance policies or you know, I think a lot of people are opting to, to go this route.

Conrad Meyer (27:08):
Well, I think, I mean, look at the difference. I mean, how many times have, have we witnessed in, in our practice where we walked in and then the doctor’s got the kiosk there and he’s not even looking at you. Oh yeah. He’s, he’s just typing in directly Right.

Rory Bellina (27:22):
Directly into Epic as you’re talking. Cause he’s not gonna get paid for documentation. Yeah.

Conrad Meyer (27:26):
Right. So I mean, to, to be able to spend time with your patients, Dr. Hoyt and, and listen

Rory Bellina (27:31):
Absolutely

Conrad Meyer (27:32):
Worth it. I mean, I mean, I mean, I tell you this, you know, my, I give my my own family. My mother and my father went to M D V I P recently. and my mother was just like, I never knew healthcare was like this. I mean, I mean this tells you that, that when they sit down with their doctor, just like you’re doing Dr. Hoyt and spending the time with your patients and listening and talking, I mean, this is why you got into medicine. Mm-hmm.

Dr. Alice Hoyt (27:56):
. That’s exactly

Conrad Meyer (27:57):
Right. I mean, this is, this is why you did this. You know, so, Yeah. So I’m very happy to hear that. And, and so, you know, let me ask you this. I know you recently started mm-hmm. , how has been how has the reaction been? Tell me, tell me. I mean, I know when you, when you open your doors, it’s kinda like, okay, if we build it, will they come ? Right. Right. Have they come? Yes.

Dr. Alice Hoyt (28:17):
Yeah.

Conrad Meyer (28:17):
So let’s talk about that. Yeah. And

Rory Bellina (28:18):
I’d love to hear, like you mentioned exactly to segue on Conrad’s question. Right. Have they come and how do they, how have they reacted to this payment model? Cause it’s, it’s not new, but it’s somewhat,

Conrad Meyer (28:29):
But also the, the approach you’re doing because that’s different mm-hmm. , the approach you’re doing is different. The payment model is different. you’re, your marketing and everything you’re doing is different. Mm-hmm. . And so I’m curious now we’re, now we’re kind of getting into q you know, halfway the q1 Q2 2022. How’s it been?

Dr. Alice Hoyt (28:49):
It’s been great. we’re a lot of word of mouth from pediatricians and from aller, my allergy colleagues, which has been really awesome. and I ask Alexis that all the time cuz Alexis is the one that talks through the payment plans and all of that stuff with, with the families. so that I don’t have to be, be so directly a part of that. I think it just makes it more comfortable for

Conrad Meyer (29:12):
Everybody. So, but break it down for me. And so, so how do you, how are your pa first off, you’re getting patients obviously. Yes. I mean, you’re doing the doors open, people are coming in. Yes. And, and it’s expanding exponentially. Mm-hmm. . Well, how do the pa how do the patients feel both on the issue of your payment model and then on the multidisciplinary approach?

Dr. Alice Hoyt (29:32):
the, the latter is very easy to answer. They, they seem very happy. I’ll, I’ll ask them all the time. what do you think about Melissa? What do you think about Alexis? How is this going? They’re like, we, we love them. We love them. And Alexis has, has so much sort of like FaceTime with them regarding texting because they can, they can text her. They have a question about important. They just text her and they get their response. Wow.

Conrad Meyer (29:55):
Wow. That’s new in itself. You know? That’s right. how often do you get that? I don’t, unless they’re a client. I’m not getting my cell’s. They don’t respond if you, you know, unless

Dr. Alice Hoyt (30:06):
You’re, No. And so regarding the payment, I always, I always ask Alexis, you know, has there been any, any pushback? And it sounds like there, there hasn’t been much pushback. I mean, we’re staying pretty busy. we get paid and my patients seem happy and I always provide my information and nobody abuses it.

Conrad Meyer (30:25):
Right. Well, you set

Dr. Alice Hoyt (30:26):
This up, I probably call and bother them more than

Conrad Meyer (30:28):
. Well, what I’m saying is, you, you’ve set this up. I don’t mean to interrupt you, but you’re fine. But you, you, you set this up and basically you’ve created your own concierge practice without the need for any service, without the need for any kind of overlay from another company. You’ve done it boots on the ground grassroots and it’s working.

Dr. Alice Hoyt (30:51):
Yes. And you know exactly how boots on the ground. I’ve done it. Cause you helped me with, that’s with how many EMRs did we look at Conrad? We,

Conrad Meyer (30:59):
We looked at quite a few. And

Dr. Alice Hoyt (31:00):
Ultimately I did not go with any of them.

Conrad Meyer (31:02):
That’s exactly right.

Dr. Alice Hoyt (31:04):
but, but no, I mean, it, it’s been an amazing experience. We do. you know, I really have a commitment that any child that walks through our door that needs our help, we’re gonna help them. Right. So however we need to make that happen, we’re gonna make that happen. Interesting. there’s just, there’s so much we can do regarding food allergy well’s. It, it’s just time for

Conrad Meyer (31:24):
Us. Pivot to that. Do that. Yeah. Now, now let’s go to the advocacy part. So, Okay. Can you tell, can you tell the listeners a little bit about Dr. Hoyt, the advocate?

Dr. Alice Hoyt (31:32):
Yeah. So I’ve always been interested in helping schools help, helping kids who, who need extra help. I came from a family that I was very blessed to have an my amazing parents. they’re one of the reasons I moved back, you know? and just to always be told, get your education and just, I, I have been so blessed. And so I’ve always wanted to, to give back to others who have not had that. Right. especially children. Especially children. And even when I was here in med school, I was a Schweitzer fellow and I, I did my fellowship teaching and nutrition class to Langston Hughes K through three students. so it’s always been something, working with schools has always been a passion of mine. When I was in allergy fellowship, I recognized that schools are not prepared for medical emergencies.

(32:21):
And having done internal medicine in pediatrics, I ran way too many codes. And I knew just how effective having closed loop communication assigned roles when you’re responding to a medical emergency, how effective that is. But schools didn’t have a way to know any of that. Right. So we started code Anna Koana Equipped Schools to be prepared for medical emergencies like anaphylaxis. one of the biggest things we do is really, we really help schools obtain epinephrine auto injectors. know how to use them. That’s a big thing. You can have a tool if you know how to use it, then that’s no good. but then also the, the bigger underlying thing is help them develop and implement their own medical emergency response plan and team.

Rory Bellina (33:06):
So I’m gonna ask a question that I, I already know the answer to, but I, our listeners may not. So what, and and I’m sure this, this also might vary on a state by state basis, but what’s the current kind of procedure for a school if they want to have, And I, I, I’m thinking of my school in particular. the, the policy is if they’re gonna hold and potentially use the injector, you have to have a doctor’s note. You have to provide it. It can’t be expired only X, Y, and Z people can do it. That’s kind of it. But what is the, the general policy for school just wants to have them on hand for a kid that doesn’t know that they’re gonna have a reaction. Mm-hmm. kind of, what, what’s the, and and I’m sure that there’s, you know, there’s obviously liabilities involved with that, but kind of can you go through what’s the state right now for schools that, that want to have these injectors or that are considering it, but might not know what the policy is?

Dr. Alice Hoyt (33:57):
Absolutely. so what you’re describing is called stock epinephrine. Stock epinephrine is epinephrine typically in the form of an autoinjector that’s prescribed to an entity, whether it be a school, a business, it’s prescribed to that entity to be used during an anaphylactic emergency. Whether somebody has a known diagnosis and doesn’t have their autoinjector, or they’re one of the kids who has their first reaction at school, that is stock epinephrine. That is different regarding legislation and regulations than epinephrine that’s prescribed to a student. and so we can, we can talk about that later. Sure. Regarding stock epinephrine, there is the, the heterogeneity of stock epinephrine legislation in this country is amazing. 49 states have stock epi legislation. Hawaii does not. Meaning they do not have protection for a school or non-school entity to have their own epinephrine auto injector. And you, you made a very interesting comment. You, you commented on liability in so many times, schools that do not have stock epi they are concerned about liability. But I think when we do this podcast in 10 years, maybe even five years, it will be perceived as more of a liability to not have stock epi

Rory Bellina (35:14):
Enough. Right. I’m sure those, there’s liability on both sides of having it and injecting it wrong or injecting it to a child that wasn’t having a reaction or not having it and, and something terrible goes wrong. So I think, like you mentioned, there’s, there’s liability on both sides. But let’s take Louisiana for example mm-hmm. . Cause I think, I think most of our listeners are, are here. you know, what’s the, the policy for a school or a business business if school’s probably the best example, but school or business, if they, if they want to have this on hand, is it similar to kind of the process of an A E D where you just get it and you get a little bit of training and if you need to use it, use it? Or is it, is it totally different?

Dr. Alice Hoyt (35:52):
Every state is different. Here in Louisiana we have stock epi legislation for K through 12 schools. It is permitted, it is not mandated. When we look at the 49 states that have stock epi legislation, some of them, those 49 states mandate that schools have stock epinephrine. They do not always fund the mandate which can leave schools in lch or it’s written in the law that it’s mandated pending there is funding and that if there’s not funding, then it is permitted, but not

Rory Bellina (36:19):
Required. Meaning the cost of the actual drug training, the auto objective, all of that. Right. Okay.

Dr. Alice Hoyt (36:24):
All of that. Right. Okay. Typically in the legislation, it is written how somebody becomes trained and permitted to use the device. And in all of the legislation that I have seen, anyone who is trained as described by however the legislation describes it, if they are trained and they recognize somebody or they suspect somebody in good faith is having an allergic reaction, then they are dignified against. Okay.

Rory Bellina (36:49):
Yes. So like a good Samaritan provision.

Conrad Meyer (36:51):
But here’s the sad thing, some states don’t have that.

Rory Bellina (36:54):
So there’s obviously hesitancy to use it in those states. If

Dr. Alice Hoyt (36:58):
49 states have stock epi legislation permitting the acquisition and use of stock epi in schools. Okay. Some of them are mandated, meaning they have to have it. Sure. Some school, some states they don’t have to have it. It’s permitted. But that is just K12

Conrad Meyer (37:12):
Schools is there. Now let me ask you this. Maybe I’m wrong on this, but, but, but, but are there good Samaritan laws directly attributable to stock epi use in the 49 states?

Dr. Alice Hoyt (37:24):
That would be, yes. That would be within the actual stock EPI legislation is where you find that

Conrad Meyer (37:29):
Signification language. So, so they do have that. So, so there is, And so in 49, Okay, well I did not know that. I thought, I thought there was states that might not have it. So, so even if so, all for United States that have it also have the identification. So there’s really, so there’s really no reason why schools shouldn’t take advantage of this.

Dr. Alice Hoyt (37:47):
True.

Conrad Meyer (37:48):
Right. Well, okay.

Rory Bellina (37:49):
Interesting. Well, it comes down to a cost factor. Cost factor, obviously cost. Do they wanna have,

Conrad Meyer (37:54):
How much is a stock he be pen? I don’t even know.

Dr. Alice Hoyt (37:57):
depending on the device that you are procuring. I know for a fact that a vq is available for $246 and 99 cents through one of their distribution companies.

Conrad Meyer (38:08):
Okay. I mean that’s, I mean, I think, I mean, if, if I’m a parent,

Rory Bellina (38:11):
Right, You want your school to have it, I

Conrad Meyer (38:13):
Want my school to have it just like I want the aed just like a Correct. I want them to have the tools Right. To be able to respond, not just for my child, but for any child. I mean, I think all of us sitting here in the studio would be devastated. Sure. If you’re, you know, one of your class, one of your child’s classmates didn’t have something available

Rory Bellina (38:30):
That was $200.

Conrad Meyer (38:32):
That was $200. Right. Now, some people, that’s a lot of money. Well, I mean, you know what, when you think about it, you know, is it, is it worth that over some child having some severe injury or death?

Dr. Alice Hoyt (38:43):
I was speaking with a state trooper with a safe schools program the other day, and we were, they, they focus on the intruder alert part of it. And that, that aspect of safety and having medical emergency res or having emergency response protocols. But we both agree the least likely thing to occur in a school when you’re comparing intruder, tornado hurricane and emergency and fire, there hasn’t been a fire in a school for decades. Decades. Is it still very important We have fire drills? Absolutely. Is it important to have fire extinguishers? Yes, of course. But how many times is somebody having sudden cardiac arrest on a school campus? Right. Whether it’s a student or somebody coming in for grandparents’ day or an athlete at a tournament. and how many of these kids have, or kids, not just any child have a food allergy or they’re one of the younger kids who hasn’t had their initial reaction yet, and so they don’t even know they have a food allergy. They have a reaction. They don’t have a, a device at school. And that’s why as this legislation continues to, to take through the country, I do think that five, 10 years from now, it’s going to be looked at as a liability to not embrace this type of preparedness.

Conrad Meyer (40:01):
So let’s talk about that five or 10 years from now. Okay. Code Anna, you mentioned that that program mm-hmm. and, and you know, we’re both very familiar with that. Yes. so where, what kind of market penetration right now does Koana have in the United States? Where, where is Koana now involved?

Dr. Alice Hoyt (40:20):
We’re across the country. We have education specifically for early learning centers, and we’re doing a new train the trainer model where we’re actually teaching childcare health consultants, how they can teach about food allergy in their early learning centers, daycare’s, preschools. And that’s across the country. We have a very strong presence in New York, especially New York City where our early childhood education for AFL access stock, stock epinephrine in particular, is very popular. And then also in the state of Ohio where I just came from, we work very closely with the Allison Rose Foundation. the young lady that I mentioned passed away at college. Her parents started the Allison Rose Foundation in her memory. And we have a course going live across the state next month that is me accessible for school staff to take, They get continuing education credit for, it is no cost to them.

Conrad Meyer (41:10):
So how many, how many I know we, we, we’ve gotten approved in other states too, meaning code Anna. So how many states has koana been approved as an official training program?

Dr. Alice Hoyt (41:19):
So what you’re talking about is our stock epinephrine legis, or our stock epinephrine program being approved. states are tremendously different whether they even have an approval process. Right. So as we’re going state by state, we’ve been very successful in, in the ones we’ve applied in, which so far is 12. many of the, oh, and I think 13, we just got through to another one. because all the legislation’s very different regarding how does training occur?

Rory Bellina (41:45):
And

Conrad Meyer (41:45):
Is this I’m sorry. I’m sorry we’re talking. I’m sorry, Rory. So, because I like this, this is very, I mean, very excited about this. I’m very passionate about it. So in five years, five years, you just said 13 states, where do you predict code Anna will be in five years

Dr. Alice Hoyt (42:00):
In, in all the states? You,

Conrad Meyer (42:01):
So the goal is for you five years

Dr. Alice Hoyt (42:03):
States? Oh, no, we’re actively working on it right now. And how we, we wrote the paper, the heterogeneity of stock EPI legislation that was published in Jackie in practice, first author Matt Oxford. My mentee in Pennsylvania was because we were applying to get our EPI program approved. It’s, and, and the states don’t always know, know how to do it. Right. But we found all that out because we’re literally going state by state finding is a Department of public health, this department of education and, and all.

Conrad Meyer (42:33):
But it’s not just that though. I’m sorry. It’s not just that. It’s What about the response, the, the response plan isn’t, do y’all just do, How does that fit in? I mean, the emergency response plan, I know you told me in the past mm-hmm. about that. What is it, How does KOANA help? So

Dr. Alice Hoyt (42:47):
You’re talking about our Medi Ready program, Right. Medi Ready is a logistics program that teaches, and it can be done online. It’s free of charge, go to cody.org. It teaches schools how they can develop and implement their own medical emergency response plan, including a team for their school. They build upon their intruder alert, their fire drill, They build upon the protocols they already have in place, make a few adaptations using their crisis response team that most schools already have. And they practice having a medical emergency so that when, not if, when a medical emergency happens, they have a core group of adults responding quite promptly to that emergency with the tools they need. And they know how to use those tools.

Rory Bellina (43:31):
So if a school or a, a private business, maybe we’ll get outta the public sector for a second, but if a school or a private business is interested in having stock ey, like you mentioned, is that something that they could reach out to your non-profit to find out about how to order it, how to get trained on it, how to kind of make themselves available to the, the protections and the, and the, the Good Samaritan or the indemnification things? Is that something that they could reach out to you to navigate?

Dr. Alice Hoyt (43:57):
Yes, absolutely. And I’ll point out that not all states have stock epi legislation for, we call non-school entities. Meaning for, for businesses, for universities, for early learning centers. So here in Louisiana, we’re actually working on some legislation to have that type of indemnification legislation so that any entity, especially our early learning centers, can have stock up if they want it.

Conrad Meyer (44:22):
Interesting. I mean, I’ve watched this grow over the years. This is really, I I gotta say conna. And, and what you’re doing is monumental for, I mean, I can’t even tell you how many families you probably touched. You never know. I mean, if it helps prevent one death mm-hmm. or one severe injury mm-hmm. , you’ve succeeded.

Dr. Alice Hoyt (44:45):
Yeah. It’s nice to get the emails from the school nurses, from the school principals saying, We, we did a drill, or we had an actual emergency and we got to the child in 52 seconds. or the emails about a, a Cody and a trainee use stock epinephrine on a child, and the child’s doing great. Like, it, it’s incredibly rewarding. But it, to your point, it’s, it’s incredibly important work. And it needs to be, it needs to be in all schools.

Rory Bellina (45:11):
So your nonprofit is able to go in, I think you mentioned before we started recording to go into a school and, and kind of sit down with the faculty, or if they have a nurse or whoever it may be, sit down with them and kind of say, Here are the signs and symptoms and here’s how to administer, Here’s what you need to do after administration. Kind of everything from me to

Dr. Alice Hoyt (45:31):
Absolutely. We, we first start with an assessment to really understand where the school’s starting point is. And from there we work with the schools to identify their goals and then provide education and guidance on how to achieve their goals regarding medical emergency

Conrad Meyer (45:43):
Preparedness. But it’s not just schools, though. You said businesses too.

Dr. Alice Hoyt (45:46):
So we haven’t done medi ready for businesses, but if, if businesses want stock epinephrine, if businesses have questions about AEDs for sudden cardiac arrest, those are things we absolutely

Conrad Meyer (45:57):
Cannot do you know where I see this Rory Airline in the plane? I mean, how many stewardists or stewards would, you know, know how to respond to an anaphylaxis situation?

Dr. Alice Hoyt (46:09):
It’s a very interesting discussion. We, we should dive down that rabbit hole.

Conrad Meyer (46:15):
Aed AEDs is one thing. Cause I mean, you know, the AEDs, you know, you put the, put the paddle here, you put it here, and you press the button. Right? So, but I mean, imagine all the peanuts and crackers and all whatever that are served on planes. I mean, I can’t imagine, you know, that that would be an interesting situation. I would think.

Rory Bellina (46:34):
So Dr. Hoyt, where do you see the biggest need is for, That’s a great question. More of the, the stock epi, Is it, is it schools? Is that where you kind of, is that like the big, the big fish that you want to kind of encapsulate to get your dream goal is to have every school across the, the country, I’m sure have this stock? Is that, is that kind of what The

Dr. Alice Hoyt (46:50):
Schools and early learning centers. Okay. Okay. Because that is where students might not have their own devices. that is where students might not yet have manifested their disease process yet. And it, it’s not just having the actual device there. That is incredibly important in teaching people how to use it, but it’s also the secondary benefits that our society as a whole really gains from sort of demystifying food allergy and, and having everybody on the same page that yes, food allergy is real. Yes, food allergy is life threatening, and yes, epinephrine is the way you treat it.

Conrad Meyer (47:28):
Interesting. Interesting. Well, I think, I think we could go on and on on code, Anna, We could go on and about food allergies. but I, I, I want to think, I think it’s time that we try to wrap this up because I think I want to continue to have you on for more episodes. I mean, I think Oh, thank you. I think we’re gonna have to, you know, do like a part series. Right. Because I, I honestly think that this is a real thing. I, I, she, you know, Dr. Ho has corrected me over the years, I’ve, I’ve watched this happen, and where before I was sort of, Oh, is this just a, you know, helicopter parents and all this? And Oh, come on. I mean, I peanut butter and jelly as a kid, I mean, I had all over my face, nothing would happen. Right. But no, I mean, now I genuinely recognize it. I see it in other parents, I see it in kids. So I gotta tell you Dr. Ho, I mean, both private practice, family, and advocate on a nonprofit. You got, you got yourself pretty busy there.

Dr. Alice Hoyt (48:26):
I, yes. True statement.

Rory Bellina (48:29):
So if someone, and, and to, to kind of wrap this up, if someone wants to contact you for personal reasons, you know, for their child, like you mentioned within their clinic, or if they’re involved with a school or a business that wants more information about your the stock epi program, what’s the best way for them to reach you? So

Dr. Alice Hoyt (48:46):
They can go to hoit allergy.com and that’s gonna go to my practice. The number on there is the number you call, and you’re gonna get Alexis, she’s gonna answer the phone. and then if you want more information about our advocacy code, anna.org, c o d e a n a one a, like anaphylaxis.org.

Conrad Meyer (49:02):
Well, great. Well, I wanna thank you, Dr. Hort, for coming in the studio today. Oh, this has been fantastic. And very educational very educational show today. And we wanna thank you again. So we hope Thank you. We want you to come back. So

Dr. Alice Hoyt (49:15):
Thank you. I should have y’all on my podcast, Food allergy and your kiddo.

Conrad Meyer (49:18):
There we go. We should, we should do that. We’re gonna go, we’re gonna go to Dr. Hoyt’s podcast.

Rory Bellina (49:22):
Well, we don’t have to. Let’s not wrap. Let’s jump 30 more seconds. Tell us about your podcast. Yeah, that’s, I’d love to hear that. Yeah, tell us what’s, what is the podcast about? I’d love hear

Dr. Alice Hoyt (49:30):
More. So it’s called Food Allergy and Your Kiddo, and it’s all about food allergy and children. Okay. And I, I started it when I was on maternity leave. I think Adelaide was eight weeks old when I started the podcast. Wow. I just, I love what I do. I love, I love the knowledge that I’ve acquired and continue to acquire, and I just wanna share it with everybody. And I know that in my, in my small clinic, I, I can’t, I can’t share it with the world, but I, I mean, I get emails from Tennessee, Georgia, Ohio, like all these places. Sure. So if you want evidence based practice, proven information about food allergy, food allergy in your kiddo.com,

Conrad Meyer (50:03):
So that’s great. So we, so I mean, podcaster advocate, non-profit, private practice, and mom mean everything mean. I mean, can you, can you,

Rory Bellina (50:12):
Can you, what are you doing in your free time? Right?

Conrad Meyer (50:14):
What free time is that? What, what? Free time.

Dr. Alice Hoyt (50:17):
I eat fancy king cakes.

Conrad Meyer (50:18):
No, that’s good. There we go. Well Dr. Hoyt, thank you very much for coming in. Again, everyone, if you want to contact Dr. Hoyt, you’ve, you’ve got the contact information for not only her private practice for the Advocate Group, and now you know the name of the podcast. So stick around for another episode of Health Lot Talk. This has been really fun. Dr. Hoy. Thank you very, very much. Thank you. And and thank you all you listeners. Again, if you wanna drop us a line send us an email, talk to us about episodes that you wanna see or hear, please do so. and again, thank you for listening to Health Law Talk.

Dr. Alice Hoyt (50:52):
Thanks for listening to this episode of Health Law Talk, presented by Chehardy Sherman Williams. Please be sure to Subscribe to our channel. Make sure to give us that five star rating and share with your friends, Chehardy Sherman Williams is providing this podcast as a public service. This podcast is for educational purposes only. This podcast does not constitute legal advice, nor does this podcast establish an attorney client relationship. Reference to any specific product or entity does not count as an endorsement or recommendation by Chehardy Sherman Williams. The views expressed by guests on the show are their own, and their appearance does not imply an endorsement of them or their entity that they represent. Remember, please consult an attorney for your specific legal issues.

Dr. Alice Hoyt is a board-certified internal medicine, pediatric, and allergy & immunology physician in the Greater New Orleans area.  Her practice, Hoyt Institute of Food Allergy, is located in Metairie, Louisiana, and focuses on an evidence-based family approach to addressing the needs of children and adults dealing with food allergies.   Previously practicing at the Cleveland Clinic, Dr. Hoyt has now returned to her hometown to open up her new practice by bringing a multidisciplinary approach to her patients and their families dealing with food allergies.   In addition to her practice, Dr. Hoyt created a nonprofit organization, the Teal schoolhouse, that produces and disseminates a program called Code Ana to assist schools and businesses in educating/training their personnel on the identification of anaphylaxis, the emergency response to anaphylaxis and the use of autoinjector epi-pens to deal with allergic reactions.  Currently, the Code Ana program is already involved with multiple states providing this educational material to help schools and businesses alike. We sit down with Dr. Hoyt to get her perspective on her new practice, discuss with her about the need for food allergy medical services for families and individuals, and chat about her nonprofit organization, the Teal schoolhouse and its Code Ana program.  

Health Law Talk, presented by Chehardy Sherman Williams, one of the largest full service law firms in the Greater New Orleans area, is a regular podcast focusing on the expansive area of healthcare law. Attorneys Rory Bellina, Conrad Meyer and George Mueller will address various legal issues and current events surrounding healthcare topics. The attorneys are here to answer your legal questions, create a discussion on various healthcare topics, as well as bring in subject matter experts and guests to join the conversation.

We handle everything from regulatory and compliance check-ups to employment matters, Medicare and Medicaid issues to state and federal fraud and abuse regulations. Our healthcare attorneys are always staying up to date on the latest state and federal regulations to ensure that our knowledge is always accurate.

Our team has the expertise to assist you with compliance matters, HIPAA violations, payor contracts and employee negotiations, practice and entity formation, and insurance reimbursement issues, in addition to the full spectrum of other healthcare related issues.

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