MDAdvisor Summer 2012

Alan J. Lippman, MD, David Gallinson, DO, and Denise Johnstone

CLINICAL PRACTICE ISSUES IN ONCOLOGY

Donald M. Chervenak, MD

THE IMPACT OF HEALTHCARE REFORM IN THE OB/GYN COMMUNITY

SIGNIFICANT & IMMEDIATE INFLUENCES ON PEDIATRIC PRIMARY CARE

Steven Kairys, MD, Richard Lander, MD, et al.

NJ ACADEMY OF FAMILY PHYSICIANS RESPONDS TO THE CHALLENGES OF HEALTHCARE REFORM

NJAFP Executive Committee, Ray Saputelli, MBA, CAE, et al.

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VOLUME 5 • ISSUE 3 • SUMMER 2012

Medical Professionals…

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MDAdvisor is published by MDAdvantage Insurance Company of New Jersey.

…on healthcare reform and the future of medicine

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MDADVISOR

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MDADVISOR A Journal for the New Jersey Medical Community

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! n o i t a s r e v n o C

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PUBLISHED BY MDADVANTAGE INSURANCE COMPANY OF NEW JERSEY Two Princess Road, Suite Two, Lawrenceville, NJ 08648 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE. Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company of New Jersey and any affiliated companies (all as “MDAdvantage™”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage™, their directors, officers or employees or institutions affiliated with the authors.

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MDADVISOR | SUMMER 2012

Spoeaukt!

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LETTER FROM MDADVANTAGE™ CHAIRMAN & CEO PATRICIA A. COSTANTE

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CLINICAL PRACTICE ISSUES IN ONCOLOGY IMPACTED BY HEALTHCARE REFORM | By Alan J. Lippman, MD, David Gallinson, DO, and Denise Johnstone

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THE IMPACT OF HEALTHCARE REFORM IN THE OB/GYN COMMUNITY | By Donald M. Chervenak, MD

HEAR THE VOICE OF NEW JERSEY PHYSICIANS: AN OPEN LETTER TO OUR STATE AND FEDERAL LEGISLATORS, REGULATORS AND KEY HEALTH POLICY LEADERS | By Patricia A. Costante, Chairman & CEO of MDAdvantage™

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THE UNION COUNTY MEDICAL SOCIETY RESPONSE TO HEALTHCARE REFORM | By Jay E. Bowen, DO

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THE IMPACT OF HEALTHCARE REFORM ON THE PROFESSION OF MEDICINE IN ATLANTIC COUNTY | By Zubair Syed, DO

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NEW JERSEY ACADEMY OF FAMILY PHYSICIANS RESPONDS TO THE CHALLENGES OF HEALTHCARE REFORM | By Robert Eidus, MD, on behalf of the NJAFP Executive Committee, Ray Saputelli, MBA, CAE, and Theresa J. Barrett, MS, CMP, CAE

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STUDENT VOICES | By Oren Johnson, MD, Ivan Georgiev, Arveny Negron and Neil Kaushal, MD

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THE DERMATOLOGIC SOCIETY OF NEW JERSEY REFLECTS ON HEALTHCARE REFORM | By Robert M. Paull, MD

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A VIEWPOINT FROM THE MONMOUTH COUNTY MEDICAL SOCIETY | By Alan Zaccaria, MD

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HEAR THEIR VOICES: OR WE ALL WILL BEAR THE CONSEQUENCES | By Michael J. Schoppmann, Esq.

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NEW JERSEY ORTHOPAEDIC SOCIETY CALLS “HEALTHCARE REFORM” A MISNOMER | By Wayne Colizza, MD

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SIGNIFICANT & IMMEDIATE INFLUENCES ON PEDIATRIC PRIMARY CARE | By Steven Kairys, MD, Richard Lander, MD, Larry Frenkel, MD, Meg Fisher, MD, Stephen Rice, MD, Michael Weinstein and Fran Gallagher, MEd

MDADVISOR

SUMMER 2012 – CONTENTS

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: s n of sicia e c hy i o V ey P e h ers t r HeaNew J An Open Letter to Our

By Patricia A. Costante, Chairman & CEO of MDAdvantage™

State and Federal Legislators, Regulators and Key Health Policy Leaders

As Chairman and CEO of MDAdvantage Insurance Company of New Jersey, a leading provider of medical professional liability insurance in New Jersey, I have the opportunity to speak with physicians regularly. Over the past year, every time I speak with physicians, I get bombarded with feelings of escalating frustration, loss of control and loss of status. I even hear from physicians who are unsure whether they want to or are able to continue to run their practices. And that makes me concerned.

While change is a constant in medicine, it seems like there has never before been a time when so many changes were impacting physicians all at once. Managing a career and a successful practice seems to only grow more challenging for physicians, who are extremely busy on a daily basis caring for their patients and managing their practices, all the while facing unprecedented administrative and regulatory challenges. The myriad challenges are putting pressure on physicians from every angle. So much so that physicians in small practices don’t see a long-term solution for continuing to function in their current structure, and many are considering selling to hospitals or giving up their practices.

In the past, a physician was able to function in a small practice with a receptionist, one to two nurses, a few

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administrative staff and minimal equipment. Now, with all of the administrative and technology requirements placed on physicians, this practice structure is no longer feasible. Physicians need to invest in electronic health record systems and add sophisticated equipment to their offices, which has added greatly to overhead costs. They must also comply with dozens of new regulations and manage the increasingly complex billing process with multiple payers. And all the while, physicians continue to look down the barrel of Medicare cuts.

What will all of this mean for our future physician workforce? More often than not, physicians indicate that they do not recommend their sons and daughters follow in their footsteps to a medical career. We are already experiencing a physician shortage in New Jersey, particularly in primary care. There simply does not appear to be enough money to sustain primary care doctors in New Jersey, and students are not selecting primary care as a specialty because of the economics.

We already have a documented shortage of physicians, particularly primary care physicians. We also know that medical students, upon completing their residencies, are leaving New Jersey to find friendlier states to start their practices. And yet no clear recruitment or retention programs are currently in place.

This special Summer issue of MDAdvisor was developed to give the leading physician organizations and physician leaders in New Jersey a collective voice. The authors of the articles in this issue were all asked to comment on the same questions, all of which were thoughtfully selected to give our legislators much-needed insight into the challenges physicians are currently facing. We received responses from organized medicine and healthcare leaders in a diverse range of specialties, geographic regions and practice sizes and types. The topics of discussion included the following:

How are your member practices affected by the increase in patients’ out-of-pocket expenses for in-network and out-of-network medical care?

How is healthcare reform affecting the way your members are practicing medicine now, and how will it affect the way they practice medicine in the next two years?

What are your members’ strategy and your organization’s goals for helping physicians maintain autonomy as the business of medicine evolves?

What is the actionable message that you and/or your organization would want to convey to the Governor of New Jersey, our state and federal healthcare regulators and the Centers for Medicaid & Medicare Services (CMS)?

What advice does your organization have for students in medical school?

Physicians need to be included in the conversations that healthcare policy advisors and legislators are currently engaged in, and their voices need to be heard. I am committed to doing everything I can to assist in moving those efforts forward. After all, as a resident of New Jersey, I have a large stake in making sure that the quality of care provided to New Jersey residents continues to be the quality that we have all come to expect.

I view this issue of MDAdvisor not as a one-time initiative but as the first step in opening up

an ongoing dialogue between physicians and those who make the decisions that have a significant impact on the way physicians practice medicine and manage their practices.

I look forward to hearing from even more physicians, legislators, regulators and healthcare leaders on these topics.

Please send your responses to Editor@MDAdvisorNJ.com.

Let’s continue the conversation!

Patricia Costante is the Chairman and CEO of MDAdvantage Insurance Company of New Jersey in Lawrenceville, New Jersey.

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Oncology Clinical Practice Issues in

Impacted by Healthcare Reform

By Alan J. Lippman, MD, David Gallinson, DO, and Denise Johnstone

When discussing the impact of healthcare reform on clinical practice in oncology, an issue that cannot be ignored is the increase in patients’ out-of-pocket expenses for in-network and out-of-network medical care. Several problems in the delivery of oncology care are related to the effect of the following increased expenses: 1. Impaired adherence to diagnostic and surveillance testing and to treatment regimens (particularly orally administered agents) in cases where patients are unable to afford high copayments.

2. Increased work burden imposed on office staff who are required to address insurance coverage and reimbursement issues with patients.

3. The need to transfer the treatment site from the office setting to the hospital’s outpatient facility in cases where patients are uninsured or underinsured–and unable to meet copayment requirements.

4. The switch by many employers to high-deductible health insurance plans that have large, out-of-pocket expenses, representing a significant increased burden for patients and families.

5. The pharmaceutical industry’s “indigent patient” programs, intended to help pick up some of the costs, which, when available, are frequently limited in scope and duration.

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Increased expenses in medical care have an especially significant impact in the field of oncology. In a recent study, cancer patients were found to have a disproportionately high burden of out-of-pocket expenses, compared with those having other chronic illnesses. The authors suggested that such high burdens may affect treatment choice and deter patients from getting care.1 A survey of 216 patients receiving treatment for cancer, conducted by the Duke Cancer Institute in 2011, revealed that despite having insurance coverage, participants were still paying more than $700 a month for their cancer care. Among these participants, 26 percent did not fill medication prescriptions because of cost, and 22 percent filled only part of a prescription, suggesting they had taken less than the prescribed amount. The authors suggest that policymakers recognize the financial burdens assumed by patients and the potentially adverse impact these burdens may have on quality of care.2 THE IMPACT OF HEALTHCARE REFORM ON THE PRACTICE OF ONCOLOGY Healthcare reform has impacted the way many oncologists practice medicine. It has particularly affected solo practitioners and small group practices, many of which have joined larger and perhaps more well-established

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oncology groups, hospitals or practice management organizations. Some older physicians have chosen to retire. Some larger groups have been compelled to cut employees, bonuses and/or benefits to remain economically viable. Some physicians have taken salary cuts in order to meet payroll requirements. Some practices experiencing financial challenges have opened lines of credit to facilitate payment for large drug bills.

Traditionally, community oncologists have taken pride in running efficient infusion centers where there is direct control over staffing and operational procedures and where provision of care can be carried out in a personalized setting.

Now, more patients are being referred to hospital infusion centers, often located at some distance from oncologists’ offices, with the potential to disrupt continuity of care.

Additionally, the Community Oncology Alliance (COA), a nonprofit advocacy organization dedicated to communitybased oncology practice, maintains that current healthcare reform legislation fails to address what it regards as inadequacies in Medicare reimbursement. This oversight threatens the economic security of community practices and further

encourages the establishment of hospital-based systems.

Paradoxically, as shown in an analysis conducted by Avalere Health, under COA auspices, treatment for patients receiving chemotherapy in a hospital outpatient department was found to cost on average 24 percent more than treatment 3 received in a physician’s office.

Because of factors such as these, the future does not look brighter. Private practices are contemplating what may be potentially adverse impacts represented by competition with hospital-based practices and the establishment of accountable care organizations and medical homes.

Additionally, the cost of doing business has increased, due to the adoption of electronic health records and the need to adhere to prior authorization guidelines for diagnostic and therapeutic activities.

A PATH TO POSSIBLE SOLUTIONS Future practice management strategies will continue to emphasize a multidisciplinary approach to oncology care, but will more and more often revolve around integrated healthcare systems and collaboration with hospitals, with the

A Strategy to Address Growing Copay Burdens

C$

ertainly, the financial impact of a cancer diagnosis can be devastating, and the resulting economic burdens can adversely affect medical outcomes. Thus, a strategy to address this burden is absolutely necessary. Collaboration between oncology practices and payers represents what appears to be an effective strategy to achieve cost savings while promoting improvements in patient care.

One West Coast oncology practice’s experience illustrates what may well be an effective strategy to overcome such burdens. In California, the Wilshire Oncology Medical Group, an affiliate of the US Oncology/McKesson Specialty Health Network, has developed a medical oncology home pilot program in cooperation with one of the large California health plans. This collaboration has enabled the practice to deliver comprehensive

cancer care to their patients while creating significant savings for those patients facing growing copay burdens.

Details about this pilot program can be found in the May 2012 supplement to Journal of Oncology Practice in the article “Partnering With a Payer to Develop a Value-Based Medical Home Pilot” by L. D. Bosserman and colleagues.

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goals of restraining costs and streamlining efficiencies.

Success will be measured and driven by data the practice can provide. Standardizing treatment plans and adhering to evidence-based clinical decision-making will be essential.

The Oncology Society of New Jersey (OSNJ) provides an environment for the exchange of ideas and mutual support.

Thought leaders are invited to present ideas and strategies at regularly scheduled meetings. OSNJ leaders are visible and remain accessible to members and fellow physicians to provide support and mutual assistance in helping all parties play an active role in shaping the future of healthcare delivery.

The American Society of Clinical Oncology, with more than 30,000 members, is the world’s leading professional organization representing physicians who care for cancer patients.

Among others, the organization has made the following 4 recommendations regarding new healthcare legislation : 1. Advocate for policies that ensure access to cancer care for the underserved, including insurance reform and the reduction of economic barriers to quality healthcare.

2. Require insurers to cover appropriate follow-up testing without patient deductibles or copays, to enhance prevention and screening efforts.

3. Develop quality of care measures, standards to improve care and methodologies to reduce disparities in care.

GOING FORWARD Our American society has always valued independent thinking and encouraged the development of innovative methodologies. As healthcare reform evolves, strategies to assure continued vigorous research and development must be encouraged, and ways to promote translational research and to permit appropriate adoption of new and improved treatments should be considered essential.

Progress will necessitate more effective collaboration between and among all healthcare sectors, including the pharmaceutical industry, regulatory bodies and the public. (An example, arguably, would be the need for effective collaboration to address the challenges posed by the phenomenon of so-called drug shortages that have recently caused consternation in the medical profession and among affected patients.)

At the same time, attention must be given to the challenges facing those embarking on a medical career.

Foremost, arguably, is the financial challenge represented

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by skyrocketing costs of college and post-graduate education. Although some have called for shortening the period of commitment to formal studies, the need for extended post-graduate training for those pursuing specialty or subspecialty practices will remain.

Some loss of traditional autonomy is inevitable in a field in which the model of solo practice is being superseded by one of group practice or employment by larger healthcare entities, such as hospitals, medical centers and multispecialty clinics. This should not, however, be a deterrent to those with a commitment to a medical profession undergoing change but nevertheless adhering to long-standing and well-established principles underlying the physician-patient relationship.

Issues of healthcare reform aside, going forward, medical students should be encouraged to recognize that service in the medical profession remains satisfying and fulfilling. Emphasis ought to be placed on an appreciation of the importance of caring for patients and on the recognition of the physicians’ role in promoting public health and prevention strategies.

Alan J. Lippman, MD, is Past President of the Oncology Society of New Jersey; David Gallinson, DO, is President of the Oncology Society of New Jersey; and Denise Johnstone is Executive Director of Essex Oncology of North Jersey, PC. 1

Bernard, D. S., Farr, S. L., & Fang, Z. (2011). National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008. Journal of Clinical Oncology, 29(20), 2821–2826.

2

Zafar, Y., & Abernethy, A. P. (2011, August 15). A need for health care reform: Cancer care costs and the patient.

Kaiser Health News. www.kaiserhealthnews.org/stories/ 2011/august/15/different-takes-zafar-abernethy.aspx

3

Avalere Health. (2012, March). Total cost of cancer care by site of service: Physician office vs outpatient hospital. www.avalerehealth.net/news/2012-04-03_COA/Cost_of_ Care.pdf

4

Moy, B., Polite, B. N., Halpern, M. T., Stranne, S. K., Winer, E. D., Wollins, D. S., & Newman, L. A. (2011). American Society of Clinical Oncology policy statement: Opportunities in the Patient Protection and Affordable Care Act to reduce cancer care disparities. Journal of Clinical Oncology, 29(28), 3816–3824.

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Recently, due to the availability of new technologies and advanced treatments, healthcare costs have exploded. Even when patients have excellent healthcare coverage, they are burdened with huge deductibles.

Many times these deductibles are hidden costs, and so the patient who works daily for good healthcare benefits is still unable to pay bills.

This economic situation highlights the clinical practice issues impacted by healthcare reform.

CHALLENGES FOR PATIENTS AND PHYSICIANS Healthcare reform is drastically transforming patients’ perception of care and the way that physicians can render that care.

Smaller practices certainly have been impacted by the reform movement. Physicians in these practices are seeing fewer patients, thus strangulating cash flow. This then leads to difficulty in making payments and payroll and in meeting new national standards of quality. In many cases, smaller practices cannot meet federal goals without integration into larger groups or hospitals or through lateral integration.

Large practices, too, have felt the impact. They often cope with the problems brought on by the changing healthcare environment through depersonalization of the billing system. Although legal, this strategy suffers from a lack of heart and does not work in the best interest of the consumer. Frequently, laws designed to champion the consumer actually take away the ability to help

THE

By Donald M. Chervenak, MD, FACOG

IMPACT

OF HEALTHCARE REFORM IN THE OB/GYN COMMUNITY

that same consumer as a patient. To compensate, larger practices will become even larger and will integrate with each other to have stronger bargaining potential.

While this integration helps physicians deal with the impact of healthcare reform, we must remember that this whole integration mechanism is a corporate model with the main goal of profit. Any one political party, hospital or health corporation analyzes healthcare from a perspective that helps meet political and/or economic goals. The real driving principle, however, should be appropriate standards set by our leading subspecialty societies, always keeping in mind what is best for the patient. This would provide safety, both legal and economic, for the physician meeting these standards.

The net effect of integration is regimentation of healthcare, with little wiggle room to help the patient. Physicians in-network must see several patients per hour to maintain economic solvency. If the physician is forced to render lessthan-optimal care and at the same time is not compensated by the insurance (for the large deductibles that patients are

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“

Physician requirements and patient goals are set by boards that have little direct input from rank-and-file physicians.

unable to pay), why not work outside the system? This reasoning forces many physicians to drop out of network. By doing this, the physician renders better care and is better compensated. At the same time, the consumer who pays large premiums and then finds that needed healthcare and medication are not covered drops out of network as well.

Adding to this problem of discombobulated, over-managed care is the fact that federal guidelines are frequently contradictory. Physician requirements and patient goals are set by boards that have little direct input from rank-and-file physicians. New courses, exams, work guidelines and office mandates are often idealistic. Trying to meet these goals without feedback or tort reform makes the patient a cog in a continuously moving machine. At the same time, the physician becomes an apologist for implementing the rules.

THE FUTURE OF MEDICINE When considering what a career in medicine will look like in 2020, we must define what comprises a physician.

In the past, the entity of a physician’s practice was that of a solo practitioner or of a group of practitioners applying their skills in a community. Tomorrow the climate will be radically different. The new physician frequently expects fixed working hours, good coverage and a compensatory stable salary. The concept of a physician being constantly “on call” will become maudlin or regulated out of existence.

In the future, we can expect increasing work hour mandates, increasing requirements for documentation and a shrinking scope of practice with increasing requirements.

Additionally, there are proposed decreases to graduate medical education and decreased payments pending from insurers and the federal government. With these changes ahead, we can expect that new and veteran practicing physicians will be in exactly the same boat sooner or later, whether they choose solo, small or large practice models.

ADVICE FOR MOVING FORWARD THROUGH HEALTHCARE REFORM The goal of the New Jersey Obstetrical and Gynecological Society and the Medical Society of New Jersey is to reinforce the public’s understanding that their physicians are well trained and demonstrate excellence. Our societies, while encompassing excellence, try to enable the physician

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to demonstrate compassion. Our societies eliminate and try to spot complex and contradictory regulation by the federal and state governments. This is something no private individual, healthcare system or large group can do without an aura of self-interest.

The New Jersey Obstetrical and Gynecological Society and the Medical Society of New Jersey essentially represent the “supreme court” of the healthcare system. However, unlike the Supreme Court justices, our Societies have little clout in making their decisions the law.

If there is one message or request our Society would propose, it would be to have a true meeting of the minds.

This meeting would encompass the Governor’s office, both major political parties, insurance carriers and trial attorneys.

All of these groups are part of the problem and also part of the solution. At this meeting, areas of commonality could be defined. From this, agendas could be formulated.

Then task forces with set goals and deadlines could be initiated. Until now, issues have been randomly approached by only one or two of these parties. In our great state of New Jersey, it should not be unthinkable that the Health Commissioner, heads of Health and Human Services and managed care plans, trial attorneys and society leaders could sit down and talk. The OB/GYN Society is happy to pay for the lunch. Once common goals are defined, we can actually work effectively on them.

As the New Jersey OB/GYN Society works to create this meeting of the minds, there is one critical message for all medical students. Join your subspecialty societies and your state medical society. Remember your history.

The Greek Empire, the Roman Empire, European empires and even the United States all weakened when they became isolationistic. Whether you work for a hospital, a large group, a small group or a health maintenance organization (HMO), you are under the same umbrella.

You weaken yourself in the long run by staying “isolationist.”

The only way to keep the idealism you trained for is to have a state advocate so we can all stick together. To quote Benjamin Franklin, “Gentlemen, we must all hang together or we shall most assuredly all hang separately.”

Donald M. Chervenak, MD, FACOG, is President, New Jersey Obstetrical and Gynecological Society; President-Elect, Morris County Medical Society; and Secretary-Treasurer, American College of Obstetricians and Gynecologists–New Jersey Section.

”

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THE UNION COUNTY MEDICAL SOCIETY

RESPONSE TO HEALTHCARE REFORM IMPACT OF INCREASE OF PATIENTS’ OUT-OF-POCKET EXPENSES As of yet, the Union County Medical Society (UCMS) membership has seen no apparent decrease in patient visits. We view the problem not so much as out-of-pocket- expense as out-of-network accessibility, particularly for patients in health maintenance organizations (HMOs). However, in this economy, with copays and deductibles increasing, and coverage of certain tests decreasing or disappearing, it is a distinct possibility in the near future.

IMPACT OF HEALTH REFORM ON MEDICAL PRACTICES Patients have less time with physicians, and physicians feel that things are only going to get worse. Some physicians are allowing hospitals and larger groups to purchase their practices; others are in a holding pattern waiting to see if healthcare reform plan is overturned and/or who will become president. If things remain the same, more physicians will drop commercial insurance, and there is always the possibility that they will leave Medicare. Physicians continue to adopt electronic health records (EHRs), but are inundated with too many current and additional regulations and other constraints on their practices. At the same time that physicians need to change their electronic transaction version from 4010 to 5010, they have to change over to ICD-10 and keep closer track of electronic prescriptions and other patient data. The more time physicians spend on administrative and regulatory matters, the less time there is for actual patient care. In addition, physicians as employers are reducing health insurance coverage or the percentage paid as an employee benefit because of the rising insurance cost and declining business reimbursement.

STRATEGY FOR MAINTAINING AUTONOMY AS THE BUSINESS OF MEDICINE EVOLVES Unfortunately, physicians are not organized well as a group, and autonomy is seen only as it relates to a particular practice and not to the profession as a whole. While there are many thoughts, there is no clear strategy among physicians due to a lack of cohesiveness and the unpredictability of the future of medicine. Organized medicine can take the lead by not only commenting on proposed regulations but also by sitting down with legislators

By Jay E. Bowen, DO

and mapping out a strategy that will ease the regulatory burdens of medicine and improve patient care.

UCMS MESSAGES FOR LEGISLATORS AND HEALTHCARE LEADERSHIP >> Realize that the more time physicians spend on compliance with state and federal regulations, the less time physicians have for patient care. >> Minimize the regulations in business and medicine and allow physicians to focus on the needs of their patients. >> Focus more on improving health and wellness and less on managing disease. >> Change healthcare to non-profit so the benefits go to the patients, and incorporate the best ideas for healthcare coverage from other countries, where feasible. >> Control pharmaceutical costs. >> Allow physicians to organize and negotiate with insurance carriers as a group, rather than individual medical practices trying to negotiate on their own. >> Allow insurance negotiation with carriers outside the state. >> Empower patients to make truly informed financial decisions about their care, instead of being shielded by copays and not understanding the true cost of medical care. >> Ensure that insurance companies educate their customers about the coverage they or their employer chose. >> Allow patients to collectively negotiate for coverage in addition or in place of employer provided coverage.

UCMS ADVICE FOR MEDICAL STUDENTS Avoid hospital-based employment, if possible. It is better to start your own practice or join a group in which you can eventually be a partner. Get involved in organized medicine to effect any change. Keep an eye on current legislation and regulations, and get to know your legislators and initiate a dialogue with them.

Medicine is an art, and physicians are professionals.

The business side of medicine (the many rules, regulations, legislation and insurance policies) should not become such a distraction that it detracts from the true calling of physicians to heal. Patients should be free to consult whomever they need to and not have to worry about coverage. Legislators should ensure that patient care comes before insurance carriers and pharmaceutical companies, and physicians should reclaim their profession.

Jay E. Bowen, DO, is President of the Union County Medical Society and maintains a group practice in Summit, New Jersey.

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E R A C H T L A HE ORM on thoe f Medicine REF ession ounty

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Healthcare reform has, indeed, changed the way physicians practice medicine, conduct their business affairs and look to the future.

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By Zubair Syed, DO

THE TRUE COST OF OUTOF-POCKET EXPENSES There’s no doubt that the increase in patients’ out-of-pocket expenses has affected the quality of patient care. The cost of high deductibles and barebones insurance policies cause patients to reduce their level of medical care. Instead of keeping their four-week appointment, they stretch it out to three or four months. In many medical practices, patients need regularly scheduled monitoring, especially for chronic issues such as diabetes, hypertension or glaucoma, for example, which require monitoring and medication dosage adjustments. But the increased costs of office visits discourage patients from keeping appointments.

Additionally, patients know that the cost of the appointment is not the end.

After that doctor visit, they may then need additional medication, or tests or specialist referral–all costing more. Patients weigh the value of the visit over the need to spend their money in some emergent area. Certainly, there are patients who come for their appointments, but don’t pay the bill. But the bigger concern is those who don’t come at all, thereby reducing the quality of their medical care.

Physicians are not generally aware of each patient’s deductible, or of what portion has yet to be met, or how much of the bill will be out-of-pocket. A good deal of this financial uncertainty could be reduced if patients took time to study their insurance policies. Many do not realize how high their deductibles are and then are shocked

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“How many times will a patient come for office visits, only to hear that the insurance policy will not allow for certain tests or treatments, before giving up on those visits?”

when they’re handed the bill. They then vow never to return, not realizing that having met the out-of-pocket deductible, the bill will not be as large the next time.

THE RESTRAINT OF REGULATIONS From the physician’s point of view, healthcare reform, in many cases, has really changed the way we practice medicine. The regulation guidelines now determine both the diagnosis and treatment in ways that were not the case before. Regulations from the government and from the insurance companies tell physicians what tests can be ordered, what medications can be prescribed, what referrals can be made and so on. It is not uncommon for a physician to make a diagnosis after evaluating the patient and then find that the treatment plan is regulated by an outside agency.

In my practice in ear, nose and throat, for example, when an older patient comes in complaining about hearing loss, Medicare says that on initial evaluation, I can do a hearing test. But if this is a returning patient, perhaps one I have been seeing over the years for different medical concerns, Medicare says I cannot do a hearing test. Even a commercial insurance carrier can dictate my treatment plan, saying, for example, that I can do only four hearing tests per year, even in the case of a

young child with chronic ear disease.

In many cases, to meet the criteria of the disease and therefore qualify for the needed tests, some patients have to come back for several visits over time–paying the copay and meeting the deductible each time. Of course, if I really think the test is necessary, I can do it at any time based on my own good judgment, but the patient will have to pay the entire bill. Then I’m right back to scaring off my patients with high out-ofpocket costs.

As time goes by, I worry about more regulations that will continue to steer patients away from the care they need. How many times will a patient come for office visits, only to hear that the insurance policy will not allow for certain tests or treatments, before giving up on those visits?

In the back of my mind, I know that test is going to happen eventually, but I have to keep waiting to check off each notation on the criteria list, visit after visit, before the test can be prescribed. By that time, some of my patients will have stopped showing up.

STAYING IN PRACTICE AND IN NETWORK It has become extremely difficult for primary care and specialty physicians to maintain an independent solo practice.

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“It is important to really like what you do because the financial payback can no longer be the reason to enter this field.”

It can be done, especially if the physician is willing to reduce his or her financial expectations. But the truth is, the office staff workers are probably not willing to do that, and so the solo, independent, autonomous practice is getting harder and harder to maintain.

To counter the negative effects of cost and regulation, many physicians are consolidating into larger groups.

This does require the forfeit of some autonomy, but some group models allow the member physicians to maintain their own independent offices while combining administrative services.

In that kind of group, the physicians are, of course, all expected to uphold certain financial agreements to bring in money to the group. This expectation has physicians worried when they consider, for example, Congress’s inability to fix the sustainable growth rate (SGR), which dictates the way services are paid for in Medicare. If the expected reduction in Medicare payments does occur, the lack of action will affect not only those payments but also the payments of private insurance companies that are all tied to the Medicare rate. The insurance contract stipulates, for example, that payment will be made based on Medicare rate plus 10 percent. So when Medicare payments decrease, so do all insurance payments. In that case, even physicians in group practices must figure out how to survive financially.

Some will survive by choosing to take fewer insured patients. They will seek full-payment patients instead.

This decision also reduces the headache of insurance forms, payments, deductibles, etc. and reduces the need for full-time office staff to work exclusively on insurance paperwork. This seems very reasonable and even practical, but what does this do to our insured patients? It is not their fault that the system is working against them.

WORKING TOGETHER TO FIND A SOLUTION I cannot say exactly what will solve these problems, but let’s start with a focused effort to fix the SGR and the way it affects Medicare payments. If our legislators would agree to give the SGR their time and attention, it would create a wealth of goodwill, which has not been shown for a long time. The tort reform legislation has also been hanging in

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the background for too long and needs to be addressed.

I also think our healthcare and government leaders need to lessen the burden of regulation. I understand the reasons behind many of the regulations that strive to verify the legitimacy of their payments, that prevent medical billing fraud and that seek to protect the American consumer. But I do not think the people making these regulations and creating this labyrinth of paperwork realize that the regulations have created a level of fear in the profession–like we are being constantly watched in a scenario where “gotcha” can happen on any given day.

The bottom line is that the issues of Medicare and excessive regulations that are getting in the way of practicing medicine need to be put on the table and addressed.

GOING FORWARD Unfortunately, I personally know physicians who say they will not encourage their children to go into the healthcare field. Their position is supported by surveys that have found the number of healthcare professionals who recommend the field to their children is plummeting.

I still would be happy if one of my four children entered the medical field. If that happens, I would hope that child understands that medicine is more of a calling than a job. It is important to really like what you do because the financial payback can no longer be the reason to enter this field.

In addition, I would advise young residents to resist the lure of employed positions and spend some time enjoying the experience of having a private practice. In employed positions, something is lost in the physician’s growth as a professional. The doctor becomes a commodity that can be traded, fired and/or hired. If a new doctor wants to work directly with patients, I would say that it is important to take time to experience what it really means to be a physician by starting in a private practice.

Zubair Syed, DO, is President of the Atlantic County Medical Society and a board-certified ear, nose and throat surgeon in private practice in Somers Point, New Jersey.

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By Robert Eidus, MD, on behalf of the NJAFP Executive Committee, Ray Saputelli, MBA, CAE, and Theresa J. Barrett, MS, CMP, CAE

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NEW JERSEY ACADEMY OF FAMILY PHYSICIANS

RESPONDS TO THE CHALLENGES OF HEALTHCARE REFORM

Family physicians and their patients are definitely affected by recent healthcare reform. The primary challenges are economic and administrative.

THE ECONOMIC CHALLENGES The increase in out-of-pocket expenses for innetwork and out-of-network medical care has affected the way our patients view health maintenance. As patients face the costs of high copays or deductibles, they sometimes put off treatment or don’t follow up with regular visits. They may tell their family physician that they want to schedule their diabetes lab and visit in six months rather than three months. They may not get their colonoscopy at all because they just needed one more reason not to get it done. They may request medication prescriptions for a full year to avoid having to pay for office visits between refills. Each of these patient-initiated strategies to reduce healthcare costs affects the quality of the patient’s care.

Our physicians have responded by changing the way we practice medicine. For example, we have discussed the challenges of managing medical problems during “preventive visits” to save our patients future office visits while improving patient care and compliance. We have shifted our mindset from a straight fee-for-service approach to population management. We have also found shared savings opportunities with insurance companies and hopefully with the Centers for Medicare & Medicaid Services (CMS), too. We have sharpened our ability to measure costs

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and quality to defend our “ask” from these entities.

Additionally, there is the continuing debate about whether a small or solo practice is still viable in this commercial insurance market. In an attempt to maintain autonomy, some practices with like-minded, progressive physicians have merged to become a bigger dot on the map. There is a great deal of pressure from several sectors to acquire practices. Accountable care organizations (ACOs) are forming, and hospital networks are scrambling. Members are trying to watch their flank.

These changes in the economic model of the family physician practice are challenging to our members. However, they are necessary if we hope to stay financially solvent and continue offering quality care to our patients.

THE WORKLOAD CHALLENGE The best use of a primary physician’s time is attending directly to patient care and coordinating healthcare teams made up of nurses, patient care coordinators, physician extenders and medical assistants. Filling out forms and dealing with multiple payer systems and different rules for formularies and precertification procedures is not a good use of time and is exhausting. In fact, the amount of effort expended after office hours and the lack of reimbursement for that work are major deterrents for medical students to go into primary care. Those who lead and enforce the healthcare reform movement need to be aware of this.

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The U.S. Senate Commerce Committee determined that the national average for commercial insurer over1 head is 26 cents of the premium dollar. The national average for primary care payments is 5.2 percent of the premium dollar.2 There needs to be legislation that forces commercial insurers to provide adequate payments for primary care to flourish. New Jersey, specifically, is losing its primary care base, and that trend must be actively reversed.

ADVICE FOR NEW DOCTORS FACING THESE CHALLENGES Medicine is still an extremely rewarding career, and medical students should not be discouraged by the negative things they hear. Primary care is becoming viable again, but it requires a willingness to adapt to change. Physicians must learn to be efficient by, for example, taking advantages of technology such as electronic medical records. New doctors should associate with forward-thinking professional colleagues and share the challenges. Certainly, solo practice is not for the faint of heart, but private group practice can be rewarding, financially viable and fun. Nurture your office

staff and pay attention to morale. You can all have fun together, and your patients will benefit from the mood they perceive when they are seeking your help.

Robert Eidus, MD, is President of the New Jersey Academy of Family Physicians (NJAFP). Ray Saptuelli, MBA, CAE, is the Executive Vice President for the NJAFP, and Theresa J. Barrett, MS, CMP, CAE, is the Deputy Vice President for the NJAFP. The members of the executive committee are Sal Bernardo, MD; Tom Shaffrey, MD; Krishna Bhaskarabhatla, MD; Bob Gorman, MD; Tom Ortiz, MD; and Adity Bhattacharyya, MD. 1

United States Senate, Committee on Commerce, Science, and Transportation, Office of Oversight and Investigations, Majority Staff. (2010, April 15). Implementing health insurance reform: New medical loss ratio information for policymakers and consumers (Staff Report for Chairman Rockefeller). www.pnhp.org/sites/default/files/docs/2010/MLR-Report.pdf.

2

Rhode Island Office of the Health Insurance Commissioner.

(2009, February 16). Proposed rate factor standards for medical cost improvement (draft). www.ohic.ri.gov/documents/ Committees/HealthInsuranceAdvisoryCouncil/February%20 Materials%202009/3_%20standards%20for%20HIAC%20%20 Feb2009%20draft.pdf.

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STUDENT VOICES

By Oren Johnson, MD

Looking Ahead at the Future of Medicine

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I am entering my intern year this summer, and it is proving to be an interesting time to start my career in medicine.

The passing of the recent healthcare reform legislation has created a large degree of uncertainty. In the wake of these changes, I have had numerous conversations with fellow classmates about how this reform will affect our future and the way we will practice medicine. Unfortunately, most of these conversations have led to more questions. The questions discussed often focus on the role business/legislation will play in clinical decision making, the concern of funding graduate medical education and the issue of preserving physician autonomy.

As a medical student, I have felt somewhat removed from the changes taking place. I have not personally had my reimbursement cut or seen the nature of my work change. It is hard

MDADVISOR | SUMMER 2012

for me to put into perspective the gravity of the upcoming changes to our field. As a student, I am making plans for patient care without constraint. I am challenged to make a plan for my patient applying evidence-based medicine–and not necessarily on what works in the context of our healthcare system. As I begin residency, one of the biggest challenges I will face is making patient management decisions in the milieu of a changing healthcare system.

One part of the legislation that hits close to home is the threat to graduate medical education funding. I will be in training for the next six years, and the funding of my education is linked to Medicare. The entire infrastructure for graduate medical education rests on this legislation, with almost all U.S. residency positions receiving funding from Medicare. With the new healthcare reform, how will this change over the next few years? If funding is cut from these programs, will university hospitals be able to support resident education in the future? This aspect of healthcare reform is rarely discussed. The public is not aware of the link between Medicare and graduate medical education and the implications for a decrease in funding.

It has been difficult to follow what will actually change in daily practice. My classmates and I attempted to follow the reform legislation to consider how its mandates might affect our choice in specialty. It quickly became evident that the specialties we are exploring now may be very different by the time we are done with training. One reoccurring question has been whether or not we would have autonomy as future physicians.

The physicians of my generation will most likely work within larger practices and for large hospital systems. It will be a challenge for the individual physician to maintain autonomy in these healthcare delivery systems. However, I

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believe that with proper physician leadership, there is opportunity for autonomy to be preserved. These “new” work environments present challenges that require skills not necessarily taught in medical school. I think that formal training in business, public policy and leadership would help address this void. Physicians of the future will need to understand how finance and legislation affect their clinical decisions. Autonomy can be preserved if the physician is as much involved in the business or administrative aspects of patient care as he or she is in the medical aspects.

I would urge legislators to consider graduate medical education when making changes to Medicare. In addition, legislators should allocate resources to curriculum advancement in medical school. The solutions to many of the problems that plague our medical system will come from physician leaders who can bridge the gap between business, legislation and clinical medicine.

Oren Johnson, MD, a 2012 graduate of the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, plans to pursue an academic career in interventional oncology and will complete his training at Brigham and Women’s Hospital.

By Ivan Georgiev

Anticipating How Healthcare Reform Will Affect a Medical Practice of the Future The theory behind healthcare reform is sound on paper, but the way the reform is approached may be from the wrong end.

Many young physicians have a deep sense of stress and anxiety that often stems from their moral battle between wanting to help patients and needing to survive their $150,000 medical school debt. Although our country needs to overhaul the healthcare system, we should not start the process from the top down but rather from the foundations up.

Healthcare reform as it now stands will put tremendous stress on practitioners (one of whom will be me) to have the income to offset their enormous debt. Although I did not intend to open a solo practice, the healthcare reform movement solidified the idea that I need partnership to maintain a constant flow of patients, as well as an intraoffice system of support and referrals.

In this partnership system, the best way to maintain autonomy in the business of medicine may be to become a part of something greater. Doctors who are mostly self-dependent may feel they control their businesses, but in essence, those businesses control the doctors because everything falls on their shoulders. For solo doctors, all decisions come through their doors–whenever and wherever they are. To ensure the survival of their businesses, the calls must always be answered. However, doctors who give up some of their “independence” to become a part of something bigger (a group practice, a hospital team, etc.) benefit from sharing ideas and delegating duties. The best way to maintain autonomy in a larger practice is most likely with a cross-disciplinary group combined of medical, legal and business personnel. In this structure, a little independence is surrendered to ensure autonomy as a whole. Most importantly, this cross-disciplinary model has a built-in support system that can withstand the many changes that may come from this ever-evolving medical and business world.

WHAT I WOULD ASK OF OUR GOVERNMENT AND HEALTHCARE LEADERS The most important message to all government officials and healthcare leaders is a request to take a step back and consider the idea of a bottom-up reform in which educational debt is the first consideration. Most practitioners are apprehensive about healthcare reform, among other reasons, and how it will affect their livelihood as many are in tremendous debt after graduation from medical school. By lowering the educational debt (whether through increased government aid, stipends, etc.), any healthcare reform that follows will have support rather than opposition from practitioners and will pave the way to tackling other issues such as rising hospital and pharmaceutical costs. In addition, as one of the most important effects of lowering the debt, new practitioners, such as I, would not be as anxious about the road following graduation, and future students would not be deterred from the medical

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field by the fear of endless debt. Although I realize that this move to bottom-up reform is much easier said than done, it should be seriously considered, as it may be, in the long run, a more effective way to reach the desired healthcare reform objectives.

Ivan Georgiev, a member of the Class of 2013 University of Medicine & Dentistry of New Jersey–New Jersey Dental School, is working toward entering an oral and maxillofacial surgery residency.

By Arveny Negron

The Physician Assistant’s Viewpoint

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The current healthcare reform movement will greatly impact the way I practice medicine.

This act will increase the number of patients in need of primary care practitioners, and I intend to practice in this capacity. The profession of the physician assistant was established to help with the primary care physician shortage in the 1960s. Today, the objective is the same–primary care is the foundation of patient and practitioner relationships. One of the core values of our field is patient education and working closely with physicians to develop good lifestyle habits for our patients. As a bilingual Spanish-speaking student, I have experienced firsthand how many medical offices would benefit from having bilingual physician assistants to better serve their patients. With about 17 percent of New Jersey’s population of Latino descent1 and Hispanic physician assistants accounting for 9 percent of the profession nationwide,2 Spanishspeaking skills are essential.

In practice, healthcare reform mandates will allow me to provide primary care to underserved patients

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who cannot afford more than the minimal insurance plan that will be required. With the new guidelines and payment options, I would be able to bring more cost-effective care through working with a supervising physician. I am looking forward to being a physician assistant, and I am confident that aspects of healthcare reform will enable me to do more for patients who are in need.

However, despite my optimism, there are areas of concern that I would like our government and healthcare leaders to be aware of. I would ask them to continue allowing physician assistants to assume the rights and responsibilities provided to other medical practitioners. As a student, I am being trained in the medical model and have the foundation to work in any medical field. Many times physician assistants are not allowed to perform procedures that are within the scope of our practice but are not included in the law. It is also important to give the physician assistant the ability to write prescriptions without counter signatures. The New Jersey statute allows for prescriptions to be written by the physician assistant, but they must be countersigned with 24 hours by the supervising physician. This hinders the physician assistant in cases where the physician may not be able to sign the prescription. A supervising physician must sign patient orders, and I believe this should be sufficient as all medical information would be available to the physician within the required time frame.

I would also ask the Legislation to lower student loan rates for all health profession students. As members of the medical community, we work to help others; however, high loan rates make it extremely difficult to be financially sound postgraduation. Many physician assistants go on to work in underserved areas, but still have tens of thousands of dollars in student loan debt. New Jersey is currently the third wealthiest state in the United States and should provide some financial assistance to those who are providing quality medical care to its residents. This alone would be an incentive for medical practitioners to stay in state.

Arveny Negron is studying to become a physician assistant at Seton Hall University School of Health and Medical Sciences and is a member of the Class of 2014.

1

U.S. Census Bureau. (2012). State and county quickfacts. http://quickfacts.census.gov/qfd/states/34000.html.

2

National Council of LaRaza. (2009). Profiles of Latino health: The top twelve questions about Latinos and health care. www.nclr.org/images/uploads/pages/Question11.pdf.

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By Neil Kaushal, MD

Glass Half-Full or Half-Empty?

Guarded Optimism for Young New Jersey Physicians At the University of Medicine and Dentistry of New Jersey (UMDNJ)– New Jersey Medical School, students are taught the art of medicine as it revolves around the patient.

Compassion, empathy and, uniquely, humanism are concepts all future physicians are taught to integrate into their daily practices.

However, one can submit that today’s young physicians are not educated to embrace a culture of cost-reduction in the delivery of healthcare. As healthcare evolves in New Jersey and throughout the nation, reform efforts should not lose sight of this foundation of future healthcare delivery: training the next generation of physicians cost-effectively and encouraging the same prudence while in practice.

Let’s start from the beginning of a young doctor’s journey in the state of New Jersey. According to the UMDNJ Financial Aid Office that supports students at the Newark-based New Jersey Medical School, Robert Wood Johnson Medical School and the School of Osteopathic Medicine, the average student debt at graduation in 2012 was approximately $150,000. Furthermore, this figure does not include the student debt accumulated from an undergraduate education.

The rise in the cost of medical education, along with the cost of malpractice premiums and declining reimbursements, has had negative implications on medical care. New Jersey, along with other states, continues to struggle to fill the void of primary care providers needed to serve the population. Regardless of our excellent medical training, the economic reality of practicing medicine while managing multidimensional debt invariably leads to defensive medicine. In fact, according to a 2012 Medscape Physician compensation report, an alarming 24 percent of physician respondents stated that they will not

reduce testing to curtail medical costs because they feel obligated to practice “defensive medicine.”1 Clearly, we need a fundamental paradigm shift, and such responsibility must be shared by the government, insurance companies and physicians.

On the spectrum of healthcare reform, the necessary changes need to begin and end at the level of the state government, with the initiative from the Governor’s office.

Cost-cutting in healthcare begins with educating our young doctors efficiently. In the past year, Governor Christie established a UMDNJ Advisory Committee that recommended a restructuring of biomedical education in the state of New Jersey. According to the committee, one of the primary goals of this process should be to streamline the university system in an effort to save administrative costs and inefficiencies. Although the Governor’s committee made a valiant effort to improve higher education in the state, the plan will serve only to exacerbate existing problems by driving up the cost of education and debt and by failing to produce enough healthcare providers for the citizens of New Jersey.

Newark’s University Hospital, for example, is the largest provider of charity care in the state, and serves as a hub for training thousands of medical students and residents.

By conservative estimates, the Governor’s plan will cost $50 million to transition the UMDNJ units in New Brunswick to Rutgers University, and the cost to maintain the financial viability of the Newark campus will require $55 million a year for the next five years. The cost to taxpayers will be significant; the cost to future generations of medical students and their rising tuition costs will be even more damaging.

Certainly, there are several facets of healthcare reform, and in this article, I have focused only on a small aspect of a broader issue. Still, as a proud graduate of New Jersey Medical School, I cannot underestimate the impact that streamlining graduate medical education and minimizing student debt can have on students’ future career decisions and the way they will approach the practice of medicine in the future.

Neil Kaushal, MD, a 2012 graduate of the University of Medicine and Dentistry of New Jersey–New Jersey Medical School, is a resident in orthopaedic surgery at NYMC-Westchester Medical Center.

1

Kane, L. (2012). Physician compensation report 2012. www.medscape.com/sites/spysician-comp/2012.

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“Healthcare reform has definitely changed the way dermatologists practice medicine and has good things to offer, but there have been bumps in the road.”

The Dermatological Society of New Jersey Setting the Standard in Dermatology™

The Dermatologic Society of New Jersey Reflects on Healthcare Reform

By Robert M. Paull, MD

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THE IMPACT OF INCREASED PATIENT EXPENSES ON THE PRACTICE OF DERMATOLOGY As our patients are being asked to shoulder an increasing financial burden, they are using services less and presenting ultimately with more problems. This is problematic for patients, of course, but delay in treatment also dramatically affects dermatologists. The decreasing insurance reimbursements experienced over the past several years, combined with the increased time and effort required to give adequate care to patients, has created a business problem for the medical professional. To maintain revenue, one then has to see more patients in the same amount of time, work longer hours or expand the practice in other revenue-generating areas.

Our Dermatologic Society of New Jersey (DSNJ) members may choose different solutions to this problem.

Other specialties and providers are also faced with this same problem, and the path they choose to solve the problem may include expanding practice opportunities in areas providers perceive as lucrative and not subject to insurance reimbursement, such as cosmetic skin procedures. Since dermatology is an office-based specialty, dermatologists are outside the realm of credentialing bodies such as hospitals and free-standing surgical centers.

These facts provide an avenue for those outside the practice of dermatology to engage in cosmetic endeavors with little oversight.

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The DSNJ has been working hard to maintain high-quality dermatologic care for New Jersey.

Unfortunately, the public is not yet savvy enough to understand and question the credentials of the person providing the services. In some instances, a patient can go to a practice advertising itself as a dermatology practice, yet be taken care of by physicians other than dermatologists, or nonphysician providers supervised by or collaborating with physicians other than dermatologists. The DSNJ has met with the Board of Medical Examiners on this subject and has not yet been successful in curtailing such practices. We continue to work with the Legislature in supporting truth-in-advertising legislation, though legislative paths are long ones to travel.

We continue to advertise our mantra that dermatologists are the real experts in the care of and biology of the skin. No other specialists have the amount of training and education focusing directly on the skin as do true dermatology residency-trained physicians. We feel a person has a right to know the background of the practitioner caring for his or her skin problems.

THE EFFECT OF HEALTHCARE REFORM ON THE PRACTICE OF DERMATOLOGY Healthcare reform has definitely changed the way dermatologists practice medicine and has good things to offer, but there have

“Previous models of healthcare delivery are broken and will been bumps in the road. expanded to include much be changed.�

The earliest change has been the result of the push toward electronic health records.

Here, larger groups seem to have an advantage. In larger group practices, costs per practitioner seem to be lower, as is individual time expenditure in identifying and implementing an office system.

Additionally, it is easier for some younger physicians, who grew up with computers and are social media savvy, to make this change than it is for physicians with 20 to 30 years of experience in paper charts. As the years go on, I think there will be a push to earlier retirement by some physicians who are unable or unwilling make the change to electronic health records.

The next two years will be pivotal.

Now that the Supreme Court has upheld the individual mandate requiring Americans to buy health insurance, there will be many changes to come.

In New Jersey, the then pending Supreme Court ruling was cited as the main reason health insurance exchange (HIE) legislation was vetoed. Now, there is a timetable for HIE implementation by the states vs. imposition of federal exchanges that will certainly affect the way we practice medicine. These are indeed exciting times.

To keep up with the evolving business of medicine that affects the day-to-day practices of our physicians, the DSNJ has expanded its scope of concern. In the past, the Society served as an avenue for continuing medical education and social events. More recently, our efforts have

work on the legislative and regulatory fronts. We are striving to maintain as high a level of dermatologic care in the state as is feasible.

We continue to champion the dermatologist as the skin care professional and will continue our efforts to ensure the quality of skin care services throughout the state.

ADVICE TO THE GOVERNMENT AND TO NEW PHYSICIANS Many areas of medical care delivery need to be improved in the country. We are not world leaders in several categories of health outcome statistics, though we shine in dollars spent on healthcare. The U.S. government needs to focus on why this inequity exists and implement plans to repair it, because all Americans should have access to good healthcare.

At the same time, our new physicians need to understand that previous models of healthcare delivery are broken and will be changed. New members of the profession will have to love what physicians do to be successful. In the past, I have told students that if their primary reason for going to medical school was financial gain, they should have gone to business school. In the years to come, earning a business degree might just become a requirement for physicians.

Robert M. Paull, MD, is the Legislative Chairperson of the Dermatological Society of New Jersey and is in private practice at the Center for Dermatology and Laser Skin Surgery in North Edison and Warren, New Jersey.

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A VIEWPOINT

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FROM THE

MONMOUTH COUNTY MEDICAL SOCIETY

“

I believe the situation will surely lead to the demise of the subspecialty solo practitioner in the State of New Jersey and in the country.

By Alan Zaccaria, MD

”

As a plastic surgeon in solo private practice, I have had the luxury of being able to maintain an out-of-network status with all insurance companies. (I participate only in Medicare; I perform skin cancer surgery and am the Medical Director of a hospital outpatient wound care center, both of which have a high proportion of Medicare patients.)

However, my out-of-network patient list is being significantly affected as the insurance policies offered to private patients and small businesses have changed drastically.

Low or reasonable out-of-network deductibles are no longer offered.

Thus, the goal of the insurance companies of trying to keep patients within their own network is becoming more and more effective.

My personal health insurance policy with Horizon Blue Cross & Blue Shield had a $500 out-of-network deductible when I first went into practice in the early 1990s. The company no longer offers this plan, nor does it offer $1,000 deductibles. The cost for even a $2,500 deductible has become so outrageous

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that I was forced to go with a $5,000 deductible plan. These deductibles are becoming the rule rather than the exception. Fewer and fewer patients are opting to go out of network and are even willing to travel out of the area just to see a specialist within their network.

The result adversely affects my practice and other solo practitioners in specialty practices. A trend is developing in the plastic surgery community of doctors opting to contract with these insurance companies just to capture these patients. This is a complete reversal of how things were in our geographic area in the past. As more and more plastic surgeons come into the county, more and more competition is created, and the patient pool continues to dwindle. With the declining economy, fewer patients are willing to have expensive cosmetic procedures, and even fewer are willing to go out of network to see a plastic surgeon. Thus, we are now seeing plastic surgeons playing right into the insurance companies’ hands by signing contracts with them and agreeing to accept substandard reimbursement for procedures that require many years of training and expertise. This is a vicious cycle with no end in sight in the immediate future. I believe the situation will surely lead to the demise of the subspecialty solo practitioner in the State of New Jersey and in the country.

Alan Zaccaria, MD, FACS, is Past President of the Monmouth County Medical Society and Medical Director of the Wound Treatment Center at Monmouth Medical Center in Long Branch, New Jersey.

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By Michael J. Schoppmann, Esq.

Voices:

Hear Their

Or We All Will Bear the Consequences Let me stress at the outset that I am not a physician. I am a healthcare attorney. Thus, I believe I am able to provide a unique, albeit somewhat biased, “internal and external” perspective on the current state of medicine.

BEARING THE BURDEN OF REFORM We, as a society, have regrettably, at our own expense, completely misplaced our priorities and our values and have thereby threatened our future. As we set our standards, we must decide whom we place highest in our society. Whom we value and appreciate the most. Whom we wish our children to emulate. Movie stars? Television reality-show participants? Professional athletes? Career politicians? I think we can all agree that no one should be ranked higher or rewarded more than the healers–the devoted, dedicated physicians–to whom we turn for life’s most critical answers, treatments and cures. Even such a noble profession as teaching quickly becomes irrelevant when a child is ill. It is self-evident that the pursuit of good health has never been, and will never be, supplanted as our highest shared priority.

THE EFFECT OF HEALTHCARE REFORM As we acknowledge the value of society’s healers, we must ask how healthcare reform is affecting the way they practice medicine. In broad terms, healthcare reform has left physicians–as a collective group–frustrated, disenchanted and disheartened. According to a recent survey reported

by Mark Crane, “Dissatisfaction with medicine is intensifying, although a majority of physicians would again choose the same career path. In 2012, just over half of all physicians (54 percent) would choose medicine again as a career, far less than in the previous year’s report, where 69 percent of 1 physicians would choose medicine again.”

We, as a society and through our role as voters, have elected and empowered government officials who have mandated that physicians practice burdened with a seemingly unmanageable, yet ever increasing, body of indecipherable regulations. At the same time, physicians face the highest level of investigations ever mustered by our government–second

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only to terrorism. From 1991 through 2011, the number of disciplinary actions brought against physicians rose an 2 astonishing 92 percent. Over the past five years alone, disciplinary actions nationwide have risen 13.4 percent, (even with a 1.2 percent dip in 2010).3 Incredibly, as we subject physicians to these unprecedented burdens and threats, their compensation is declining.

Moreover, healthcare reform is purposefully designed to further reduce that compensation. So we should not be surprised that more and more physicians are retiring early, leaving medicine altogether and encouraging their children to enter other professions. As far back as 2004, dissatisfaction was reported in The New England Journal of Medicine: “Surveys administered within the past 10 years have shown that 30 to 40 percent of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.”4 Today, these numbers are even more discouraging as a recent survey finds that 9 out of 10 physician respondents indicate an unwillingness to recommend healthcare as a profession.5 It is incomprehensible that anyone could agree with a healthcare system design wherein the healers of our society often feel downtrodden, unappreciated and disenfranchised.

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“What Are We Saying to Today’s Doctors?”

• Whom do we value and appreciate the most?

• Whom do we wish our children to emulate?

• Are we promising physicians a brighter future in return for their commitment?

• What messages and/or incentives are we sending physicians and the generations behind them?

• Are we placing physicians at the highest level of respect and reward?

• As physicians graduate and are saddled with hundreds of thousands of dollars in debt, what future are we promising them?

FIGHTING BACK All physicians must first, and immediately, take control of (or at a minimum, come to understand) their role and value in healthcare–understanding what they can earn, what they are entitled to be paid, what others are obligated to pay them and how they can maximize their return/compensation.

In a broader, collective sense, physicians must also be willing to consider building and/or participating in new and/or differing structures to gain strength and economic efficiencies. Group practices–either based on specific specialties or a multispecialty model–are gaining ever greater success and increased market share throughout the country. However, physicians who blindly acquiesce to hospital-based, seemingly attractive, practice purchase offers are quickly finding themselves without power or position to object to unanticipated extended work hours and greater administrative and patient responsibilities, juxtaposed against ever-decreasing compensation.

As we bear witness to these changes, physicians must protect the integrity of the profession. It is vital to convey to the President of the U.S., the Governor of New Jersey and state and federal authorities/agencies that they must be open and honest with the American public. They must determine if they are purposefully building a healthcare system wherein physicians bear a dramatically lesser role, if they are purposefully creating a system in which patients will rarely be seen and/or treated by physicians and if the purpose of healthcare reform is to have patients be cared for primarily (if not exclusively) by physician assistants and/or nurse practitioners.

If these are, in fact, the goals of healthcare reform, then our government and healthcare leaders must say so–openly and candidly. If these are not the goals, then our leaders should place this form of healthcare reform aside immediately, as it is already bringing about those results.

Looking ahead, consider the fear and anxiety the current state of medicine is imposing upon our future healers–medical school students and residents. What do we say to those who we ask to, and hopefully will, undergo excessively high

levels of education and training? Are we promising them a brighter future in return for their commitment? Are we placing them at the highest level of respect and reward? If we are not, what message and/or incentive are we sending them and the generations behind them? As they graduate and are saddled with hundreds of thousands of dollars in debt, what future are we promising them? At a minimum, we need to educate all students and residents embroiled in today’s tumultuous healthcare arena that they need to accept and act on the hard fact that they can no longer only or simply be a healer. Today, they must also be their own business leader, their own advocate and their own risk manager.

History provides ample examples of laws that brought about unintended consequences–unintended and harmful to our society. It is time now to realize the healthcare reform laws have already brought about unintended negative consequences within the medical profession, and thus have begun to harm, demoralize and disenfranchise the healers of this country. It is time to listen to the voices of those who have chosen this noble profession, or we all will bear the dire consequences of our deafness.

Michael J. Schoppmann, Esq., is a principal of the healthcare law firm Kern Augustine Conroy & Schoppmann, P.C. 1

Crane, M. (2012, April 24). Physician frustration grows, income falls. Medscape News. www.medscape.com/ viewarticle/761870.

2

Westgate, A. (2012, May 30). Disciplinary actions against physicians increase. Physicians Practice. www.physicianspractice.com/ blog/content/article/1462168/2077161.

3

Krupa, C. (2012, June 4). Medical boards get more tools to investigate physicians. American Medical News. www.ama-assn.org/amednews/2012/06/04/prl10604.htm.

4

Zuger, A. (2004). Dissatisfaction with medical practice.

The New England Journal of Medicine, 350, 69-75.

5

The Doctors Company. (2012, February 29). The future of health care: A national survey of physicians. The Doctors Company Market Research. www.thedoctors.com/ecm/ groups/public/@tdc/@web/documents/web_content/con_ id_004676.pdf.

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“The negative

By Wayne Colizza, MD

financial impact felt

New Jersey Orthopaedic Society

by patients is

Calls “Healthcare Reform” a Misnomer

shared by physicians as well. We think the term ‘healthcare

As treating physicians and as employers, the members of the New Jersey Orthopaedic Society have certainly noticed the impact of healthcare reform on the practice of medicine.

reform’ is a bit of a misnomer.”

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THE FINANCIAL IMPACT AND ITS RAMIFICATIONS As cost sharing is on the rise, out-of-pocket expenses have changed the way patients seek medical care. The products being sold by insurance companies are offering less insurance to patients–in the in-network and out-ofnetwork setting. The problem is particularly acute in the out-of-network market, where premiums continue to rise but the actual benefit obtained by patients is reduced each year. For example, many insurance companies are offering plans that cap reimbursement for out-of-network physicians at a Medicare-based rate. To avoid increased cost sharing, patients are either avoiding treatment or seeking care with nonpreferred providers. As patients forgo treatment from recommended consultants because of financial implications, their healthcare is jeopardized.

We are also troubled because the reduction in benefits does not appear to translate into premium reductions.

The negative financial impact felt by patients is shared by physicians as well. We think the term “healthcare reform” is a bit of a misnomer. Our costs continue to rise, bureaucratic compliance costs and demands continue to rise and reimbursements continue to decline. At the same time, policy makers have turned a blind eye towards malpractice reform. Since there has not been an increase in reimbursement to counterbalance increased costs, sustaining the level of care provided to patients is becoming increasingly difficult. For our members to

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“If present expense, compliance and reimbursement trends continue, the days of small groups and solos may come to an end.” keep their heads above water and at the same time maintain in private practice, many are considering mergers and other practice structures. These business decisions provide physicians with the size to obtain economies of scale and some leverage in the marketplace to deal with insurance companies and hospitals and/or accountable care organizations (ACOs).

This circumstance does not bode well for the future of medicine. If present expense, compliance and reimbursement trends continue, the days of small groups and solo practices may come to an end. A tremendous amount of consolidation is taking place in the industry, and in light of what is transpiring in the market, the “bigger is better” argument continues to gain traction among our members. As an organization, we have been very active in educating our members on business trends impacting the business of orthopaedics. Through robust e-mail communication and presentations by industry experts at all of our meetings, we make an aggressive effort to keep membership informed and educated on the “latest and greatest.”

A MESSAGE TO GOVERNMENT AND HEALTHCARE LEADERS The first message our society would like to send to those who are defining the parameters of healthcare involves the level of regulation, bureaucracy and “paperwork” that has become overbearing and currently requires an ever-increasing amount of our providers’ time.

Allocating more time to addressing regulation and insurance issues reduces the amount of time that providers can spend with each individual patient. Lessening the burden of regulations and paperwork would allow providers to spend more time treating each patient and less time jockeying around red tape.

Second, government and healthcare leaders need to know that converting to an electronic health record sys-

tem, while also complying with new ICD-10 requirements, has increased costs. Though the federal government has offered some incentives to make the costs associated with these changes more bearable, greater coordination and streamlining of the process are required.

Additionally, malpractice reform is long overdue and should be a key element of reform. This will help bring down costs and ensure that patient care is driven by medical decision making–not by the monied interests that are preventing the proper functioning of the healthcare marketplace.

And finally, our representatives and leaders should not forget that the healthcare sector–and the healthcare practices comprising it–is a major catalyst of economic growth.

The healthcare sector has been the largest contributor to employment over the last two years and is projected to add some 5.6 million jobs by 2020. For this growth to be sustainable, state and federal governments, as well as insurance companies, must recognize that reimbursements rates must rise alongside rising costs.

ADVICE FOR STUDENTS IN MEDICAL SCHOOL Remain true to the ideals that led you to pursue medicine.

Do not lose focus on what matters most: taking good care of your patients. At the same time, arm yourself with the knowledge and skills necessary to tackle the ever-evolving healthcare marketplace. This may require incorporating business courses into your curriculum, associating yourself with a practice that is sophisticated from a business perspective and generally staying abreast of the different practice structures and arrangements that are being used to deliver care. Finally, develop an appreciation of the fact that the practice of medicine is highly regulated and that participating in the political process is vital to protecting the private practice of medicine.

Wayne Colizza, MD, is a practicing orthopaedic surgeon with Tri-County orthopaedic and Sports Medicine, PA, in Morristown, New Jersey, and is Chief, Sports Medicine Service at Morristown Medical Center.

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SIGNIFICANT

& IMMEDIATE INFLUENCES ON PEDIATRIC PRIMARY

By Steven Kairys, MD, Richard Lander, MD, Larry Frenkel, MD, Meg Fisher, MD, Stephen Rice, MD, Michael Weinstein and Fran Gallagher, MEd

Healthcare reform and the responses to the identified federal priorities by individual states, insurance companies, consumers and medicine itself have led to the emergence of significant and immediate influences on pediatric primary care. These influences include the following: advancement in information technology, the increasing importance of the family-centered medical home and emphasis on the quality and value of present and future healthcare.

A SEA OF CHANGE IN THE PRACTICE OF PEDIATRIC MEDICINE Practices large and small are navigating a sea of change, simultaneously confronting industry consolidation, billing procedures and various options for transitioning to electronic health records (EHRs). The explosion in information technology offers numerous advantages, now and down the line, including helping practices improve communication with patients, advancing care coordination and helping practices develop the platform for a more effective and robust medical home.

However, there are also profound challenges impinging on pediatric practices–especially smaller practices. Among the most pressing are the skyrocketing costs in converting to EHRs and weighing the benefits/drawbacks of aligning with a hospital, accountable care organization (ACO) or a group practice under a common tax ID for financial survival.

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Medical home, a concept originated by Cal Sia, MD, a Hawaii-based pediatrician, and adopted by the American Academy of Pediatrics (AAP) in the 1970s, reflects another immediate impact of reform. Every pediatric practice across New Jersey is making proactive changes toward more coordinated and evidence-based care. And although movement to improve payment rates for primary preventive care is a stated focus of the current reform plan, other aspects of reform are much slower in developing. Efforts at comparative effectiveness, health information exchanges, Medicaid ACO and gainsharing do not involve, or altogether overlook, preventative child healthcare; instead they remain focused on the near-term savings associated with acute adult care.

The pediatric community itself has initiated several reforms, in part as a response to the national dialogue on the quality and value of healthcare. First, postgraduate pediatric training is more tightly monitored, and expectations are for demonstration of not only medical knowledge but also professionalism, practice and system-based interdisciplinary care. Additionally, certification as a pediatrician or pediatric subspecialist has gone through revolutionary changes. What had been a once-everyseven-year test of knowledge is now an every-five-year documented effort to improve quality of care, which includes a patient survey as part of the process.

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THE DELETERIOUS EFFECT OF OUT-OF-POCKET COSTS Escalating out-of-pocket healthcare expenses continue to have a deleterious effect on patients and pediatric practices of all sizes. Copayments continue to rise, often ranging from $40 to $50 or more per office visit. Private insurance plan deductibles for inpatient and outpatient care have skyrocketed to $1,000 or more per year, and care often touted as “fully” covered can leave patients owing 20 percent for in-network care and with 30 to 40 percent payment balances for out-of-network coverage.

Many families, unfortunate enough to require prolonged hospitalization or complicated acute care, can find themselves living under the specter of bankruptcy.

Soaring copayments serve as a barrier, thwarting practices from providing families with essential preventative healthcare. They cause families to postpone or abandon well care visits, which may result in a neglected and easily treated medical condition becoming more serious and difficult to treat–in turn, costing considerably more in healthcare resources. In addition, practices are reporting an increase in nonpayment of deductibles by patients, placing these practices in the unenviable position of providing services without knowing if payment will be made.

The consequences are devastating, costly and counterproductive. Much sicker children, who are more difficult to treat, might not respond as well to treatments, may have to be hospitalized or may even die. Additionally, by neglecting preventive care and delaying sick visits, the likelihood of long-term disability increases, medical costs rise and long-term societal benefits are reduced. A child with untreated obesity, for example, may develop a series of chronic diseases such as hypertension, diabetes, heart disease and a host of other complications, which collectively reduce the child’s lifelong productivity in the labor force, require costly chronic care management and create stressful burdens for the family.

THE ROLE OF THE AAP/NJ The AAP/NJ Chapter strives to help our members keep current on pediatric healthcare trends in today’s everchanging landscape and assist members in addressing the inherent challenges. For example, in the transformation to EHR systems, AAP/NJ partnered with the New Jersey

Regional Extension Center to help pediatric practices work toward becoming “meaningful users” and to qualify for federal incentives to assist with the financial challenges.

On behalf of AAP/NJ Chapter members, our organization maintains a proactive stance in linking pediatric expertise to healthcare providers, parents, legislators and the public at large, helping to ensure that children’s healthcare concerns and challenges are recognized, understood and appropriately addressed. To succinctly focus energies and efforts supporting this initiative, AAP/NJ developed and published its Agenda for Children, clearly identifying the chapter’s eight priorities for best meeting the healthcare needs of children, their families and the pediatricians who care for them. A link to the Agenda for Children can be found at www.aapnj.org.

AAP/NJ remains at the forefront in supporting the ongoing education of pediatric practices. The Pediatric Council on Research & Education (PCORE), the chapter’s quality improvement arm, offers pediatricians an array of Maintenance of Certification (MOC), Continuing Medical Education (CME) and Continuing Education Unit (CEU) programs. These activities engage entire practice teams in efforts to improve quality of care and to incorporate evidence-based prevention, wellness and chronic care management procedures into routine protocols in oral health, mental health, obesity prevention, child abuse, neglect prevention and other areas critical to providing quality healthcare to children.

A MESSAGE FROM AAP/NJ TO GOVERNMENT AND HEALTHCARE LEADERS First, it is imperative that federal and state leaders recognize the vital importance of elevating all facets of healthcare for children to a level equivalent to adult care.

In addition, it is essential that pediatricians be acknowledged as the most highly trained and qualified medical professionals providing specialized healthcare to children.

And lastly, it is crucial that our leaders speak out with unequivocal support for proven medical interventions that protect children from chronic and/or lethal disease.

For example, over the past 50 years, the development and mandated use of vaccines has dramatically altered the face–and deadly impact–of disease in children and, to some extent, adults. Vaccination is the single most successful and cost-effective protective action in healthcare. During the past decade, however, a minority voice supported by misinformed

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LEADERS AT “THEOURFEDERAL AND celebrity and Internet-driven propaganda has spawned the needless resurgence of deadly outbreaks of vaccinepreventable diseases across the nation.

While our nation must continue efforts to address our economic challenges, we must resist any action calling for the reduction in funding and support for prevention efforts; both are dangerous and penny-wise and pound-foolish.

Our leaders at the federal and state levels must reject partisan politics and speak out loudly and clearly in support of spending public funds to prevent disease. Accordingly, funding for vaccine purchase and administration payments for healthcare providers should be increased. Federal and state funding for public health departments, state immunization registries and lay education on immunization should be augmented and should include new immunization program funding through Medicare, Medicaid, the Centers for Disease Control and Prevention (CDC), etc. Leadership at the state level must zealously reject efforts to weaken or repeal mandates and to expand exemptions for immunization.

These leaders must also be encouraged to support efforts to rein in fallacious claims of religious and/or philosophical exemptions.

STATE LEVELS MUST REJECT PARTISAN POLITICS AND SPEAK OUT LOUDLY AND CLEARLY IN SUPPORT OF SPENDING PUBLIC FUNDS TO PREVENT DISEASE.

”

AAP/NJ ADVICE FOR MEDICAL STUDENTS As an organization, AAP/NJ has limited interaction with medical students. However, many of our member pediatricians practice in academic settings and regularly interact with medical students. It has become increasingly clear that a key component of medicine today, especially within the context of a medical home, is clear and concise communication.

We encourage medical students to learn to communicate. In pediatrics, this means effectively listening and speaking with patients, parents, family members, nurses, physicians, subspecialists and other members of the healthcare team.

Communication is an acquired skill that must be practiced, and as pediatricians, we remain committed to serving as role models for today’s medical students.

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AAP/NJ members resolutely believe primary care to be rewarding, and we encourage medical students to consider primary care specialties. The practice of medicine is challenging; this profession requires long hours and commitment to patients. Although salary cannot be discounted, it should not be the sole reason for selecting a specialty. As pediatricians (and an organization), we want to convey the joy and fulfillment that come from spending the day with children, and we’d like to emphasize that pediatrics makes for an excellent and rewarding career choice.

Our members who teach future doctors make students aware of the wonderful opportunities within pediatrics, from general practitioner to subspecialist. Pediatricians care for children in hospitals, offices, clinics and schools.

We believe in the medical home concept, and we make every effort to explain the value of this system to medical students. We encourage them to become patient advocates and to find opportunities to continually improve the quality and access to healthcare for all people.

We hope that many medical students will choose pediatrics. Children are our future, and pediatricians are the most highly trained and qualified physicians to ensure that all children thrive and reach their full potential.

Steven Kairys, MD, MPH, FAAP, is the Medical Director for AAP/NJ and the New Jersey Pediatric Council on Research & Education (PCORE) and the Chair of Pediatrics at Jersey Shore University Medical Center.

Meg Fisher, MD, FAAP, is the Vice President of the AAP/NJ Chapter, the Co-chair of New Jersey Immunization Network and the Chair of Pediatrics at Monmouth Medical Center. Stephen Rice, MD, PhD, MPH, FACSM, FAAP, is the President of AAP/NJ and Director of the Jersey Shore Sports Medicine Fellowship at Jersey Shore University Medical Center. Richard Lander, MD, FAAP, is a general pediatrician and the Co-chair of the AAP/NJ Pediatric Council & Practice Management Committees. Larry Frenkel, MD, FAAP, is an immunologist and an infectious disease specialist; he is the AAP/NJ Co-chair of the New Jersey Immunization Network.

Michael Weinstein is the AAP/NJ Director of Communications and a PCORE Program Co-Director. Fran Gallagher, MEd, is the Executive Director of AAP/NJ and PCORE.

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MDAdvantage Two Princess Road, Suite 2 Lawrenceville, NJ 08648

&

HONOR Honor Your Profession By Honoring Your Peers.

NOMINATIONS NOW BEING ACCEPTED. OUTSTANDING MEDICAL EDUCATOR AWARD OUTSTANDING MEDICAL EXECUTIVE AWARD EDWARD J. ILL PHYSICIAN’S AWARD® VERICE M. MASON COMMUNITY SERVICE LEADER AWARD OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR BASIC BIOMEDICAL RESEARCH OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR CLINICAL RESEARCH PETER W. RODINO, JR., CITIZEN’S AWARD®

A TRADITION OF HONORING EXCELLENCE.

Written nominations will be accepted through August 17, 2012.

Log on to www.EJIawards.org for nomination guidelines and further information about the event, or call us at 609-803-2350.

Nominations are open to all New Jersey physicians, healthcare professionals and community leaders, and should be submitted to: Paul J. Hirsch, MD, Chairman, Edward J.Ill Excellence in Medicine Foundation, c/o MDAdvantage Two Princess Road, Suite 2, Lawrenceville, NJ 08648 Nominations may also be submitted electronically to Jpuro@EJ Iawards.org.