Med Monthly March 2012
BRAIN INJURIES ON THE RISE
Head trauma more frequently linked to athletic fatalities
GENERAL EQUIVALENT MAPPINGS Plus a mini quiz to get you prepared!
CARING FOR CHAMPIONS Exclusive interview with Duke's head men's basketball athletic trainer, Jose Fonseca
THE MANY BENEFITS OF PLASMA THERAPY P.45
Caring for Champions
features 12 BLOODY GOOD MOVE
Is platelet-rich plasma therapy a good idea?
20 INJURIES RISE IN SPORTS
An investigation into frequent head trauma
30 CHANGE WITHOUT TEARS 5 steps to managing change
research and technology
40 GENERAL EQUIVALENT MAPPINGS
10 HEALTH CARE IT TO REDUCE READMISSION
A guide to what the flags really mean
18 NEW ORTHOPEDIC DEVICE ANNOUNCED
44 HOSPITAL ACQUISITION STRATEGY
The second in a two part series
48 CARING FOR CHAMPIONS
Duke's head men's basketball athletic trainer
Irish Soda Bread Recipe
24 DIVERSITY TRAINING 26 MEDICAL MARKETING WITH THE WEB 34 WHAT TO EXPECT FOR A LAB INSPECTION
legal 36 ELECTRONIC FUNDS TRANSFER STANDARDS 38 MALPRACTICE CAPS IN JEOPARDY 38 PHYSICIAN EMPLOYEE AGREEMENT PITFALLS
the arts 52 FINDING A CURE ON THE HORIZON
the kitchen 55 IRISH SODA BREAD
in every issue 4 editor’s letter 8 news briefs
62 resource guide 76 top 9
COVER PHOTO COURTESY ISTOCKPHOTO
editor’s letter Greetings Medical Professionals! Athleticism is one of society’s most highly regarded and admirable virtues. Those who exhibit superior endurance, strength, agility, speed and skill in competition are universally respected by opponents and spectators alike. An athlete’s body is a model of perfection, anyone providing them with health care must possess the highest level of medical proficiency and empathy for their patients. Our March issue is dedicated to the medical professionals working in the field of sports medicine. We thank you for keeping our beloved athletes in action and functioning at their best. Sports medicine physicians provide body and mind health care to our athletes so that they can entertain their fans. Our cover story, “Caring for Champions,” is based on our interview with Jose Fonseca, head athletic trainer for the men’s basketball team at Duke University. Fonseca was gracious enough to share his perspective on caring for a team of burgeoning, nearly professional basketball champions. The following pages will also bring you reports of fascinating research in platelet plasma-rich therapy and its potential to allow injured athletes to return to play much faster. You’ll also learn about the new found connection between concussive injuries and the mortality of a growing number of athletes. No issue of Med Monthly would be complete without a plethora of knowledge to improve your practice, bring more patients through your doors and significantly increase your cash flow. In our March issue we follow up with the conclusion of Cameron Cox’s two-part series on hospital acquisition only to bring you the beginning of another informative, multiple-part piece. Amanda Kanaan, an expert in Internet medical marketing, stresses how crucial it is for today’s medical practices to have tremendous web visibility in order to survive in our technologically reliant society. Marla Broadfoot reports on innovative research in health informantics that aims to decrease hospital readmissions by giving primary care providers improved follow-up instructions that will allow them to properly handle outpatient treatment and greatly diminish health care costs. Cathy Warcshaw explains how imperative it is for your staff to have training in cultural relativism in order to provide high quality customer service to all of your patients. Suzanne Leder has put together another stellar article on general equivalent mappings, accompanied by an interactive worksheet that will allow you to test your skills in ICD-10 coding. Also, be sure to review our legal section for important announcements involving the jeopardy being placed on malpractice statutory caps in various states, and CMS’s new electronic funds transfer standards and how they could greatly reduce administrative burden and overhead in your practice. It was truly a pleasure to prepare this (and every) issue of Med Monthly. I’d like to thank you all for your continued support and readership; I hope that you enjoy our March issue. Be sure to check out our April issue as it is an absolute must read! Our editorial theme for next month is on practice management and the magazine is already shaping up to be one of our best editions yet! Thank you to our loyal following for continuing to allow us to bring you the most pertinent news in health care today. Sincerely,
Leigh Ann Simpson Managing Editor 4 | MARCH 2012
Med Monthly March 2012
Leigh Ann Simpson
Mary Pat Whaley, FACMPE Nancy Walsh Hary Stafford, MD, CAQSM Marla Broadfoot Amanda Kanaan Tatiana Melnik J. Benjamin Dolan Ralph Levy, Jr. Ashley Acornley, MS, RD, LDN Suzanne Leder, BA, M. Phil., CPC, COBGC Cameron Cox, III, MHA, FACMPE Cathy Warschaw
Med Monthly is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices. We are currently accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at medmonthly.com/writers-guidelines P.O. Box 99488 Raleigh, NC 27624 email@example.com Online 24/7 at medmonthly.com
Cathy Warschaw is the Director of the Warschaw Learning Institute. She has participated in hotel management overseas, owned an international restaurant, supported and worked on the boards of a number of multi-cultural organizations. Cathy is also the Director of the Dental Management Club a unique membership site for dentists and dental team members worldwide.
Ashley Acornley, RD, LDN holds a BS in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and recently completed her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog can be found at: ashleyfreshfromthefarm.wordpress.com
Amanda Kanaan is the owner/founder of WhiteCoat Designs – an online marketing agency committed to growing doctors’ practices through cost-effective and powerful online marketing solutions. Amanda regularly speaks at medical association meetings and conventions and is a published expert in the field of medical marketing. To learn more or for a free website evaluation, contact her at Amanda@ whitecoat-designs.com or www.whitecoat-designs.com
Mary Pat Whaley, FACMPE is board certified in health care management and a Fellow in the American College of Medical Practice Executives. She has worked in health care and health care management for 25 years. She can be contacted at firstname.lastname@example.org
Elizabeth “Libby” Knollmeyer, B.S., MT (ASCP) has over 40 years experience in the laboratory industry. She specializes in financial, operational management and compliance issues for hospital and physician office laboratories. Libby has a wide variety of experience with her areas of special expertise including financial review and management, compliance and regulatory assistance and lab design. She can be reached at email@example.com. MEDMONTHLY.COM |5
SOMETIMES, THE GAME THEY LOVE DOESN’T LOVE THEM BACK. More and more, young athletes are focusing on a single sport and training for that sport year-round — a practice that’s led to an increase in Overuse Injuries. Left untreated, overuse trauma to young shoulders, elbows, knees and wrists may require surgery and have lifelong consequences. For information on preventing and treating Overuse Injuries, visit these sites: orthoinfo.org
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DE P AR
Studies Suggest Club Drug Offers Quick Relief from Depression
Monitored Heart Bracelet May Prevent Sudden Death in Sports
Recent studies conducted by Yale University researchers indicate that low doses of ketamine can rapidly reduce symptoms of depression. Ketamine has been used as an anesthetic for years and is also a popular illegal club drug known as “special k.” Depression is commonly treated with prescription antidepressants such as Prozac, Paxil or Zoloft, however, these drugs can take weeks to improve symptoms. The delayed relief is problematic as it leaves patients suffering in their depressive state for weeks, waiting for the antidepressants to take effect. In cases of severe or suicidal depression health care providers are sometimes forced to take drastic measures such as hospitalization to monitor a patient until their symptoms decrease to ensure their safety. A drug that could immediately elevate symptoms of depression would render such drastic measures and some hospitalizations unnecessary. The usage of ketamine for fast acting relieve of depression could potentially be a tremendous leap forward in mental health – reducing the social stigma and fear associated with psychiatric treatment.
Estimates show that 200,000 athletes around the world experience sudden death each year. The IC-Life business project has developed a heart bracelet for athletes of all interests, ages and fitness levels, that could prevent cases of sudden death in sports. The heart bracelet can detect cardiac abnormalities that prelude sudden death as early as 60 minutes before cardiac arrest occurs. The heart bracelets are connected via information and communication technologies (ICT) that track and monitor an athlete’s pulse in real time. If an abnormality is detected the device sends three signals to warn the control monitor, any medical assistance in the sports facility (if available) and the nearest hospital, greatly reducing response time. Medical professionals have only a small window of time COMING SOON to save a patient suffering from cardiac arrest. Such an imIN MED MONTHLY mense decrease in response ting Med Monthly is investiga time could increase the likeli. this research on ketamine hood of saving a patient’s life Look forward to a detailed and/or preventing negative h and long-term effects caused by report in our Mental Healt cardiac arrest. Substance Abuse Issue in May, 2012. 8 | MARCH 2012
Medical Device Makers Reach User Fee Deal with FDA
HHS Announces Intent to Delay ICD-10 Compliance Date As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services (HHS) Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition (ICD-10) diagnosis and procedure codes. The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of Oct. 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward. “ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.” ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.
The Food and Drug Administration (FDA) has made a deal with medical device makers to pursue the goal of making reviews more predictable and transparent in exchange for a 100 percent increase in user fees from manufacturers, in a preliminary agreement. Although the deal is not finalized, it solidifies a program in which the medical device industry has supplemented the FDA’s budget with company payments for years. The decision was announced in early February, 2012 and is set to give the FDA $595 million in user fees, essentially doubling the $295 million paid by medical device makers over the past five years. The FDA is planning to use the money to add 200 new scientists to the agency staff. The medical device industry has been negotiating with the FDA for the past year behind closed doors to push for shorter, more predictable review times. Medical device makers are frustrated because regulations in Europe and other foreign countries allow devices to be approved much faster than in the United States. The FDA has said that it will send the agreement to Congress once they have sorted out the final details. Congress must then draft and approve the agreement before Oct. 1, 2012 in order for it to become law.
research & technology
Health IT Aspires to Reduce Readmissions Researchers aim to utilize health informantics to improve outpatient care given after hospital release By Marla Broadfoot 10 | MARCH 2012
fforts to keep recently discharged patients from returning for another hospital stay could mean better health for patients and save hospitals millions of dollars. Hospital readmission is a nationwide problem as one out of every five Medicare
patients return to the hospital within 30 days of their release. With the passage of Health Care Reform, hospitals with excessive readmission rates will soon be subject to severe financial penalties. A project being worked on by researchers at the North Carolina Translational and Clinical Sciences Institute (NC TraCS) may be able to reduce those rates by giving primary care doctors the information they need to effectively care for their patients once they go home. The venture makes discharge summaries available electronically and uses health informatics to mine the summaries for important information regarding follow-up. “Let’s imagine someone gets admitted to the hospital with a really bad urinary tract infection,” explains Carlton Moore, MD, a clinical associate professor of medicine at the University of North Carolina (UNC) in Chapel Hill, N.C., and a leader of the project. “That patient would get a chest x-ray as part of their admission, and if the x-ray were to show an abnormality, the hospital physician would typically not make them stick around to get it worked up, but would allow the result to be followed as an outpatient.”
“The way the current health care system is structured, the burden lies with the patients or physicians to remember to follow up. Unfortunately, human beings are fallible and things can fall through the cracks,” continued Moore. “Now the trend is toward developing systems that absorb human fallibility so that when doctors or patients forget to follow up there is something built into the system that alerts them to follow up on an abnormal test result or doctor’s appointment.” With a $500,000 informatics grant from the Duke Endowment, Moore and Don Spencer, MD, vice president of ambulatory care for the UNC Health Care System, led a team that transferred complete discharge information for UNC patients to Community Care of North Carolina (CCNC). Moore says UNC is the first hospital in the state to put this information into CCNC’s provider portal (an electronic system that helps case managers ensure that patients are taking their medications) and following up with primary care doctors after their hospitalizations. “The bottom line is that case managers to date have not had access to the discharge summaries to know how to best take care of their
patients,” said Brent Lamm, director of information technology at NC TraCS. “Even then, these discharge summaries can be pages long, making it challenging for the case workers to read in their entirety and glean what is relevant. So we are using informatics technology to distill down a complex discharge summary into actionable information the case managers can efficiently use in their work.” The researchers are employing an informatics technique known as natural language processing to analyze the discharge summaries, pull out relevant textual information and flag abnormal findings for follow-up. Armed with a NC TraCS $50,000 pilot award, Moore and his colleagues will use their approach to identify abnormal results from a test set of computerized axial tomography (CAT) scans, mammography and Pap smears before expanding to other types of visual data. “I am looking at it more from a quality of care perspective, just to make sure that these abnormal results actually get followed up on,” sai Moore. “The vast majority of the time these masses are benign, but every once in a while they are malignant and warrant surgery or chemotherapy. We don’t want to miss those.”
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research & technology
Bloody Good Move Many athletes today are asking for platelet-rich plasma therapy when they are injured, but is it a good move?
By Harry Stafford, MD, CAQSM, Mark Sakr, DO, Natasha Harrison, MD, Josh Berkowitz, MD & David Berkoff, MD
latelet-rich plasma therapy (PRP) has been a hot topic in sports medicine over the past few years. Many high-profile athletes who have undergone this cutting edge treatment have generated headlines, leading injured athletes at all levels to wonder if PRP might be right for them. Here is just a short list of professional athletes who have used the therapy. In 2009, Pittsburgh Steelers players Hines Ward and Troy Polamalu reportedly used PRP before winning the Super Bowl. Tiger Woods had PRP injections after knee surgery the same year. Tennis player Tom Mendenhall and Major League Baseball pitcher Takashi Saito have undergone the treatment on their elbows. NBA star Brandon Roy used PRP to help heal an injured hamstring last year. MEDMONTHLY.COM |13
PRP is not a novel treatment; it has been used for more than 20 years, mainly outside the sports medicine field. The first clinical application of PRP appeared in the treatment of cutaneous ulcers to promote wound healing. Since then, PRP has been utilized and studied in multiple fields including plastic surgery, oral implantology, maxillofacial surgery, orthopedics and sports medicine. PRP has been used to treat athletes of epicondylitis, achilles and patellar tendinopathy, ligament sprains, knee osteoarthritis and muscle strains. Additionally, orthopedic surgeons have utilized PRP as an intra-operative measure not only to promote healing, but also to aid in bone and cartilage growth. The PRP movement is gaining steam because of its potential to get injured athletes back in action faster. Through this simple injection doctors are finding that PRP can promote muscle and tendon healing. This is not to say that PRP is a panacea – studies are not conclusive on its efficacy. Sports medicine providers have utilized PRP with varying degrees of success, and it only works in conjunction with a closely followed rehab plan.
How it Works Understanding how PRP works starts with taking a look at its inherent healing and growth-promoting factors. Blood contains plasma and platelets that travel throughout the body and spring into action when an injury occurs. Platelets primarily promote blood clotting, tissue proliferation, healing, and remodeling by triggering growth factors and cytokines from within their alpha granules. The idea behind PRP is to use high concentrations of platelets to promote healing. Most PRP 14 | MARCH 2012
preparations contain a concentration of three to five times more platelets and growth factor concentrations up to 25 times that of normal blood. This rich concentration is achieved through collecting the patients’ own blood and using varying substrates, filters and centrifugation to produce the platelet-rich solution. The particular method of concentrating the PRP solution produces different concentrations of cells and growth factors. Treatment with PRP can be used on many different types of injuries, but most have found that PRP works best for muscular injuries. Great success has been seen with hamstring injuries in particular – no reoccurrences of pain or disability after treatment. PRP also works well for tendon injuries, likely because of the normally limited blood supply to tendons. These are purely anecdotal findings, study results have been mixed at best. Unfortunately, it is not clear why PRP works well in some cases and not in others.
PRP Procedure In the first step of PRP graft formation, a volume of whole blood is drawn from the patient, which can range from 10 to more than 60 cubic centimeters, depending on the separation system being used. Following the draw, the blood must be separated into its various components. There are several separation techniques available including: gravitational platelet sequestration (centrifugation), standard cell separators or plasmapheresis. The most common technique is centrifugation. Using gravity, a centrifuge separates the blood into its component layers based on molecular weight, size and type of cell. Most centrifuge systems work in a similar manner, with the
end product varying according to the centrifuge timing and speed. Once spun, the cells form distinct layers. The top layer of red blood cells (RBC) will have both platelets and plasma and is usually yellow in color. The buffy coat layer, which is cloudy yellow, contains both highly concentrated platelets and white blood cells (WBC). The bottom layer is the red cell layer and is red in color. The medical community is still debating the best concentration of the different components since clinical studies are in the early stages of providing a definitive answer. Most physicians continue to experiment with PRP preparation. Some physicians use plasma-based systems, in which only the top layer is used for the PRP graft. Others opt for a buffy coat-based system, in which the top layer may or may not be used. The highly concentrated buffy layer is taken with a small amount of the accompanying RBC layer. Based on the initial volume of blood taken and the preparation system used, final platelet concentrations will vary from 1.7 times baseline to greater than 10 times the patients’ baseline platelet values with variable amounts of both WBC and RBC contained in the final preparation. Because the different preparation techniques lead to significant variations in the final product, Alan Mishra, MD, has created a PRP classification template. The template divides PRP into types based on three factors: the presence of WBC, if WBC are activated and the absolute platelet concentration. In addition to the differences already mentioned, other variations exist among how the PRP preparations are implemented. Some require the addition of anti-thrombotic agents during the preparation phase
while others use an activator at the time of application. It is critical for any physician using this technique to be very knowledgeable about the various PRP preparations. For example, the transforming growth factor beta (TGF-beta) found in PRP that promotes fibrosis at too high of a concentration has increased re-injury rates. In addition, the final PRP treatment graft will vary according to the preparation technique applied to the patients’ whole blood. After deciding on the PRP type, the timing and number of injections must be carefully considered. Currently, no formalized recommendations exist. Some providers advocate the use of up to three injections that are given two weeks apart, while others are much more conservative. Our experience has been that a single injection will typically accomplish the treatment goal. If a second injection is necessary, wait at least one month after the rehabilitation process. An exception to this recommendation is for the treatment of athletic pubalgia, which requires two injections separated by one week. In many cases, these decisions are guided by the patient’s financial situation. Because most insurance companies do not cover PRP treatments, patients must weigh the cost before choosing the therapy – each injection costs between $500 and $2,000. In order to maximize recovery, the PRP must be injected into the damaged area properly. This is best achieved with the guidance of an ultrasound. Tendon injections typically require the provider to not only inject the injured area, but also use the needle to make several holes into the injured tendon (fenestration). The hole openings will facilitate an increased inflammatory response to promote healing. PRP treatments given to
ligaments, muscles, bones and joints do not require needle fenestration.
Rehabilitation Phase Following the injection procedure, the treated area is typically protected by using a brace, sling or crutches for 24 to 48 hours. The rehabilitation phase takes four to six weeks and is perhaps the most important element of the PRP treatment process. We believe the particulars of the rehabilitation phase account for much of the variability in PRP study outcomes. The rehabilitation phase should start with gentle range of motion activities and move to strengthening of the opposing muscle groups, at which point the muscle tendon unit should be attended to. The treated unit should be strengthened slowly, allowing adequate time for the tendon to continue the healing process, while stress on the unit is increased. Athletic trainers must pay attention to the flexibility and strength of opposing muscle groups. If not properly managed, re-injury is likely to occur. Patients should progress to the next level only when they are able to perform the exercises and use the modalities without pain.
Treatment Outcomes The use of PRP in clinical practice has increased tremendously. As a result, there is far more clinical experience, anecdotal evidence and uncertainty than there is highquality data from well-designed clinical trials. However, there are some published results that can be used as a guide during the use of PRP for specific injuries. Note that this article is not meant to serve as an exhaustive summarization of the literature. Additionally, because there is no consensus regarding the most
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appropriate concentration, preparation or administration procedures, or post-administration protocols for PRP therapy, there is significant variation in the published literature with regards to what PRP therapy entails. However, general trends are emerging. The safety and efficacy of autologous blood injections was demonstrated in a 2002 study in rabbits. Since that time, research has assessed the potential therapeutic value of PRP in various tendinopathies. Some of the strongest evidence favoring PRP therapy has come from studies of patients with chronic lateral epicondylosis (tennis elbow) recalcitrant to conservative therapies. Research published in 2010 demonstrated PRP was superior to corticosteroid injections in such a patient population, while a 2006 study found PRP to be more beneficial than bupivacaine injections in these patients. Patellar tendinopathy has been studied less in humans, but research shows promise. A study showed decreased pain and improved activity level in patients treated for refractory chronic patellar tendinopathy with PRP and physical therapy compared to a control group that received only physical therapy. Other uncontrolled human studies have suggested efficacy in this setting as well. PRP treatment has shown mixed results in the treatment of Achilles tendinopathy. One small case controlled study found more rapid recovery in range of motion and return to training for surgical patients augmented with PRP injections when compared to surgical patients who did not receive PRP injections. Another showed improvement in a small case series. However, a recent randomized controlled trial failed to show significant benefit with a combination of PRP injection and 16 | MARCH 2012
eccentric exercise program versus eccentric exercise alone. Studies of PRP therapy for rotator cuff tendinopathy have also been inconsistent. While one suggested improved functional scores in patients who received PRP therapy after arthroscopic repair of rotator cuff tears with some benefit continuing beyond the immediate post-operative window, other studies have been unable to confirm this benefit. Acute muscle injuries: Although no high-quality human studies of PRP treatment for acute muscle tear or strain injuries have been done, there is some evidence of rat models demonstrating shortened recovery time after a PRP injection as compared to a platelet-poor plasma injection and no injection. Anecdotally, our group has found PRP treatment for hamstrings, quadriceps, and other muscular injuries brings good results and faster return to play. Ligamentous injuries: The potential for PRP therapy to improve outcomes in patients with ligamentous injury has also been explored. A study over a decade ago demonstrated improved mechanical strength in injured rabbit medial collateral ligaments (MCL) treated with PRP. In addition, recent anecdotal reports suggested athletes can return to play earlier than expected when these injuries are treated with PRP. However,
FAST FACT PRP injections contain high concentrations of platelets to promote healing, allowing athletes to return to play faster.
no compelling data to this effect has been published. Several randomized controlled trials have failed to show any benefit of autologous platelet-rich products in the surgical repair of ACL tears. One non-human study did find improved mechanical strength three months post-operatively in the ACLs of pigs treated with a PRP-supplemented collagen scaffold. Other soft tissue conditions: In a small 2004 case series, researchers assessed the efficacy of PRP injections for treatment of chronic, refractory plantar fasciitis. Seven of the nine patients achieved complete resolution of symptoms after treatment with PRP. Bone and cartilage conditions: PRP therapy has also been performed in conditions other than soft tissue injuries. Weak evidence from a prospective study demonstrated mild improvement in certain patient populations with knee osteoarthritis from intra-articular PRP injections. In terms of meniscal injuries, one study involving rabbits showed improved healing when treated with sustained-release PRP from gelatin hydrogels. The evidence for treatment of chondral defects exists largely as animal data, with studies demonstrating improved cartilaginous healing with various plateletrich therapies. There also exists a published case report of a good outcome in a child with a chondral avulsion lesion who was treated with PRP. Hopefully, future research will shed more light on how and when to use PRP. In the meantime, we are finding anecdotal evidence that the procedure will help decrease return to play times after injury, as long as a proper post-PRP therapy protocol is carefully followed. ď‚˘
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research & technology
Medical Group Announces U.S. Launch of Orthopedic Device Pre-operative navigation and alignment guide set to revolutionize total ankle replacement surgery
right Medical Group, Inc., a global orthopedic medical device company, announced the 510(k) clearance and limited launch of the Prophecy Inbone Pre-Operative Navigation Alignment Guides for total ankle replacem�������� ent. Designed for use with the company’s Inbone Total Ankle Replacement Systems, the Prophecy Inbone PreOperative Navigation Alignment Guides are now available in select sites in the U.S. through Wright Medical’s specialized foot and ankle sales force. Full U.S. commercial release is anticipated to take place in the second half of 2012. The Prophecy Inbone Pre-Operative Navigation Alignment Guides, along with the Inbone Total Ankle Replacement Systems and other orthopaedic product solutions, was on display at the American Academy of Orthopaedic Surgeons (AAOS) 2012 Annual Meeting at the Moscone Convention Center in San Francisco. Initially developed by Wright Medical for total knee replacement, the Prophecy Pre-Operative Navigation Alignment Technology utilizes computed tomography (CT) scans to create
18| MARCH 2012
patient-specific ankle alignment guides that facilitate the surgeons’ ability to precisely size, place and align the Inbone Total Ankle Replacement components during surgery. Gregory Berlet, MD, a foot and ankle surgeon with the Orthopedic Foot & Ankle Center in Columbus, Ohio, performed the first surgical procedure using the new system. “The Prophecy Inbone Pre-Operative Navigation Alignment Guides enable me to accurately position the Inbone Total Ankle Replacement components while providing predictable implant alignment from case to case,” stated Dr. Berlet. “With this new addition to our growing suite of foot and ankle products, surgeons now have a visual plan that details implant placement in advance of the actual surgery, which can reduce the amount of standard in-
strumentation required in the operating room and streamline the surgical procedure,” said Robert Palmisano, president and chief executive officer. “We are committed to developing innovative devices to improve patients’ quality of life, as well as surgeons’ experiences while they operate.” With an estimated 4,000 procedures expected to occur in the U.S. in 2012, total ankle replacement represents a growing market opportunity to treat the approximately 50,000 people per year in the U.S. who experience severe ankle pain due to end-stage ankle arthritis. Today, approximately half of these patients are treated with ankle fusion, but advances in implant design have made ankle replacement a feasible surgical option for many people. In addition to providing pain relief, ankle replacements can offer patients better mobility compared to fusion.
More information on Wright Medical’s foot and ankle products, including the Prophecy Inbone PreOperative Navigation Alignment Guides and the Inbone Total Ankle Replacement Systems, can be found at www.wmt.com/footandankle/ About Wright Medical Wright Medical Group, Inc. is a global orthopedic medical device company and a leading provider of surgical solutions for the foot and ankle market. The Company specializes in the design, manufacture and marketing of devices and biologic products for extremity, hip and knee repair and reconstruction. Wright Medical has been in business for more than 60 years and markets its products in over 60 countries worldwide. For more information about Wright Medical, visit the company’s website at www.wright.com.
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research & technology
Injuries Rise in Sports An investigation into the neglect and morbid reality of frequent head trauma in athletes By Nancy Walsh
he tragic toll from traumatic brain injury continues to climb among athletes who routinely hit their heads – or use them as weapons – during play on the field or fights on the rink. The Boston University Center for the Study of Traumatic Encephalopathy, where researchers last spring diagnosed the late football star Dave Duerson as having chronic traumatic encephalopathy (CTE), now has 60 confirmed cases of athletes with CTE in its brain bank, according to neuro-
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psychologist Robert A. Stern, PhD, codirector of the center.
Cases from the Gridiron The first case of sports-related CTE was reported in Neurosurgery in 2005. The report enraged NFL officials who vehemently denied the possibility of a causal connection. By 2008, however, it had become clear that some football players indeed were experiencing sequelae of their frequent head trauma. The Boston
University research initiative was established at that time, soliciting tissue donations from deceased players. In addition to Stern, co-directors include Ann McKee, MD, Robert Cantu, MD and Chris Nowinsky, a former football player and professional wrestler with a history of multiple concussions. “When we first started our center
over three years ago we expected to find CTE in a small number of athletes, and specifically in those who had a history of significant concussion,” Stern said. That turned out to be wrong. Not only have there been many more cases than anticipated, but several of the affected individuals had only subconcussive injuries – though lots of them. “These are
the types of hits that a lineman in football gets, where in every play of every game and every practice – some 1,000 to 1,500 times each season – he hits his head against his opponents with a force of about 20 G, which is not a minimal force,” Stern explained. The end results in susceptible individuals, according to autopsies done by his group, include
widespread abnormalities similar to those seen in Alzheimer’s disease, including neurofibrillary, glial and astrocytic tangles and abnormalities in tau proteins.
The Rules Tighten In response to the escalating concerns about brain injury, the NFL has tried to crack down on dangerMEDMONTHLY.COM |21
BRAIN DRAIN Researchers have 60 confirmed cases in which fatalities were linked to chronic traumatic encepalopathy and neglect.
ous play, instituting a program of enhanced enforcement for safety violations. This season, for instance, Detroit Lions player Ndamukong Suh received a two-game suspension after being observed stomping on another player’s arm in a Thanksgiving Day game. More recently, the Pittsburgh Steelers’ James Harrison was suspended for one game in December as punishment for a helmet-to-helmet hit that left quarterback Colt McCoy of the Cleveland Browns with a concussion. Even though the blow was witnessed by millions on television, the Browns’ medical staff failed to realize he had suffered a head injury and cleared him to return to play a few minutes later. The Sport Concussion Assessment Tool – mandatory in the NFL since 2009 – was not administered to him until the next morning. Stung by criticism of the oversight, the NFL responded with a new system in which certified athletic trainers, stationed in the coaches’ booth above the field, will watch specifically for potential concussions. They will then tell teams on the sidelines when they need to evaluate players with the assessment tool. A growing number of players are not satisfied with the NFL response and are determined to force the league to acknowledge their longterm health problems relating to concussions. Recently, four former players sued the NFL in U.S. District Court in Atlanta, according to an Associated Press report. In their lawsuit, Jamal Lewis, Dorsey Levens, Fulton Kuykendall and Ryan Stewart allege that the league has been aware 22| MARCH 2012
of the risks of head injury for decades and “has done everything in its power to hide the issue and mislead players associated with concussions.” The players claim to experience problems such as headaches, memory loss and sleep disruptions.
who also had experienced periods of depression and died in uncertain circumstances at 35 after playing for a number of teams including the Toronto Maple Leafs.
Hockey Under Scrutiny
Research into CTE is still in its infancy, Stern said. But because of the similarity in pathologic findings between CTE and Alzheimer’s disease, his group has been building on the substantial body of knowledge about Alzheimer’s, using the latest technologies and techniques such as neuroimaging and basic science approaches. “All the neurodegenerative diseases have complex neuropathogenetic pathways, involving genetics and epigenetics, environmental risks and aging-related factors,” Stern said. “Although the initiating event in CTE appears to be trauma, early in the disease course there is some disturbance of neuronal integrity leading to a cascade of pathophysiologic events that ultimately results in neurodegeneration,” he explained. But not everyone with repetitive head trauma develops CTE, so Stern and his colleagues are now trying to tease apart other potential contributory factors, such as individual players’ specific trauma history, age at first injury, total duration of trauma exposure and the length of rest between injuries. Stern also has recently been awarded a grant from the National Institutes of Health to develop biological markers that could be used to identify CTE earlier, rather than in postmortem neuropathologic exams. To do this, his group has enrolled 100 former NFL players who were linemen, linebackers and defensive backs – the positions with the greatest exposure to repetitive brain trauma – and 50 non-contact sport athletes with no history of brain in-
The focus on head injury also now has expanded to violence on the hockey rink. The death of the NHL player Derek Boogaard in May from an overdose of alcohol and pain killers, and the subsequent finding of extensive CTE – in a man only 28 years old – added to concerns about safety in contact sports. Boogaard, known as Boogeyman, had been an “enforcer” for the NHL, meaning that he was a designated fighter who routinely collided with other players and engaged in fistfights on the ice to intimidate his opponents and delight the audience. During the 2009-2010 season, he had been knocked down during a fight and struck his head on the ice, after which he complained of headaches. According to a story in the New York Times, he became withdrawn and sullen and was having memory losses while drinking heavily and taking numerous drugs such as oxycodone. He entered rehab, but left and became more reclusive, erratic and returned to substance abuse. He was found dead in his New York City apartment on May 13, 2011. Unlike the NFL, the NHL has shown no interest in banning fighting or otherwise changing the culture of the game, according to the Times article, despite the deaths of other scrappy players. These included Rick Rypien, who committed suicide at 27 after struggling with clinical depression during a career with the Vancouver Canucks marked by frequent fighting, and Wade Belak,
The Alzheimer’s Link
jury. They are performing extensive clinical, neurologic and neuropsychological examinations to look for factors common among those who develop the disease. Stern and his colleagues also are collecting blood for DNA genotyping, doing lumbar punctures to analyze proteins (such as tau) and conducting extensive brain scans including diffusion tensor imaging, as they puzzle out the steps in the lethal pathway to CTE.
Kids at Risk It isn’t just professional athletes who are at risk for these injuries. “We are appreciating more the particular potential vulnerability of, and long-term consequences to the young brain as a result of concussive and subconcussive brain trauma experienced through participating in certain youth sports,” said Michael Bergeron, PhD, of the University of South Dakota in Sioux Falls, S.D.. Participation in sports can provide numerous benefits to young people, as well as being fun. “However, the motivations of some adult stakeholders are sometimes in conflict with these objectives, and the professional model of development and high-impact styles of play for young players are increasingly encouraged, prevalent and accepted,” cautioned Dr. Bergeron, who is also the executive director of the National Youth Sports Health and Safety Institute. “My hope is that there will be a change in the way children and adolescents train, compete and safely return to play after an injury. By promoting healthy coaching, training and competition overall and emphasizing fitness, skill acquisition, diversified athletic experiences and fun – we can reduce overall injury risk, including head trauma,” he said. Reprinted from Med Page Today
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practice. Your front office staff also manages the administrative duties of your practice including scheduling, finances and patient information; therefore they should understand how to effectively communicate with all of your patients, regardless of their cultural distinction.
How important is diversity training? Diversity training is often misunderstood by instructors who do not realize the extent of what should be covered. Proper training will discuss the following areas: culture religion race ethnicity sexual orientation gender disabilities
Cultural Relativism in the Medical Practice The importance of staff training in social diversity and its potential effects on your bottom line By Cathy Warschaw, Director of the Warcshaw Institute
hen should you implement diversity training into your practice? The answer is sooner than later but, sadly, this issue is rarely addressed until there is reason to. If you and your staff have not had some form of diversity training you are missing a crucial element in your ability to provide superior customer service to
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your patients. Diversity training is also important in establishing good employee relations among your staff. Although your entire office should be trained in diversity, it is paramount for your front office to be well versed in the cultural differences of your patients; they answer your phones and are often the first face that your patients see when they come to your
These are all important factors in maintaining quality care to your patients. You may not think that you have ever had an issue with these subjects or you may feel as though your practice does not need to address these topics, however, you will deal with all of these areas at some point. As health care professionals we interact with a diverse population and have vowed to assist everyone that requires treatment. Understanding other cultures will provide a more positive experience for every patient that is seen in your practice. For example, a person who rejects treatment or will not take certain medications may do so because of their culture or religion. Knowing the reason why an individual rejects treatment will allow you to change your approach, leading to better quality care.
How will diversity training positively impact my practice? Do you think that diversity training (or a lack of) affects the reputation of
your office? If you answered yes, you are 100 percent correct. If your staff poorly communicates with patients because of language barriers, lacks respect for cultures or religions that are not their own, or treats people of other races and sexual orientation differently it will lead to poor customer service and bad word of mouth. The health care community may seem large, but bad news travels quickly through it and if your staff is rude and disrespectful, everyone will soon know. The small amount of time and money it takes to properly train your staff will pay off in the end. Utilizing diversity training can also assist with employee confrontations to avoid a hostile work environment. If your staff does not show respect for one another, your patients will notice.
Where do you begin? The first hurdle in providing diversity training is deciding where to begin. If you work in a hospital or larger medical facility, training is usually set up by a human resource department. In smaller practices, the responsibility will fall on the doctor or office manager to provide instruction. It may be best to seek outside assistance from vendors that specialize in diversity training. Organizations that provide diversity training
assistance can be found on the Internet or through recommendations from other practices. Online training is a convenient option that allows classes to be arranged around the practice’s schedule to prevent having to close the office. When selecting a training program remember that the instruction should cover all aspects of diversity and help you make the necessary changes to accommodate the different cultures you may encounter. A great recommendation is the Warschaw Learning Institute; they will be offering diversity webinars beginning in March 2012.
Making necessary changes Upon completion of your diversity training program, it is important to set standards and guidelines of what is now expected. Look into your patients’ profiles and decide if you need to make changes to accommodate any of your patients. Perhaps you have several Spanish speaking patients and you are experiencing a breakdown in communication with them. If you have not already, you should hire new staff members that speak Spanish and/or provide brochures and literature in Spanish. Studying the demographics of the areas around your practice is extremely important and can assist you
in providing quality care to everyone that enters your practice for treatment. Diversity training is not just taking a course, and although training will provide you with the tools, it needs to be maintained and reviewed. Discussing possible scenarios or role playing is a good way to continue with your training and can be done periodically at staff meetings. In the end, your practice will become more successful by knowing and respecting your patients and fellow team members. Diversity is a touchy subject for some people and not everyone is open to discussing things that make them uncomfortable. However, everyone working in health care should be open-minded and respectful even in situations that put us outside of our comfort zones. Diversity training is not about asking you to forget what you believe in, it is about cultural relativism – respecting beliefs other than our own. It is also about breaking communication barriers so that patients leave your office understanding what they have been told regarding their treatment. Do not settle with just getting by and waiting until you fall upon a situation to address diversity. To find out more about the Warschaw Learning Institute’s cultural diversity training programs go to www.WarschawLearningInstitute.com
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Turn Your Website into a Medical Marketing Machine Discover the benefits of search engine optimization, social media and online reputation management in today’s health care market By Amanda Kanaan This is part one of a two part series on marketing your practice
ow more than ever patients are empowered to research their doctors online. Many choose a provider based solely on their first impressions from a practice’s website – a process that is actually a lot like online dating. That means in order to attract a new patient, your website must be available, and appealing enough to spark interest into a first date (i.e., new patient appointment). In this first part of a two part series I’ll share tips and techniques for how to ensure your website is “available” by increasing the number of visi-
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tors your site attracts through search engine optimization (SEO). Part two of the series reveals how to use effective medical website design to convert your website visitors into actual patients.
Google It When you can’t remember the name of a movie; what do you do? You Google it. When your teenager texts you with seemingly encrypted abbreviations; what do you do? You Google
it. And when you’re looking for a new family medicine practice in your area; what do you do? You Google it. Not everyone uses Google. Perhaps you consider yourself a rebel for turning to Bing or Yahoo instead, but regardless, you probably use some type of online search engine on a near daily basis. This habitual behavior to rely on the internet for information consumption has propelled medicine into a new age – the age of the “e-patient.”
E-patients are internet savvy health consumers eager to research their medical conditions online and use electronic communication tools to manage such conditions. In other words, they want to be active participants in their health care. According to a 2010 study by the Pew Research Center, 80 percent of all internet users – 61 percent of all adults – search online for their health information. Of those searching, 44 percent are specifically looking for a health care provider.
Location, Location, Location With that many patients now searching online for your services, how do you ensure they find you? Just like in real estate it all comes down to location, and I don’t mean the physical location of your practice. In this instance, location refers to your placement in the search engine results. Let’s say you are a family doctor in Raleigh, North Carolina. If I conducted an online search for the phrase “family doctor Raleigh,” what position in the search engine results would your practice appear? Would it appear at all? From an e-patient’s perspective, if your practice does not appear in the search engine results then you might as well not exist. In fact, to them you don’t. The best way to ensure your practice ranks high in the search engine results is through search engine optimization (SEO). SEO refers to the process of improving the volume of quality traffic to your website from search engines such as Google, Bing and Yahoo, via organic (unpaid) search results. Since organic click-through rates are three times higher than paid search listings, practices will reap the greatest benefit by predominantly focusing on SEO versus paid online ads. That does not mean that utilizing pay-perclick advertising tools such as Google Adwords is not beneficial as it certainly
can be. However, for those on a limited budget, your best long-term investment rests in SEO.
Creating a Strategy While SEO offers the greatest benefit, it is also increasingly difficult to achieve desired rankings and is certainly not an overnight process. Google is constantly changing the algorithm (think of it like a secret recipe) used to determine the order in which results are displayed. Even if you do everything right, it will still take time for your efforts to be fully realized. Below are three elements every SEO strategy should include in order to be effective. These are not the only tools but they are certainly among the most powerful.
Organic Search Engine Optimization There are two types of organic SEO efforts that should be given equal attention. The first is “on-page” SEO; this refers to optimizing the content on your website itself so search engines can accurately recognize you as a match for the keyword. For example, if you are a dentist in Dallas, Texas, you will want to include keywords on your website that relate to both what you do and where you do it (e.g., “dentist Dallas,” “teeth cleaning Dallas,” etc.). The search engines will also take into account factors such as how long your site has been operating, how often you update it and the title tags used at the top of each page. “Off-page” SEO is the process of securing links on other websites, blogs and directories that point back to your website. It’s a way for Google to validate your website, and each outside link is considered a vote of confidence. An important source of off-page SEO is Google Places. This section of the search results lists the businesses you
searched for in your area and provides a corresponding map of their locations. Google merged this section with the organic listings so they blend together in the results. Therefore, it’s vital that you claim your Google Places listing in order to include your practice in these results. Go to www.google. com/places to establish a free account if you don’t already have one.
Social Media Some of you might cringe when I mention the words “social media” and “health care” in the same sentence, but this is not a fleeting trend. Social media is here to stay and the physicians who learn to use it to their advantage stand to gain exponentially. A survey released in 2011 by the National Research Corporation polled nearly 23,000 patients and found that 41 percent of them use social media sites to look for health information. The three most popular sources of social media are Facebook, Twitter and YouTube. As of 2011, there were more than 845 million Facebook users, 200 million registered Twitter accounts and YouTube is the second most powerful search engine in the world (just behind Google). While Facebook is the most popular social media source, more than 1,300 doctors have already registered with TwitterDoctors.net, a database of physicians who tweet. Online patient-to-patient referrals are a beneficial by-product of social networking, but from an SEO standpoint, the primary goal of your social media pages is to lure patients to your practice website. Whatever you do online to boost your off-page SEO – social media, writing articles or blogging – the whole point is to attract patients back to your practice website. Health care social media comes with its own unique set of concerns, one the biggest being Health Insurance and Portability Accountability Act (HIPAA) MEDMONTHLY.COM |27
modern dental practice marketing
Personalize. Promote. Profit.
compliance. You must not discuss patients’ private health information online even if they initiate the conversation. If a patient does this, politely ask them to schedule an appointment if it is an issue that needs to be addressed in the office. You can also write a social media policy for your practice to help guide these conversations.
Online Reputation Management When you search online for a physician’s name, you’ll notice that many of the search engine results are not just for a practice website but also for review sites such as Healthgrades, RateMDs, Vitals and Avvo. Patients are even using what used to be retail driven review sites to rate health care providers. Examples include Google Places, Angie’s List, InsiderPages, Superpages and even Yelp. Managing your review site listings will help boost your rankings in Google. Start by searching your doctors’ names online to see which review sites appear in the search engine results. You’ll first need to claim your listing if you haven’t already. For most sites, that just means signing up for a free account and verifying that you are the owner. By doing so, you have the opportunity to update your contact information, expand the listing with a description of your practice and, most importantly, add a link to your website (that’s where the SEO comes in). You’ll need to do this for all the major review sites, especially the ones that your practice didn’t show up for in the search engine results as you may not be listed. The other reason to manage your review listings is to monitor the reviews themselves. With e-patients more active than ever in critiquing their health care providers on the Internet, it’s important to monitor your online reputation and manage the reviews. Even if you have a fantastic website that effectively sells your practice, one
bad review can deter a patient from picking up the phone. You can monitor review sites yourself using Google Alerts or many medical marketing agencies will now do this for you. While the review websites don’t allow you to delete negative reviews, you can respond to them in a professional manner to show patients that you are listening. You should also encourage your loyal patients to write positive reviews to dilute the potency of a negative review. Monitoring your online reputation will alert you of a negative review so you can promptly tend to the situation.
Having a website is not enough Having a website and not investing in search engine optimization is like trying to start a relationship without ever going on a single date. Inversely, a practice that ranks number one in the search engine results but has an outdated website can be just as detrimental. It’s not enough to just have a website; your website must also be visually appealing, have strong messaging, be easily navigated, engage patients with meaningful content and ultimately call them to action. To discover the elements of effective medical website design, read next month’s issue of Med Monthly where we’ll reveal part two of the series “How to Turn Your Website into a Medical Marketing Machine.” In “Part II: Elements of Effective Medical Website Design,” you’ll learn five website design tips that help convert website visitors into actual patients. Amanda Kanaan is the owner/ founder of WhiteCoat Designs – an online marketing agency committed to growing doctors’ practices through cost-effective and powerful online marketing solutions. To learn more or for a free website evaluation, contact her at Amanda@whitecoat-designs.com or http://www.whitecoat-designs.com
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Easy Steps to Manage Change Without Tears
A real world example that demonstrates the level of detail and specificity required to successfully implement change in a practice By Mary Pat Whaley, FACMPE
t’s taken me a long time to realize that I’m part of a small group people that like – or at least tolerate – change. Change is hated universally and most people will do anything to avoid it. So what is a manager to do when charged with making changes, or when leading your own change initiative? The following are five steps that will help make sure your change transpires smoothly. Befor you change anything, carefully consider every aspect of your plan. For instance, let’s say your plan is to offer Saturday clinic hours, make sure you:
Understand the Change
Be aware of every possible implication that the change could bring. Map out the process, find a trusted colleague or mentor to review the plan with you. Make sure you haven’t neglected to consider any angle. Before going through
with the implementation process makes sure that your plan has:
A budget for the change Are all of the stakeholders in agreement on the amount of money that will be spent to make the change? Is this change a pilot for only a specific time period or will the new Saturday hours be continued regardless of the patient volume?
Addressed staffing and personnel issues How will it be decided which staff will work Saturdays? Will working Saturdays be optional or mandatory? Will staff be allowed to earn overtime, or will they have to adjust their weekday schedule? Have issues with pay, call and time off been resolved?
Because they are so personal, staffing and payroll will always be the stickiest parts of making change happen, so assign them as top priority!
A specifically defined model Will all services be offered on Saturdays, or will it be modeled after on an urgent care? If it is an urgent care model, will it be billed as an urgent care visit and will co-pays be collected for urgent care services? How will an urgent care model be communicated to patients so they are not surprised?
Frame the Change Message
Let everyone know why the change is being considered/happening. Craft your change message into something repeatable. Everyone must understand the reason why the change is occurMEDMONTHLY.COM |31
ring and must be able to attach the reason to a change message. Whatever messages you choose, repeat them in your “Rule of Seven” (see below) and throughout your change process. Explain that the change is coming because: More patients want services than time is available. More patients want services than exam rooms are available. A half-time provider wants to go full-time. The practice wants to add a halftime provider. The practice wants to increase revenue to counter expenses. The practice wants to add new services. The urgent care down the street is seeing your patients on Saturdays when you could be. Your Accountable Care Organization (ACO) requires that you have Saturday hours to help keep patients out of the ER.
Use the Rule of Seven
The old adage is that your message has to be delivered seven times before a listener is willing to take action or buy into your message. What could those seven ways be? Here are some examples. An announcement via newsletter, email or as a small part of a staff meeting that the board, administration or physicians are considering expanding hours. An announcement that everyone (physicians, mid-level providers, staff) will be receiving an invitation to take a survey about their ideas for expanded hours. A confidential electronic survey (try www.surveymonkey.com) asking for their feedback on expanding office hours and what their suggestions are. A staff meeting with a physician or upper-level management in attendance to discuss the results of the 32 | MARCH 2012
survey and how the results fit in with financial projections for the change and to start the change in a specific direction. Department meetings to brainstorm how the change could affect teams in the office and how change could be positively addressed. Email ideas from each of the teams to everyone. A weekly email update on the new initiative.
Use a Change Timeline
Create a timeline by working backward from the desired launch for the change, or forward if the change requires a remodel or other change relying on external factors. Attach responsibilities to the timeline so everyone is involved and everyone knows their job.
Communicate Early and Often
When you don’t tell employees what’s going on, they speculate, and speculation can drag your practice down and focus employees on something besides taking care of patients. It’s easy to think that because you feel positive about the change, everyone else will too, but that’s typically not the case. Would a practice really have to go through all this just to add some office hours on Saturdays? Couldn’t this be done faster and with a lot less fanfare? Absolutely! It could also fail, which I have seen happen twice during my career. I have seen two practices attempt to add Saturday hours and have the initiative fail because of improper planning and poor change management. Whether your change is large or small, use these five steps to make it as smooth as possible. Life in health care is all about change and your ability to manage change could be a careermaker or breaker. Read more of Mary Pat Whaley’s helpful practice management insight on her blog, ManageMyPractice.com
By the numbers... NPI and DEA numbers
What you need to know about the National Provider Identifier and the Drug Enforcement Administration numbers
National Provider Identifier A National Provider Identifier (NPI) is a 10-digit identification number issued to health care providers in the United States. The number is issued by Centers for Medicare and Medicaid Services (CMS). The NPI began replacing the unique provider identification number (UPIN) in 2006 as the required identifier for Medicare services and other payers, including commercial health care insurers. The change to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the first numbers were issued in October of 2006. The NPI was proposed as an eight-position alphanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit in the last position to help detect keying errors. The NPI contains no embedded intelligence; that is it contains no information about the health care provider, such as the type or location. All individual HIPAA covered health care providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapist, athletic trainers, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes. More information regarding NPI numbers can be found at http://nppes.cms.hhs.gov
DEA Number The Drug Enforcement Administration (DEA) is a U.S. Department of Justice law enforcement agency tasked with enforcing the Controlled Substances Act of 1970. It shares concurrent jurisdiction with the Federal Bureau of Investigation (FBI) in narcotics enforcement matters. A DEA number is a series of numbers assigned to a health care provider allowing them to write prescriptions for controlled substances. Legally the DEA number is supposed to only to be used for tracking controlled substances, however, the DEA number is often used by the industry as a general “prescriber” number that is a unique identifier for anyone who can prescribe medication. A valid DEA number consists of two letters, six numbers and a one check digit. More information regarding DEA numbers can be found at www.deanumber.com MEDMONTHLY.COM |33
What to Expect When you’re Expecting (or not Expecting) a Lab Inspection Understand what inspectors look for to keep your lab ahead of the game
The enactment subjected all laboratories to inspection, required all nonwaived laboratories to be inspected and gave CLIA the right to appear at any time to inspect a lab.
By Libby Knollmeyer, BS, MT (ASCP)
There are two types of inspections for non-waived labs: routine and non-routine
rior to the Clinical Laboratory Improvement Amendments (CLIA) of 1988, only laboratories participating in interstate commerce underwent inspections.
34| MARCH 2012
Routine inspections take place every two years as mandated by CLIA, regardless of which agency is respon-
sible for the examination. If a lab has a Certificate of Compliance, CLIA will be their inspecting agency. If the laboratory has opted for a Certificate of Accreditation from one of the approved accrediting organizations, their inspections will be performed by that agency. Inspections are set on a two year cycle and the renewal of the laboratory’s certificate is dependent upon successful results. If no deficiencies are cited, the certificate will be renewed after the inspection is completed. If deficiencies are cited during the inspection, the laboratory will receive a deficiency report and a timeline to submit a plan of correction. Once the plan of correction is accepted by the inspecting agency, the certificate will be renewed. Failure to achieve a successful conclusion to the inspection process will result in the cancellation of the lab’s certificate, and therefore loss of privileges to do lab testing and to bill for such services. The inspection cycle differs slightly for a new laboratory. CLIA or the accrediting agency will do an inspection after the lab has been in operation for three to six months to ensure all regulations are being followed. CLIA and the accrediting agencies do not inspect prior to the lab starting test operations because the lab has not generated data for them to review. It should be noted that states which require state lab licensing in addition to CLIA certification frequently require an inspection of the lab before the license number can be assigned and before the lab begins to operate. The CLIA application will not be released to Centers for Medicare and Medicaid Services (CMS) until the state is satisfied that the lab has everything in order. Both state lab licensing and CLIA certification depend on this inspection. Check your state’s requirements to determine if it has regulations for laboratories in addition to those enforced by CLIA. Non-routine inspections include
validation inspections, off-cycle inspections and inspections generated by a complaint against the laboratory. Validation inspections occur when the primary inspection is performed by an accrediting agency, and CLIA opts to inspect the lab again behind the accrediting agency. CLIA has an assigned number of validation inspections to perform each year, but the selection process is random. Being selected for a validation inspection doesn’t necessarily mean CLIA thinks there are any problems; the lab could have been selected for a validation inspection merely because it was convenient in location and scheduling for the CLIA inspector. Off-cycle inspections occur when there have been problems identified in the lab and the routine inspection led to serious deficiencies. CLIA and the Commission on Office Laboratory Accreditation (COLA) will frequently follow up a routine inspection that prompted deficiencies with a second inspection to prove that the plan of correction (plan of required improvement if COLA) was actually put into place and effective. Sometimes labs do so poorly on an inspection that they request an off-cycle inspection to get back in good standing and have their Certificate of Accreditation renewed.
Regardless of when an off-cycle inspection takes place, the routine inspection will remain on the established every-two-year cycle tied to the expiration date of their certificate. Any complaint against a laboratory can generate an inspection, and usually does. The agency to which the complaint was sent will normally do the inspection. The extent of the inspection will depend on the severity of the complaint, but the inspector has the right to look into any part of the laboratory on a complaint-generated inspection. Waived labs do not generally undergo inspections by CLIA, but are subject to be inspected at any time if there is a complaint generated, or if they are selected as one of the small percentage of waived labs that CLIA inspects routinely. There has been discussion of including waived labs in the routine inspection cycle, but to date that has not occurred. CLIA and COLA follow the same policies regarding waived labs; the College of American Pathologists (CAP) does not recognize the waived test category and treats all tests with the same regulations as for moderate or highly complex laboratories. The Joint Commission (TJC) operates almost exclusively in the hospital arena
where waived labs are nonexistent; it is unlikely that any physician office laboratory (POL) would opt for TJC accreditation so inspection of waived labs is a non-issue for TJC.
Should I bring in a consultant to prepare for an inspection? The answer to that question depends on the training and experience of the staff running the laboratory, but in general, getting a consultant’s opinion and input on the lab’s preparedness for an inspection is a good idea. The time to benefit most from a consultant’s input, however, is early on in the setup of the laboratory. If the lab is set up in compliance with all lab regulations, the staff is educated adequately about those requirements and if good processes for maintaining regulatory compliance are established from the beginning, then passing an inspection becomes just another day’s work. Want more information about inspections? Libby Knollmeyer has a wonderful checklist called “I’m Your CLIA Inspector – What am I Going to Look for?” that she will be glad to share with Med Monthly readers who email her with a request (email@example.com)
Nutrition and physical activity for all ages! Our mission is to provide customized, simple nutrition solutions to enhance health and optimize sports performance. We offer many individualized services in nutrition, fitness, and corporate wellness according to your specific needs and interests. We are also a Blue Cross Blue Shield of North Carolina insurance provider. BCBS participants are eligible for up to 6 free face-to-face nutrition counseling sessions per year with a Registered Dietitian. Refer to us today! Tracy Owens, MPH, RD, CSSD, LDN Ashley Acornley, MS, RD, LDN 6200 Falls of Neuse Road, Suite 200 Raleigh, NC 27609 919-876-9779
Recently Issued CMS HIPPA Electronic Funds Transfers Standards
New standards aim to simplify administrative burden and save money By Tatiana Melnik
n Jan. 5, 2012, Centers for Medicare and Medicaid Services (CMS) issued an interim final rule that specifies new standards under Health Insurance Portability Accountability Act (HIPAA) for
36 | MARCH 2012
electronic funds transfers (EFT) and remittance advice transactions. Comments are due within 60 days after publication of this regulation, which is the second in a series of regulations to be issued over the next five years as required by Sec-
tion 1104 of the Affordable Care Actâ€™s administrative simplification provisions to standardize electronic health care transactions. Once finalized, all covered entities must comply by Jan. 1, 2014. The common interchange struc-
ture standards adopted under HIPAA will minimize the industry’s reliance on multiple formats for electronic data interchange (EDI). By creating greater uniformity in data exchange and reduction in the amount of paper forms needed for transmitting data, the administrative burden on covered entities will dramatically decrease. CMS estimates that as a result of this interim final rule, covered entities could reduce administrative costs by up to $4.5 billion dollars over the next 10 years. Despite the gains made since the passage of the initial EDI and EFT standards, health care policy makers determined that new EFT standards were required, in part, because the administrative burden in processing health care related transactions remains high. CMS, for example, cites a May 2010 study in the journal Health Affairs which found that physicians spend nearly 12 percent of every dollar they receive from patients to cover the costs of filling out forms and performing other excessively complex administrative tasks. With the interim final rule, the U.S. Department of Health and Human Services (HHS) has adopted two standards for the health care EFT:
Cash Concentration and Disbursement Plus (CCD+) Addenda implementation specifications in the 2011 National Automated Clearing House Association Operating Rules & Guidelines. Reassociation trace number (TRN) segment implementation specifications in the X12835 type three technical reports (TR3) for the data content of the Addenda Record of the CCD+ Addenda.
By creating greater uniformity in data exchange and reduction in the amount of paper forms needed for transmitting data, the administrative burden on covered entities will dramatically decrease.
CMS anticipates that health care EFT standards will have the most substantial cost and benefit impacts on commercial and government health plans, physician practices and hospitals. Specifically, health plans
will have direct costs associated with implementing and using the standards due to required software upgrades and associated training. CMS anticipates that because physician practices and hospitals receive payments electronically and do not remit payments in this manner, these providers will incur little to no cost to implement the standards. Even so, physician practices and hospitals must upgrade billing software to address the changes and staff members must be trained on the new standards. Despite these initial and recurring costs, CMS estimates that over 10 years, the savings for commercial health plans could be as much as $40 million and $31 million for Medicaid, the Children’s Health Insurance Program and the Indian Health Service. Similarly, physician practices and hospitals should see savings of $3 billion to $4.5 billion over the next 10 years as health plans implement the health care EFT standards. Future administrative simplification rules will address adoption of a standard unique identifier for health plans, a standard for claims attachments and requirements that health plans certify compliance with all HIPAA standards and operating rules.
Non-Clinical Careers for Physicians www.nonclinicalcareers.com
Your Action Plan for the Future October 20–21, 2012, Chicago, IL
Also featuring recruiters and employers MEDMONTHLY.COM |37
Medical Malpractice Statutory Caps in Jeopardy By J. Benjamin Dolan Challenges to statutory limitations on jury verdicts in medical malpractice actions are on the rise. In two recent cases, juries in Florida and Michigan issued verdicts awarding millions of dollars to illustrate different methods of attaching the legislative caps that states have imposed on non-economic damages in malpractice actions. In Florida, a jury awarded $2 million in damages for pain and suffering, and loss of companionship suffered by the parents of a woman who died during childbirth, allegedly due to medical negligence. Normally, Florida law imposes a $1 million cap on non-economic damages in such cases. Attorneys for the plaintiff claimed that the cap violates the U.S. Constitution on equal protection and protection from government taking grounds. The Florida federal district court denied the plaintiff ’s claims on U.S. Constitutional grounds, but referred the case to the Florida Supreme Court to determine whether the cap violates the Florida Constitution. 38| MARCH 2012
Michigan limits non-economic damages in medical malpractice actions to $280,000 generally and $500,000 in certain special cases (adjusted annually for inflation), including spinal cord injury cases. A Michigan jury recently awarded the family of a quadriplegic $130 million in damages due to alleged malpractice. The verdict represents the plaintiff ’s estimate of the cost of caring for the child until 2077, which is presumably an element of non-economic damages not capped by the statute. Regardless of whether or not the jury intended some of the $130 million award to compensate the plaintiff for non-economic damages, the verdict is so large that it renders the legislative cap on economic damages meaningless, at least in that particular case. Health care providers should closely monitor developments in this area to determine if they should adjust their reserves, self-insured retention amounts or professional liability insurance limits in states where liability caps are invalidated.
Beware of Ambiguous Provisions in Physician Employment Agreements By Ralph Levy, Jr. Great care should be taken when drafting employment agreements with physicians. Despite much judicial focus on covenants not to compete and non-solicitation provisions, as illustrated by a recent case, this word of caution should apply equally to all elements of employment agreements. An Oklahoma federal judge was asked to interpret a physician employment agreement in which an issue arose in regards to the location where the doctor was to perform their services. The agreement in question provided that the physician was required to work “primarily” for a hospital-employer at a specific hospital and at another hospital “from time to time.” As a result of this ambiguity, the court refused to find that as a matter of law, the hospital-employer had breached the terms of the agreement when it had assigned the physician to work at the alternative location specified in the physician’s employment agreement. Ultimately, the court concluded that the jury who hears the trial of the lawsuit – not the trial judge of the case – must interpret the meaning of the clause in question.
It was just a simple fall. Yesterday.
Every year, one out of three Americans over 65 falls in the home. For older Americans, falls are the most common cause of injury. And the leading cause of potentially lethal hip fractures. Yet, almost half of home falls can be easily prevented. To learn how to make yourself, or a loved one, safer at home, visit orthoinfo.org/falls.
GEMs: Making This “True Crosswalk” Assumption Could Cost You Time and Money Follow this guide to find out what each flag really means By Suzanne Leder, BA, M. Phil, CPC, COBGC, certified AHIMA ICD-10 trainer
ou have seen plenty of International Classification of Diseases, Ninth Revision (ICD-9) to International Classification of Diseases, 10th Revision (ICD-10) bridges online, but beware: these bridges are based on general equivalent mappings (GEM), which are only about 50 percent accurate. If you rely solely on this mapping tool, you are likely to miss important coding subtleties, which could land your claim in limbo. Follow this stepby-step explanation to master GEMs and what each digit really means. Know the Basics: The important term to remember in general equivalent mappings is “general.” The GEMs are the raw material from which providers, health information vendors and payers can
40 | MARCH 2012
derive specific applied mappings to meet their needs. You can use GEMs to study the differences between ICD-9-Clinically Modified (CM) and ICD-10-CM/(Procedure Coding System (PCS). The GEM file is a “flat file,” meaning this is a record with no structural relationships. You can download it at http://go.cms.gov/ xPmF3D
Are GEMs a true crosswalk? The word “crosswalk” is often used to refer to code mappings (as in, data element mappings between two distinct data models: ICD-9 and ICD10), but be advised: GEMs are not true crosswalks. They are reference mappings, to help the user navigate the complexity of translating meaning from one code set to the other.
They are tools to help you understand, analyze and make distinctions that manage the complexity, and to derive their own applied mappings (if that’s your goal). The GEMs are more complex than a simple one-to-one crosswalk. GEMs reflect the relative complexity of the code sets clearly. The relationship between them is not simple. GEMs effectively demonstrate this, rather than making the transition from the old to the new code system in an oversimplified way.
What are GEMs relationships like? You can have a variety of different code relationships in the GEMs file. Here are a few: Some codes have a one-to-one correlation. Code 003.21 (salmonella
meningitis) in ICD-9 matches up to A02.21 (salmonella meningitis) in ICD-10-CM. Some codes won’t match because of specificity. For instance, 649.53 (spotting complicating pregnancy) does not exactly equal O26.851 (spotting complicating pregnancy, first trimester). To arrive at the correct code in ICD-10-CM, you have to know the trimester. Also, ICD-10-CM codes may combine multiple diagnoses or concepts, such as: a chronic condition with acute manifestation (G40.911, epilepsy, unspecified, intractable, with status epilepticus); two concurrent acute conditions (R65.21, severe sepsis with septic shock); acute condition with external cause (T39.012A, poisoning by aspirin, intentional self-harm, initial encounter). On the other hand, ICD-10-CM code Z72.3 (lack of physical exercise) doesn’t have an ICD-9 target at all. So given you can have varied code relationships between the old system and the new, that’s why you can’t count the GEMs file as being cut-and-dried.
What key terms should you know? Target system means the destination code set. In other words, this is the set the GEM is mapping to. Source system means the original code set. In other words, this is the set the GEM is mapping from. Forward mapping is when you see your ICD-9-CM code targeting an ICD-10-CM code.
QUIZ ALERT Pay attention to the key terms for the quiz at the end of the article!
Backward mapping is when you see an ICD-10-CM code targeting an ICD-9-CM code. Reverse lookup means that you’re using a GEM by looking at a target system code and examining the codes that translate to it.
What is an Example of a GEM? Let’s look at the file itself. Here’s an example of what your GEM file looks like.
62130 N8500 00000 In GEM terms, 62130 is your source (which is code 621.30 with your decimal applied); N8500 is your target; and 00000 represents your flags. Translation: This means 621.30 (endometrial hyperplasia, unspecified) maps directly to N8500 (endometrial hyperplasia, unspecified).
What Do the Flags Mean? Each digit of the “00000” number represents five different flags. Key: The “0” means off. The “1” means on. These flags are: first digit: approximate flag second digit: no map flag third digit: combination flag forth digit: scenario flag fifth digit: choice flag
Examine the Approximate Flag “Approximate” is flag one, which is in column one of the flags. The majority of alternatives are considered an approximate match. “0” means the translation is an identical match. This is rare in the procedure GEMs
but more common in the diagnosis GEMs. Remember this example?
62130 N8500 00000 The first flag is a “0,” meaning you already know that 621.30 has an identical match in N8500. On the other hand, check out this example:
K3189 5363 10000 K3189 5375 10000 K3189 53789 10000 The first flag is a “1,” it implies that the complete meaning of the source code differs from the complete meaning of the target system code. In other words, K31.89 (other diseases of stomach and duodenum) includes the meanings of all three codes: 536.3 (gastroparesis), 537.5 (gastroptosis), and 537.89 (other specified disorders of stomach and duodenum). This isn’t a direct match; all of these meanings are approximate.
Find out what ‘no map’ flag means “No Map” is flag two, which is in column two of the flags. A “1” means there is no plausible translation for the source system code. A “0” means there is at least one plausible translation for the source code. Let’s refer back to our familiar example:
62130 N8500 00000 This means you have at least one plausible translation for the source code. Code 621.30 has a plausible translation in N8500. However, look at this example:
T500X6A NODX 11000
Because you see a “1” as flag 2, you can see that T500X6A (underdosing of mineralocorticoids and their antagonists, initial encounter) has no plausible translation. The “NODX” means no description found.
Conquer the combination flag “Combination” is flag three, the scenario and choice list flags. When you see a “0” in this position, as in our example, this means the code maps to a single code.
62130 N8500 00000 In other words, 621.30 only maps to N8500. On the other hand, when you see a “1” in this position, this means the code maps to more than “1” code. Look at this example:
I25111 41401 10111 I25111 4139 10112 See the “1” in the third digit? This means that I25.111 (atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm) maps to 414.01 (coronary atherosclerosis of native coronary artery) with 413.9 (other and unspecified angina pectoris). Remember the term “with,” means “associated with” or “due to.”
Figure out the scenario flag Now that you have identified flags one through three, let’s examine flags four and five (or the fourth and fifth digits). Flags four and five clarify combination entries. For the scenario flag (forth digit), you’ll see “0” meaning off, or digits “1” through “9” meaning, “In a combo entry, this is a collection of codes from the target system containing the necessary codes that combined as directed will satisfy the equivalent meaning of a code in 42 | MARCH 2012
the source system.” Source: General Equivalence Mappings: Documentation for Technical Users. Download at www.cdc.gov/nchs/icd/ icd10cm.htm Here’s our previous example:
62130 N8500 00000 The “0” turns the scenario column off, so you know that you don’t need to worry about this. But this won’t always be the case:
T422X1A T422X1A T422X1A T422X1A
9662 E8558 9660 E8551
10111 10112 10121 10122
Notice how you have “1” and “2” in the fourth digit column. This breaks down these codes into two scenarios, as follows: Scenario 1: Code T42.2x1A (poisoning by succinimides and oxazolidinediones, accidental [unintentional], initial encounter) maps to 966.2 (poisoning by succinimides) with E855.8 (accidental poisoning by other specified drugs acting on central and autonomic nervous systems). Scenario 2: Code T42.2x1A (poisoning by succinimides and oxazolidinediones, accidental [unintentional], initial encounter) maps to 966.0 (poisoning by oxazolidine derivatives) with E85.58 (accidental poisoning by other specified drugs acting on central and autonomic nervous systems).
Choice flag can be a challenge Finally, in the choice column or fifth digit, you’ll see “0” meaning off or digits “1” through “9” meaning, “In a combination entry, this is a list of one or more codes in the target system from which one code must be chosen to satisfy the
equivalent meaning of a code in the source system.” Source: General Equivalence Mappings: Documentation for Technical Users. Download at www.cdc.gov/nchs/icd/ icd10cm.htm Here’s our previous example:
62130 N8500 00000 Because the last digit is a “0,” this means the choice column is off. On the other hand, look at this backwards mapping example:
R6521 99592 10111 R6521 78552 10112 The last digits here are “1” and “2.” This means that ICD-10-CM code R65.21 (severe sepsis with septic shock) matches to both 995.92 (severe sepsis) and 785.52 (septic shock). The ICD-10CM code combines them both.
What should you do with this GEMs knowledge? You might be reading through the GEMs flags and thinking, this is a very cumbersome process. Software folks are doing it, so you may think you don’t have to learn about GEMs. But you may have to verify your software for accuracy and find inconsistencies. Action step: Start with the top 25. Pull the most common diagnoses you use in your office, and look into your system to see if they map correctly from ICD-9-CM to ICD-10-CM. Then you can get your vendor to correct them. Remember, inaccurate coding will result in increased denials and delayed payments. This was a broad overview of GEMs. If you want to learn more, download this PDF: “General Equivalence Mappings: Documentation for Technical Users” at www.cdc.gov/nchs/icd/ icd10cm.htm
TEST YOURSELF Occasionally, you’ll find an activity or game to help you digest your ICD-10 coding knowledge. Try your hand at this filling-in-the-blank challenge, based on this article. All you need to do it match the GEMs terms to the statements below.
Did you catch what forward/backward mapping means? GEMs stand for ________. You need to know about GEMs because you may have to ________ and ________. You might classify R65.21 as a __________. ________ means the destination code set. In other words, this is the set the GEM is mapping “to.” When you look up ICD-10-CM code Z72.3’s equivalent, you will find _______. Because the GEMs are a record with no structural relationships, you would classify it as a _______. GEMs are NOT a ________.
TERMS A. General Equivalence Mappings B. True crosswalk C. Flat File D. One-to-one E. No match F. Combination code G. Target system H. Source system
I. Forward mapping
You could classify the correlation between 003.21 and A02.21 as _______. ________ means the original code set. In other words, this is the set the GEM is mapping “from.” ________ means on.
J. Reverse lookup K. 1 L. 0 M. Verify your software for accuracy N. Find inconsistencies
________ means that you’re using a GEM by looking at a target system code and examining the codes that translate to it.
O. Inaccurate coding P. Backward mapping
When you see an ICD-10-CM code targeting an ICD-9-CM code, then that is called ________. ________ means off. When you see your ICD-9-CM code targeting an ICD-10-CM code, then that is called ________. ______ will result in increased denials and delayed payments.
ANSWERS: 1A, 2MN, 3F, 4G, 5E, 6C, 7B, 8D, 9H, 10K, 11J, 12P, 13L, 14I, 15O MEDMONTHLY.COM |43
Perspective on Hospital Acquisition Strategy Part II: Tools and Ideas for Continued Independence By Cameron M. Cox, III, President and CEO, Management Services On-Call (MSOC)
ndergraduate school, medical school, residency, fellowship and, subsequently, private practice all seem like logical steps in the life of a physician. For many years, this multi-step process worked without much effort and produced healthy financial results. In fact, many physicians paid money to become partners; some physicians
44 | MARCH 2012
sold their interests to junior partners; others were so well-designed that the practice incorporated both junior AND senior partner levels within the organization. Though this world still exists in some cases, it is definitely becoming an endangered species as a recent Medical Group Management Association (MGMA) survey demonstrates: in 2001, less than 3 percent
of physicians desired to be employed versus greater than 22 percent desiring employment in 2008. As discussed in the first part of this article (see Med Monthly February 2012), owning an independent physician practice is no longer a simple business model. Historically, the primary â€œcustomerâ€? was the referring physician for specialists. Primary care physicians still had to market to patients but the level of competition was typically low and thus a diligent, focused effort was not necessary for success. Expenses were not important except as they related to physician compensation. Revenue generation was based on the concept of seeing more patients or doing more proce-
dures. Many will argue that this is exactly why the industry is in the state that it is in today. Historical success was easy and did not require constant improvement in the “business” side of the practice. This article will cover objective tools and ideas to consider with the goal of continued independence as an outcome. Physician practices that have a passion and desire for creating and maintaining their independence can potentially see a profitable return on their investment. A successful practice or business stems directly from the diligence of its owner(s). With declining reimbursement, increased competition and mounting regulatory policies, having the drive to succeed is essential. The four tools/ ideas that can support this effort are: Understanding overhead and its value to the organization Employing physician extenders effectively Embracing the many facets of technology Developing a web purpose – not just a presence
Understanding Overhead and its Value to the Organization Many physicians can immediately identify their respective overhead percentage. Unfortunately, physicians are familiar with this number because the focus is on compensation. The first step in understanding what overhead truly means is to uncover how overhead is created. Identification of dollars being applied to labor, marketing, development, clinical supplies, etc… is essential to understanding the return on the investment of each of these functions. As with any business, knowing the details of how an organization utilizes its resources is the first key to
understanding its infrastructure. For example, according to Science Daily, the pharmaceutical industry spent almost 25 percent of their sales dollars on marketing in 2004. Regardless of the philosophy, the point to note here is the understanding of the return on the investment of these dollars. Knowledge of the amount spent and revenue generated enables the business to comprehend the effectiveness of the overhead. Similarly, comparing practice staffing levels with industry benchmarks also allows the practice to assess the investment to ensure it is generating its expected return. Many of these benchmarks are available through management associations and specialty societies, and are simple to use as comparisons to your practice. Effective use of overhead can generate higher levels of profitability, thereby driving improvements in owner compensation rather than letting owner compensation drive the overhead.
Employing Physician Extenders Effectively Physicians have utilized physician assistants and nurse practitioners for many years. Specialties such as OB/ GYN and orthopedics have embraced the use and value of placing physician extenders in active roles within the practice setting. These roles vary from setting-to-setting but are, nonetheless, essential to the success of a practice. The use of physician extenders can increase the productivity of the provider in many facets, allowing them to work “smarter” rather than harder. Specialists can focus on more productive work such as procedures or consultations while the physician extenders handle follow-up care or post-surgical visits. Primary care physicians can potentially extend themselves among
a greater number of patients with a physician extender that is effectively integrated into the practice’s team. This simple business concept aligns organizational costs with organizational revenue. Some argue that care or quality is being sacrificed by not involving the physician in the whole continuum of patient care. There are a number of studies that demonstrate that the use of physician extenders does not sacrifice the quality of care a patient receives and, in fact, may increase patient satisfaction. Though philosophical conclusions may differ among providers, there is no doubt that the use of physician extenders is a concept that practices should seriously consider as both a cost and clinically effective resource within a practice’s health care team.
Embracing the Many Facets of Technology Technology is nothing new within the clinical arena of the health care industry. Administrative and clinical technologies are becoming increasingly necessary tools for practices. Electronic health records (EHR), health information exchanges, Mobile Health (mHealth) and various other new communication modes can all be valuable assets to practices. EHR’s can become an easy tool for analyzing what a patient needs. Practice management systems deliver information about patient in a retrospective format. EHR’s can provide information to the physician to help them better understand their patients in a prospective manner. From a marketing perspective, a practice can mine their data to help their patients be more proactive about their health and assist them in promoting a healthier lifestyle. Realizing the paradigm shift of a paternalistic model of care to a MEDMONTHLY.COM |45
facilitative model of care places more emphasis on the EHR as an essential tool. The mobile health industry is growing at a phenomenal rate. Much of the growth is in the sector of remote patient monitoring. Much like the use of physician extenders, mobile health can ultimately allow physicians to be even more productive by having the patient actively engaged and allowing technology to provide data about the patient even when he/she is not in the office. Still very much in its infancy, mobile health has the distinct possibility of changing the health care landscape; and it has the potential to be a valuable means for the provider to render lower cost care to many patients. Other aspects of technology that should be addressed center around the many forms of communications currently in existence. Face-toface and telephone interactions are no longer the only ways to communicate with patients. Both of these methodologies are time and resource intensive. With the advent of secure email, patient portals and texting, communication can be delivered faster and to more patients without the usual expenses associated with physician-patient communication. The facilitative model of care encourages active communication between patient and provider. Leveraging new forms of communication that are preferable to the patient can be beneficial for both the patient and the provider. However, caution must be exercised when communicating electronically with patients as all e-correspondence is discoverable should you encounter a malpractice claim. Please keep in mind that a patient’s health records (e-PHI) are protected under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. 46 | MARCH 2012
Developing a Web Purpose – Not Just a Presence The final tool to discuss is simply the Web. A web purpose is the future for all health care practices. A practice’s website should be objective-oriented and focused on what patients are seeking. Many practices have a “billboard” on the Internet and falsely believe it can be called a web presence. Patients are consumers – use your practice’s website to promote education and commerce, to be insightful, simplistic and wanted. Every practice’s goal should be to encourage patients to access their website to gain information about their health care. In addition, the practice’s website should simplify the patient’s life by providing convenient services such as electronic bill payment, the ability to view their statements and to see the physician’s schedule to make their medical appointments online. Keep in mind, the first practice to market these services will have an edge on all others. If a practice is not ready to deliver a web purpose, they should be developing goals and objectives to do so. Understanding and leveraging the Internet will enable practices to have a stronger web purpose within the health care space and build patient loyalty. Independence is not effortless but it’s not impossible. The desire for continued success is imperative to create forward momentum for medical practices in the next decade of health care. There will be new competition, consolidation and new regulations. A practice that has an understanding of its internal operations can begin to deploy new technologies and resources to achieve success. There will not be a shortage of patients in the coming years. Utilizing the tools in this article and continuing to explore the new ideas on the health care horizon will only serve to heighten the likelihood for your independent success.
Finally! A prescription with side effects you want.
Blueberries and red beans are powerful remedies against cancer. Research shows that fruits, vegetables, and other low-fat vegetarian foods may help prevent cancer and improve survival rates. A plant-based diet can also lower cholesterol. For a free nutrition booklet with cancer fighting recipes, call toll-free 1-866-906-WELL or visit www.CancerProject.org
Our secret weapon against smoking?
I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15 years. When I wanted to quit, I found out the average person takes 3-4 efforts to quit because nicotine is so powerful. I learned that if you pick it up again, it’s part of a process. It’s not that you failed, that’s just how it works. When I finally quit, I had more weapons to help me — my pills, my support and my nurse practitioner to talk to. Now we have Tobacco Free Nurses to help, too.
Tobacco Free Nurses is a one-stop shop for all nurses, especially nurses who want to help their patients quit smoking and nurses who want to quit themselves. We are nurses who want to benefit nurses and patients, and promote a tobacco free society. Please visit our website or call for further information.
Toll Free: 877-203-4144 | www.tobaccofreenurses.org Support for the Initiative was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, to the School of Nursing, University of California, Los Angeles in partnership with American Association of Colleges of Nursing, American Nurses Foundation / American Nurses Association, and National Coalition of Ethnic Minority Nurse Associations.
Photo: Todd Pickering
— Maria, RN
CARING FOR CHAMPIONS
A BEHIND THE SCENES LOOK AT THE QUALITY HEALTH CARE THAT IS REQUIRED TO KEEP OUTSTANDING ATHLETES FUNCTIONING AT THEIR BEST By Leigh Ann Simpson
Jose Fonseca points at the camera in celebration after Duke became national champions in 2010.
very year college basketball fans across the country work themselves into a frenzy, commonly referred to as March Madness. Friends, coworkers and even enemies arrange their brackets and put their money down on the teams they think are most likely to win the National Collegiate Athletic Association (NCAA) tournament – usually generating a list of who’s who in college basketball. Regardless of which team you pull for, odds are that Duke University is somewhere on your list of the major contenders. Statistically speaking this isn’t a surprise considering their impressive legacy with four national championships as well as 19 Atlantic Coast Conference (ACC) championships: it’s safe to conclude that the men’s basketball program at Duke is one of the best in the country. Such success doesn’t come easy; it requires diligence, dedication and most of all, maximum performance from each player during every practice, game and throughout the year. The task of providing such an enormous amount exceptional health care to an entire team (who are pushing themselves to their physical limits and risking injury on a daily basis) should not be assigned to the faint of heart. So who is in charge of maintaining and improving the health of these champions? For the past eight years, Jose Fonseca, BS, MA, athletic trainer for the Duke University men’s basketball team has successfully undertaken this challenge. During our exclusive interview with Fonseca, we learned what it takes to keep these playMEDMONTHLY.COM |49
ers running like well oiled machines.
Ongoing care Each player is given three biomechanical assessments at the beginning, middle and end of the year. The results are tailored into a customized preventative medicine program designed to correct whatever physical concerns a player is having and reduce the likelihood of injury in the future. “If a player has a limited range of motion, we try to increase their range of motion; if they have muscular weaknesses, we try to increase their strength; if they have an incorrect firing pattern, we try to correct their firing pattern.” With the help of Nick Potter, BS, DPT, assistant director of athletic rehabilitation, a preventative medicine program is designed and used as a reference for each player based on the results of their individual assessment. Fonseca and Potter work closely with Duke University’s strength coach, William Stevens, CSCS, who also uses this preventative medicine program during the players’ strength and conditioning training. The goal of the program is to work with each player; focusing on their individual health concerns to optimise their physical ability and keep them from getting hurt.
When it's game time During basketball season, Fonseca explains, the team practices every afternoon, with the pre-practice process starting about an hour before the actual practice begins. For the players who are not injured, athletic trainers work on prevention treatment; some get their ankles taped; some are stretched and work with Potter on physical therapy or manipulations on their back before going onto the court. If a player has an injury (recent or ongoing) they meet with athletic trainers in the morning before their classes for physical therapy treatments and have their injury assessed to determine if they are able to practice that day or 50| MARCH 2012
not. Fonseca writes an injury report based on his evaluations and sends it to the coaches by late morning. This lets the coaches know who will, and who will not be practicing that day, or if a player will be practicing with some sort of limitation, so that they can plan their practice accordingly and be able to get the most out of each player that day. “So what injuries keep these guys out of practice?” we asked Fonseca. “There are definitely some absolutes – if they have a break or a swollen knee,” he says. “But for the most part (my decision) is based on if I feel that a person can protect themselves on the basketball court and function at a high level.”
Training tools Upon walking into the training room at Duke, you’ll find what you would expect; a few exam tables, athletes being worked with, along with various medical devices etc… However, Fonseca showed us the training room’s most recent state-of-the-art addition. “Last summer, Coach (Mike Krzyzewski, head coach of Duke University’s men’s basketball team) provided me with a very nice gift,” says Fonseca. “He allowed me to renovate the training room." The gift was apFonseca checks out a cut on Kyle Singler's chin.
proximately $800,000 for the renovation project that was completed last December. Today the room has three large aquatic training tools; a cold plunge, a hot tub and a therapy pool. The cold plunge is set to about 50 degrees Fahrenheit and is used after practice to help with sore ankles, knees and muscles. The hot tub is kept at approximately 104 degrees Fahrenheit ans is used before games to loosen muscles, increase flexibility and allows the players to relax. Both the cold plunge and the hot tub can accommodate nearly ten players and are even equipped with a television for the players to watch while soaking. “Yeah, before and after games you’ll have eight, nine, ten of the guys in here hooting and hollering,” says Fonseca jokingly. The third is a therapy pool, with a floor that is actually a treadmill and has served as a crucial rehabilitation tool during several injured athletes’ recovery processes. The height of the floor controls the water level in the treadmill-pool and can be adjusted based on the height of the player and how much weight a player needs to support on their ankle, knee or foot. “So if you’re a six foot tall guy and I don’t want to put any weight on your foot, I will lower the floor all the way down so that your head is just barely above water, or
Fonseca looks at the knee of Nolan Smith during a game.
just a bit below, so you’re just floating as your running and there is less pounding going on in your joints,” Fonseca explains. “Then as you (the player) get(s) stronger, I’ll raise you (the player) up so that you’ll feel more true weight.” Once the player reaches a point they can put weight on their ankle, knee or foot they continue their therapy running on a regular treadmill until they are able to play – allowing a seamless transition back onto the basketball court. The pool is also equipped with jets that can be used for additional resistance while the player is submerged. Two cameras, located within the pool, film the front and side view allowing athletic trainers to observe and record the players as they run. Data and images from each training session are stored on a computer and can be referenced by other athletic trainers to continue monitoring the progress of the player, regardless of which athletic trainer they're working with that day.
An essential bond Trust is absolutely paramount in the relationship between a player and their
athletic trainer. Fonseca is aware of the vital role that he plays in the lives of these young athletes; he makes the call on who plays and who stands on the sidelines. Many of these players are hoping to pursue a professional career in basketball – a dream that can be easily thrown away by a severe injury. However, on the other side of that argument, the players want and need to play in order to gain exposure and impress NBA recruiters. “I would never put in an injury report saying that a player is out without explaining what is going on with them and give them all the exact details,’ says Fonseca. “So it’s kind of like this ongoing revolving wheel that we are (athletic trainers and players) always in great communication with each other, asking each other ‘what can I do today, what can I not do today,’ to try to find a happy medium.” Fonseca explains that being an athletic trainer is much more than monitoring an athlete’s physical health. They must know each player very personally so that they can read them, especially in critical situations involving their health. Their intuition has to be dead on so that they can pick up on
exactly how they are feeling – regardless of how they say they are feeling. Fonseca has become so connected with his team, that not only does he know when a player is too injured to play, but also when they are able to play, even when the player's confidence is shaken. Recently, Fonseca proved his ability to do this during a match up between Duke and North Carolina State University (NCSU) on Feb. 16, 2012. During the first minute of the game, Duke junior, Seth Curry, suffered an ankle injury that he and Krzyzewski thought would take him out of the game. After surveying the injury and knowing Curry’s level of strength and ability, Fonseca not only cleared Curry to play, he didn’t leave him a choice: “You have to go,” he said. With the order from his athletic trainer, Curry returned to score an amazing 21 points during the second half, leading Duke to a victory over NCSU and making Curry the hero of the game. If Fonseca hadn’t given Curry the clearance and the confidence that night in the locker room, he probably would have not returned to the game to save the day – making Fonseca a hero’s hero.
FINDING A CURE ON THE HORIZON By Leigh Ann Simpson
52| MARCH 2012
cientific breakthroughs in traditional medicine have saved lives and improved the quality of life for millions – billions – of people. However, healing can also stem from less obvious remedies. Nicholas Down, MD, illustrates this point perfectly. He has been practicing as a family medicine physician for nearly 30 years. Down is also an artist, using his tranquil paintings to provide soulsoothing treatment for his patients, in addition to typical medicinal therapies. Down’s love for both art and medicine developed at an early age. As a teenager, he struggled with his career decisions, having to choose between art and medicine. After much deliberation, science and medicine prevailed as his initial career choice, but art has never separated from him. “My work as a general practitioner over the last 27 years has always been at the edge of the ‘art’ of medicine, with my interests being in people and the way in which illness and suffering impact their lives,” Down says. “Increasingly, as an artist over the years, my work has attempted to bridge the gap between the sublime and the unknown, and in some of my paintings, I attempt to communicate the mysteries where body suffering gives way to pure spirit.” It comes as no surprise that Down’s upbringing greatly influenced both his painting and his medical career. Spending much of his childhood in Uganda and Tanzania, his experiences were richly impacted by the beauties and mysteries of the natural world. “I love the expansive, vast horizon lines and the drama of skies and broad landscapes,” Down explains. In the midst of such beauty, Down also experienced
tragedy that made a profound impression on him. “As a child, I was closely involved with the realities of life and death and the realities of sickness and disease,” he recalls. “I lost two of my young friends to cerebral malaria, and I became increasingly aware that life and health are precious gifts that we cannot take for granted.” Art critic Jenny De Soutter at Surrey Life magazine has hailed his work as genius, stating “the link he forges between direct observation and abstract expression is a hallmark of his work, and his technical mastery.” His unique use of color hypnotizes observers, almost making them second guess exactly what they are seeing, ultimately being stunned by the realization of the painting’s subject. The depictions of horizons that Down paints have been inspired by a transcendental sense he has found in certain natural settings, including the White Sands of New Mexico, the Canyonlands in Utah, and Death Valley in Nevada. “They are all unique gifts from the natural world where a sense of color, form and grandeur can co-exist,” says Down. Down particularly enjoys painting the majestic scenery of the mountains of Scotland and the North West Highlands and Islands. Recently, he has been enchanted by the magnificent landscapes of the American Southwest and the Sierra and Cascade Mountains. At the age of 55, Down is soon retiring from his medical practice to pursue a full-time career as a professional artist, something he says he has always dreamed of. To find out more about Nicholas Down visit: http://artisandirectltd.net/ artists/down_nicholas/ MEDMONTHLY.COM |53
What’s your practice worth? When most doctors are asked what their practice is worth, the answer is usually, “I don’t know.” Doctors can tell you what their practices made or lost last year, but few actually know what it’s worth. In today’s world, expenses are rising and profits are being squeezed. A BizScore Performance Review will provide details regarding liquidity, profits & profit margins, sales, borrowing and assets. Out three signature sections include: Performance review Valuation Projections
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h s i r I e h t f o k Luc Soda Bread By Ashley Acornley, MS, RD, LDN
oda bread is an Irish staple that can also be a nutritious treat. This festive soda bread recipe uses whole grain flour, a heart healthy option that is high in fiber and low in cholesterol, saturated fat and sodium. Enjoy it as toast, with a salad or to dip into homemade soups. This recipes is easy to make, hearty, and believe it or not, healthy!
WHOLE WHEAT IRISH SODA BREAD Makes: 2-pound loaf (12 slices) Active Time: 10 minutes | Total Time: 1 1/2 hours Ingredients: 2 cups whole wheat flour 2 cups all-purpose flour, plus more for dusting
1 teaspoon baking soda 1 teaspoon salt 2 1/4 cups buttermilk
Preparation: Preheat oven to 450 degrees Fahrenheit. Coat a baking sheet with cooking spray and sprinkle with a little flour. Whisk whole-wheat flour, all-purpose flour, baking soda and salt in a large bowl. Make a well in the center and pour in buttermilk. Using one hand, stir in full circles (starting in the center of the bowl workin g toward the outside of the bowl) until all the flour is incorporated. The dough should be soft but not too wet and sticky. When it all comes togeth er, in a matter of seconds, turn it out onto a well-floured surface. Clean dough off your hand.
Nutrition facts per slice: 165 calories 1g fat (0g sat, 0g mono) 2mg cholesterol 37g carbohydrates 8g protein 3g fiber 347mg sodium 179 mg potassium
Pat and roll the dough gently with floury hands, just enough to tidy it up and give it a round shape. Flip over and flatten slightly to about 2 inches. Transfer the loaf to the prepared baking sheet. Mark with a deep cross using a serrated knife and prick each of the four quadr ants.
Bake the bread for 20 minutes. Reduce oven temperature to 400 degrees Fahrenheit and continue to bake until the loaf is brown on top and sounds hollow when tapped, 30 to 35 minutes more. Transfe r the loaf to a wire rack and let cool for about 30 minutes.
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U.S. OPTICAL BOARDS Alaska PO Box 110806 Juneau, AK 99811 (907)465-5470 http://www.dced.state.ak.us/occ/pdop.htm
Idaho 450 W. State St., 10th Floor Boise , ID 83720 (208)334-5500 www2.state.id.us/dhw
Oregon 3218 Pringle Rd. SE Ste. 270 Salem, OR 97302 (503)373-7721 www.obo.state.or.us
Arizona 1400 W. Washington, Rm. 230 Phoenix, AZ 85007 (602)542-3095 http://www.do.az.gov
Kentucky PO Box 1360 Frankfurt, KY 40602 (502)564-3296 http://1.usa.gov/xMFQAK
Rhode Island 3 Capitol Hill, Rm 104 Providence, RI 02908 (401)222-7883 www.health.state.ri.us
Arkansas PO Box 627 Helena, AR 72342 (870)572-2847
Massachusetts 239 Causeway St. Boston, MA 02114 (617)727-5339 http://1.usa.gov/zbJVt7
South Carolina PO Box 11329 Columbia, SC 29211 (803)896-4665 www.llr.state.sc.us
Nevada PO Box 70503 Reno, NV 89570 (775)853-1421 http://nvbdo.state.nv.us/
Tennessee Heritage Place Metro Center 227 French Landing, Ste. 300 Nashville, TN 37243 (615)253-6061 www2.state.tn.us/health
California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 (916)263-2382 www.medbd.ca.gov Colorado 1560 Broadway St. #1310 Denver, CO 80202 (303)894-7750 www.dph.state.ct.us Connecticut 410 Capitol Ave., MS #12APP PO Box 340308 Hartford, CT 06134 (860)509-7603 ext. 4 http://www.dph.state.ct.us/
New Hampshire 129 Pleasant St. Concord, NH 03301 (603)271-5590 www.state.nh.us New Jersey PO Box 45011 Newark, NJ 07101 (973)504-6435 http://bit.ly/wLM20Y
Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 doh.state.fl.us
New York 89 Washington Ave., 2nd Floor W. Albany, NY 12234 (518)402-5944 firstname.lastname@example.org
Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 www.sos.state.ga.us
North Carolina PO Box 25336 Raleigh, NC 27611 (919)733-9321 http://www.ncoptometry.org/
Hawaii PO Box 3469 Honolulu, HI 96801 (808)586-2704 email@example.com
Ohio 77 S. High St. Columbus, OH 43266 (614)466-9707 http://optical.ohio.gov/
Texas PO Box 149347 Austin, TX 78714 (512)834-6661 www.roatx.org Vermont National Life Bldg N FL. 2 Montpelier, VT 05620 (802)828-2191 www.vtprofessionals.org Virginia 3600 W. Broad St. Richmond, VA 23230 (804)367-8500 www.state.va.us/licenses Washington 300 SE Quince PO Box 47870 Olympia, WA 98504 (360)236-4947 www.doh.wa.gov
U.S. DENTAL BOARDS Alabama Alabama Board of Dental Examiners 5346 Stadium Trace Pkwy, Ste. 112 Hoover, AL 35244 (205) 985-7267 http://www.dentalboard.org/ Alaska P.O. Box 110806 Juneau, AK 99811-0806 (907)465-2542 http://bit.ly/uaqEO8 Arizona 4205 N. 7th Ave. Suite 300 Phoenix, AZ 85103 (602)242-1492 http://azdentalboard.us/ Arkansas 101 E. Capitol Ave. Suite 111 Little Rock, AR 72201 (501)682-2085 http://www.asbde.org/ California 2005 Evergreen Street, Suite 1550Â Sacramento, CA 95815 877-729-7789 http://www.dbc.ca.gov/ Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7800 http://www.dora.state.co.us/dental/ Connecticut 410 Capitol Ave. Hartford, CT 06134 (860)509-8000 http://www.ct.gov/dph/site/default.asp Delaware Cannon Building, Suite 203 861 Solver Lake Blvd. Dover, DE 19904 (302)744-4500 http://1.usa.gov/t0mbWZ Florida 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399 (850)245-4474 http://bit.ly/w1m4MI
58 | MARCH 2012
Georgia 237 Coliseum Drive Macon, GA 31217 (478)207-2440 http://sos.georgia.gov/plb/dentistry/ Hawaii DCCA-PVL Att: Dental P.O. Box 3469 Honolulu, HI 96801 (808)586-3000 http://1.usa.gov/s5Ry9i Idaho P.O. Box 83720 Boise, ID 83720 (208)334-2369 http://isbd.idaho.gov/ Illinois 320 W. Washington St. Springfield, IL 62786 (217)785-0820 http://bit.ly/svi6Od Indiana 402 W. Washington St. Room W072 Indianapolis, IN 46204 (317)232-2980 http://www.in.gov/pla/dental.htm Iowa 400 SW 8th St. Suite D Des Moines, IA 50309 (515)281-5157 http://www.state.ia.us/dentalboard/ Kansas 900 SW Jackson Room 564-S Topeka, KS 66612 (785)296-6400 http://www.accesskansas.org/kdb/ Kentucky 312 Whittington Parkway, Suite 101 Louisville, KY 40222 (502)429-7280 http://dentistry.ky.gov/ Louisiana 365 Canal St. Suite 2680 New Orleans, LA 70130 (504)568-8574 http://www.lsbd.org/
Maine 143 State House Station 161 Capitol St. Augusta, ME 04333 (207)287-3333 http://www.mainedental.org/ Maryland 55 Wade Ave. Catonsville, Maryland 21228 (410)402-8500 http://dhmh.state.md.us/dental/ Massachusetts 1000 Washington St. Suite 710 Boston, MA 02118 (617)727-1944 www.mass.gov Michigan P.O. Box 30664 Lansing, MI 48909 (517)241-2650 www.michigan.gov Minnesota 2829 University Ave., SE. Suite 450 Minneapolis, MN 55414 (612)617-2250 http://www.dentalboard.state.mn.us/ Mississippi 600 E. Amite St. Suite 100 Jackson, MS 39201 (601)944-9622 http://bit.ly/uuXKxl Missouri 3605 Missouri Blvd. P.O. Box 1367 Jefferson City, MO 65102 (573)751-0040 http://pr.mo.gov/dental.asp Montana P.O. Box 200113 Helena, MT 59620 (406)444-2511 http://mt.gov/ Nebraska 301 Centennial Mall South Lincoln, NE 68509 (402)471-3121 http://bit.ly/uBEqwK
Nevada 6010 S. Rainbow Blvd. Suite A-1 Las Vegas, NV 89118 (702)486-7044 http://www.nvdentalboard.nv.gov/
Oklahoma 201 N.E. 38th Terr. #2 Oklahoma City, OK 73105 (405)524-9037 http://www.dentist.state.ok.us/
Utah 160 E. 300 South Salt Lake City, UT 84111 (801)530-6628 http://1.usa.gov/xMVXWm
New Hampshire 2 Industrial Park Dr. Concord, NH 03301 (603)271-4561 http://www.nh.gov/dental/
Oregon 1600 SW 4th Ave. Suite 770 Portland, OR 97201 (971)673-3200 http://www.oregon.gov/Dentistry/
New Jersey P.O Box 45005 Newark, NJ 07101 (973)504-6405 http://bit.ly/uO2tLg
Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 (717)783-7162 http://bit.ly/s5oYiS
Vermont National Life Building North FL2 Montpelier, VT 05620 (802)828-1505 http://bit.ly/zSHgpa
New Mexico Toney Anaya Building 2550 Cerrillos Rd. Santa Fe, NM 87505 (505)476-4680 http://bit.ly/vCnCP4
Rhode Island Dept. of Health Three Capitol Hill, Room 104 Providence, RI 02908 (401)222-2828 http://1.usa.gov/u66MaB
New York 89 Washington Ave. Albany, NY 12234 (518)474-3817 http://www.op.nysed.gov/prof/dent/
South Carolina P.O. Box 11329 Columbia, SC 29211 (803)896-4599 http://www.llr.state.sc.us/POL/Dentistry/
North Carolina 507 Airport Blvd. Suite 105 Morrisville, NC 27560 (919)678-8223 http://www.ncdentalboard.org/
South Dakota P.O. Box 1079 105. S. Euclid Ave. Suite C Pierre, SC 57501 (605)224-1282 https://www.sdboardofdentistry.com/
North Dakota P.O. Box 7246 Bismark, ND 58507 (701)258-8600 http://www.nddentalboard.org/ Ohio Riffe Center 77 S. High St. 17th Floor Columbus, OH 43215 (614)466-2580 http://www.dental.ohio.gov/
Tennessee 227 French Landing, Suite 300 Nashville, TN 37243 (615)532-3202 http://health.state.tn.us/boards/dentistry/ Texas 333 Guadeloupe St. Suite 3-800 Austin, TX 78701 (512)463-6400 http://www.tsbde.state.tx.us/
Virginia Perimeter Center 9960 Maryland Dr. Suite 300 Henrico, VA 23233 (804)367-4538 http://bit.ly/zDkIU2 Washington 310 Israel Rd. SE P.O. Box 47865 Olympia, WA 98504 (360)236-4700 http://1.usa.gov/tKBFHT West Virginia 1319 Robert C. Byrd Dr. P.O. Box 1447 Crab Orchard, WV 25827 1-877-914-8266 http://www.wvdentalboard.org/ Wisconsin P.O. Box 8935 Madison, WI 53708 1-877-617-1565 http://bit.ly/sEhr0Q Wyoming 1800 Carey Ave. 4th Floor Cheyenne, WY 82002 (307)777-6529 http://plboards.state.wy.us/dental/index.asp
U.S. MEDICAL BOARDS Alabama P.O. Box 946 Montgomery, AL 36101 334-242-4116 http://www.albme.org/
Florida 2585 Merchants Row Blvd. Tallahassee, FL 32399 850-245-4444 http://www.doh.state.fl.us/
Alaska 550 West 7th Ave., Suite 1500 Anchorage, AK 99501 907-269-8163 http://bit.ly/zZ455T
Georgia 2 Peachtree Street NW, 36th Floor Atlanta, GA 30303 404-656-3913 http://bit.ly/vPJQyG
Arizona 9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258 480-551-2700 http://www.azmd.gov
Hawaii DCCA-PVL P.O. Box 3469 Honolulu, HI 96801 808-587-3295 http://hawaii.gov/dcca/pvl/boards/medical/
Arkansas 1401 West Capitol Ave., Suite 340 Little Rock, AR 72201 501-296-1802 http://www.armedicalboard.org/ California 2005 Evergreen St., Suite 1200 Sacramento, CA 95815 916-263-2382 http://www.mbc.ca.gov/ Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 303-894-7690 http://www.dora.state.co.us/medical/ Connecticut 401 Capitol Ave. Hartford, CT 06134 860-509-8000 http://www.ct.gov/dph/site/default.asp Delaware Division of Professional Regulation Cannon Building 861 Silver Lake Blvd., Suite 203 Dover, DE 19904 302-744-4500 http://dpr.delaware.gov/ District of Columbia 899 North Capitol St., NE Washington, DC 20002 202-442-5955 http://www.dchealth.dc.gov/doh
60 | MARCH 2012
Idaho Idaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720 208-327-7000 http://bit.ly/orPmFU Illinois 320 West Washington St. Springfield, IL 62786 217-785 -0820 http://www.idfpr.com/ Indiana 402 W. Washington St. #W072 Indianapolis, IN 46204 317-233-0800 http://www.in.gov/pla/ Iowa 400 SW 8th St., Suite C Des Moines, IA 50309 515-281-6641 http://medicalboard.iowa.gov/ Kansas 800 SW Jackson, Lower Level, Suite A Topeka, KS 66612 785-296-7413 http://www.ksbha.org/ Kentucky 310 Whittington Pkwy., Suite 1B Louisville, KY 40222 502-429-7150 http://kbml.ky.gov/default.htm
Louisiana LSBME P.O. Box 30250 New Orleans, LA 70190 504-568-6820 http://www.lsbme.la.gov/ Maine 161 Capitol Street 137 State House Station Augusta, ME 04333 207-287-3601 http://bit.ly/hnrzp Maryland 4201 Patterson Ave. Baltimore, MD 21215 (410)764-4777 http://www.mbp.state.md.us/ Massachusetts 200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 781-876-8200 http://www.mass.gov Michigan Bureau of Health Professions P.O. Box 30670 Lansing, MI 48909 517-335-0918 http://www.michigan.gov/lara Minnesota University Park Plaza 2829 University Ave. SE, Suite 500 Minneapolis, MN 55414 612-617-2130 http://bit.ly/pAFXGq Mississippi 1867 Crane Ridge Drive, Suite 200-B Jackson, MS 39216 601-987-3079 http://www.msbml.state.ms.us/ Missouri Missouri Division of Professional Registration 3605 Missouri Blvd. P.O. Box 1335 Jefferson City, MO 65102 573-751-0293 http://pr.mo.gov/
Montana 301 S. Park Ave. #430 Helena, MT 59601 406-841-2300 http://bit.ly/obJm7J p
North Dakota 418 E. Broadway Ave., Suite 12 Bismarck, ND 58501 701-328-6500 http://www.ndbomex.com/
Texas P.O. Box 2018 Austin, TX 78768 512-305-7010 http://bit.ly/rFyCEW
Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 402-471-3121 http://www.hhs.state.ne.us/
Ohio 30 E. Broad St., 3rd Floor Columbus, OH 43215 614-466-3934 http://med.ohio.gov/
Utah P.O. Box 146741 Salt Lake City, UT 84114 801-530-6628 http://www.dopl.utah.gov/
Oklahoma P.O. Box 18256 Oklahoma City, OK 73154 405-962-1400 http://www.okmedicalboard.org/
Vermont P.O. Box 70 Burlington, VT 05402 802-657-4220 http://1.usa.gov/wMdnxh
Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 971-673-2700 http://www.oregon.gov/OMB/
Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 804)-367-4400 http://1.usa.gov/xjfJXK
Nevada Board of Medical Examiners P.O. Box 7238 Reno, NV 89510 775-688-2559 http://www.medboard.nv.gov/ New Hampshire New Hampshire State Board of Medicine 2 Industrial Park Dr. #8 Concord, NH 03301 603-271-1203 http://www.nh.gov/medicine/ New Jersey P. O. Box 360 Trenton, NJ 08625 609-292-7837 http://bit.ly/w5rc8J New Mexico 2055 S. Pacheco St. Building 400 Santa Fe, NM 87505 505-476-7220 http://www.nmmb.state.nm.us/ New York Office of the Professions State Education Building, 2nd Floor Albany, NY 12234 518-474-3817 http://www.op.nysed.gov/ North Carolina P.O. Box 20007 Raleigh, NC 27619 919-326-1100 http://www.ncmedboard.org/
Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 717-787-8503 http://bit.ly/havKVj Rhode Island 3 Capitol Hill Providence, RI 02908 401-222-5960 http://1.usa.gov/xgocXV South Carolina P.O. Box 11289 Columbia, SC 29211 803-896-4500 http://www.llr.state.sc.us/pol/medical/ South Dakota 101 N. Main Ave. Suite 301 Sioux Falls, SD 57104 605-367-7781 http://www.sdbmoe.gov/ Tennessee 425 5th Ave. North Cordell Hull Bldg. 3rd Floor Nashville, TN 37243 615-741-3111 http://health.state.tn.us/
Washington Public Health Systems Development Washington State Department of Health 101 Israel Rd. SE, MS 47890 Tumwater, WA 98501 360-236-4085 http://www.doh.wa.gov/PHIP/default.htm West Virginia 101 Dee Dr., Suite 103 Charleston, WV 25311 304-558-2921 http://www.wvbom.wv.gov/ Wisconsin P.O. Box 8935 Madison, WI 53708 877-617-1565 http://drl.wi.gov/section. asp?linkid=6&locid=0 Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 307-778-7053 http://wyomedboard.state.wy.us/
medical resource guide
ACCOUNTING Boyle CPA, PLLC 3716 National Drive, Suite 206 Raleigh, NC 27612 (919) 720-4970 www.boyle-cpa.com
6881 Maple Creek Blvd, Suite 100 West Bloomfield, MI 48322-4559 248-819-6838 www.ringringllc.com
Find Urgent Care
PO Box 15130 Scottsdale, AZ 85267 602-370-0303 www.findurgentcare.com
Ring Ring LLC
6881 Maple Creek Blvd, Suite 100 West Bloomfield, MI 48322-4559 248-819-6838 www.ringringllc.com
ANSWERING SERVICES Corridor Medical Answering Service
3088 Route 27, Suite 7 Kendall Park, NJ 08824 866-447-5154 www.corridoranswering.net
Docs on Hold
14849 West 95th St. Lenexa, KS 66285 913-559-3666 www.soundproductsinc.com
BILLING & COLLECTION Advanced Physician Billing, LLC
PO Box 730 Fishers, IN 46038 866-459-4579 www.advancedphysicianbillingllc.com 62| MARCH 2012
3562 Habersham at Northlake, Bldg J Tucker, GA 30084 866-473-0011 www.ajishra.com
Applied Medical Services
Sweans Technologies 501 Silverside Rd. Wilmington, DE 19809 302-351-3690 www.medisweans.com
4220 NC Hwy 55, Suite 130B Durham, NC 27713 919-477-5152 www.ams-nc.com
PO Box 1350 Forney, TX 75126 214-499-3440
Axiom Business Solutions
4704 E. Trindle Rd. Mechanicsburg, PA 17050 866-517-0466 www.axiom-biz.com
Frost Arnett 480 James Robertson Parkway Nashville, TN 37219 800-264-7156 www.frostarnett.com
Gold Key Credit, Inc. PO Box 15670 Brooksville, FL 34604 888-717-9615 www.goldkeycreditinc.com
PO Box 98313 Raleigh, NC 27624 919-747-9031
Ajishra Technology Support
Horizon Billing Specialists 4635 44th St., Suite C150 Kentwood, MI 49512 800-378-9991 www.horizonbilling.com
Management Services On-Call 200 Timber Hill Place, Suite 221 Chapel Hill, NC 27514 (866) 347-0001 www.msocgroup.com
SEAK Non-Clinical Careers Conference Oct. 21-22, 2012 in Chicago, IL 508-457-1111 www.nonclinicalcareers.com
Doctorâ€™s Crossing 4107 Medical Parkway, Suite 104 Austin, Texas 78756 (512)517-8545 http://doctorscrossing.com/
CODING SPECIALISTS The Coding Institute LLC 2222 Sedwick Drive Durham, NC 27713 800-508-2582 http://www.codinginstitute.com/
Marina Medical Billing Service 18000 Studebaker Road 4th Floor Cerritos, CA 90703 800-287-8166 www.marinabilling.com
American Medical Software
6451 Brentwood Stair Rd. Ft. Worth, TX 76112 800-378-4134 www.mediservltd.com
Practice Velocity 1673 Belvidere Road Belvidere, IL 61008 888-357-4209 www.practicevelocity.com
1180 Illinois 157 Edwardsville, IL 62025 (618) 692-1300 www.americanmedical.com 300 N. Milwaukee Ave Vernon Hills, IL 60061 866-782-4239 www.cdwg.com/
Instant Medical History
4840 Forest Drive #349 Columbia, SC 29206 803-796-7980 www.medicalhistory.com
medical resource guide
CONSULTING SERVICES, PRACTICE MANAGEMENT Manage My Practice
103 Carpenter Brook Dr. Cary, NC 27519 919-370-0504 www.managemypractice.com
24 Cherry Lane Doylestown, PA 18901 888-348-1170 www.myemrchoice.com
Urgent Care America
17595 S. Tamiami Trail Fort Meyers, FL 33908 239-415-3222 www.urgentcareamerica.com
Medical Practice Listings
The Dental Box Company, Inc.
PO Box 101430 Pittsburgh, PA 15237 412-364-8712 www.thedentalbox.com
Dentistry’s Business Secrets
9016 Phoenix Parkway O’Fallon, MO 63368 636-561-5445 www.dentrysbusinesssecrets.com
Modern Dental Marketing Practices
504 N. Oak St. #6 Roanoke, TX 76262 940-395-5115 www.moderndentalmarketing.com
ELECTRONIC MED. RECORDS
ABELSoft 1207 Delaware Ave. #433 Buffalo, NY 14209 800-267-2235 www.abelmedicalsoftware.com
Laboratory Management Resources
3729 Greene’s crossing Greensboro, NC 27410 336-288-9823 www.managemypractice.com
17815 Sky Park Circle , Suite J Irvine, CA 92614 949-474-7774 www.acentec.com
200 Welsh Rd. Horsham, PA 19044 215-657-7010
Synapse Medical Management
18436 Hawthorne Blvd. #201 Torrance, CA 90504 310-895-7143 www.synapsemgmt.com
DENTAL Biomet 3i
4555 Riverside Dr. Palm Beach Gardens, FL 33410 800-342-5454 www.biomet3i.com
Dental Management Club
4924 Balboa Blvd #460 Encino, CA 91316 www.dentalmanagementclub.com
Sigmon Daknis Wealth Management 701 Town Center Dr. Ste. #104 Newport News, VA 23606 757-223-5902 www.sigmondaknis.com Sigmon & Daknis Williamsburg, VA Office 325 McLaws Circle, Suite 2 Williamsburg, VA 23185 Phone: 757-258-1063 http://www.sigmondaknis.com/
INSURANCE, MED. LIABILITY Jones Insurance
8317 Six Forks Rd. Suite #205 Raleigh, NC 27624 919-848-4202 www.medicalpracticelistings.com
10011 S. Centennial Pkwy Sandy, UT 84070 800-825-0224 www.amdsoftware.com
CollaborateMD 201 E. Pine St. #1310 Orlando, FL 32801 888-348-8457 www.collaboratemd.com
DocuTAP 4701 W. Research Dr. #102 Sioux Falls, SD 57107-1312 877-697-4696 www.docutap.com
820 Benson Rd. Garner, North Carolina 27529 (919) 772-0233 www.Jones-insurance.com
Medical Protective 5814 Reed Rd. Fort Wayne, In 46835 800-463-3776
1849 W. North Temple Salt Lake City, UT 84116 800-969-6447 www.mgis.com
Professional Medical Insurance Services
16800 Greenspoint Park Drive Houston, TX 77060 877-583-5510 www.promedins.com
Wood Insurance Group
4835 East Cactus Rd. #440 Scottsdale, AZ 85254-3544 602-230-8200 www.woodinsurancegroup.com
LOCUM TENENS Physician Solutions
2600 Garden Rd. #112 Monterey, CA 93940 800-458-2486 www.integritas.com
PO Box 98313 Raleigh, NC 27624 919-845-0054 www.physiciansolutions.com MEDMONTHLY.COM |63
medical resource guide LOCUM TENENS (CONT.) Simply Locums, Inc. Your direct, simple & comprehensive source for locum tenens and permanent positions for physicians and other healthcare professionals. Simply Locums was developed to provide a source for both healthcare providers and healthcare facilities to efficiently and directly manage and negotiate their locum tenens and permanent assignments. Weâ€™ve streamlined the process, eliminated the costly middleman, and directly link highly qualified healthcare professionals to healthcare facilities. By prohibiting 3rd party recruiter access to our site, we provide cost savings to healthcare facilities and maximize your income. 3949 Hester Lane Salem, IL 62881 firstname.lastname@example.org www.simplylocums.com
Marianne Mitchell 215-704-3188 http://www.mariannemitchell.com http://www.colordrop.blogspot.com Nicholas Down http://bit.ly/yHwxb0
9115 Hague Rd. Indianapolis, IN 46250-0457 317-521-2000 www.roche-diagnostics.us
MEDICAL EQUIPMENT Abaxis
3240 Whipple Road Union City, CA 94587 800-822-2947 www.piccoloxpress.com
100 Abbott Park Road Abbot Park, Il 60064 (847) 937-6100
MedMedia9 PO Box 98313 Raleigh, NC 27624 919-747-9031 www.medmedia9.com WhiteCoat Designs Web, Print & Marketing Solutions for Doctors 919-714-9885 www.whitecoat-designs.com
MEDICAL PRACTICE SALES
1295 Walt Whitman Road Melville, NY 11747 888-862-4050 www.allproimaging.com
9975 Summers Ridge Road San Diego, CA 92121 858-805-8378 www.biosite.com
Medical Practice Listings
8317 Six Forks Rd. Ste #205 Raleigh, NC 27624 919-848-4202 www.medicalpracticelistings.com
MEDICAL PRACTICE VALUATIONS
Brymill Cryogenic Systems
105 Windermere Ave. Ellington, CT 06029 860-875-2460
Deborah Brenner 877 Island Ave #315 San Diego, CA 92101 619-818-4714 www.deborahbrenner.com Martha Petty 316 Burlage Circle Chapel Hill, NC 27514 919-933-4920
800 Shoreline, #900 Corpus Christi, TX 78401 888-246-3928
PO Box 99488 Raleigh, NC 27624 919-846-4747 www.bizscorevaluation.com
MEDICAL RESEARCH www.cryopen.com
Carolina Liquid Chemistries, Inc.
391 Technology Way Winston Salem, NC 27101 336-722-8910 www.carolinachemistries.com
500 Chipeta Way Salt Lake City, UT 84108 800-242-2787
Julie Jennings 678-772-0889 email@example.com http://silksynergy.com/ http://www.coroflot.com/naddie09
Chimerix, Inc. 2505 Meridian Parkway, Suite 340 Durham, NC 27713 (919) 806-1074 www.chimerix.com
Eduardo Lapetina 318 North Estes Drive Chapel Hill, NC 27514 919-960-3400 eduardolapetina.com/index.shtml
64| MARCH 2012
548 Wald Irvine, CA 92618 800-377-2617
524 Huffman Rd. Birmingham, AL 35215 866-324-9700 www.radicalradiology.com
Clinical Reference Laboratory 8433 Quivira Rd. Lenexa, KS 66215 800-445-6917
medical resource guide Peters Medical Research
507 N. Lindsay St. 2nd Floor High Point, NC 27262 www.Petersmedicalresearch.com Sanofi US 55 Corporate Drive Bridgewater, NJ 08807 (800) 981-2491 www.sanofi.us
STAFFING COMPANIES Additional Staffing Group, Inc. 8319 Six Forks Rd, Suite 103 Raleigh, NC 27615 (919) 844-6601 Astaffinggroup.com
Scynexis, Inc. 3501 C Tricenter Blvd. Durham, NC 27713 (919) 933-4990 www.scynexis.com
NUTRITION THERAPIST Triangle Nutrition Therapy 6200 Falls of Neuse Road, Suite 200 Raleigh, NC 27609 919-876-9779 http://trianglediet.com/
BSN Medical 5825 Carnegie Boulevard Charlotte, NC 28209 800-552-1157 www.bsnmedical.us CNF Medical 1100 Patterson Avenue Winston Salem, NC 27101 877-631-3077 www.cnfmedical.com
Dermabond Ethicon, Route 22 West Somerville, NJ 08876 877-984-4266 DJO 1430 Decision St. Vista, CA 92081 760-727-1280 ExpertMed 31778 Enterprise Dr. Livonia, MI 48150 800-447-5050
4444 East 153rd St. Cleveland, OH 44128-2955 216-581-3030 www.gebauerspainease.com
15 Barstow Rd. Great Neck, NY 11021 877-566-5935 www.scarguard.com
Buying or selling? We can help! Listing Benefits • • • • •
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• Accurate practice pricing • Detailed reports and financials • Largest selection of health care facilities • Work one-on-one with an experienced team of qualified professionals
Medical Practice Listings Scan this QR code with your smartphone to learn more
A Philip Driver Company
Classified To place a classified ad, call 919.747.9031
North Carolina (cont.)
Immediate Full Time opportunity for Board Certified Occupational Health Care MD in Greensboro NC. Excellent working environment, wage and professional liability insurance provided. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: firstname.lastname@example.org
sideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: email@example.com
Occupational Health Care practice in Fayetteville North Carolina has 2 to 5 days of locums work per week. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: firstname.lastname@example.org Occupation Health Care Practice located in Greensboro, N.C. has an immediate opening for a primary care physician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability insurance and an excellent CME, vacation and sick leave package. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: email@example.com Family Practice physician opportunity in Raleigh, N.C. This is a locum’s position with three to four shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from one year of age to geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: firstname.lastname@example.org Methadone Treatment Center located near Charlotte, N.C. has an opening for an experienced physician. You must be comfortable in the evaluation and treatment within the guidelines of a highly regulated environment. Practice operating hours are 6 a.m. till 3 p.m. Monday through Friday. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate con-
Family Practice physician is needed to cover several shifts per week in Rocky Mount, N.C. This high profile practice treats pediatrics, women’s health and primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: email@example.com Cardiology practice located in High Point, N.C. has an opening for a board certified cardiovascular physician. This established and beautiful facility offers the ideal setting for an enhanced lifestyle. There is no hospital call or invasive procedures. Look into joining this three physician facility and live the good live in one of North Carolina’s most beautiful cities. Send copies of your CV, N.C. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail. com Board Certified Internal Medicine Physician position is available in the Greensboro, N.C. area. This is an outpatient opportunity within a large established practice. The employment package contains salary plus incentives. Please send a copy of your current CV, N.C. medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624. Email: firstname.lastname@example.org or phone with any questions, PH: (919) 845-0054. Locum Tenens opportunity for Primary Care MD in the Triad area N.C. This is a 40 hour per week on-going assignment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wage, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, N.C. medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624. E-mail: email@example.com or phone with any questions, PH: (919) 845-0054. MEDMONTHLY.COM |67
: d e t Wan Hospi
n Dall i e c i t c a r ce P
We have a qualified buyer that is looking for an established hospice practice in the Dallas,Texas area. To review your hospice practice options confidentially, contact Medical Practice Listings at 919-848-4202 or e-mail us at firstname.lastname@example.org.
N.C. OPPORTUNITIES LOCUMS OR PERMANENT
Physician Solutions has immediate opportunities for psychiatrists throughout N.C. Top wages, professional liability insurance and accommodations provided. Call us today if you are available for a few days a month, on-going or for permanent placement. Please contact Ashley at 919-845-0054 or email@example.com For more information about Physician Solutions or to see all of our locums and permanent listings, please visit physiciansolutions.com
To view our national listings visit www.medicalpracticelistings.com
compound noun: 1. The action of calling attention to medical goods or services for sale. Exclusively refers to advertising in Med Monthly.
Come see why weâ€™re not your fatherâ€™s medical journal Scan this code with your smartphone or visit medmonthly.com
Med Monthly 919.747.9031 | firstname.lastname@example.org | medmonthly.com
Hospice Practice Wanted Hospice Practice wanted in Raleigh/ Durham area of North Carolina.
Med Monthly is the premier health care magazine for medical professionals.
By placing an ad in Med Monthly youâ€™ll reach: family medicine, internal medicine, physician assistants and more!
Medical Practice Listings has a qualified physician buyer that is ready to purchase. If you are considering your hospice practice options, contact us for a confidential discussion regarding your practice.
Call us today to place your classified!
To find out more information call 919-848-4202 or e-mail email@example.com www.medicalpracticelistings.com
EXCELLENT FAMILY PRACTICE FOR SALE North Carolina family practice located about 30 minutes from Lake Norman has everything going for it.
Medical Practice Listings For more information call (919) 848-4202. To view other practice listings visit medicalpracticelistings.com
Gross revenues in 2010 were 1.5 million, and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established. Excellent medical equipment, staff and hospital near-by, you will be hard pressed to find a family practice turning out these numbers. Listing price is $625,000.
Also available online 24/7
Wanted: Urgent Care Practice Urgent Care Practice wanted in North Carolina. Qualified physician is seeking to purchase an established urgent care within 100 miles of Raleigh, North Carolina. If you are considering retiring, relocations or closing your practice for personal reasons, contact us for a confidential discussion regarding your urgent care. You will receive cash at closing and not be required to carry a note.
Medical Practice Listings Buying and selling made easy
Call 919-848-4202 or e-mail firstname.lastname@example.org www.medicalpracticelistings.com MEDMONTHLY.COM |69
MD STAFFING AGENCY FOR SALE Great opportunity for anyone who wants to purchase an established business. One of the oldest Locums companies Large client list Dozens of MDs under contract Executive office setting Modern computers and equipment Revenue over a million per year Owner retiring List price is over $2 million
Please direct all correspondence to email@example.com. Only serious, qualified inquirers.
PRACTICE FOR SALE
OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina Well-established practice serving the Greensboro and High Point areas for over 15 years. Five exam rooms fully equipped, plus digital X-Ray. Extensive corporate accounts as well as walk-in traffic. Lab equipment includes CBC. The owning MD is retiring, creating an excellent opportunity for a MD to take over an existing patient base and treat 25 plus patients per day from day one. The practice space is 2,375 sq. feet. This is an exceptionally opportunity. Leased equipment includes: X-Ray $835 per month, copier $127 per month, and CBC $200 per month. Call Medical Practice Listings at (919) 848-4202 for more information.
Asking price: $385,000
To view more listings visit us online at medicalpracticelistings.com
MODERN MED SPA AVAILABLE Located in beautiful coastal North Carolina
Modern, well-appointed med spa is available in a picturesque part of the state. This practice is positioned in a highly traveled area with positive demographics adding to the business appeal and revenue stream. A sampling of the services and procedures offered are: BOTOX, facial therapy and treatments, laser hair removal, eye lash extensions and body waxing as well as a menu of anti-aging options. If you are currently a med spa owner and looking to expand or considering this high profile med business, this is the perfect opportunity. Highly profitable and organized, you will find this spa poised for success. The qualified buyer can obtain detailed information by contacting Medical Practice Listings at 919-848-4202.
MedicalPracticeListings.com | firstname.lastname@example.org | 919.848.4202 70| MARCH 2012
Classified To place a classified ad, call 919.747.9031
North Carolina (cont.)
Internal Medicine practice located in High Point, N.C., has two full time positions available. This well-established practice treats private pay as well as Medicare/ Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your N.C. medical license to email@example.com. View this and other exceptional physician opportunities at www.physiciansolutions.com or call (919) 845-0054 to discuss your availability and options. Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in N.C. and Va. Call today to discuss your options and see why Physician Solutions has been the premier physician staffing company on the Eastern seaboard. Call 919-845-0054 or review our corporate capabilities at www.physiciansolutions.com.
Virginia Urgent Care opportunities throughout Virginia. We have contracts with numerous facilities and eight to 14-hour shifts are available. If you have experience treating patients from Pediatrics to Geriatrics, we welcome your inquires. Send copies of your CV, Va. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: firstname.lastname@example.org. Pediatric Locums Physician needed in Harrisonburg, Danville and Lynchburg, Va. These locum positions require 30 to 40 hours per week, on-going. If you are seeking a beautiful climate and flexibility with your schedule, please consider one of these opportunities. Send copies of your CV, Va. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, E-mail: email@example.com.
Impressive Internal Medicine Practice in Durham, N.C.: The City of Medicine. Over 20 years serving the community, this practice is now listed for sale. There are four well equipped exam rooms, new computer equipment and a solid patient following. The owner is retiring and willing to continue with the new owner for a few months to assist with a smooth transition. Contact Medical Practice Listings at (919) 8484202 for more information. View additional listings at: www. medicalpracticelistings.com. Modern Vein Care Practice located in the mountains of N.C. Booking seven to 10 procedures per day, you will find this impressive vein practice attractive in many ways. Housed in the same practice building with an Internal Medicine, you will enjoy the referrals from this as well as other primary care and specialties in the community. We have this practice listed for $295,000 which includes charts, equipment and good will. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at www.medicalpracticelistings.com. Family Practice located in Hickory, N.C. Well-established and a solid 40 to 55 patients split between an MD and physician assistant. Experienced staff and outstanding medical equipment. Gross revenues average $1,500,000 with strong profits. Monthly practice rent is only $3,000 and the utilities are very reasonable. The practice with all equipment, charts and good will are priced at $625,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, N.C. 27624. PH: (919) 848-4202 or E-mail: firstname.lastname@example.org.
MEDICAL PRACTICE LISTINGS Are you looking to sell or buy a practice? View national practice listings by visiting our website or contact us for a confidential discussion regarding your practice options. We are always ready to assist you.
919.848.4202 email@example.com | medicalpracticelistings.com We have in-house practice experts and an attorney ready to assist.
MEDMONTHLY.COM | 71
Classified To place a classified ad, call 919.747.9031
Practice for sale
Practice for sale
North Carolina (cont.)
South Carolina (cont.)
Internal Medicine Practice located just outside Fayetteville, N.C. is now being offered. The owning physician is retiring and is willing to continue working for the new owner for a month or two assisting with a smooth transaction. The practice treats patients four and a half days per week with no call or hospital rounds. The schedule accommodates 35 patients per day. You will be hard pressed to find a more beautiful practice that is modern, tastefully decorated and well appointed with vibrant art work. The practice, patient charts, equipment and good will is being offered for $415,000 while the free standing building is being offered for $635,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, N.C. 27624. PH: (919) 848-4202 or Email: firstname.lastname@example.org. Primary Care practice specializing in women’s care. The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider. Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several wellappointed exam rooms throughout. New computers and medical management software add to this modern front desk environment. This practice is being offered for $435,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, N.C. 27624. PH: (919) 848-4202 or E-mail: email@example.com.
South Carolina Lucrative ENT practice with room for growth, located three miles from the beach. Physician’s assistant, audiologist, esthetician and well-trained staff. Electronic medical records, mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/ thyroid surgery. Room for establishing allergy, cosmetics, laryngology and trans-nasal esophagoscopy. All the organization is done; walk into a ready-made practice as your own boss and make the changes you want, when 72| MARCH 2012
you want. Physician will to stay on for smooth transition. Hospital support is also an option for up to a year. The listing price is $395,000 for the practice, charts, equipment and good will. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, N.C. 27624. PH: (919) 848-4202 or E-mail: firstname.lastname@example.org.
Washington Family Practice located in Bainbridge Island, Washington has recently been listed. Solid patient following and cash flow makes this 17 year old practice very attractive. Contact Medical Practice Listings for more details. Email: email@example.com or (919) 848-4202.
Practice wanted North Carolina Pediatric Practice wanted in Raleigh, N.C. Medical Practice Listings has a qualified buyer for a Pediatric Practice in Raleigh, Cary or surrounding area. If you are retiring, relocating or considering your options as a pediatric practice owner, contact us and review your options. Medical Practice Listings is the leading seller of practices in the U.S. When you list with us, your practice receives exceptional national, regional and local exposure. Contact us today at (919) 848-4202.
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Pediatrics Practice For Sale Minneapolis, Minn.
Pediatrics Practice Wanted Pediatrics Practice wanted in N.C.
Located in the beautiful suburbs of Minneapolis, Minn., this two year old pediatric practice is successful and growing steadily. Averaging 14 patients per day and projected numbers top 35 per day within a short few months. Contracts have been established with Blue Cross Blue Shield of Minnesota, HealthPartners, Medica, PreferredOne, UCare, Minnesota Medicaid, and Americaâ€™s PTO. Providers include one MD, one LPN and two CMAs.
Considering your options regarding your Pediatric Practice? We can help. Medical Practice Listings has a well qualified buyer for a Pediatric Practice anywhere in central North Carolina.
Fully equipped with modern computer networking in this 3,370 sq. foot leased medical space. Contact Medical Practice Listings for more information.
Medical Practice Listings 919.848.4202 | firstname.lastname@example.org www.medicalpracticelistings.com
Contact us today to discuss your options confidentially. Medical Practice Listings Call 919-848-4202 or e-mail email@example.com www.medicalpracticelistings.com
FAMILY PRACTICE FOR SALE An beautiful practice located in Seattle, Washington This upscale primary care practice has a boutique look and feel while realizing consistent revenues and patient flow. You will be impressed with the well appointed layout, functionality as well as the organization of this true gem of a practice. Currently accepting over 20 insurance carriers like; Aetna, Blue Cross and Blue Shield, Cigna, City of Seattle, Great West and United Healthcare. The astute physician considering this practice will be impressed with the comprehensive collection of computers, office furniture and medical equipment such as Welch Allyn Otoscope, Ritter Autoclave, Spirometer and Moore Medical Exam table. Physician compensation is consistently in the $200,000 range with upside as you wish. Do not procrastinate; this practice will not be available for long. List price: $255,000 | Year Established: 2007 | Gross Yearly Income: $380,000
Medical Practice Listings Selling and buying made easy
MedicalPracticeListings.com | firstname.lastname@example.org | 919.848.4202 MEDMONTHLY.COM |73
Primary Care Practice For Sale
Exceptional North Carolina Primary Care Practice for Sale
Medical Practice Listings
Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 1 hour from Raleigh, 15 minutes from Lumberton and about an hour from Wilmington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff. The gross revenue for 2010 is $856,000, and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building. Our Services: • Primary Health • Well Child Health Exams • Sport Physical • Adult Health Exams • Women’s Health Exams • Management of Contraception • DOT Health Exam • Treatment & Management of Medical Conditions • Counseling on Prevention of Preventable Diseases • Counseling on Mental Health • Minor surgical Procedures
919.848.4202 | email@example.com www.medicalpracticelistings.com
For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.
Wilmington, N.C. Established primary care on the coast of North Carolina’s beautiful beaches. Fully staffed with MD’s and PA’s to treat both appointment and walk-in patients. Excellent exam room layout, equipment and visibility. Contact Medical Practice Listings for more information.
Private Medical and Mental Health Care Practice for Sale Coastal North Carolina, Minutes from Atlantic Beach
Established private internal medicine practice treating general as well as adolescent patients and licensed clinical psychologist’s combine for a high profile multi-disciplinary practice. The staff includes a medical doctor, physician assistant, three licensed clinical psychologists, and a complement of nurses and administrators. The internal medicine practice also uses locum physicians to treat primary care patients as needed. Excellent gross income with solid profits are enjoyed in this evergrowing practice located in a bustling community with handsome demographics. Two all brick condominiums house these practices which are offered for lease or purchase. This expanded services private health care facility has a solid following and all the tools necessary for enhanced services, income and expansion. For more details which include a BizScore Practice Valuation, financial statements, patient demographics and furniture and equipment details, contact one of our professionals.
Medical Practice Listings PH: (919) 848-4202 Email: firstname.lastname@example.org www.medicalpracticelistings.com 74| MARCH 2012
N.C. MedSpa For Sale MedSpa Located in North Carolina We have recently listed a MedSpa in N.C. This established practice has staff MDs, PAs and Nurses to assist patients. Some of the procedures performed include: Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, Fractional Laser Resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing, and we are in the valuation process. Contact Medical Practice Listings today to discuss the practice details.
For more information call Medical Practice Listings at 919-848-4202 or e-mail email@example.com.
Practice for Sale in Raleigh, NC Primary Care practice specializing in Women’s care Raleigh, North Carolina The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however, that could double with a second provider. Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several well-appointed exam rooms, tactful and well appointed throughout. New computers and medical management software add to this modern front desk environment. List price: $435,000.
Call Medical Practice Listings at (919) 848-4202 for details and view our other listings at www.medicalpracticelistings.com
ADVERTISE YOUR PRACTICE BUILDING IN MED MONTHLY
Practice at the beach Plastic Surgery practice for sale with lucrative ENT specialty Myrtle Beach, South Carolina Practice for sale with room for growth and located only three miles from the beach. Physician’s assistant, audiologist, esthetician and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of Otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing Allergy, Cosmetics, Laryngology & Trans-nasal Esophagoscopy. All the organization is done, walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000. For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.
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Surgeons & Physicians Treating Professional Athletes
NEAL ELATTRACHE, MD (Kerlan-Jobe Orthopaedic Clinic, Los Angeles) Dr. ElAttrache is the team physician for the Los Angeles Dodgers, and serves as an orthopedic consultant to the Anaheim Mighty Ducks, St. Louis Rams and the Los Angeles Lakers.
March’s Top 9 List recognizes a few of the country’s most renowned orthopedic surgeons and team physicians who routinely care for some of the greatest athletes playing in U.S. professional sports today. Compiled by Leigh Ann Simpson
PATRICK MCKENZIE, MD (Orthopedic & Sports Medicine Specialists, Green Bay, Wis.) Dr. McKenzie is the medical director and orthopedic surgeon for the Green Bay Packers, and is currently the president of the NFL Team Physician’s Society.
RUSSELL WARREN, MD (Hospital for Special Surgery, New York) In addition to his position as head team physician for the New York Giants, he has been inducted to the American Orthopaedic Society of Sports Medicine Hall of Fame.
THOMAS J. GILL, MD (Massachusetts General Hospital, Boston) Dr. Gill serves as the medical director for the Boston Red Sox as well as the New England Patriots, and is a team physician for the Boston Bruins.
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DAVID A. FISCHER, MD (TRIA Orthopaedic Center, Minneapolis, Minn.) Dr. Fischer is the team physician for the Minnesota Timberwolves and a former team physician for the Minnesota Vikings and the 1992 U.S. Olympic Basketball Team.
CHRISTOPHER AHMAD, MD (Columbia Orthopaedics, New York) Dr. Ahmad is the head team physician for the New York Yankees.
XAVIER DURALDE, MD (Peachtree Orthopaedic Clinic, College Park, Ga.) Dr. Duralde is the team physician and surgeon for the Atlanta Braves and a member of the Major League Baseball Physicians Association. PETER DELUCA, MD (Rothman Institute, Philadelphia) Dr. DeLuca is the head team physician for the Philadelphia Eagles and the Philadelphia Flyers.
JAMES ANDREWS, MD (Andrew Aports Medicine & Orthopaedic Center, Birminham, Ala.) Dr. Andrews is the senior orthopaedic consultant for the Washington Redskins; medical director for the Tampa Bay Rays and an affiliate of the Chicago White Sox. He also serves as the co-medical director of the Ladies Professional Golf Association.
A simple question can reveal as much as a test. “WHAT ARE OUR GOALS FOR TODAY?” Ask your patients about their health priorities at each visit. When you do, both you and your patient can make the most out of the time you have together, and they’ll feel more invested in their own care. Not only does that improve efficiencies, but it also helps improve health outcomes.
For tools and tips to share with your patients, visit www.ahrq.gov/questions