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Med Monthly April 2015


ng Developi al a Referr Network issue

What to Do When Your Referral Sources Dry Up pg. 32

Physician Referrals: Communication is the Key pg. 38

Physician to Physician Referrals:

How-to Get em’ and Keep em’ pg. 30



insight 6










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Med Monthly April 2015 Publisher Creative Director Contributors

Philip Driver Thomas Hibbard Ashley Acornley, MS, RD, LDN. Naren Arulrajah Vinay Bhupathy Amanda Chay Vishal Gandhi, BSEE, MBA Jennifer S. Geetter Alexis Gopal Barbara Hales, M.D. Ellen L. Janos Marina Liem Laura Marusinec Abby Matousek Chelsea M. Rutherford Andrew J. Shin Denise Price Thomas Florence Wang Marlee Ward

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

P.O. Box 99488 Raleigh, NC 27624 Online 24/7 at

contributors Amanda Chay serves as the Director of Physician Liaison & Affiliate Programs at WhiteCoat Designs, a company that specializes in marketing solutions for the healthcare industry. With a healthcare marketing background spanning 13 years, Amanda has a strong understanding of the challenges faced by doctors and their practices in this competitive market.

Alexis Gopal M.D. is a physician and medical writer with years of clinical experience in Internal Medicine and medical education in NYC and CT and has been published in The American Journal of Emergency Medicine and She is the owner and operator of Gopal Medical Communications and can be reached at

Barbara Hales, M.D. is a skilled expert in promoting your health services. As seen on NBC, CBS,ABC and FOX network affiliates as well as Newsweek, Dr. Hales writes all the content you need to promote your medical services. Her latest book is on the best seller list and she can do the same for you. Check out her site at

Laura E. Marusinec, MD is a board-certified pediatrician and medical writer with experience in general pediatrics, pediatric dermatology, and pediatric urgent care. She has supported an electronic health record implementation and optimization and is pursuing further medical writing education and opportunities.

Denise Price Thomas retired in 2009 as a surgical practice administrator where she was employed for 32 years. She is certified in healthcare management through Pfeiffer College. Speaking invitations have taken her from NC to SC, Georgia, Florida, Chicago, Alaska and more. Website: WWW.MEDMONTHLY.COM |5


Does the Recent Measles Outbreak Have a Silver Lining for the Pro-Vaccine Cause?

By Laura E. Marusinec, MD, Urgent Care Pediatrician

6 | APRIL 2015

The vaccination debate has been going strong for years. It has recently received even more attention with the recent measles outbreaks, including one stemming from Disneyland that has affected over 140 children in at least seven states as of early March.

The mismatch of this year’s influenza vaccine and the prevalent strain fueled some anti-vaccine concerns.


“This recent measles outbreak has brought the vaccine debate, and the debate about rights, back in the spotlight – in the news, on TV, and on social media.”

With poor coverage of the prevalent strains this winter, the effectiveness of the influenza vaccine has been reduced to about 20%¹.This brings up the argument, “The vaccine doesn’t even work, why should we get it?” Unfortunately, with influenza vaccination, this is sometimes the case. Despite best efforts to match strains, sometimes they get it wrong. However, this shouldn’t affect people’s decisions on vaccinating for influenza in future years, and certainly not for vaccinating for other serious illnesses such as measles, for which the vaccine is about 98% effective and is long-lasting.

Parents report a variety of reasons for refusing vaccines for their children. Rarely, a child has a medical contraindication or has had a severe adverse reaction from a vaccine–this can be a valid reason for declining certain vaccines. However, this is the minority. Most of the other reasons for not vaccinating are not based on evidence-based science–such as concerns that vaccines contain “toxins” or will overwhelm their child’s immune system, or that vaccines often cause major harm, such as autism and even death. They don’t realize the seriousness and contagiousness of the vaccine-preventable diseases–since we almost never see them thanks to the efficacy of most current vaccines. They often harbor mistrust and feel that we (doctors, pharmaceutical companies, or the government) are only interested in the money, are telling them what to do, or worse, somehow out to harm them. They believe in the “n of 1”i.e., “my child doesn’t get vaccines and doesn’t get sick” or, “my child got sick after getting the vaccine” instead of the results of large, scientific, evidence-based studies. Unfortunately, the one study parents opposed to vaccines seem to trust is the study linking autism with the MMR vaccine by Andrew Wakefield–which we now know to be fraudulent and which has been fully retracted and discredited.

However, much of the vaccine debate is actually related to personal freedoms and rights more than actual vaccine risks, especially when considering vaccination for herd immunity. Parents ask, “Why should my child have to get the vaccine to protect yours?” They fail to realize that the 95% or more of children getting the vaccines are already protecting their children as well as their own. They benefit from herd immunity, but by not vaccinating, put the whole herd at risk. How do we decide which child–the child who is not vaccinated (and putting others at risk)–or the child who is at risk due to age or immune status–should be able to attend school or daycare? Don’t children have a right to go to school, daycare, and even Disneyland, without being exposed to vaccinepreventable diseases?

With the recent measles outbreak, many children unvaccinated by choice are among those getting sick, and parents are facing more pressure to vaccinate. Now that we are seeing more cases of measles, chances increase that unvaccinated children will get infected. They are affected by herd immunity just as much as they are responsible for it.

continued on page 8


continued from page 7

Will seeing how serious and highly contagious measles actually is help parents rethink their positon? And will increasing pressure to vaccinate or face consequences affect their choice? In 2014, the US saw a record number of measles cases, with 644 cases from 27 states reported to the CDC–the greatest number of cases since the elimination of measles was documented in the U.S. in 2000². The majority of people who got measles were unvaccinated. Measles is one of the most highly contagious organisms– it is easily spread through the air, and it can live on surfaces and in the air for up to two hours. So if a child with measles is in a classroom, daycare, or doctor’s waiting room, people are at high risk even two hours after the child leaves. And, as children are most contagious several days before the rash occurs, parents aren’t usually aware they have measles and aren’t taking precautions not to expose others. In addition, besides causing typical symptoms of high fever, cough, runny nose, rash, and conjunctivitis, measles infection can lead to complications such as ear infections, pneumonia, encephalitis, hearing loss, and rarely, even death. This recent measles outbreak has brought the vaccine debate, and the debate about rights, back in the spotlight– in the news, on TV, and on social media. A new article is posted almost every day, with titles such as “The Return of the Vaccine Wars³.” For some time, those who refused vaccinations seemed to have the upper hand. More schools and daycares, even doctors’ offices, bended to the wishes of parents and allowed unvaccinated children in the name of parents’ rights. But things seem to be changing. People are getting scared–and angry. Parents with babies too young to vaccinate or children with weakened immunity already have enough to worry about–now they have to worry about measles because someone chose not to vaccinate their children. There are more stories about children with cancer or other conditions asking for THEIR rights. Parents with unvaccinated children causing others to be infected are facing blame. And more schools, daycares, and even doctors’ offices are becoming stricter in requiring vaccines to be admitted. Currently, all states allow exemptions of vaccinations for medical reasons, and all but two states allow exemptions for religious reasons. Many states allow parents to decline vaccinations for ill-defined philosophical reasons. However, partly in response to the recent measles outbreaks, lawmakers in at least ten states–including California–are promoting legislation that would make it harder for parents to obtain exemptions to vaccination. This includes requirements for parents to meet with a healthcare provider to obtain information on the risks and benefits of immunization to their child and others, for school staff to be fully vaccinated except for medical 8 | APRIL 2015

reasons, and for schools to post immunization rates. The most restrictive laws would eliminate philosophical exemptions and even limit religious exemptions. It’s unfortunate that it takes children getting sick from vaccine-preventable diseases such as measles to change the culture. But perhaps this is the silver lining to the recent outbreaks. Instead of children at risk being required to be homeschooled or being isolated, it’s time for those who choose not to vaccinate to make the sacrifice. Parents can still exercise their rights and choose not to vaccinate their children, but they and their children will face consequences that may cause them to rethink this decision, including denial of attendance at school and daycare…and even Disneyland. Of course the best outcome would be for parents against vaccination to hear and truly understand the evidence that clearly shows that the benefits of vaccines far exceed the risks for their children and for others–and to fully vaccinate their children.  Resources: 1. 2. 3.

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Employers Expect Changes to Employee Health Care Programs to Retain Competitiveness According to New Towers Watson Survey

The majority of U.S. employers (84%) are expecting to make changes to their full-time employee health benefit programs over the next three years, despite cost increases remaining at historically low levels, according to new research from global professional services company Towers Watson (NYSE, NASDAQ: TW). In addition to aggressive cost management, employers are evaluating the implications of the changing provider landscape, embracing new ways to deliver care through innovative network arrangements, focusing on increasing employee engagement and exploring new options for delivering benefits. This includes assessment of active employee private exchanges and a rapid migration of Medicare retirees to private exchanges. The 2015 Emerging Trends in Health Care Survey found that employers project health care costs to increase 4% in 2015 after plan changes, compared to the 4.5% employers predicted for 2014. Without plan changes, projections are for an increase of 5.2%. These modest increases are still more than double the current rate of inflation and are a primary factor driving employers’ affordability concerns as the 2018 excise tax in the Patient Protection and Affordable Care Act approaches. Two in five employers that have done extensive modeling of their plans say they will trigger the excise tax in 2018. Two-thirds say the 10

| APRIL 2015

tax will have an impact on their health program strategies. “Historically, employers have strived to keep their cost increases at the market average, but increasingly, this just isn’t enough,” said Randall Abbott, a senior consulting leader at Towers Watson. “The new focus is on reducing cost trends to the overall CPI or below. This means driving cost growth to roughly 2% or less, which requires an acute focus on all aspects of health plan performance. In addition to solving the rate of cost trend, employers must pay attention to the base cost. We are seeing a wide variation across and within industries even after adjusting for unique group characteristics. High-performance health care has become the new mantra emphasizing not just reducing costs but improving workforce health, better engaging employees and leveraging new health technologies,” he added.

Managing Costs by Addressing Program Participation Among the actions gaining traction are changes to benefits for spouses and dependents. For example, the percentage of employers using spousal surcharges (when coverage is available elsewhere) is expected to nearly double, from 32% now to 61% in three years. Half of respondents (53%)

plan to significantly reduce subsidies for spouses and dependents by 2018. In addition, four in 10 employers (41%) say they may adopt a defined contribution arrangement (capping employer contributions at a flat dollar amount) by 2018.

Seeking Sources of Measurable Added Value Employers reported greater resolve to improve health outcomes per dollar spent, with two-thirds planning to use data extensively to evaluate plan performance and employee behavior changes in lifestyle and health management. In addition, the use of centers of excellence (either within health plans or via a separate network) and narrow networks are expected to triple over the next three years. The use of telemedicine services in place of in-person physician visits, when appropriate, will continue to be rapidly adopted, already expanding by more than one-third (35%) in 2015 over 2014. Over 80% of employers say they could be offering telemedicine services by 2018. Over the next few years, more than 80% of employers will carefully evaluate specialty pharmacy programs and benefits embedded in their medical plans. Over half (61%) of employers report including coverage and utilization restrictions in their specialty pharmacy strategy today.

Increasing Employee Engagement Employers recognize the business value of a healthy workforce and are encouraging employees to take control of their health. Two of the top five areas employers say will be the focus of their health care activities in 2016 link to employee engagement and accountability: developing or enhancing a workplace culture where employees are responsible for their health (66%), and adopting or expanding the use of financial incentives to encourage healthy behaviors (51%). Among employers surveyed, the most popular tactics for boosting employee engagement in health care are: • Education and tools for better decision making. Nearly half of employers (48%) will place more emphasis on educating employees about how to select providers based on quality and cost information over the next two years. In 2016, 43% of employers will provide price and quality transparency tools to help employees make better consumer choices. • Mobile apps to deliver health messages. Today, 60% of employers deliver health and wellness messages through mobile apps and portals. That percentage will increase to 95% by 2018. • Account-based health plans (ABHPs) as the only plan option. While 17% of employers currently offer full-replacement ABHPs (high-deductible plans tied to tax-advantaged health savings accounts), the percentage may increase to nearly 50% by 2018.

Exploring New Benefit Delivery Channels Employer confidence in private exchanges is increasing: 17% view private exchanges as a viable alternative for active full-time workers

in 2016. Confidence more than doubles to 37% by 2018. In addition, a quarter of employers (26%) have extensively analyzed private exchanges, and 20% say they are more interested in adopting a private exchange today than they were a year ago. Companies that have completed extensive analysis of private exchanges (versus companies that have not) are twice as likely to find private exchanges a viable alternative in 2016. Employers report that cost savings and administrative simplicity are key factors in prompting use of private exchanges. Finance will play a role in shifting to a private exchange model: More than half (53%) report that finance will influence the decision to move to a private exchange or continue to maintain traditional employer-managed health plans. “Employers are using and actively considering various options to manage cost, change employee behaviors and optimize program performance,” said Julie Stone, senior consulting leader at Towers Watson. “And the real business risk of the 2018 excise tax creates a sense of urgency for them to take decisive action. While future-proofing health care strategy is impossible, employers can exceed average performance by making changes that meet business needs and fit with the total rewards strategy.”  About the Survey Towers Watson surveyed 444 midsize to large U.S. employers representing 7.2 million employees in January 2015 for its 2015 Emerging Trends in Health Care Survey. The survey yields insights into how employers are thinking about health care benefits and the key actions they anticipate taking over the next three years. Source: http://www.pressreleasepoint. com/employers-expect-changesemployee-health-care-programsretain-competitiveness-according-newtowers-w

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practice tips

How Monitoring Employee Productivity Can Increase Profits for Healthcare Organizations

By Vishal Gandhi, BSEE, MBA Founder and CEO


| APRIL 2015

At its core, healthcare is a business. As with any business, smart decisions ensure a profitable bottom line. In healthcare, smart decisions are those that promote quality services, compliant documentation and coding, competitive prices, and most importantly, productive employees. However, running a successful business isn’t just about ensuring a profitable bottom line. Businesses must constantly strive to increase profits. To accomplish this, businesses must consider the following strategies: (1) lower prices, (2) lower operating costs, or (3) measure and increase employee productivity. For the purposes of this article, we’ll focus on why it’s important to measure employee productivity specifically in the healthcare setting.

The importance of productivity

Productivity is important in any setting; however, it’s particularly important in healthcare organizations in which the volume of work seems to increase daily. Coders face increased demands in terms of preparing for ICD-10, capturing all relevant conditions, ensuring clinical validation for diagnoses that are coded, and querying physicians when necessary. Clinical documentation improvement specialists are faced with the daunting task of educating physicians about ICD-10 and providing documentation audits to identify gaps. Physicians, nurses, and other providers are inundated with new patients who have entered the healthcare marketplace thanks to the Affordable Care Act. The influx of new patients into the system also places an increased demand on administrative staff who must answer patient inquiries, schedule appointments, and more. Healthcare organizations don’t necessarily have the financial resources to hire additional FTEs to accommodate for unexpected changes in workflow and other demands. This means that they must essentially increase the productivity of current staff members to remain fully operational. Organizations must have a solid process in place to ensure that all employees perform at predicted productivity levels, particularly as new tasks are added. This process is particularly important as new employees are hired. Those organizations that are unable to closely monitor and enhance productivity will likely start to see a slow decline in profits that can ultimately lead to the need to cut FTEs during a time when those FTEs are needed most.

Finding the right candidates

Productive employees are those who not only work hard but who also believe in the overall mission of the organization. When recruiting employees, healthcare organizations really need to take the time to sort through employees who may be looking for a short-term job vs. those who understand the critical nature of the work they perform and how it fits in with the goals of the institution. This begins with crafting an article job posting and providing online application capability. During the interview, itself, consider asking the following questions to get a sense of candidates’ work ethic: • Why is this job important to you? • Why do you think this job is important to the organization overall? • How would you describe your own work style? • Provide an example of how you’ve handled a time when you needed to multi-task and how you handled that. • Describe a time when you set a goal at work. Explain how you accomplished that goal.

Performing ongoing productivity analyses

Setting productivity goals and monitoring those goals regularly is an important component of overall success. The specific goals will vary according to function; however, what’s most important is that organizations take the time to establish these goals and hold employees accountable for achieving them. This includes tracking employee time management and attendance, both of which are critical to productivity. Revisit these goals throughout each month. When productivity has declined, identify and address the root cause of the problem. When productivity has remained constant or increased, praise employees for the good work that they perform. continued on page 14 WWW.MEDMONTHLY.COM | 13

continued from page 13

Providing training, when necessary

Knowledge is power, and employees remain productive when they have the most updated information they need to perform their jobs. For example, coders require ongoing training regarding ICD-10, quarterly changes published in Coding Clinic, and more. Patient registration and billing staff members need ongoing training regarding medical necessity and other insurance policy changes. Providers need training regarding the most updated clinical protocols and/or how to use the EMR. Some employees could benefit from refresher training or more specialized education in an area in which they need improvement. Establish a schedule for employee-specific training and then track employee compliance with that schedule.

Thinking ahead

Measuring employee productivity is an important aspect of running a business that no healthcare organization can afford to overlook. Employee productivity is important for nearly all roles within an organization, and it is particularly important for those roles that are task- and volumedriven. Take the time to establish role-specific productivity standards, educate employees about these standards, and then hold individuals accountable for meeting—and exceeding—these requirements.


| APRIL 2015

Monitoring employee productivity ensures that employees are performing at full capacity, maximizing their time and producing a quality outcome. When all employees give 100% effort to ensure productivity, the business benefits from these efforts. Dedicated employees who strive to improve performance and increase their knowledge make the company a stronger one that can withstand change and prevail financially as demands and costs increase. 

Vishal Gandhi, BSEE, MBA

is the founder and CEO ClinicSpectrum Inc. He is a well-known and widely respected authority on the “nitty-gritty” of medical practice workflow and technology. His Hybrid Workflow Model is quickly becoming a new healthcare industry standard model for combining human and computer workflow, to maximize revenue and minimize cost and he has appeared in prominent health IT publications.

practice tips By Barbara Hales, M.D.

How to Get the Media to Endorse You and Build Your Practice Getting promoted by the media is one of the best (and free) ways to publicize yourself and your services. It distinguishes you and your brand in a more nuanced way. The media spreads your message and gives you visibility. Can you imagine competing for patients with Dr. Oz or Dr. Sanjay Gupta? The perception is that if the media wants to showcase them and hang on to each “pearl of wisdom” they share, then they must be the best. Right? They not only get a ton of free publicity but they also know how to really profit from the media coverage through increased sales, name recognition, speaking engagements and more.

Why couldn’t it be you?

Because publicity is not only a cost-effective marketing strategy but also a great way to build credibility, press releases are a great way for you to get a foot up over your competitors and build credibility through positive publicity. Press releases are among the most economical ways to get your message out without spending tons of cash on 16 | APRIL 2015

advertising and marketing. Done correctly, this marketing tool can bring in significant revenue increases and improve the practice. When the media publishes your story, it exposes your company to the masses, thus potentially increasing your marketing reach and ultimately the bottom line. It is a win for everyone- your practice increases and the community gets healthier!

Press releases vs. advertising

Press releases differ from advertising because advertising controls the message. That is, when you see an ad for a product, you know that it is a subjective point of view, beneficial to the company making the product. A press release is something that is published by the media- something that most of us still view as having an objective opinion.

Press releases help the media help You

Let’s face it. The media constantly needs interesting newsworthy or sensational material as part of their job. The media is driven by buzz, news breaking stories and what’s

trending now. Getting a compelling or enticing piece of information is appreciated because it helps them perform their job. The knack is to make your information compelling and enticing. In other words, make your communication “newsworthy”.

What constitutes being newsworthy?

You may be asking yourself at this point, what can I point out about myself, my medical practice or services that would seem so exciting? Newsworthy information includes announcements of: • Awards • Accomplishments • Change of Staff • New Discoveries • Events • Participation in health fairs • Addition of partners or new physicians to the practice Press releases are among the easiest ways to combine journalistic writing with marketing. Not convinced that press releases will help you? Then read on.

9 Benefits those press releases offer The value from press releases include the following:

1. Branding - a press release that is picked up and spread virally online and in multiple media channels, significantly strengthens your brand, practice and services, making them well known. 2. Visibility - your practice and services gain more exposure.

7. Increased response - when a professional copywriter creates the press release, the chances are greater that the media will “pick it up” and run with it story for production of news stories in papers or magazines. 8. Increased popularity - perception of greatness snowballs to increased perception of greatness. When the media has published you, chances are with each story that you give them; they are more likely to promote you again. 9. Improves ROI (Return on Investment) - press releases give “more bang for your buck”. There are free distribution sites in case your budget does not allow for marketing. Sites like PR web have very reasonable plans for package deals on multiple press releases over a specified time period. In contrast to the amount of money that would need to be spent in advertising for the same exposure, press releases are very reasonable so that the net amount the practice generates is significantly higher. Want to pursue press releases as part of your health marketing? Start it free! Ask for your press release template and list of free distribution sites at: Support@ 

The Write Treatment

3. Leads - when the press release is syndicated, a larger audience views the news that you want broadcasted. This increases the number of prospective patients. 4. Ranking - As the press release is viewed across the internet on various sites and multiple channels, links are created between them and your website which increases your search engine ranking, making your exposure even greater. 5. Zoning in - rather than spending money on generic advertising, press releases are geared to target the exact audience that match your demographics and location. 6. Encourages social media connections - When your name or the name of your practice goes viral across multiple media channels, people want to connect with you and follow what you have to say. Everyone loves a winner and wants to be associated with one. You are also perceived as an authority in your field and people will want to connect with you and get your advice or hear your solutions to the problems that they are struggling with.

Ezines and NewslettersCost Effective Powerful Tools • Drive traffic to your business website • Build relationships between yourself and patients • Get new patients • Announce a new service or product • Give great impact Have you got a newsletter yet or want to spread a message? Contact Barbara Hales, M.D. for a free consultation. 516-647-3002


research & technology

NIH-led Effort Launches Big Data Portal for Alzheimer’s Drug Discovery

A National Institutes of Health-led public-private partnership to transform and accelerate drug development achieved a significant milestone today with the launch of a new Alzheimer’s Big Data portal — including delivery of the first wave of data — for use by the research community. The new data sharing and analysis resource is part of the Accelerating Medicines Partnership (AMP), an unprecedented venture bringing together NIH, the U.S. Food and Drug Administration, industry and academic scientists from a variety of disciplines to translate knowledge faster and more successfully into new therapies. The opening of the AMP-AD Knowledge Portal and 18

| APRIL 2015

release of the first wave of data will enable sharing and analyses of large and complex biomedical datasets. Researchers believe this approach will ramp up the development of predictive models of Alzheimer’s disease and enable the selection of novel targets that drive the changes in molecular networks leading to the clinical signs and symptoms of the disease. “We are determined to reduce the cost and time it takes to discover viable therapeutic targets and bring new diagnostics and effective therapies to people with Alzheimer’s. That demands a new way of doing business,” said NIH Director Francis S. Collins, M.D., Ph.D. “The

AD initiative of AMP is one way we can revolutionize Alzheimer’s research and drug development by applying the principles of open science to the use and analysis of large and complex human data sets.” Developed by Sage Bionetworks , a Seattle-based nonprofit organization promoting open science, the portal will house several waves of Big Data to be generated over the five years of the AMP-AD Target Discovery and Preclinical Validation Project by multidisciplinary academic groups. The academic teams, in collaboration with Sage Bionetworks data scientists and industry bioinformatics and drug discovery experts, will work collectively to apply cutting-edge analytical approaches to integrate molecular and clinical data from over 2,000 postmortem brain samples. The National Institute on Aging (NIA) at NIH supports and coordinates the multidisciplinary groups contributing data to the portal. The AMP Steering Committee for the Alzheimer’s Disease Project is composed of NIA and the National Institute of Neurological Disorders and Stroke, both of NIH, the U.S. Food and Drug Administration, four pharmaceutical companies (AbbVie, Biogen Idec, GlaxoSmithKline and Lilly) and four non-profit groups (Alzheimer’s Association, Alzheimer’s Drug Discovery Foundation, Geoffrey Beene Foundation and USAgainst Alzheimer’s) and is managed through the Foundation for the NIH. “The enormous complexity of the human brain and the processes involved in development and progression of Alzheimer’s disease have been major barriers to drug development,” said NIA Director Richard J. Hodes, M.D. “Now that we are gathering the data and developing the tools needed to tackle this complexity, it is key to make them widely accessible to the research community so we can speed up the development of critically needed therapies” The consortium of academic teams contributing the data are led by researchers at the following institutions: Eric Schadt, Ph.D., Icahn School of Medicine at Mount Sinai, New York; Philip De Jager, M.D., Ph.D., Eli and Edythe L. Broad Institute of MIT and Harvard, Boston; Todd Golde, M.D., Ph.D., University of Florida, Gainesville; and Alan Levey, M.D., Ph.D., Emory University, Atlanta. Researchers from Rush University, Chicago; Mayo Clinic, Jacksonville, Fla.; Institute for Systems Biology, Seattle; the University of California, Los Angeles and a number of other academic centers are also participating. Because no publication embargo is imposed on the use of the data once they are posted to the AMPAD Knowledge Portal, it increases the transparency, reproducibility and translatability of basic research discoveries, according to Suzana Petanceska, Ph.D., NIA’s program director leading the AMP-AD Target Discovery Project.


“We are determined to reduce the cost and time it takes to discover viable therapeutic targets and bring new diagnostics and effective therapies to people with Alzheimer’s.” — Francis S. Collins, M.D., Ph.D. Director, National Institute of Health

“The era of Big Data and open science can be a gamechanger in our ability to choose therapeutic targets for Alzheimer’s that may lead to effective therapies tailored to diverse patients,” Petanceska said. “Simply stated, we can work more effectively together than separately.”  About AMP-AD: The Alzheimer’s disease initiative is a project of the Accelerating Medicines Partnership, a joint venture among the National Institutes of Health, the Food and Drug Administration, 10 biopharmaceutical companies and multiple non-profits, managed by the Foundation for the NIH, to identify and validate promising biological targets of disease. AMP-AD is one of the three initiatives under the AMP umbrella; the other two are focused on type 2 diabetes and the autoimmune disorders rheumatoid arthritis and systemic lupus erythematosus. To learn more about the AMP-AD projects please visit: alzheimers/amp-ad About the National Institute on Aging: The NIA leads the federal government effort conducting and supporting research on aging and the health and well-being of older people. It provides information on age-related cognitive change and neurodegenerative disease specifically at its Alzheimer’s Disease Education and Referral (ADEAR) Center at About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit Source: htm WWW.MEDMONTHLY.COM | 19

research & technology

FDA Approves New Treatment for Varicose Veins By Alexis Gopal MD Gopal Medical Communications, LLC

In a decision that will provide a new, permanent treatment option for symptomatic varicose veins, the US Food and Drug Administration (FDA) approved the VenaSeal closure system. The VenaSeal system delivers a specially formulated adhesive via catheter through the skin to the diseased vein to seal it. This is an in-office procedure which allows patients to quickly return to their usual activities, with less bruising. Cosmetics aside, varicose veins and their complications can be disabling. Patients report leg heaviness and aching, throbbing pain, muscle cramps, leg swelling, and in severe 20 | APRIL 2015

cases, painful skin ulcers near the ankles. Blood clots can also result from chronic venous insufficiency (CVI). Although ulcers only affect up to 1% of the population, the less severe manifestations are prevalent in 2-56% of the population worldwide. CVI is one of the most commonly reported medical conditions in the United States, and associated venous ulcers account for greater than US$ 1 billion annually in healthcare costs. Treatment of varicose veins traditionally include lifestyle changes such as avoiding tight clothes, high heels, increase in physical activity and weight loss, and avoiding standing

for prolonged periods of time. Compression stockings keep blood from pooling and reduce swelling. Procedures used to treat symptomatic varicose veins include: • Sclerotherapy: A chemical is injected into the vein, causing irritation and scarring inside the vein, which then closes off and fades away. Often used to treat spider veins, and smaller varicose veins. • Laser Surgery: Laser energy is directed to the vein, which fades away. Also used to treat smaller varicose veins.

• Endovenous Ablation Therapy: This treatment uses heat via a catheter to close off the vein. Usually patient can go home the same day. • Endoscopic Vein Surgery: In this procedure, the physician makes a small cut in the skin near the varicose vein, and inserts a tiny camera at the end of a catheter that moves through the vein. A surgical device attached to the camera closes the vein. This procedure is usually only used in severe cases where ulceration is present. Recovery time is several weeks. • Ambulatory Phlebectomy: A same-day procedure to remove superficial varicose veins. • Vein Stripping and Ligation: Involves tying shut and removing veins through small cuts in the skin. Done only for severe varicose veins. Recovery time is about 1 to 4 weeks.

The more invasive procedures have a longer recovery period than that of the VenaSeal system. The VenaSeal system is intended for patients with symptomatic, superficial varicose veins. Clinical data reviewed by the FDA in a premarket approval application shows the device to be safe and effective for vein closure in varicose vein treatment. Adverse effects included vein inflammation (phlebitis) and tingling (paresthesia) in the treatment area. Contraindications to the use of the VenaSeal system are acute sepsis, acute thrombophlebitis, and hypersensitivity to the VenaSeal adhesive, n-butyl-2-cyanoacrylate.  Sources: Newsroom/PressAnnouncements/ ucm435082.htm viewarticle/778728

About Alexis Gopal MD: Gopal Medical Communications is owned and operated by Alexis Gopal, MD, a physician and medical writer with years of clinical experience in Internal Medicine and medical education. Dr. Gopal is a member of the American Medical Writer’s Association, and specializes in writing medical news, clinical research abstracts, posters, website and marketing content, and education materials in a diverse array of specialties. Engaged in researching, writing, and editing publications for healthcare professionals and lay audiences. Well versed in critically evaluating, analyzing, and interpreting the medical literature in a wide range of therapeutic areas. Dr. Gopal is especially gifted in translating complex medical information into layperson’s language. She has been published in The American Journal of Emergency Medicine, and Yahoo. com. She can be reached at info@

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research & technology


By Marina Liem M.D.

Neurostimulation is a recognized therapeutic option for advanced stages of Parkinson’s disease typically reserved for cases in which medication has become less effective or has induced motor complications. Would neurostimulation be beneficial at an earlier stage by augmenting medical therapeutic response before the onset of motor complications or disability? Parkinson’s disease is a debilitating progressive neurodegenerative disease afflicting a significant proportion of the older population. The most recognizable aspect of Parkinson’s are motor symptoms of tremors, rigidity and bradykinesia (extreme slowness of movement and reflexes). These motor symptoms are disabling if left untreated. The cognitive, emotional and autonomic symptoms including depression, anxiety, memory loss, constipation, urinary changes, sleep disorders also negatively impact daily life. Parkinson’s disease stems from the reduced production of the neurotransmitter dopamine by dopaminergic neurons in the midbrain and hypothalamus. Established pharmaceutical treatment act on divergent pathways by supplementing dopamine production with its chemical precursor (levodopa), blocking the enzymatic breakdown of dopamine with MAO-B inhibitors (rasagiline and selegiline) or mimicking dopamine at the receptor level with dopamine agonists (pramipexole, rotigotine, ropinirole). Levodopa is the most effective therapy for the motor symptoms but over time, patients may develop 22 | APRIL 2015

motor complications from the levodopa itself, specifically dyskinesias (involuntary rocking, twisting, writhing movements and grimacing facial expressions) and motor fluctuations (on-off mobility transition periods).1 Deep brain neurostimulation has been a FDA approved neurosurgical procedure for the treatment of Parkinson’s disease and essential tremor since 1977. Electrodes are stereotactically guided and implanted into deep brain targets, specifically subthalamus, globus pallidus or thalamus, and an impulse generator is implanted in the chest wall near the clavicle. The impulse generator modulates an electrical current that interferes and blocks neural signal impulses. Subthalamic neurostimulation is effective for all major Parkinson’s motor symptoms, consequently reducing medication dose reduction and alleviating dyskinesias. Globus pallidal neurostimulation is effective for Parkinson’s symptoms without change in average medication dose and may be safer for language and cognition. Thalamic neurostimulation alleviates essential tremor.2,3 A randomized multicenter European trial showed that neurostimulation combined with medical therapy significantly alleviated symptoms in patients at a relatively early stage of Parkinson’s disease compared with medical therapy alone.4 Because of subthalamic neurostimulation’s efficacy in advanced Parkinson’s disease, the EARLYSTIM researchers hypothesized that neurostimulation would improve quality of life at an earlier stage of Parkinson’s

disease by optimizing dopaminergic treatment response. A total of 251 patients in Germany and France with mean disease duration of 7.5 years, mean age of 52 years and relatively mild parkinsonian motor signs were enrolled for a 2 year period and randomized to the neurostimulation plus medication group and medication only group. Medical therapy conformity with practice guidelines was confirmed by an independent expert panel. Motor scores by video recordings were graded by reviewers who were blinded to study assignments in order to offset the lack of blinding in the neurostimulation group. Quality of life change from baseline to 2 years was the primary end point as assessed by the Parkinson’s Disease Questionnaire (PDQ-39) summary index. Since quality of life is a complex variable, PDQ-39 addresses cognitive and psychosocial factors in addition to motor function. Quality of life improved by 26% in the neurostimulation group and worsened by 1% in the medication group. Motor disability, activities of daily living, levodopa-induced motor complications, off-medication motor signs and time with good mobility and no dyskinesia were significantly improved in the neurostimulation group compared to the medication group. Substantial medication changes occurred in both groups. Levodopa-equivalent daily dose decreased by 39% in the neurostimulation group and increased by 21% in the medication group. Compared to a prior randomized trial of neurostimulation in advanced Parkinson’s disease,5 the

EARLYSTIM group had greater improvement in activities of daily living, emotional well-being and cognition. Serious adverse events were more frequent in the neurostimulation group (54.8%) than the medication group (44.1%). Postoperative adverse events occurred in 17.7% of neurostimulation patients with all but one resolving completely. Mobility and medication related side effects were more frequent in the medication group and major depression in the neurostimulation group. Suicidal behavior had equivalent frequency in both groups. “We found that neurostimulation was superior to medical therapy alone at a relatively early stage of Parkinson’s disease, before the appearance of severe disabling motor complications. Neurostimulation may be a therapeutic option for patients at an earlier stage than current recommendations suggest,” concluded the researchers. The EARLYSTIM trial was described as “one of the most rigorously conducted trials of neurostimulation” in the accompanying editorial.6 However, there are caveats to consider for wider clinical applications. The study patient population is not representative of the majority of Parkinson’s patients. Neurostimulation is effective in selected motor symptoms and does not change the progression of other symptoms. The experience of large, multidisciplinary teams impact the surgical benefits. Therefore, whether the trial results could be replicated in older Parkinson’s patients or in less experienced medical centers is unknown. Nevertheless, “for carefully chosen, highly functioning patients, [neurostimulation] may provide many additional years of good functioning.”6  References 1 Valeo T. Parkinson’s with fewer side effects. Neurology Now Oct/Nov 2014; 10:7-12. doi: 10.1097/01. NNN.0000455749.86977.7e 2 Deep brain stimulation for Parkinson’s disease. WebMD. Accessed March 16, 2015. 3 Surgical treatment options: deep brain stimulation. National Parkinson Foundation. parkinson-s-disease/treatment/surgical-treatment-options/ deep-brain-stimulation. Accessed March 16, 2015. 4 Schuepbach W, Rau J, Knudsen K, Neurostimulation for Parkinson’s Disease with Early Motor Complications. N Engl J Med 2013; 368:610-622. doi: 10.1056/ NEJMoa1205158 5 Deuschl G, Schade-Brittinger C, Krack P, et. al. A randomized trial of deep-brain stimulation for Parkinson’s disease. N Engl J Med 2006; 355:896-908. doi: 10.1056/ NEJMoa060281 6 Tanner C. A second honeymoon for Parkinson’s disease? N Engl J Med 2013; 368:675-676. doi: 10.1056/NEJMe1214913 WWW.MEDMONTHLY.COM | 23


Medicare Advantage Insurers May See Positive Growth in 2016 Despite CMS’ 0.95% Payment Rate Cut Announcement By Florence Wang and Vinay Bhupathy SheppardMullin

The Centers for Medicare and Medicaid Services (CMS) proposed a 0.95 percent decrease in Medicare Advantage payment rates for 2016 in its Advance Notice and Draft Call Letter released on February 20, 2015.1 Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Unlike “original Medicare,” in which the government pays for Medicare benefits when a beneficiary receives them, Medicare pays these private companies to cover beneficiaries’ Medicare benefits based on a risk-adjusted, per-patient payment formula that varies annually.2 CMS’ proposed payment rate cut for 2016 was a stark contrast to the estimated 2 percent rate increase previewed in December 2014 by CMS.3 This is likely due to updated figures relating to actual Medicare costs and the rate of feefor-service (FFS) Medicare spending growth. MA payments are calculated based on several factors, including a plan’s quality ratings, particular mix of sick and healthy patients or level of risk, Medicare’s cost growth, and spending growth of traditional FFS Medicare.4 Since December, CMS found that Medicare costs actually increased by 2.68%, compared with its December projection of 2.45%, while FFS Medicare spending growth did not increase as projected, down from a projected 2.02% in December to 1.47%.5 Because the Affordable Care Act mandated rate changes to Medicare Advantage payments to bring them on par with FFS payments, the actual increase in Medicare costs combined with the lower-than-projected FFS 24 | APRIL 2015

Medicare spending rate resulted in the proposed payment rate cut. In spite of the proposed 0.95 percent rate cut, CMS estimated that insurers would likely see overall revenue increase by about 1.05 percent due to an expected, continued growth in the delivery of more intense services and consequent growth in plan risk scores due to coding.6 CMS Principal Deputy Administrator Andy Slavitt reasoned that the modest, proposed rate cuts would “enhance the stability of [the] MA program and minimize disruption to seniors and care providers.” In addition to the proposed payment rates, other significant aspects of CMS’ proposal include: • Transitioning entirely to using risk scores calculated from the community, institutional, new enrollee, and Special Needs Plans (SNP) new enrollee segments of the clinically-revised hierarchical condition categories (HCC) model in Part C payment for aged/disabled beneficiaries; 7 • Not precluding the use of in-home visits for risk assessments, which was under increased scrutiny out of concerns of inflated risk scores; • Altering the MA star quality rating system to help beneficiaries determine which MA plans are performing well in terms of both quality and beneficiary satisfaction; and • Requiring MA Plans to maintain accurate provider directories and to make those directories widely available.

CMS’ press announcement noted that the rate proposal and other proposed changes will continue the popularity of Medicare Advantage programs “by providing fair payments to plans, rewarding high-quality care, and spending our health care dollars wisely.” The proposed rates and expected revenue growth mean that MA plans would on average, receive payment rates slightly higher than FFS equivalent payments, depending on other region- and plan-specific factors. This is expected to translate into more stable premiums for 2016 MA Plan beneficiaries from 2015. While CMS sees its proposal as a step towards Department of Health and Human Services Secretary Sylvia M. Burwell’s vision of building a “better, smarter health care system and moving the Medicare program… toward paying providers based on the quality, rather than the quantity of care they give patients,” not all in Congress or in the healthcare insurance industry agree. A bipartisan group of more than 50 senators, led by Democratic Senator Chuck Schumer (NY) and Republican Mike Crapo (ID) sent a letter to CMS this past week urging the agency to protect the more than 16 million seniors enrolled in Medicare Advantage by maintaining the current payment levels in 2016. Intense lobbying by insurance industry heavyweights and those opposing any MA Plan payment rate cuts is expected prior to CMS’ release of final payment rates on April 6, 2015. Karen Ignagni, CEO of America’s Health Insurance Plans, the national trade association representing the health insurance industry, responded to CMS’ proposed rate cut saying that CMS is “now proposing additional cuts to [MA] at a time when health care costs are projected to increase…Protecting the millions who rely on this program should mean no further cuts.” The proposed changes to payment rates and the impact they will have on MA organizations are certain to be contentious, as the early comments above indicate. For MA organizations, a key consideration will be how to adjust their financial projections if the rates go into effect and what will be the impact on their bottom line if further cutbacks are made due to political pressures. These changes will also trickle down to providers. Consumers and advocacy groups on the other hand, should monitor whether the beneficiary protection provisions are instituted in a final rule. The deadline for public comments on the proposal was March 6, 2015.  ______________ 1 The Advance Notice and Draft Call Letter can be found here. 2 MA Plans must cover all services that original Medicare covers except hospice care. Beneficiaries must pay, in addition to Medicare Part B (Medical Insurance) coverage premiums, one monthly premium for services included in an MA Plan. The total cost of the premiums, copayments and deductible paid under an MA Plan is often lower

than the total costs associated with original Medicare. Private companies offering MA Plans often claim to be able to achieve this lower cost to beneficiaries because of its provision of higher quality plans and narrower provider network available to beneficiaries, which allows them to negotiate lower rates. 3 The December 2, 2014 CMS rate preview announcement can be found here. 4 The Affordable Care Act mandated rate changes to Medicare Advantage payments to bring them on par with fee-for-service (FFS) payments. See the Advance Notice and Draft Call Letter pages 5-8. 5 Please see the Advance Notice and Draft Call Letter page 6. 6 The CMS press release can be found here. 7 Previously, risk scores used in Part C payment were a blend of the risk scores from the 2013 model and the updated 2014 model that recalibrated formulas based on more recent coding and expenditure patters in FFS Medicare, as well as the newly constructed hierarchical condition categories (HCCs). See Advance Notice and Draft Call Letter page 19. Source: articles/centers-for-medicare-and-medicaid-services-cms/ medicare-advantage-insurers-may-see-positive-growth-in2016-despite-cms-0-95-payment-rate-cut-announcement/

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A Closer Look at the White House’s Precision Medicine Initiative

By Jennifer S. Geetter and Chelsea M. Rutherford McDermott Will & Emery

On January 20, 2015, as part of his State of the Union address, President Obama announced the upcoming launch of the White House’s Precision Medicine Initiative (Initiative). The Initiative seeks to allocate $215 million in 2016 toward a series of efforts aimed at collecting and using genomic, lifestyle and other clinical data in furtherance of precision medicine research. The response to the Initiative has been rapid and significant: in the short time since its announcement, a two-day workshop on the Initiative has been held, with working papers and presentations from multiple stakeholders, and an advisory committee has been formed to help develop and implement a significant portion of the Initiative. Viewed alongside other noteworthy developments from the past six months, the Initiative exemplifies current trends and challenges related to health technologies, data privacy and security, and biomedical research, and provides insight into the future of data-driven medicine.

Precision Medicine Goals

Precision medicine is not new. Sometimes called personalized or tailored medicine, precision medicine is an approach to diagnosis and treatment that departs from 26 | APRIL 2015

the standard “one-size-fits-all” approach to care. Although some in the field argue that the difference between the terms “precision medicine” and “personalized medicine” is negligible, the term precision medicine has been actively developed and popularized within the last 10 years as a way to more accurately emphasize molecular-level information aiding patient diagnosis and treatment decisions. Precision medicine takes as its starting point the basic idea that an individual’sP genetic makeup, environment, lifestyle and other patient-specific information may be predictive not only to the individual’s future health, but also to the individual’s responsiveness to treatment alternatives. For example, a precision medicine approach to treating a patient might involve genetic testing to help a treating provider determine which of several available therapeutic agents for a given condition will yield the best patient response. Precision medicine therefore prioritizes therapeutic and cost-control objectives by providing the best care quickly and without costly missteps.

Aspects of the Initiative

The Initiative aims to support precision medicine and its goals in two principal resource-building ways. First, the

Initiative intends to provide funding to various agencies for the evaluation and reform of existing processes and regulations to better address the large-scale data collection and analysis that is foundational to precision medicine. Second, the Initiative seeks to provide research funding to expand efforts in oncology genomics and to develop a research cohort study of at least one million Americans who would participate by sharing genomic and clinical data, biospecimens and biofluids, and other information. This collected information would be shared with both researchers and participants in a variety of ways that might include electronic health record (EHR) and mobile health device utilization. Together, these efforts would result in a more coherent and harmonized regulatory framework to facilitate precision medicine, while building the data and recruitment resources to leverage that improved framework.

The Initiative also intends to focus on the following goals:

Ensuring a commitment to rigorous privacy protections by identifying and addressing precision medicine data privacy and security-related issues Supporting clinical trials, in partnership with pharmaceutical companies, to test specific drug therapies selected using precision medicine techniques Developing a new approach to the U.S. Food and Drug Administration’s (FDA’s) approval for next generation sequencing technologies Supporting new interoperability standards for crosssystem data exchanges as part of the national research cohort


President Obama’s 2016 proposed budget plans to distribute the allocated funds to three different agencies: $130 million to the National Institutes of Health (NIH) to aid in the development of the national research cohort; $70 million to the National Cancer Institute (part of NIH) to aid the research and application of the genomic drivers of cancer; $10 million to the FDA to support the development and regulation of databases and next generation sequencing technologies; and $5 million to the Office of the National Coordinator for Health Information Technology (ONC), which helps to coordinate federal data privacy policy, to develop interoperability standards addressing the privacy and security of sharing research data These allocations require congressional approval, and there have been early signs of bipartisan support for the Initiative. This funding is part of an overall research funding package proposal (including a nearly $1 billion increase in funding to the NIH) that reflects the Obama administration’s intention to invest in biomedical research innovations.

Developing the Initiative: Workshops, White Papers and Advisory Panels

Many of the Initiative’s specific research aims and measures are understandably still under development, so it remains unclear how much data the Initiative will gather and the methods it will use to do so. On February 11 and 12, 2015, the NIH held a workshop on the creation of the precision medicine cohort, exploring the opportunities and operational challenges of this undertaking with experts and leaders from the public and private sectors. Prior to the workshop, the NIH also assembled four working groups. Each group developed a white paper to aid the discussion at the workshop. The focus of these white papers is cohort identification and recruitment; participant engagement, data privacy and return of results; data collection and mobile technologies; and EHR opportunities and challenges for research. The papers mirror the topics explored at the workshop and provide helpful insight into the details that must be resolved before the Initiative can be fully operational. For example, the white paper from the working group focusing on cohort building emphasized the need to utilize subjects and data from existing longitudinal studies in the cohort, envisioning a large consortium of cohorts with a central infrastructure to minimize the time and cost constraints of such an endeavor. The working group on participant engagement similarly addressed the cost, participant attrition, data-sharing and governance challenges of the Initiative. The white paper from the working group focusing on EHR opportunities and challenges explored a variety of pathways by which participants’ clinical data could become available to researchers, including existing research cohorts, organizational partnerships and individual releases. This paper also focused on enhancing patients’ access to their own clinical and administrative data, and emphasized that privacy pathways/consent management systems would be imperative to the Initiative’s implementation. Finally, the white paper from the data collection and mobile technologies working group emphasized that the widespread use of mobile technology would be key to capturing and tracking relevant health data for the Initiative. During the Initiative workshop, NIH leaders announced the creation of a new working group of the NIH Advisory Committee. This group will develop the specifics of the million-person research cohort envisioned by the Initiative and will make recommendations regarding its implementation to the director of the NIH. Kathy Hudson, NIH deputy director for science, outreach and policy, and Richard Lifton, Yale University’s Genetics Department continued on page 28 WWW.MEDMONTHLY.COM | 27

continued from page 27

chairman, were appointed to co-chair the group. The NIH plans to name the rest of the panel in the coming weeks and have the group provide an initial report to the Advisory Committee by September 2015. While its specifics remain under development, the Initiative is another source of public support and funding for potential future breakthroughs using precision medicine and other novel approaches; it aims to create a framework where researchers, and eventually clinicians, can utilize as many individuals as possible to collect as much data as possible to improve the quality and efficacy of medicine.

Departing from the Status Quo

The Initiative’s announcement is part of a trend that has emerged during President Obama’s tenure that shows the current administration confronting and supporting the modernization of U.S. medicine in the genomic age. Not only has the president issued significant reports on big data and genomic privacy, the administration has also begun examining and reforming major rules affecting progressive research, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Federal Policy for the Protection of Human Subjects (Common Rule). Although the funding allotted by the Initiative is small compared to the overall budgets for the NIH (around $30.3 billion), FDA (around $4.4 billion) and ONC (around $60.4 million), the Initiative’s real significance may be the national policy recognition of the need to reconfigure treatment approaches. The Initiative recognizes the public and private sector’s interest in precision medicine and views precision medicine as a powerful tool, rather than a passing trend. The Initiative also recognizes the need for multi-stakeholder buy-in and involves the technology, medical, research and patient populations. For example, the Initiative emphasizes patient engagement as integral to success by incorporating patients and subjects into the planning and research process and building the patient engagement concept into most of its endeavors. Even the Initiative’s budget, spread among several different agencies, may be viewed as a high-level acknowledgment that precision medicine, and the Initiative itself, requires a coordinated, interdisciplinary effort to accomplish its goals.

The Initiative in Context

The Initiative tracks the current landscape of policy statements and proposed regulations aimed at modernizing medical data stewardship around three principles—data privacy, data security, and data utility. It is the latest attempt to balance the potential utility of large-scale data collection and data sharing against the privacy and security concerns 28 | APRIL 2015

that come with that data, and should be examined in light of other recent proposals. Some of these other proposals include the following: August 27, 2014: The NIH issued its Genomic Data Sharing Policy, which promotes the sharing of largescale genomic data generated from NIH-funded studies and includes new subject data protections. November 19, 2014: The NIH proposed a draft policy to ensure all NIH-funded trials are registered for and submit summary results to January 23, 2015: The FDA permitted the marketing of the first system of mobile medical applications for continuous glucose monitoring. January 27, 2015: The House of Representatives’ Energy and Commerce Committee released its highly anticipated discussion draft of the 21st Century Cures Initiative legislation. This draft targeted comprehensive research and medical innovation reform, while incorporating patient perspectives and modernizing regulatory frameworks. These regulatory efforts and the Initiative share several common themes. First, they indicate that the current research infrastructure—for example, the regulations, research modalities, data capture and sharing pathways, and funding—is anachronistic and inadequate to harness genetic and genomic data on the scale contemplated by the Initiative. They also acknowledge the emerging privacy and security concerns stemming from large-scale research and data-sharing endeavors, and, in varying degrees, contemplate updated privacy and security protections to address these issues. Ultimately, these data stewardship efforts point to shortcomings that cannot be addressed in a piecemeal fashion and thus require comprehensive change. They are also valuable acknowledgements that scientific and medical advancements require modernized infrastructure and better resources to ensure optimal research power, appropriate and relevant security protocols, and practical and reliable data privacy practices in the future. In context, the Initiative is also important because it shows a growing interest in data sharing, aggregation and utilization on a very large scale. This may be evidence that the social and legal perspectives on clinical/genomic privacy are evolving. This trend may also suggest a general acceptance of increased data sharing as a necessary driver of innovation. Given this momentum, it is reasonable to expect continued efforts to modernize the U.S. research system, and to ultimately expect a significant shift away from the current regulatory framework.  Source:


Proposed Replacement of Sustainable Growth Rate Addresses Telehealth

By Ellen L. Janos, Abby Matousek, and Andrew J. Shin Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. On March 19th, Representative Michael C. Burgess, M.D. (R-TX) and Senate Finance Committee Chairman Orrin Hatch (R-UT) unveiled a bipartisan plan to repeal and replace the sustainable growth rate (SGR) physician payment system for physician reimbursement under Medicare. Without reform or another patch, physicians would face a close to 25 percent cut in payments when the current patch expires at the end of this month. The SGR replacement plan repeals the SGR and institutes a 0.5 percent payment update each year for five years following repeal while also seeking to incentivize the use of alterative payment models (AMPs) and tweaking the fee-for-service (FFS) system. In addition to addressing meaningful use, remote monitoring, and interoperability, the SGR replacement plan deals with telehealth in several ways. First, the plan includes two provisions also outlined in the 113th Congress SGR replacement plan crafted by then-Senate Finance Chairman Max Baucus (D-MT). Under “Clinical Practice Improvement Activities,” for Merit Based Incentive payments the use of telehealth for timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehealth is included as a means of care coordination. Second, under “Incentive Payments for Eligible Payment Models,” the bill states that nothing in the Act shall be construed as precluding an alternative payment model or a qualifying APM participant from furnishing a telehealth service for which payment is not made under section 1834(m) of the Social Security Act. On a related note, the

Obama Administration on March 10 unveiled its newest ACO program called the “Next Generation ACO” through the CMS Innovation Center. The announcement stated that the new ACO model would have flexibility around Medicare telehealth rules, thus allowing ACOs to utilize the technology regardless of a patient’s geographic location. If passed, the SGR legislation could open the door for CMS to test telehealth payment in more than just a limited number of models currently being implemented.” Finally, the plan outlines a new provision requiring a GAO study and report on the use of telehealth in federal programs and in remote patient monitoring services. The bill says the GAO will study: • How the definition of telehealth across various Federal programs and Federal efforts can inform the use of telehealth in the Medicare program; • Issues that can facilitate or inhibit the use of telehealth under the Medicare program under such title, including oversight and professional licensure, changing technology, privacy and security, infrastructure requirements, and varying needs across urban and rural areas; • Potential implications of greater use of telehealth with respect to payment and delivery system transformations under the Medicare and Medicaid programs; and • How CMS monitors payments made under the Medicare program to providers for telehealth services.  Source: http://www.healthlawpolicymatters. com/2015/03/20/proposed-replacement-of-sustainablegrowth-rate-addresses-telehealth/#more-6630 WWW.MEDMONTHLY.COM | 29



How-to Get em’ and Keep em’

By Marlee Ward President & Founder Rx MD Marketing Solutions

30 | APRIL 2015

For many physicians, especially specialty practitioners, building a profitable medical practice requires building strong referral relationships with other doctors. For those who love to rub elbows this can be a very easy and fun marketing activity. For others, building a database of referring physicians is not fun and may even be intimidating. The good news is it doesn’t have to be that way.

How to Build a Referral Network to Support Consistent Flow of Patient Referrals to Your Practice The very first thing you need to do before building a network of referral sources for your medical practice is to create a list of every potential referral source for your practice. Next, narrow the list down to those physicians who currently refer to your practice most often. Also include any prospective referrers with high referring power. Then, apply the following techniques to the physicians on your list.

Professional Networking Building a network of physician referral sources begins with professional networking. The truth is physicians refer to other physicians that they like, trust, and respect. Basically, they refer to physicians that they have positive feelings about, and it’s your job to make that happen. Several ways to make networking with a potential referral source simple would be to invite your prospective referral source to attend a seminar, send a referral source a letter of introduction with an invitation to visit your practice, or if you discover common interests with a potential referral source –- participate in them together. The key to success in professional networking rests on your ability to nurture the connections you make. Personal and professional relationships require time and attention to maintain and grow, so make the time to give attention to the people who refer to you. You will reap the benefit tenfold. If you master professional networking and increase the number of physicians referring to your practice, you could boost your bottom line dramatically.

Marketing to Referring Physicians & Their Staff Don’t forget that when it comes to healthcare marketing, it is equally as important to market to prospective patients as it is to market to referring physicians. The goal in marketing yourself and your practice to other physicians and their staff is to create in them a top of mind awareness with respect to your practice. To accomplish this, you must

make contact with these target physicians briefly but often. The easiest way to remind referring physicians and their staff of your practice is through email marketing and social networks. Make this contact, quick, fun, and often. For example, e-mail a 3 question pop quiz about your specialty or practice to your referring physicians and their staff and offer a gift card to the one person who answers them all correctly within a specified time period. Quick and fun marketing tactics like these will have the referring office talking about you and your practice all of the time.

Make it Easy to Work with You and Your Office If you implement the strategies above you will definitely generate additional referrals for your medical practice. Now, you must focus on keeping them. The three following practices will ensure that you keep the referral sources you obtain. 1. Report back to the referring physician about their patient quickly. Basically, never let the referred patient get back to the referring physician before you do. 2. Assist the referring physician with any paperwork that you might share. For example, take a moment to write all of the Rx’s affiliated with your treatment and leave them in the patients chart so that the referring physician doesn’t become burdened with the responsibility. 3. Refer back to your referring physician. When you see a patient with an undesignated primary care physician, or obtain a patient that is new to the area, tell them about your referring physician’s practice. Remember, it is in giving that you receive. Above all, strive to develop a strong and positive rapport with your referring physicians. By making it easy for them to work with your office, and by building solid relationships, these physicians will want to do business with you and help you grow your medical practice.  Rx MD Marketing Solutions is a no nonsense healthcare marketing firm that believes healthcare marketing doesn’t have to be unaffordable, complicated, or unethical to be effective. We provide you with the knowledge you need to successfully market your medical practice or health care organization and achieve your desired practice lifestyle. We also offer turn-key marketing systems, marketing products, web design, and in-person or virtual one-onone consulting services to provide you with the affordable marketing support you need for success. Learn more at Source: WWW.MEDMONTHLY.COM | 31


What to Do When Your Referral Sources Dry Up

By Amanda Chay WhiteCoat Designs On a recent phone call with an urologist discussing his marketing strategy, the physician lamented about his “trusted doctor friends” dramatically stopping the number of patients they send to him each month. This ongoing decrease has significantly reduced his patient volume and overall practice revenue. The urologist was at a cross road with his practice as a result of these decreases. Unfortunately, this is not a unique situation, as the majority of the physicians that we talk to each week speak of similar situations. Whether the referring relationships become strained from competition encroachments, hospital buy-outs, or newly formed alliances, the results are the same. Patient referrals from trusted sources are drying up. To combat this trend, the following suggestions are recommended: contribute to your relationships; keep abreast of changes in the referrals; 32 | APRIL 2015

follow up if changes are noted; and implement a program dedicated to increasing patient referrals.

Reinvest back into your relationships “Make new friends, but keep the old. One is silver and the other is gold.”

- Lyrics from a Girl Scouts song

In the medical community, relationships are built on trust, understanding, and clear communication as physicians typically send their patients to other physicians whom they have established relationships with. Research backs this concept too. According to the Advisory Board Physician Survey, twothirds of all referral decisions are based solely on the physician’s preference. It is important that you don’t take for granted that these referral sources will continue to stream into

your practice if you don’t invest back into the relationship. Relationships are a two-way street. You have to consciously contribute to relationships or they can weaken. This can be achieved by providing prompt communication to the referring physician on their patients, such as sending out treatment reports within two weeks after the patient is seen. In addition, an occasional “thank you” goes a long way. A brief phone call or email will suffice as a means to way to say “thanks.” At top referring office(s) a special way to thank the practice is with a food item to be shared with the entire staff and not just the doctors, such as a tray of cookies or lunch. Other ways to reinvest back into the relationship include: - Provide ongoing education to your referrers to add value to your relationship with them (especially if it helps them better understand when to refer certain patients to you), - Be accessible (offer up your email and/or cell phone number for whenever they need a quick consult on a patient), and - Return the favor (reciprocate by referring patients back when possible).

Keep up-to-date on referral patterns Frequently, medical practices will notice an overall decrease in patient referrals as they analyze their annual reports for the practice. The referral trends that they discover may have shifted months ago, but not noticed until long after the referral patterns have been altered. Referrals are the life force for specialty practices as 60% to 90% of all referrals (such as oncology, bariatrics, or orthopedics) come from primary care. Even patient referral drops of 10% can make a substantial impact on the overall practice. As you analyze the referral data, review the number of referrals sent to your practice on a consistent basis. Options should include monthly,

quarterly, and on an annual basis. Compare these numbers to the same timeframes for the previous year. Keep an eye out for data outliers, such as a significant decrease of patients sent from a particular city, specialty, or month. Decreases of 25% and higher should merit an immediate follow up. When analyzing the numbers, look for patterns of referral behavior from both practices and physicians. Such as one physician at a practice sending fewer patients across the span of three months, while the other physicians continue to send a higher number. It is good practice to analyze the service and procedures that referring practices are sending as well. By doing this, you can identify certain services/procedures to promote more. If the tasks become overwhelming, consider reaching out for assistance from an outside medical marketing agency or setting up an online CRM (customer relationship management) system to track the referrals internally.

Follow up When a significant decrease or increase in referrals has been uncovered, take note of this change. Make a point to follow up with this practice with direct contact through either your physician liaison or staff member (physician, office manager, nurse). If there is an established relationship among physicians, encourage your physician to make a brief phone call to ask questions, such as: - Thank you for trusting us with your patient’s care. Is there anything that we can do to better serve your practice? - Are you experiencing any difficulty when referring patients to us? - Or perhaps: We have noticed that you are not sending as many patients as usual. Is there anything that we can do to win back your business? Be aware that a delicate approach is needed here as relationships are fragile and need to be handled carefully.

Consider a program designed to increase referrals If your practice has experienced a significant decrease in referrals and your competition is increasing, the best solution to this problem is a physician liaison program. A physician liaison program is designed to increase patient referrals, strengthen relationships with providers and staff, and provide valuable customer service. The ultimate goal of the program is to increase patient referrals from existing providers and secure new business from non-referring physicians. Physician liaisons serve as the link between your practice and referring providers. The liaisons are not a pharmaceutical rep, and they are not random employees you pluck from your practice that visit referring practices twice a year to hand out business cards. They are skilled, knowledgeable, and strategically-minded professionals who are responsible for driving a steady flow of new patient referrals to your practice. The physician liaison works to cultivate a positive, open and helpful relationships among practices, physicians, and medical staff and alike. With a watchful eye, you can stay on top of the referral trends at your practice so that your referral sources don’t dry up. 


Developing a Referral Network By Naren Arulrajah with Vikas Vij Ekwa Marketing

34 | APRIL 2015

Networking with others is essentially an interpersonal skill that can be employed effectively to build a profitable referral network for doctors. Engaging with the right kind of referral network partners that share the same values and commitment as the doctor will go a long way in developing a sustainable and effective referral network.

Create a Short-list of Potential Names

In an online world that has an overload of individuals, agents and firms claiming to provide successful referral networking, it is critically important to choose the right type of referral network partners. To begin with, the doctor should create a list of the specialty areas within their practice that could potentially generate a fair number of referrals and create a significant income stream. Once the list is finalized, the doctor may look for potential network partners, and possibly have three to five names shortlisted for each specialty area. References can be sought from colleagues and peers in the industry, Google search, and via respected online forums, blogs and sites that are focused on the medical community.

Seek One-on-One Meetings for Evaluation

To evaluate the right referral network partners, it is important to engage in one on one discussions rather than simply relying on an individual’s claims. The meetings can be held online via Skype, Google Hangouts or other means. The doctor should prepare a list of standard questions that address their key expectations and requirements from a network partner. The doctor should try to understand the niche or specific areas of strength of a potential referral partner. The medical field is highly specialized and the best results can be achieved when a doctor creates a referral network that is in harmony with the areas of the strength of their medical practice.

Adopt a Proactive Approach to Network Development When a medical professional adopts a “wait and see� approach, it will usually not lead to creation of the desired level of

continued on page 36 WWW.MEDMONTHLY.COM | 35

continued from page 35

networking in a highly competitive environment. If the network partner says: “If I learn about someone requiring your services, I will get in touch with you,” that is not going to be of much help. Doctors who really achieve an incremental level of referrals every month are usually the ones who proactively ask for the referral, and not wait and hope. Periodic engagement with colleagues and existing network partners, and seeking new referrals will yield results.

Focus the Efforts on Motivated Network Partners

The doctor should spend time and effort on networking with potential colleagues if they have the commitment, motivation and time to send them the proper referrals. A successful referral relationship will happen when both parties are equally enthusiastic and work for mutual benefit. If the potential referral partner shows laxity or lack of professionalism, they may not be the best partner to work with. Referrals will be generated when both parties spend a dedicated amount of time to make it happen. The vision of the doctor must match with that of their referral colleagues. Personal meetings and visiting the offices of referral colleagues can also go a long way in developing a strong


“The medical field is highly specialized and the best results can be achieved when a doctor creates a referral network that is in harmony with the areas of the strength of their medical practice.”

referral network. A visit to the partner’s office will allow the doctor to know the referral coordinators and engage with them personally. More often than not, it is the staff members who are initiating the referrals. Therefore, a rewarding interpersonal engagement with the entire team of the partner can support the network in the long run.  About the Author: Naren Arulrajah is the President and CEO of Ekwa Marketing, a complete Internet marketing company that focuses on website development, SEO, social media marketing, and the online reputations of medical professionals. Vikas Vij is the marketing manager for Ekwa Marketing. Visit Ekwa Marketing at


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Physician Referrals: Communication is the Key By Denise Price Thomas


nce upon a time there was a family practice and a surgical practice side by side, even sharing the same parking lot. What a wonderful opportunity to better serve their patients. The surgical practice administrator had visited the family practice group, welcoming them to the neighborhood and had introduced the referral coordinators. They scheduled a meeting with a desire to better understand what each needed when referring

38 | APRIL 2015

patients. The surgical practice asked how the physicians would like to be kept informed. The family practice physicians said, “a phone call, chat in the parking lot or a letter works for us. Whatever works best for you.� The surgical practice administrator and employees were very understanding about work-ins and when at all possible, would offer same day appointments. Patients very much appreciated this, conveniently walking over from right next door. To the patient, the family practice

physician appeared to be “Super-Doc,” having extraordinary powers in requesting that the neighboring surgeon address their surgical needs so quickly. It was a win-win for both practices. Occasionally, a patient would have to be sent directly to the hospital for urgent surgery. They were able to bypass the emergency department. This made the family practice physician, the surgeon, the patient and patient’s family members very happy. Then one day a patient who had previously been referred by the family practice physician to the surgeon had returned to see his family physician for flu-like symptoms. While there, the family physician said, “I see in my notes that I had referred you to a surgeon about possible gallstones, did you see anyone?” the patient confirmed stating, “Yes sir, I had surgery months ago. I have the scar to prove it. I really liked that surgeon.” The patient pulled up his shirt and low and behold, he was right! There it was, one of the nicest post gallbladder scars ever seen. How embarrassing this was to the family physician. He liked to be kept informed about his patients. The family practice physician understood that mistakes happen so he called over next door to inquire. Copies of physician notes were hand delivered by the staff but one important piece was missing. There was no follow up with the physician, informing him of what the surgeon had found. This was quickly brought to the practice administrator’s attention. When she brought it to the surgeon’s attention, he said, “they should know by now that we are going to take care of their patients. There is no need for all that back and forth. If that’s a problem, then they don’t have to send me anyone else.” And they didn’t. The moral to the story is without effective, timely communication between physicians, both the quality of care and the patient experience can suffer. Physicians who reported a lack of timely communication regarding referrals had less confidence in their ability to provide high-quality care than colleagues who received timely communication. Primary care physicians know that if they don’t get information about referrals back from specialists, particularly for patients with complex conditions, it impacts the quality of the health care they provide. Gaps in communication may lead to patient harm, delays in care, continuation of incorrect treatment, prolonged length of stay, and increased costs. Lack of direct communication between physicians leads to delays in patients receiving the assessment and treatment they need. In order for the patient, family members, physicians, surgeons and staff to live “happily ever after” it takes 100% from all players. When one person drops the magic wand, the entire referral process looses all its miraculous powers. Communication is the essential key. Make it a priority to understand what each practice and each player needs to better serve your patients. 

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healthy living

Balsamic Green Bean Salad

(Adapted From Taste of Home)

By Ashley Acornley, MS, RD, LDN


• 1.5 pounds of fresh green beans, trimmed and cut into 1 ½ inch pieces • ¼ cup olive oil • 3 tablespoons olive oil • 4 tablespoons balsamic vinegar • ¼ teaspoon salt • ¼ teaspoon garlic powder • ¼ teaspoon ground mustard • ⅛ teaspoon pepper • 1 large red onion, chopped • 4 cups cherry tomatoes, halved • 1 cup (4 ounces) crumbled feta cheese


Nutrition Information: Serving Size: 3/4 cup Calories: 77 Fat: 5 g Saturated fat: 1 g Cholesterol: 4 mg Sodium: 112 mg Carbohydrates: 7 g Fiber: 3 g Protein: 3 g


| APRIL 2015

1. Place string beans in a large pot with a steamer basket, and steam until crisptender. Drain and place string beans in ice water. Drain and pat dry and place in large bowl. 2. In a small bowl whisk the oil, lemon juice, vinegar, salt, garlic powder, mustard and pepper. Drizzle over the string beans, add the chopped onions and toss to coat. 3. Cover and refrigerate for at least 1 hour. Just before serving stir in the tomatoes and cheese.

U.S. OPTICAL BOARDS Alaska P.O. Box 110806 Juneau, AK 99811 (907)465-5470

Idaho 450 W. State St., 10th Floor Boise , ID 83720 (208)334-5500

Oregon 3218 Pringle Rd. SE Ste. 270 Salem, OR 97302 (503)373-7721

Arizona 1400 W. Washington, Rm. 230 Phoenix, AZ 85007 (602)542-3095

Kentucky P.O. Box 1360 Frankfurt, KY 40602 (502)564-3296

Rhode Island 3 Capitol Hill, Rm 104 Providence, RI 02908 (401)222-7883 page=DetailDeptAgency&eid=260

Massachusetts 239 Causeway St. Boston, MA 02114 (617)727-5339

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Nevada P.O. Box 70503 Reno, NV 89570 (775)853-1421

Tennessee Heritage Place Metro Center 227 French Landing, Ste. 300 Nashville, TN 37243 (615)253-6061

Arkansas P.O. Box 627 Helena, AR 72342 (870)572-2847 California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 (916)263-2382 Colorado 1560 Broadway St. #1310 Denver, CO 80202 (303)894-7750 Connecticut 410 Capitol Ave., MS #12APP P.O. Box 340308 Hartford, CT 06134 (860)509-7603 ext. 4 asp?a=3121&q=427586 Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 plb/20 Hawaii P.O. Box 3469 Honolulu, HI 96801 (808)586-2704 dispensingoptician/

New Hampshire 129 Pleasant St. Concord, NH 03301 (603)271-5590 New Jersey P.O. Box 45011 Newark, NJ 07101 (973)504-6435 ophth/ New York 89 Washington Ave., 2nd Floor W. Albany, NY 12234 (518)402-5944 North Carolina P.O. Box 25336 Raleigh, NC 27611 (919)733-9321 Ohio 77 S. High St. Columbus, OH 43266 (614)466-9707

Texas P.O. Box 149347 Austin, TX 78714 (512)834-6661 Vermont National Life Bldg N FL. 2 Montpelier, VT 05620 (802)828-2191 opticians/ Virginia 3600 W. Broad St. Richmond, VA 23230 (804)367-8500 HAS-Opticians/ Washington 300 SE Quince P.O. Box 47870 Olympia, WA 98504 (360)236-4947 aspx


U.S. DENTAL BOARDS Alabama Alabama Board of Dental Examiners 5346 Stadium Trace Pkwy., Ste. 112 Hoover, AL 35244 (205) 985-7267 Alaska P.O. Box 110806 Juneau, AK 99811-0806 (907)465-2542 ProfessionalLicensing/BoardofDentalExaminers.aspx Arizona 4205 N. 7th Ave. Suite 300 Phoenix, AZ 85103 (602)242-1492

Hawaii DCCA-PVL Att: Dental P.O. Box 3469 Honolulu, HI 96801 (808)586-3000 Idaho P.O. Box 83720 Boise, ID 83720 (208)334-2369

Arkansas 101 E. Capitol Ave., Suite 111 Little Rock, AR 72201 (501)682-2085

Illinois 320 W. Washington St. Springfield, IL 62786 (217)785-0820

California 2005 Evergreen Street, Suite 1550Â Sacramento, CA 95815 877-729-7789

Indiana 402 W. Washington St., Room W072 Indianapolis, IN 46204 (317)232-2980

Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7800

Iowa 400 SW 8th St. Suite D Des Moines, IA 50309 (515)281-5157

Connecticut 410 Capitol Ave. Hartford, CT 06134 (860)509-8000 asp?a=3143&q=388884

Kansas 900 SW Jackson Room 564-S Topeka, KS 66612 (785)296-6400

Delaware Cannon Building, Suite 203 861 Solver Lake Blvd. Dover, DE 19904 (302)744-4500

Kentucky 312 Whittington Parkway, Suite 101 Louisville, KY 40222 (502)429-7280

Florida 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399 (850)245-4474 42

Georgia 237 Coliseum Drive Macon, GA 31217 (478)207-2440

| APRIL 2015

Louisiana 365 Canal St., Suite 2680 New Orleans, LA 70130 (504)568-8574

Maine 143 State House Station 161 Capitol St. Augusta, ME 04333 (207)287-3333 Maryland 55 Wade Ave. Catonsville, Maryland 21228 (410)402-8500 Massachusetts 1000 Washington St., Suite 710 Boston, MA 02118 (617)727-1944 dentist/ Michigan P.O. Box 30664 Lansing, MI 48909 (517)241-2650,4601,7154-35299_28150_27529_27533---,00. html Minnesota 2829 University Ave., SE. Suite 450 Minneapolis, MN 55414 (612)617-2250 Mississippi 600 E. Amite St., Suite 100 Jackson, MS 39201 (601)944-9622 Missouri 3605 Missouri Blvd. P.O. Box 1367 Jefferson City, MO 65102 (573)751-0040 Montana P.O. Box 200113 Helena, MT 59620 (406)444-2511 boards/den_board/board_page.asp

Nebraska 301 Centennial Mall South Lincoln, NE 68509 (402)471-3121 crl_medical_dent_hygiene_board.aspx

Ohio Riffe Center 77 S. High St.,17th Floor Columbus, OH 43215 (614)466-2580

Nevada 6010 S. Rainbow Blvd. Suite A-1 Las Vegas, NV 89118 (702)486-7044

Oklahoma 201 N.E. 38th Terr., #2 Oklahoma City, OK 73105 (405)524-9037

New Hampshire 2 Industrial Park Dr. Concord, NH 03301 (603)271-4561

Oregon 1600 SW 4th Ave. Suite 770 Portland, OR 97201 (971)673-3200

New Jersey P.O Box 45005 Newark, NJ 07101 (973)504-6405

Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 (717)783-7162

New Mexico Toney Anaya Building 2550 Cerrillos Rd. Santa Fe, NM 87505 (505)476-4680

Rhode Island Dept. of Health Three Capitol Hill, Room 104 Providence, RI 02908 (401)222-2828

New York 89 Washington Ave. Albany, NY 12234 (518)474-3817

South Carolina P.O. Box 11329 Columbia, SC 29211 (803)896-4599

North Carolina 507 Airport Blvd., Suite 105 Morrisville, NC 27560 (919)678-8223

South Dakota P.O. Box 1079 105. S. Euclid Ave. Suite C Pierre, SC 57501 (605)224-1282

North Dakota P.O. Box 7246 Bismark, ND 58507 (701)258-8600

Tennessee 227 French Landing, Suite 300 Nashville, TN 37243 (615)532-3202

Texas 333 Guadeloupe St. Suite 3-800 Austin, TX 78701 (512)463-6400 Utah 160 E. 300 South Salt Lake City, UT 84111 (801)530-6628 Vermont National Life Building North FL2 Montpelier, VT 05620 (802)828-1505 and_commissions/dental_examiners Virginia Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4538 Washington 310 Israel Rd. SE P.O. Box 47865 Olympia, WA 98504 (360)236-4700 West Virginia 1319 Robert C. Byrd Dr. P.O. Box 1447 Crab Orchard, WV 25827 1-877-914-8266 Wisconsin P.O. Box 8935 Madison, WI 53708 1(877)617-1565 aspx?Page=90c5523f-bab0-4a45-ab943d9f699d4eb5 Wyoming 1800 Carey Ave., 4th Floor Cheyenne, WY 82002 (307)777-6529


U.S. MEDICAL BOARDS Alabama P.O. Box 946 Montgomery, AL 36101 (334)242-4116 Alaska 550 West 7th Ave., Suite 1500 Anchorage, AK 99501 (907)269-8163 ProfessionalLicensing/StateMedicalBoard.aspx Arizona 9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258 (480)551-2700 Arkansas 1401 West Capitol Ave., Suite 340 Little Rock, AR 72201 (501)296-1802 California 2005 Evergreen St., Suite 1200 Sacramento, CA 95815 (916)263-2382 Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7690 Connecticut 401 Capitol Ave. Hartford, CT 06134 (860)509-8000 asp?a=3143&q=388902 Delaware Division of Professional Regulation Cannon Building 861 Silver Lake Blvd., Suite 203 Dover, DE 19904 (302)744-4500 District of Columbia 899 North Capitol St., NE Washington, DC 20002 (202)442-5955 44 | APRIL 2015

Florida 2585 Merchants Row Blvd. Tallahassee, FL 32399 (850)245-4444 DesktopDefault.aspx?tabid=115

Louisiana LSBME P.O. Box 30250 New Orleans, LA 70190 (504)568-6820

Georgia 2 Peachtree Street NW, 36th Floor Atlanta, GA 30303 (404)656-3913

Maine 161 Capitol Street 137 State House Station Augusta, ME 04333 (207)287-3601

Hawaii DCCA-PVL P.O. Box 3469 Honolulu, HI 96801 (808)587-3295

Maryland 4201 Patterson Ave. Baltimore, MD 21215 (410)764-4777

Idaho Idaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720 (208)327-7000

Massachusetts 200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 (781)876-8200

Illinois 320 West Washington St. Springfield, IL 62786 (217)785 -0820

Michigan Bureau of Health Professions P.O. Box 30670 Lansing, MI 48909 (517)335-0918,4601,7154-35299_28150_27529_27541-58914-,00.html

Indiana 402 W. Washington St. #W072 Indianapolis, IN 46204 (317)233-0800 Iowa 400 SW 8th St., Suite C Des Moines, IA 50309 (515)281-6641 Kansas 800 SW Jackson, Lower Level, Suite A Topeka, KS 66612 (785)296-7413 Kentucky 310 Whittington Pkwy., Suite 1B Louisville, KY  40222 (502)429-7150

Minnesota University Park Plaza 2829 University Ave. SE, Suite 500  Minneapolis, MN 55414 (612)617-2130 Mississippi 1867 Crane Ridge Drive, Suite 200-B Jackson, MS 39216 (601)987-3079 Missouri Missouri Division of Professional Registration 3605 Missouri Blvd. P.O. Box 1335 Jefferson City, MO  65102 (573)751-0293

Montana 301 S. Park Ave. #430 Helena, MT 59601 (406)841-2300 boards/med_board/board_page.asp Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 (402)471-3121 state-licensing-boards/nebraska-boardof-medicine-and-surgery Nevada Board of Medical Examiners P.O. Box 7238 Reno, NV 89510 (775)688-2559 New Hampshire New Hampshire State Board of Medicine 2 Industrial Park Dr. #8 Concord, NH 03301 (603)271-1203 New Jersey P. O. Box 360 Trenton, NJ 08625 (609)292-7837 New Mexico 2055 S. Pacheco St. Building 400 Santa Fe, NM 87505 (505)476-7220 New York Office of the Professions State Education Building, 2nd Floor Albany, NY 12234 (518)474-3817 North Carolina P.O. Box 20007 Raleigh, NC 27619 (919)326-1100

North Dakota 418 E. Broadway Ave., Suite 12 Bismarck, ND 58501 (701)328-6500

Texas P.O. Box 2018 Austin, TX 78768 (512)305-7010

Ohio 30 E. Broad St., 3rd Floor Columbus, OH 43215 (614)466-3934

Utah P.O. Box 146741 Salt Lake City, UT 84114 (801)530-6628

Oklahoma P.O. Box 18256 Oklahoma City, OK 73154 (405)962-1400 Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 (971)673-2700 Pennsylvania P.O. Box 2649 Harrisburg, PA 17105  (717)787-8503 pt/community/state_board_of_medicine/12512 Rhode Island 3 Capitol Hill Providence, RI 02908 (401)222-5960 South Carolina P.O. Box 11289 Columbia, SC 29211 (803)896-4500 South Dakota 101 N. Main Ave. Suite 301 Sioux Falls, SD 57104 (605)367-7781 Tennessee 425 5th Ave. North Cordell Hull Bldg. 3rd Floor Nashville, TN 37243 (615)741-3111

Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220 Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400 Washington Public Health Systems Development Washington State Department of Health 101 Israel Rd. SE, MS 47890 Tumwater, WA 98501 (360)236-4085 West Virginia 101 Dee Dr., Suite 103 Charleston, WV 25311 (304)558-2921 Wisconsin P.O. Box 8935 Madison, WI 53708 (877)617-1565 Board-Pages/Medical-Examining-BoardMain-Page/ Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053


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Medical Practice Listings

8317 Six Forks Rd. Ste #205 Raleigh, NC 27624 (919)848-4202


Assured Pharmaceuticals Matthew Hall (704)419-3005


Tarheel Physicians Supply 1934 Colwell Ave. Wilmington, NC 28403 (800)672-0441


Bank of America

Mark MacKinnon, Regional Sales Manager 3801 Columbine Circle Charlotte, NC 28211 (704)995-9193

York Properties, Inc. Headquarters & Property Management 1900 Cameron Street Raleigh, NC 27605 (919) 821-1350 Commercial Sales & Leasing (919) 821-7177


PO Box 99488 Raleigh, NC 27624 (919)846-4747



Additional Staffing Group, Inc. 8319 Six Forks Rd, Suite 103 Raleigh, NC 27615 (919) 844-6601


Scynexis, Inc.

3501 C Tricenter Blvd. Durham, NC 27713 (919) 933-4990

CNF Medical


1100 Patterson Avenue Winston Salem, NC 27101 (877)631-3077

Bank of America


Mark MacKinnon, Regional Sales Manager 3801 Columbine Circle Charlotte, NC 28211 (704)995-9193

303, Pinetree Way Mississauga Ontario L5G 2R4, Canada (855) 345-0593


Practices for Sale Medical Practices Primary Care specializing in Women’s Practice Location: Morehead City, N.C. List Price: Just reduced to $20,000 or Best Offer Gross Yearly Income: $540,000 average for past 3 years Year Established: 2005 Average Patients per Day: 12 to 22 Building Owned/Leased: MD owned and can be leased or purchased Contact: Cara or Philip at 919-848-4202

Family Primary Care Practice

Location: Minutes East of Raleigh, North Carolina List Price: $15,000 or Best Offer Gross Yearly Income: $235,000 Average Patients per Day: 8 to 12 Total Exam Rooms: 6 Physician retiring, Beautiful practice Building Owned/Leased: Owned (For Sale or Lease) Contact: Cara or Philip 919-848-4202

Family Practice/Primary Care

Location: Hickory, North Carolina List Price: $425,000 Gross Yearly Income: $1,5000,000 Year Established: 2007 Average Patients Per Day: 24-35 Total Exam Rooms: 5 Building Owned/Leased: Lease or Purchase Contact: Cara or Philip at 919-848-4202

Med Spa

Location: Coastal North Carolina List Price: $550,000 Gross Yearly Income: $1,600,000.00 Year Established: 2005 Average Patients Per Day: 25 to 30 Total Exam Rooms: 4 Building Owned/Leased: Leased Contact: Cara or Philip at 919-848-4202

Practice Type: Mental Health, Neuropsychological and Psychological Location: Wilmington, NC List Price: $110,000 Gross Yearly Income: $144,000 Year Established: 2000 Average Patients Per Day: 8 Building Owned/Leased/Price: Owned Contact: Cara or Philip at 919-848-4202

Practice Type: Internal Medicine

Location: Wilmington, NC List Price: $85,000 Gross Yearly Income: $469,000 Year Established: 2000 Average Patients per Day: 25 Building Owned/Leased: Owned Contact: Cara or Philip at 919-848-4202

Dental Practices Place Your Ad Here

Optical Practices Place Your Ad Here

Special Listings Offer We are offering our “For Sale By Owner” package at a special rate. With a 6 month agreement, you receive 3 months free.

Considering your practice options? Call us today. 48 | APRIL 2015

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. Our three signature sections include:  Performance review  Valuation  Projections

Scan this QR code with your smart phone to learn more.


PRIMARY CARE PRACTICE - Hickory, North Carolina This is an outstanding opportunity to acquire one of the most organized and profitable primary care practices in the area. Grossing a million and a half yearly, the principal physician enjoys ordinary practice income of over $300,000 annually. Hickory is located in the foot-hills of North Carolina and is surrounded by picturesque mountains, lakes, upscale shopping malls and the school systems are excellent. If you are looking for an established practice that runs like a well oiled machine, request more information. The free standing building that houses this practice is available to purchase or rent with an option. There are 4 exam rooms with a well appointed procedure room. The owning physician works 4 to 5 days per week and there is a full time physician assistant staffed as well. For the well qualified purchasing physician, the owner may consider some owner-financing. Call us today. List price: $425,000 | Year Established: 2007 | Gross Yearly Income: $1,500,000

Medical Practice Listings Selling and buying made easy | | 919-848-4202

MD STAFFING AGENCY FOR SALE IN NORTH CAROLINA The perfect opportunity for anyone who wants to purchase an established business.

of the oldest Locums companies client list l Dozens of MDs under contract l Executive office setting l Modern computers and equipment l Revenue over a million per year l Retiring owner


or family medicine doctor needed in


l One

l Large

Please direct all correspondence to Only serious, qualified inquirers.

Comfortable seeing children. Needed immediately.

Call 919- 845-0054 or email:

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

Primary Care Practice For Sale Wilmington, NC 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.

Medical Practice Listings 919.848.4202 |

Internal Medicine Practice Wilmington, North Carolina Newly listed Internal Medicine practice in the beautiful city of Wilmington, NC. With Gross revenues over $400,000, 18 to 22 patients per day, this practice is ready for the physician that enjoys beach life. The medical office is located in a brick wrapped condo and is highly visible. This well appointed practice has a solid patient base and is offered for $85,000. Medical Practice Listings l 919-848-4202 l l

3 OCCUPATIONAL THERAPISTS POSITIONS IN JACKSONVILLE, NC These positions are 40 hour per week temp status to permanent positions with the following qualifications required: l Have graduated from an accredited Occupational Therapist program with a Masters Degree and 1 year experience or a Bachelors Degree with 3 years experience in Occupational Therapy. Program must be accredited by the Accreditation Council for Occupational Therapy Education (ACOTE). l Possess and maintain a valid license or certificate to practice as an Occupational Therapist in any of the 50 states, District of Columbia, the Commonwealth of Puerto Rico, Guam or the US Virgin Islands. l Possess and Occupational Therapist Registered (OTR) certification by the National Board for Certification of Occupational Therapy (NBCOT). l Possess a minimum of one year experience as an Occupational Therapist, preferably working in the neurological based practice setting and with a familiarity of TBI specific patient care practice needs. HOW TO APPLY: Send us your Resume/CV along with the following: available date to start, salary history, cover letter, eight hour shifts available per week. We will contact you by Email or phone to discuss our program. Make sure you provide your phone numbers and Email address. Contact Cara at: or phone (919) 845-0054 for details

PHYSICIANS NEEDED: Mental health facility in Eastern North Carolina seeks: PA/FT ongoing, start immediately Physician Assistant needed to work with physicians to provide primary care for resident patients. FT ongoing 8a-5p. Limited inpatient call is required. The position is responsible for performing history and physicals of patients on admission, annual physicals, dictate discharge summaries, sick call on unit assigned, suture minor lacerations, prescribe medications and order lab work. Works 8 hour shifts Monday through Friday with some extended work on rotating basis required. It is a 24 hour in-patient facility that serves adolescent, adult and geriatric patients. FT ongoing Medical Director, start immediately The Director of Medical Services is responsible for ensuring all patients receive quality medical care. The director supervises medical physicians and physician extenders. The Director of Medical Services also provides guidance to the following service areas: Dental Clinic, X-Ray Department, Laboratory Services, Infection Control, Speech/Language Services, Employee Health,

Pharmacy Department, Physical Therapy and Telemedicine. The Medical Director reports directly to the Clinical Director. The position will manage and participate in direct patient care as required; maintain and participate in an on-call schedule ensuring that a physician is always available to hospitalized patients; and maintain privileges of medical staff. Permanent Psychiatrist needed FT, start immediately An accredited State Psychiatric Hospital serving the eastern region of North Carolina, is recruiting for permanent full-time Psychiatrist. The 24 hour in-patient facility serves adolescent, adult and geriatric patients. The psychiatrist will serve as a team leader for multi-disciplinary team to ensure quality patient care/treatment. Responsibilities include:

evaluation of patient on admission and development of a comprehensive treatment plan, serve on medical staff committees, complete court papers, documentation of patient progress in medical record, education of patients/families, provision of educational groups for patients.

Send copies of your CV, NC medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624 PH: (919) 845-0054 | email: 52 | APRIL 2015

PRIMARY CARE PRACTICE East of Raleigh, North Carolina We are offering a well established primary care practice only minutes east of Raleigh North Carolina. The retiring physician maintains a 5 day work week and has a solid base of patients that can easily be expanded. There are 6 fully equipped exam rooms, a large private doctor’s office, spacious business office, and patient friendly check in and out while the patient waiting room is generous overlooking manicured flowered grounds. This family practice is open Monday through Friday and treats 8 to a dozen patients per day. Currently operating on paper charts, there is no EMR in place. The Gross revenue is about $235,000 yearly. We are offering this practice for $50,000 which includes all the medical equipment and furniture. The building is free standing and can be leased or purchased. Contact Cara or Philip at 919-848-4202 to receive details and reasonable offers will be presented to the selling physician.

Medical Practice Listings Selling and buying made easy | | 919-848-4202



ROANOKE RAPIDS, NC In mid December, a pediatrician or family medicine doctor comfortable with seeing children is needed full time in Roanoke Rapids (1 hour north of Raleigh, NC) until a permanent doctor can be found. Credentialing at the hospital is necessary.

Call 919- 845-0054 or email:

NC MedSpa For Sale MedSpa Located in North Carolina We have recently listed a MedSpa in NC 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 WWW.MEDMONTHLY.COM | 53

Eastern North Carolina Family Practice Available Well-appointed Eastern North Carolina Family Practice established in 2000 is for sale in Williamston, NC. This organized practice boasts a wide array of diagnostic equipment including a GE DEXA scanner with a new tube, GE case 8000 stress testing treadmill and controller and back up treadmill, Autoclave and full set of operating equipment, EKG-Ez EKG and much more. The average number of patients seen daily is between 12 to 22. The building is owned by MD and can be purchased or leased. The owning physician is retiring and will assist as needed during the transition period. The gross receipts for the past three years are $650,000 and the list price was just reduced to $240,000. If you are looking to purchase a well equipped primary care practice, please contact us today. Contact: Cara or Philip at 919-848-4202

Adult & pediAtric integrAtive medicine prActice for sAle This Adult and Pediatric Integrative Medicine practice, located in Cary, NC, incorporates the latest conventional and natural therapies for the treatment and prevention of health problems not requiring surgical intervention. It currently provides the following therapeutic modalities: • • • • •

Conventional Medicine Natural and Holistic Medicine Natural Hormone Replacement Therapy Functional Medicine Nutritional Therapy

• • • • • •


Mind-Body Medicine Detoxification Supplements Optimal Weigh Program Preventive Care Wellness Program Diagnostic Testing

There is a Compounding Pharmacy located in the same suites with a consulting pharmacist working with this Integrative practice. Average Patients per Day: 12-20 Gross Yearly Income: $335,000+ | List Price: $125,000

Call 919-848-4202 or email 54 | APRIL 2015

Physician Solutions has immediate opportunities for dentists and hygienists throughout NC. 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 Physican Solutions at 919-845-0054 or

Women’s Health Practice in Morehead City, NC

Internal Medicine Practice for Sale Located in the heart of the medical community in Cary, North Carolina, this Internal Medicine practice is accepting most private and government insurance payments.

Newly listed Primary Care specializing in Women’s care located in the beautiful coastal city of Morehead City. This spacious practice has 5 exam rooms with one electronic tilting exam table and 4 other Ritter exam tables. Excellent visibility and parking make this an ideal location to market and expand. This practice is fully equipped and is ready for a new owner that is ready to hit the ground running. The owning MD is retiring and will be accommodating during the transition period. This medical building is owned and is offered for sale, lease or lease to own. The gross receipts for the past 3 years exceed $540,000 per year. If you are looking to purchase an excellent practice located in a picturesque setting, please contact us today.

The average patients per day is 20-25+, and the gross yearly income is $555,000. Listing Price: $430,000

Medical Practice Listings Buying and selling made easy

Call 919-848-4202 or email

Primary Care Specializing in Women’s Health

Call 919-848-4202 or email

Located on NC’s Beautiful Coast, Morehead City

Practice established in 2005, averaging over $540,000 the past 3 years. Free standing practice building for sale or lease. This practice has 5 well equipped exam rooms and is offered for $20,000. 919.848.4202 WWW.MEDMONTHLY.COM | 55

Physician Solutions, Inc. Medical & Dental Staffing

The fastest way to be $200K in debt is to open your own practice The fastest way to make $100K is to choose

Physician Solutions

THE DECISION IS YOURS Physician Solutions, Inc. P.O. Box 98313 Raleigh, NC 27624 Scan this QR code with your smartphone to learn more.

phone: 919-845-0054 fax: 919-845-1947

Med Monthly April 2015  

The Developing a Referral Network issue of Med Monthly magazine.

Med Monthly April 2015  

The Developing a Referral Network issue of Med Monthly magazine.