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Med Monthly May 2012


h t l a e h mental& e s u b a e c n a t s b u s sue is


Private therapy practice expansion options



Grim reality of addiction among anesthesiologists


Success story of the Physicians Health Program



Tasty spring salmon recipe

features 34 THE PAIN PROBLEM Conundrum over prescribing pain medication 38 SIX STEPS FOR ICD-10 ORTHOPEDIC CODING What you need to know 42 CHILDHOOD TRAUMA History isn't destiny 44 DRUG ABUSE AMONG ANESTHESIOLOGISTS When medicine and drug use collides 46 A PHYSICIAN'S RECOVERY Success story of the Physicians Health Program

research and technology 10 STRESS & CHRONIC DISEASE CONNECTION 12 NEUROTECHNOLOGY Science fiction or applied science? 16 THE DSM-5 FIELD TRIALS



the arts 46 A WORLD OF EMOTION


in every issue


Doctor's pain conundrum

4 editor’s letter 8 news briefs

56 resource guide 74 top 9 list



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editor’s letter Greetings Medical Professionals! The treatment methods of mental illness and substance abuse have made enormous strides in the last century, however the social stigma that is associated with them is still prevalent, and sufferers are often ostracized and belittled because of this rampant ignorance and lack of compassion. It is disappointing that we as a society can’t see the detriment that is caused by this neglect. Mental illness and drug addiction, as stigmatized as they are, effects so many of us − 1 out of 10 adults in the U.S. suffers from depression. These facts are troubling, especially in regards to health care as many common mental disorders have proven to be linked to a vast array of chronic diseases, and because we continue to ignore this underlying problem we are driving health care costs up even higher. Our May issue investigates the recent developments in mental health advocacy and treatment breakthroughs. The American Psychological Association has released a report compiled by a taskforce to end the discrimination against mental illness. Nationally renowned psychiatrist, Dr. Lloyd Sederer, shares exciting advancements in neurological technology that are making what was once considered science fiction a reality that is transforming the treatment of mental disorders. Our cover story, "The Recovering Physician," tells the story of an anonymous physician who overcame his addiction struggles with the help of the Physicians Health Program. While there is much to be celebrated, there still is a darker side of mental health and substance abuse that greatly affects medical professionals. Jared More reveals the grim truth about drug abuse and addiction among anesthesiologist. Bretton Holmes explains the conundrum that many doctors are facing when making the decision to prescribe opioids as pain relievers because of the liability and dangers (to both physicians and patients) that are associated. Anthony Centore, a private therapy practice consultant and medical credentialing expert, submitted an article on the factors that should be taken into account when considering therapy practice growth. Med Monthly newcomer, Lisa Shock, details how to maximize the financial benefits of hiring NPs and PAs, and explains their differences in regards to reimbursements. Mary Pat Whaley has provided an employee expectations report that will help reduce over 80 percent of the personnel issues in your practice; and our coding guru, Suzanne Leder, reports on the recently proposed ICD-10 deadline. This issue carries bittersweet sentiment: as we celebrate our first year of publishing the most pertinent news in health care, we say goodbye to our talented Creative Director, Courtney Flaherty. I’d like to thank my colleague and friend for her dedication and profound influence that has helped foster the success of our publication – we wish you the best of luck Courtney! I also would like to show my appreciation to all of our loyal readers for your continued support over the past year. I hope your enjoy our May issue on mental health and substance abuse. Sincerely,

Leigh Ann Simpson Managing Editor

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Med Monthly May 2012 Publisher Philip Driver Managing Editor Leigh Ann Simpson Creative Director Courtney Flaherty Marketing & Advertising Jenna Cameron Contributors Mary Pat Whaley, FACMPE Ashley Acornley, MS, RD, LDN Suzanne Leder, BA, M. Phil., CPC, COBGC Matthew D. Erlick, MD Lloyd I. Sederer, MD Anthony Centore, PhD Andrew Ruskin Donna Lee Yesner James S. Cohen Glenn Engelman Michael W. Ryan Bretton Holmes Jared More

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 curretly accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at

contributors Suzanne Leder, M.Phil., CPC, COBGC is a certified AHIMA ICD-10 trainer, certified by the American Health Information Management Association (AHIMA), Suzanne is a Certified Obstetrics Gynecology Coder (COBGCTM). She has been the Ob-gyn Coding Specialty Alert editor for six years and counting.

Ashley Acornley, RD, LDN holds a BS in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and recently completed her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog can be found at:

Mary Pat Whaley, FACMPE is board certified in health care management and a Fellow in the American College of Medical Practice Executives. She has worked in health care and health care management for 25 years. She can be contacted at marypatwhaley@

Lisa P. Shock, MHS, PA-C is a PA who has practiced in primary care and geriatrics. She enjoys part-time clinical practice and is the President and CEO of Utilization Solutions in Healthcare – a specialty consultant company for physician practices and hospitals, offering services to help implement and improve the utilization of PAs and NPs in the health care system. Contact her with questions at

Anthony Centore, Ph.D., P.O. Box 99488 Raleigh, NC 27624 Online 24/7 at

is the founder of Thriveworks, a company that helps health care practices with business tasks including medical credentialing and medical billing. Anthony has published research in the Journal of Mental Health Counseling, is a monthly columnist for Counseling Today magazine, and is Private Practice Consultant for the American Counseling Association. Learn more at: MEDMONTHLY.COM |5

Unfortunately, its motor is inside playing video games. Kids spend several hours a day playing video games and less than 15 minutes in P.E. Most can’t do two push-ups. Many are obese, and nearly half exhibit risk factors of heart disease. The American Council on Exercise and major medical organizations consider this situation a national health risk. Continuing budget cutbacks have forced many schools to drop P.E.—in fact, 49 states no longer even require it daily. You can help. Dust off that bike. Get out the skates. Swim with your kids. Play catch. Show them exercise is fun and promotes a long, healthy life. And call ACE. Find out more on how you can get these young engines fired up. Then maybe the video games will get dusty. A Public Service Message brought to you by the American Council on Exercise, a not-for-profit organization committed to the promotion of safe and effective exercise

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news briefs

Pilot Program Demonstrates Benefits for People with Schizophrenia

OrthoNow Selects CareCloud to Launch National Urgent Care Franchise CareCloud, a leading provider of web-based practice management, electronic health care record (EHR) and medical billing software and services, today announced that OrthoNow, a new orthopedic urgent care franchise based in Miami, Fla., has selected CareCloud’s cloudbased practice management technology solution, CareCloud Central. OrthoNow urgent care centers are focused on providing patients with immediate assessment and management of any orthopedic or sports medicine problem, including offering the ability to perform on-site surgery. OrthoNow is working to expand into a nationwide network of urgent care centers and CareCloud Central will serve as the organization’s operational backbone. By powering each franchise location on the centrally-hosted CareCloud platform, OrthoNow will have unparalleled transparency into operations across its entire network of practices through a flexible, low-cost, web-based patient and appointment management system.

People with schizophrenia report improved functioning after participating in a new, evidence-based clinical program, according to results announced today from a six-month pilot. The program, Advancing Standards of Care for People with Schizophrenia, was spearheaded by the National Council for Community Behavioral Healthcare (National Council) and administered at 10 community behavioral health organizations across the country. The program significantly improved communication, social interaction and coping skills for persons recovering from schizophrenia. “Although society’s understanding of schizophrenia has progressed over the decades, we can do more to help people with the illness recover,” said Linda Rosenberg, President and CEO of the National Council. “This program promotes practitioner and consumer partnerships. Together they measure progress and reinforce what works. It’s a true step forward for people with schizophrenia and the organizations that serve them.” The program revolved around two evidence-based tools: a group curriculum to help adults better understand and selfmanage their mental health condition; and a functional assessment tool, which tracks a person’s ability to independently carry out everyday tasks. The tools encourage participants to take control of their mental illness, discuss it with others, and monitor progress. Participants said they found this helpful in addressing the misconceptions others may have about them.

Spontaneous Gene Glitches Linked to Autism Risk with Older Dads


Researchers have turned up a new clue to the workings of a possible environmental factor in autism spectrum disorders (ASDs): fathers were four times more likely than mothers to transmit tiny, spontaneous mutations to their children with the disorders. Moreover, the number of such transmitted genetic glitches increased with paternal age. The discovery may help to explain earlier evidence linking autism risk to older fathers. The results are among several from a trio of new studies, supported in part by the National Institutes of Health, finding that such sequence changes in parts of genes that code for proteins

play a significant role in ASDs. One of the studies determined that having such glitches boosts a child’s risk of developing autism 5 to 20 fold. Taken together, the three studies represent the largest effort of its kind, drawing upon samples from 549 families to maximize statistical power. They reveal sporadic mutations widely distributed across the genome, sometimes conferring risk and sometimes not. While the changes identified don’t account for most cases of illness, they are providing clues to the biology of what are likely multiple syndromes along the autism spectrum.

chec Be sure to on 2012 issue e n u J g in excit to learn medicine e v ti a v o aking inn groundbre e th t u o b ! more a ealth care h in ts n e advancem

World’s Oldest Practicing Physician Dies at age 114 Leila Denmark, MD, the world’s oldest practicing physician, died on March 31, 2012 at the age of 114. Denmark began her career as one of the first physicians to practice at the Henrietta Egleston Hospital for Children when it opened in 1928, said her grandson, Steven Hutcherson of Atlanta. In 1931 she began practicing medicine out of her Atlanta home and continued until her retirement in 2001. Her retirement was recorded in the Guiness Book of World Records as the world’s oldest practicing doctor. She also is noted as the forth-oldest living person when she died, said Robert Young, senior consultant for gerontology for Guiness World Records. MEDMONTHLY.COM |9

research & technology

APA Survey Reveals Connection Between Chronic Disease & Stress Poor stress management proves to be a major driver in escalating health care costs


he American Psychological Association’s (APA) newly released report, Stress in America™: Our Health at Risk, paints a troubling picture of the impact stress has on the health of the country, especially caregivers and people living with a chronic illness such as obesity or depression. The Stress in America survey, which was conducted online by Harris Interactive on behalf of APA among 1,226 U.S. residents in August and September of 2011, showed that many Americans consistently report high levels of stress (22 percent reported extreme stress, an 8, 9 or 10 on a 10-point scale where 1 is little or no stress and 10 is a great deal of stress). While reported average stress levels

10 | MAY 2012

have dipped slightly since the last survey (5.2 on a 10-point scale versus 5.4 in 2010) many Americans continue to report that their stress has actually increased over time (39 percent report their stress has increased over the past year and 44 percent say their stress has increased over the past five years). Yet stress levels exceed people’s own definition of what is healthy, with the mean rating for stress of 5.2 on a 10-point scale —

1.6 points higher than the stress level Americans reported as healthy. While 9 in 10 adults believe that stress can contribute to the development of major illnesses, such as heart disease, depression and obesity, a sizeable minority still think that stress has only a slight or no impact on their own physical health (31 percent) and mental health (36 percent). When considered alongside the finding that

only 29 percent of adults believe they are doing an excellent or very good job at managing or reducing stress, the APA warns that this disconnect is cause for concern. “America has a choice. We can continue down a well-worn path where stress significantly impacts our physical and mental health, causes undue suffering and drives up health care costs. Or we can get serious about this major public health issue and provide better access to behavioral health care services to help people more effectively manage their stress and prevent and manage chronic disease,” says psychologist Norman B. Anderson, PhD, APA’s CEO and executive vice president. “Various studies have shown that chronic stress is a major driver of chronic illness, which in turn is a major driver of escalating health care costs in this country. It is critical that the entire health community and policymakers recognize the role of stress and unhealthy behaviors in causing and exacerbating chronic health conditions, and support models of care that help people make positive changes.”

Caregivers under fire Millions of Americans provide care for aging or chronically ill family members at home, and that number is expected to grow as the number of elderly Americans is likely to double by the year 2030, according to the U.S. Department of Health and Human Services. Findings from the Stress in America survey suggest that we may want to pay particular attention to the impact of these responsibilities on caregivers, who report higher levels of stress, poorer health and a greater tendency to engage in unhealthy be-

haviors to alleviate their stress than the general public. Caregivers are not only more likely to report stress than other Americans; they also report it at higher levels. On a scale of 1 to 10 where 1 is little or no stress and 10 is a great deal of stress, the mean level of stress reported by caregivers was 6.5 as compared to 5.2 by the general public. Fifty-five percent of caregivers say they feel overwhelmed by the amount of care their aging or chronically ill family member requires. Caregivers are more likely than those in the general population to say they’re doing a poor/fair job practicing healthy behaviors, including managing stress (45 percent versus 39 percent) and getting enough sleep (42 percent versus 32 percent). The latest data also demonstrate that caregivers are more likely than people in the general public to have a chronic illness (82 percent versus 61 percent), rate their health as fair or poor (34 percent versus 20 percent), and point to personal health concerns as a significant source of stress (66 percent versus 53 percent). In addition, caregivers appear to manage stress in less healthy ways than the general population; for example, caregivers are twice as likely to report smoking to manage their stress (20 percent versus 10 percent).

Stress linked to obesity and depression The rate of obesity in the United States remains at epidemic proportions, and according to the Centers for Disease Control and Prevention, 1 in 10 American adults suffers from depression. Findings from Stress in America show that many people who suffer from these conditions say that

they are unable to take the necessary steps to reduce their stress and therefore engage in unhealthy behaviors. On a scale of 1 to 10, people living with depression (6.3) or obesity (6.0) report significantly higher average stress levels than the rest of the population (5.2). Those with depression (33 percent) or who are obese (28 percent) are significantly more likely than the general public (21 percent) to say they do not think they are doing enough to manage their stress. As compared to the general public (11 percent), more people who are obese (34 percent) or depressed (22 percent) report that their disabilities or health issues prevent them from making healthy lifestyle changes. “The Stress in America survey continues to show a nation at a crossroads when it comes to stress and health. We are caught in a vicious cycle where our stress exceeds our own definition of what is healthy, and those who are already living with a chronic illness report even higher levels of stress. Yet we’re ill-equipped to make changes to better manage that stress,” says Anderson. “Given the persistent nature of our stress and the serious physical health consequences associated with it, stress has the potential to become the country’s next public health crisis.” To read the full report, view the Stress in America: Our Health at Risk town hall event or to download graphics, visit the Stress in America website. For additional information on stress and lifestyle and behavior, visit APA’s Help Center and read APA’s Mind/Body Health campaign blog. Join the conversation about stress on Twitter by following @apahelpcenter and using #stressAPA  MEDMONTHLY.COM |11

research & technology

NEUROTECHNOLOGY Science Fiction or Applied Science? Advanced technology that could transform the treatment of mental disorders By Matthew D. Erlick, MD & Lloyd I. Sederer, MD


dvances in neurotechnology are capitalizing on the brain's remarkable sleight of hand. Neurotechnology refers to the applied science of understanding the brain, consciousness, thought and higher-order activities of the mind. Neurotech's brainchildren are today's mental magic. Such fantastical items include electrode-laden "thinking caps" or transcranial direct current stimulation (TDCS) to enhance human concentration; neuroimages of our dream lives, and perhaps even our waking thoughts; remote artillery weapons that soldiers can fire at a combatant by mind control; and video games operated by the player's thoughts. These aren't a sci-fi creation; now they're real. Advancing from science fiction to applied science is a fast-growing, $8 billion business with investments from commercial, military and academic interests. This might seem to be good news for countless sufferers from neurological (e.g., Alzheimer's and other dementias, Parkinson's disease, Mul-

tiple Sclerosis, stroke, etc.) and mental disorders (e.g., depression, PTSD, OCD, mania, etc.). However, for every scientific step forward, there is the chill of possible diabolical applications where there's neural firing, there is apt to be the smoke (and mirrors) of selfserving and questionable ethics. The diagnosis and treatment of behavioral health conditions has yet to fulfill the promises of the 1990s, the so-called "Decade of the Brain." Since then, technological wizardry has transformed our markets, if not our lives. The next iProduct comes with lines of consumers snaking around the block, but for the people who just want to feel well, diagnostic and treatment advances in psychiatry and neurology still lack a magic bullet. Here's the good news: With neuroimaging advances, the brain is a veritable neural Google Map. Functional MRI (fMRI) neuroimaging now allow medical scientists to observe a highly detailed landscape of the brain that reveals locations where mental diseases emerge, where behavioral

therapies might do their job, and how a drug can find entry into the brain. It can even pinpoint the brain's "funny bone" – or which neurons light up when we laugh at a joke. An fMRI scan uses an electromagnetic field to navigate the brain, much in the same way a compass has guided travelers for millennia. One notable neuroimaging explorer is Helen Mayberg, MD, a neurologist who identified a tract of brain tissue deep within the frontal cortex known as "Area 25," a region that is likely a "nerve center" for depression. When a depressed person responds to treatment with antidepressants and cognitive behavioral therapy (CBT), neuroimaging reflects a corresponding response in Area 25. Beyond imaging to pinpoint neural landmarks and monitor responses to therapeutics is repetitive transcranial magnetic stimulation (rTMS), an example of using applied science to treat depressed (and anxious) people. Resembling a large wand, rTMS is a Food and Drug Administration (FDA) approved treatment for depression in which a low-frequency electromagnetic pulse is applied to specific areas of the brain through the scalp, never directly touching the brain; it is performed safely in your Continued on page 15

12 | MAY 2012

14 | MAY 2012

doctor's outpatient office. Research demonstrates that rTMS improves mood – and without the side effects of medication or using electroconvulsive therapy (ECT). Moreover, rTMS may help lessen the intrusive thoughts of obsessive-compulsive disorder, improve the painful apathy associated with certain psychotic disorders, and diminish chronic pain due to migraine headaches and phantom limb syndrome. Broaching the realm of science fiction, rTMS may even have an effect on our thoughts and morality. When the wand is waved over the brain's right temporoparietal junction, it seems to exert a neuronal "superego" force! In one study, research subjects responded to a morality play where they were asked whether Cain should slay Abel. Chillingly, rTMS was able to dampen study participants' ability to judge right from wrong. Remember the brainwashing of Laurence Harvey in "The Manchurian Candidate?" rTMS is not alone. Modern electro – and magneto – encephalography can now detect tumors, find

stroke sites, and localize areas prone to epilepsy. Deep brain stimulation (DBS) utilizes a surgically implanted probe – a brain "pacemaker" – that stimulates brain regions instrumental to Parkinson's disease and depression. Brain-computer interfaces (BCI) are poised to enable a person's thoughts to operate a computer that could drive a wheelchair, operate a pain pump, or communicate for people who can think but not talk. Advanced drug delivery systems are being developed to zero in on diseased brain sites or turn on genes that could promote cell growth – and do so with little damage. Smart drugs or "nootropics" that selectively boost the neural circuits of memory and cognition are another budding frontier, and why not have an amnesic pill to erase bad memories or disabling trauma? Perhaps most incredible is the field of optogenetics, where specially engineered, light-activated (or inactivated) neurons are implanted in the brain to control anxiety. This work is underway with mice and only a few cortical steps away from man.

Beam me up, Scotty. As science makes a reality of what has been science fiction, we will face questions of how to best apply neurotechnologies. Should these advances be limited to helping those who have illnesses? Or should they bolster the performance of a wartime soldier, enable a C student to get straight As, or supercharge corporate CEOs? If a magnetic wand can influence human morality and tip right to wrong (or vice versa), then what mischief lies ahead in using neurotechnologies to perform Jedi mind tricks on unwitting victims? Visit Dr. Sederer's website (www. for questions you want answered, reviews and stories. The opinions expressed here are solely those of Drs. Erlich and Dr. Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical, medical device company or Med Monthly. * This article was originally published for the Huffington Post 

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research & technology

The DSM-5: Will it Work in Clinical Practice? APA conducts real-world field trials to determine effectiveness of the new edition By Lloyd Sederer, MD


he debate rages on about the Diagnosis and Statistical Manual of Mental Disorders, fifth edition (DSM-5), due for release next year by the American Psychiatric Association (APA). Arguments abound over what disorders should be included (and what should be listed within each respective disorder, like autism or psychosis) and what should not be included; what is science and what is opinion; what stigmatizing dangers may exist from diagnosis; and the sheer vol-

16 | MAY 2012

ume of conditions that will find their way into the manual’s pages. Some conspiracy theorists claim that the APA is in bed with pharmaceutical companies, while others see a psychiatrist cabal that seeks wheelbarrows of money from the sales of this next edition. A diagnostic manual of mental disorders cannot be eluded. Clinicians must have ways to declare their observations as specific conditions so they can communication with each other and to patients and caretakers.

Researchers depend on these reliable diagnoses to study the effectiveness of treatments, and the course and prognosis of diseases. Every insurance entity including Medicare, Medicaid, United, Aetna, Blue Cross Blue Shield (BCBS), Kaiser and countless others requires a diagnosis for payment – just as they do for heart and neurological conditions, asthma, diabetes, cancers and all the other maladies that impact the human race. International classifications of diseases, as well, must harmonize

with the DSM to inform global public health practices and researchers: the DSM is not going away. As the winds of controversy swirl, events are taking place that might – might – settle some of the contention. The APA is field testing the DSM draft to see how it works.

The DSM-5 field trials The draft DSM-5 is being tested in real-world clinical settings. Two studies will examine how the diagnostic criteria work with those who

will actually use and be impacted by DSM-5, namely patients and clinicians. The first (and larger) of the two field trials involves 11 Academic Medical Centers (AMC) in the United States and Canada. These sites were selected from 65 applicants based on their capabilities to recruit and study a diverse group of participants (e.g., children, adults, seniors and ethnicities). This trial will allow the APA to compare the prevalence (rates of a condition in a population) of the disorders among AMC pa-

tients who would be given a DSM-IV diagnosis with those who would be given a similar diagnosis using the new criteria in the DSM-5. The second type of field test involves routine clinical practice settings (RCPs). This DSM field trial will specifically examine small group or solo practices. The field work will involve a random selection of general adult psychiatrists and specialists in geriatric, child/adolescent and addiction psychiatry, and those that consult to medical colleagues as well as psychologists, advanced practice psychiatric nurses, licensed counselors, licensed marriage and family therapists, and licensed clinical social workers. This study will especially focus on how feasible and useful are the new criteria as well as the manual’s measures of severity of illness. The field trials will concentrate on conditions that are new (e.g., autism spectrum disorder), or that are significantly different than the preceding manuals (e.g., personality disorders), as well as conditions at the forefront of public concern such as post-traumatic stress disorder (PTSD). The field trial participants, however, will have all the new, proposed criteria for their use and input. In addition to the proposed diagnostic criteria, the field trials will assess “severity measures” and cross-cutting symptom lists (new to the manual). Participants will use a severity rating scale and measures for a clinician to record symptoms such as anxiety, depressed mood, substance use, or difficulties with sleep or attention that occur across a wide variety of diagnostic conditions. For example, in everyday practice clinicians see people with depression who Continued on page 18


also suffer from anxiety, or individuals with bipolar disorder or PTSD who have insomnia. The field trials will determine if the severity measures and symptom lists provide useful information and capture clinical change over time, which is essential to how clinicians determine response to treatments. Previous DSM-III and DSM-IV field trials did not ensure that participating clinicians were not affiliated with the manual’s development; in fact, previous field trials were done by the experts who drafted the manual. The current DSM-5 field trials also use a larger and more diverse sample of participating clinicians and patients. These actions were taken to help to reduce bias and improve the generalizability of the findings. Patients and clinicians also have an unprecedented voice in shaping the proposed manual and its measures.

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The results of the field trials will be reported at the APA annual meeting this May and shared with professional and consumer groups for their feedback. Reports will also be published in peer-reviewed scientific publications. The field trials and feedback received from patients, consumer advocacy groups, and the public will inform further revisions to diagnostic criteria or severity and symptom measures. There has been a lot of smoke from the DSM fires. The field trials should help all concerned see through the smoke and into the embers of advancing the complex and continuous process of improving what we know about diagnosis in psychiatry. For more information see the DSM-5 website: Visit Dr. Sederer’s website at for questions you want answered, reviews, commentary and stories. Editor's Note: The opinions expressed here are solely Dr. Sederer's as a psychiatrist and public health advocate. He receives no support from any pharmaceutical or device company, or Med Monthly *Article was previously published in the Huffington Post 

practice tips

Should I Grow my Solo Therapy Practice into a Group Practice? Expansion options and determining if growth right for you By Anthony Centore, PhD


enjamin Franklin is known historically for his disciplined schedule. His personal notes show that he was asleep at 10 p.m., awake at 5 a.m. – and he spent most of his waking hours working or reviewing his tasks. Starting a counseling practice isn’t a 40-hour a week job. Successful entrepreneurs either “do the Franklin,” or burn the midnight oil – or both! This is because an aspiring counselor-en-

20| MAY 2012

trepreneur must stay abreast on the practice of counseling while learning (and executing) the myriad aspects of running a business (e.g., enacting a business plan, managing finances, setting up an office, marketing, etc.). Once you’ve “done the Franklin,” for about a year, you’ll notice some changes. Your phone is ringing and your caseload is quickly filling! People will tell you that they’ve read your articles, or saw you on the news, or heard

you speak somewhere. New clients will inform you that another client, to whom you provided great care and service, referred them! If all goes well, at some point in year two your caseload will reach 35 sessions a week. At 35 sessions, you’re with clients 26.25 hours a week. You’re spending 13.75 hours a week on clinical notes and your one-office company is well-managed. You’re now working a comfortable 40-hour weekly schedule

and bringing home net earnings of six figures a year. Now that your practice is thriving you have options. You can either:

Stay small While nothing needs to change, there are several options for your small practice to consider. Should you hire administrative help? Perhaps there are some tasks you wish to delegate: reception and scheduling, billing, bookkeeping, or general office upkeep. Hiring additional staff can sometimes be done without reducing you net profit. If a counselor earns $65 per clinical hour, as long as the new employee costs less than $65 an hour, and completes their tasks efficiently, an increase in the counselor’s caseload could compensate for the administrative costs. This approach won’t reduce the counselor’s workweek, but it will allow them to trade administrative tasks for clinical work. Should you raise your rates? If your caseload is full and you’re turning clients away because you’re too busy to see them, you may have the luxury of raising your rates. This is supply and demand: There is limited supply of you, and there’s overwhelming demand of your services. By raising rates you will reduce demand—so finding a

balance is important. Don’t overdo it! Raise prices slowly and only for new clients. Or you could raise rates for the most desirable appointment times. Note: If you accept insurance, you will need to provide services at your contracted rate. However, one can reserve premium times for the highest paying insurance companies, or block out some times for cash-only clients.

Grow larger Perhaps, after years of counseling, you decide that spending the majority of your workweek in session with clients isn’t for you. Or, you decide that you want to capitalize on your practice’s extra client leads, without raising prices. A desirable option may be to bring on another counselor. Should you add another counselor? Bringing on a counselor to work in your practice is a big decision (and responsibility) as it involves much more than funneling surplus client leads. For many, to execute this well, one will need to transition from clinician to full-time manager. In addition, counselors expect a lot in exchange for a split of their session fees. Traditionally, a practice will provide: Office space: Two counselors sharing one office won’t work. Even if one counselor is part-time, there

will be scheduling conflicts during the most desirable session hours. Ample leads: The attrition rate for clients is around eight sessions. Therefore, a counselor needs over four new clients a week to build and maintain a full caseload. Billing / credentialing: Reliable, timely medical billing is crucial. Also, even if a counselor is previously paneled with insurance companies, additional credentialing is necessary to allow him/her to bill through your practice. Reception and scheduling: Counselors expect a high level of administrative help. Printing forms, ordering supplies and other office tasks are often the responsibility of the practice. Insurance: To recruit great counselors, consider a 50 percent split on health insurance, and 100 percent of professional liability insurance. Community: Counselors often wish to be part of a community, and even seasoned clinicians expect the practice to offer some clinical supervision. Changing from a solo practice to a group practice isn’t a minor alteration; it’s the start of a new business (with more risk and more reward). Get ready for an exciting journey, and to again “do the Franklin!” 


DENTAL PRACTICE ADVISOR Learn more & get the practice management CD series at MEDMONTHLY.COM |21

practice tips

GREAT EXPECTATIONS  Tell your employes CLIP AND KEEP! what you expect and This is a great checklist for employee behavior and expectations. get serious with your Demonstrate outstanding customer service • Smile with your eyes. staff about HIPPA, • Follow the 5 – 10 Rule. When you are 10 feet away from a paprofessionalism and tient, make eye contact. When you are five feet away from a patient, greet them. customer service • Thank patients, sincerely. •

By Mary Pat Whaley


o your employees “get it?” If not, add this simple form to your manager’s tool box. These three concepts – customer service, professionalism, and Health Information Portability and Accountability Act (HIPAA)-compliance – are the basis for 80 percent of your everyday performance issues. Tweak the language to fit your practice and present it to your staff. Ask your existing employees to sign it and hand it back to you personally so you have the opportunity to ask them if they have any questions, and so you can discuss any behaviors that you would like for them to improve. This constitutes as verbal counseling and you have documented it in writing. Depending on your discipline policy, if the employee continues to perform poorly in the same area, follow up with written counseling, a performance improvement plan, or specific consequences. Have this form in your new employee packet and review it with new employees during their orientation. 

22| MAY 2012

Ask patients how you can help them.

Model • • •

professionalism Keep your voice at an appropriate level at all times. Do not curse or use impolite words. Do not discuss patients personally or clinically in a derogatory way. • Do not eat meals at your workstation or other work areas of the office. • Dress appropriately. No cleavage, no sports clothing. • Speak to co-workers every day. Regardless of what you think about anyone, speak to them pleasantly when you encounter them.

Be HIPAA-compliant • Keep all patient-specific information out of view of other patients and other non-practice people. This includes charts and other patient information potentially visible at check-in, check-out, the lab, exam room doors and at the nurses’ station. • Do not access any patient information in paper or electronic form that is not required to do your job. • When clinically discussing the patient, do not use the full name of the patient on the phone or in any area where there is potential to be overheard. • Do not use the speaker function on the phone to listen to messages or speak with patients. • Do not take any medical records, patient information or patient-related information out of the office. I understand the performance standards described above and agree to adhere to them as part of my job description. Signature of Employee /Date: ____________________________________ This form is not intended to take the place of a full orientation to confidentiality and compliance, but is intended to emphasize the priorities in your medical practice. Tweak it to make it address the 20 percent of behaviors that cause 80 percent of your employee issues.

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practice tips

Should I Employ a PA or NP? Five keys to greater reimbursement success with cost effective assistance By Lisa P. Shock, MHS, PA-C


n this time of health reform, a original Federal guideline recomcrucial starting point for enabling mends full reimbursement. Not overburdened primary care pro- every state credentials PAs and NPs. viders (PCP) to move toward This results in a wide variation on enhanced primary care delivery is to reimbursement rates. It is critical to leverage nurse practitioners (NP) and understand not only the current Medphysician assistants (PA) to bolster icaid policies in your state, but also to PCP productivity and patient access. keep abreast of any political changes PAs and NPs are able to perform ap- that may be on the horizon as those proximately 80 percent of a primary changes or mandates could affect care physician’s work while collect- reimbursement for your practice. ing 70 percent as much in revenue, despite reduced billing amounts (for Third party payers instance, from Medicare). Capturing New contracts often manmaximum reimbursement is a chal- date individual credentialing of PAs lenge for any medical practice, but and NPs. Reimbursement rates vary there are some special nuances you by state, but for example in North must be aware of when working with Carolina, new Blue Cross Blue Shield PAs and NPs so that you capture all of (BCBS) and Aetna policies are mirthe proverbial “money on the table.” roring Medicare “incident to” rules The following are five keys to success- – with a flat reduction in reimburseful reimbursement when employing ment at 85 percent and no provision PAs and NPs: for incident to “capture” of funds.




Does your practice REALLY understand “incident to” services?  Have you met the criteria to bill and collect at 100 percent or are you better off billing under the PA or NP’s own provider number?  Is your documentation and coding sufficient to survive an audit of incident-to billing? Having sound processes and policies as well as an in-depth understanding of the rules is important to compliance and reimbursement success.



Third party payers such as Blue Cross Blue Shield (BCBS) are leading the charge to reward primary care practices for quality care and offer higher reimbursement rates with patient centered medical home (PCMH) designations and/or participation in blue quality recognition programs. Careful review and timely negotiation of contracts is especially important, as these new programs are unveiled. Many practices are seeing double-digit reimbursement increases as a result of participation in third party payer quality programs and PA/NP services are also included.


Uninsured and under insured

State budgets are tapped. Some states want to limit PA/NP reimClinics and hospitals must bursement even in federally qualified consider alternate payment models health centers (FQHC) where the for cash paying patients. Balancing

overhead costs and efficiency is important for any practice, but if you are in a location with a higher population of uninsured/under-insured patients, a thorough examination of collections is necessary. PAs and NPs do well in these underserved practice environments and the cost to expand the care team with a PA or NP is often cost effective.


Perpetuation of myths and bad information

This may be the most important key of all. Practice managers, consultants and office administrators frequently have little to no understanding of the supervision requirements or the clinical capabilities (and therefore “bill-ability”) of PAs and NPs. If this is the case, delivered services as well as collectible revenues are under available and underestimated. Ensuring a complete understanding of the state statutes and the medical board requirements is a must. The ability of the physician to delegate clinical duties to the PA or NP, thereby defining the scope of practice, is critical to developing efficient, quality care delivery systems as well as maximizing reimbursement. The typical PA brings in revenue of $231,000 with an average salary of $84,000, according to The MGMA Physician Compensation and Production Survey: 2008 Report Based on 2007 Data. After covering the cost of his or her own salary, benefits and incremental overhead a typical PA or NP can boost your bottom line by an estimated $30,000 or more. Developing a clear understanding of the above policies will ensure that your practice realizes a positive return on its PA/NP staffing investment. 


practice tips

CMS Proposes One-Year Delay for ICD-10 Don't count on the delay quite yet, coding experts warn By Suzanne Leder, BA, M.Phil., CPC, COBGC, certified ICD-10 trainer and Torrey Kim, MA, CPC, CGSC, editor-in-chief of Part B Insider


o doubt you have been wondering how to make contingency plans ever since Health and Human Services (HHS) Secretary Kathleen Sebelius announced on Feb. 16 that the government would be delaying the deadline for International Classification of Disease, 10th Edition (ICD-10) diagnosis coding, but failed to designate a new implementation date. Now Centers for Medicare and Medicaid Services (CMS) has nailed down its proposed new deadline: Oct. 1, 2014. That’s one year later than the October 2013 date currently in effect. CMS announced the proposal on April 9, and noted that it’s part of a rule that also includes other Health Information Portal Accountability Act of 1996 (HIPAA) -related provisions. “Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date,” CMS said in a release. “The proposed change in the compliance date for ICD-

26| MAY 2012

10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.”

Provider community offers mixed reviews Some ptices are breathing a sigh of relief that they have an extra year to switch to ICD-10. But others say that they are frustrated that their intensive ICD-10 preparation is getting stalled at this late date. The American Medical Association (AMA), which was a vocal proponent of an ICD-10 implementation delay, cheered the news. “The American Medical Association and physicians across the nation appreciate that CMS has proposed delaying the ICD10 implementation date to October 1, 2014,” said Peter W. Carmel, MD, the AMA’s president. “The postponement is the first of many steps that regulators need to take to reduce the

number of costly, time-consuming regulatory burdens that physicians are shouldering.” Don’t write the new ICD-10 deadline in pen quite yet, though. “ICD10-CM is NOT delayed until October 1, 2014,” coding expert Lisa SelmanHolman notes on her blog. The new deadline is merely a proposal. “The health care industry has the opportunity to comment on the proposal and THEN CMS can publish a final rule,” notes Selman-Holman with SelmanHolman & Associates and CoDR — Coding Done Right. The billions this delay is expected to cost providers may stymie the delay. “Only time will tell,” SelmanHolman says. You have 30 days to comment on the CMS proposal, which can be viewed in the Federal Register at To submit your comments, visit and refer to “CMS-0040-P.” 

Photo by Jade Albert

Learn more at Some signs to look for:

No big smiles or other joyful expressions by 6 months

No babbling by 12 months

No words by 16 months

Š 2012 Autism Speaks Inc. "Autism Speaks" and "It's time to listen" & design are trademarks owned by Autism Speaks Inc. All rights reserved. The person depicted is a model and is used for illustrative purposes only.


APA Task Force to End Discrimination New report suggests education and research will reduce mental health social stigma


eaching students of all ages about the value of diversity and the serious mental health impacts of bias and stereotyping will help end widespread discrimination in the United States, according to a new American Psychological Association (APA) task force report. “Not only is discrimination wrong from the perspectives of morality and justice, it is ultimately detrimental to our entire country. Diversity increases our strength,” said task force chair James M. Jones, PhD. “To thrive in a global economy within the context of the rapidly changing demographics in the United States, we must maximize our country’s potential through its diversity.” The APA Task Force on Reducing and Preventing Discrimination

28 | MAY 2012

Against and Enhancing Benefits of Inclusion of People Whose Social Identities Are Marginalized in U.S. Society was appointed by Melba Vasquez, PhD, APA’s 2011 president, to identify the best interventions to prevent and eliminate prejudice, stereotyping and discrimination and the associated heath care disparities. Psychological research has confirmed that discrimination is harmful in many ways, according to the report. For example, the psychological consequences of social rejection, exclusion and discrimination can be similar to those of physical assault. The report identifies the importance of psychological science in the development of strategies and tools that can be implemented and evaluated in the workplace, courts, schools, the media,

families and communities. Diversity improves education, business and personal relations, according to recent studies, the report said. While some critics have argued that too much focus on diversity undermines American culture and divides people, the task force maintained that emphasizing differences does not preclude recognizing shared aims and values. Referencing decades of psychological research, the task force listed several ways organizations, schools, policy makers and individuals can reduce prejudice and improve psychological well-being and accomplishment: Organizations can work to improve contact among diverse groups. Schools and caregivers can encourage children from different racial or ethnic groups to cooperate in learning exercises. Individuals can make a special effort to interact with and befriend others who are not part of their particular group. The task force also presented several recommendations to APA and the discipline of psychology for playing a larger role in decreasing health care disparities among diverse populations: Develop and distribute educational materials on prejudice and discrimination to day care, Head Start, preschool and kindergarten teachers and parents. Develop and distribute classroom curricula that incorporate research evidence illustrating the effects of bias and stereotype. Develop and encourage diversity training for psychologists and other mental health care providers. Devote more psychological research to age, gender, disability status, economic and sexual orientation discrimination. A copy of the task force report executive summary can be found online and at the APA. 

Manufacturers Affected by Recent Medicare Part D Rule CMS formalizes its Medicare Part D coverage gap discount program rules as part of an omnibus Medicare Part C and Part D rulemaking. By Andrew Ruskin & Donna Lee Yesner


n a rule (the Rule) affecting both the Medicare Part C and Medicare Part D programs, the Centers for Medicare & Medicaid Services (CMS) has recently implemented changes that impact the relationship between pharmaceutical manufacturers and the Medicare Part D program. The Rule was published in the federal register on April 12 and the changes are effective June 1, 2012.

What the Rule covers

The Rule covers a vast array of topics relating both to Medicare Advantage plans authorized under Medicare Part C and to Medicare prescription drug plans authorized under Medicare Part D.

Medicare Part D Coverage Gap Discount Program The Medicare Part D coverage gap discount program requires that manufacturers of innovator products (and their licensees) pay half of the negotiated price of their drugs for patients in the coverage gap (also called the "donut hole") in their Medicare prescription drug program as a pre-condition to coverage of their drugs under Medicare Part D. Although CMS has previously issued instructions, and has had manufacturers sign a model agreement, CMS is still codifying key requirements in regulation. Some of the specific provisions are as follows: Applicable drug The Rule identifies

HRC & American Health Lawyers Association Help Hospitals Better Serve LGBT Patients The Human Rights Campaign, the nation’s largest lesbian, gay, bisexual and transgender (LGBT) civil rights organization, and the American Health Lawyers Association released a new health care guide, "Revisiting Your Hospital’s Visitation Policy," to assist hospital administrators in revising hospital visitation policies to satisfy new requirements barring discrimination against LGBT patients and their families. The Joint Commission standards and the new Medicare Conditions of Participation (CoPs) require hospitals to explain to all patients their right to choose who may visit them during an inpatient stay, regardless of whether the visitor is a family member, a spouse, a domestic partner, or another type of visitor. These changes also protect patients’ right to choose a representative to act on their behalf, requiring hospitals to give deference to patients’ wishes concerning their representatives. "Revisiting Your Hospital’s Visitation Policy" can be viewed at

that the drugs to which the program applies are those that are authorized under a new drug application (NDA) or a biologics license applications (BLA). Negotiated price CMS defines this as the total amount the pharmacy has agreed to receive for a drug, minus any price concessions passed along to the beneficiary at the point of sale. Other health or prescription drug coverage Medicare Part D benefits

are applied before calculating the manufacturer's coverage gap liability, and non-Medicare benefits are applied afterward. CMS has determined that employer group waiver plan (EGWP) benefits are considered non-Medicare benefits, which are also known as "other health or prescription drug coverage."

Implications of decision not to sign agreement

Although a manufacturer will find no coverage of its "applicable drugs" if it fails to sign an agreement, CMS has decided to eschew the "plainest reading" of the statute, which would preclude coverage even of generics. Instead, any drug approved under an abbreviated new drug application (ANDA) will be allowed coverage.

Timing and length of agreement

Agreements must be entered into by January 30 of the year preceding the year in which a drug is to be covered under Part D. The initial term for such agreements is 24 months.

Civil monetary penalties Manufacturers that fail to timely pay their invoice must pay the amount otherwise due plus an additional 25 percent of such amount. The only exception applies if there were technical difficulties beyond the manufacturer's control. Manufacturers are allowed to appeal determinations of any such liability.  * Reprint by Morgan, Lewis & Bocking LLP MEDMONTHLY.COM |29


New FDA Medical Device Benefit-Risk Determination Methodology Principal factors that will be considered during the premarket review processes By James S. Cohen, Glenn Engelmann and Michael W. Ryan

In an attempt to improve the predictability, consistency and transparency of the medical device review process, the U.S. Food and Drug Administration (FDA) recently released final guidance describing the principal factors the agency will consider when making benefit-risk determinations during the premarket approval and de novo classification processes, respectively. The final guidance, entitled “Factors to Consider When Making Benefit-Risk Determinations in Medical Device Premarket Approval and De Novo Classifications,” describes the 30 | MAY 2012

types of medical devices to which the guidance applies, identifies the types of scientific evidence the FDA will consider when making benefit-risk determinations, enumerates a series of factors that the FDA will consider in making such determinations and provides a series of examples illustrating the manner in which the FDA will use such factors to make benefit-risk determinations.

Scope of the final guidance The final guidance applies to both diagnostic and therapeutic devices

that are subject to premarket approval (PMA) or de novo classification petitions. This represents a shift from the scope of the draft guidance, which addressed the factors for PMA devices and, “in limited cases, [for] devices subject to premarket notification (510(k)) requirements,” but did not address the factors for devices that are the subject of a de novo classification petition. The FDA states the contents of the final guidance should be considered during the design, non-clinical testing, pre-Investigational Device Exemption (IDE) and IDE phases, as well as in assembling and assessing PMAs or de novo petitions. Under the Federal Food, Drug, and Cosmetic Act, sponsors of low- to moderate-risk devices that have been determined by the FDA to be not substantially equivalent to a predicate device may submit a petition requesting de novo classification and marketing authorization for the device.

Types of scientific evidence that will be considered during risk-benefit analysis Not surprisingly, the FDA states it puts a “great deal of emphasis” on results obtained using clinical testing methods (e.g., randomized controlled trials, well-controlled investigations,

testing on clinically-derived human specimens). However, the FDA acknowledges that, in certain situations, non-clinical data (e.g., data generated by performance testing for product safety, reliability and/or characterization, computer simulations) may play an important role in demonstrating the safety and effectiveness of a medical device, as medical devices often have attributes that cannot be tested using clinical methods alone. As such, both clinical and non-clinical data may be useful in demonstrating the safety and/ or effectiveness of a device.

Factors the FDA considers when making benefit-risk determinations In the final guidance, the FDA groups the factors the agency will use when making benefit-risk determinations into three categories: the factors to be used in assessing the benefits of devices, the factors to be used in assessing the risks of devices, and additional factors to be used in the assessment of the probable benefits and risks of devices. In assessing the benefits associated with the use of a device, the FDA will consider: Types of benefits What primary endpoints, secondary endpoints or surrogate endpoints were considered? What value do patients place on the benefit? Magnitude of benefits What was the magnitude of treatment effect for each endpoint? What scale is used to measure the benefit? How did the benefit rank on that scale? Probability of a patient experiencing one or more benefits Was the study able to predict which patients will experience a benefit? What is the probability that a patient for whom the device is intended will experience a benefit? How did ben-

efits evaluated vary across subpopulations? Duration of effects Could the duration of each treatment effect (including primary and secondary endpoints) be determined (if relevant)? Is the duration of benefit achieved of value to patients? With respect to the assessment of risks, the FDA will take the following factors into account: Severity, type(s), number and rate(s) of harmful events associated with the use of the device What are the device-related serious adverse events, device-related non-serious adverse events and other procedure-related complications that a patient may be subject to? Probability of a harmful event What percentage of the intended patient population would expect to experience a harmful event? What is the incidence of each harmful event? Is there uncertainty in that estimate? How does the incidence of harmful events vary by subpopulation? Are patients willing to accept the probable risk of the harmful event given the probable benefits of the device? Duration of harmful events How long does the harmful event last? Is it reversible? What type of intervention is required to address the harmful event? Risk of false-positive or falsenegative results from diagnostics What are the consequences of a false positive? What are the consequences of a false negative? Does the device provide the only means of diagnosing the problem, or is it part of an overall diagnostic plan? Aggregate effect of harmful events—Do multiple harmful events occur at once? Finally, FDA identifies a category of “additional factors� to be used in the assessment of benefits and risks:

Uncertainty How robust were the data? How was the trial designed, conducted and analyzed? Are the results repeatable? Is the study the first of a kind, or have other studies achieved similar results? Can the results of the study be applied to the population generally, or are they intended for discrete, specific groups? Characterization of the disease How does the disease affect the patients that have it? Is the condition treatable? How does the condition progress? Patient tolerance for risk and perspective on benefit Did the sponsor present data regarding how patients tolerate the risks posed by the device? Are the risks identifiable and definable? Is the disease so severe that patients will tolerate a higher amount of risk for a smaller benefit? Is the disease chronic? How long do patients with the disease live? If the disease is chronic, is illness easily managed with less invasive or difficult therapies? Are patients willing to take the risk of this treatment to achieve the benefit? How well are patients able to understand the risks and benefits? Availability of alternative treatments or diagnostics What other therapies are available for this condition? How effective are the alternative treatments? How welltolerated are the alternative treatments? What risks are presented by the alternative treatments? Risk mitigation Are there ways to mitigate risks (e.g., product labeling, establishing educational programs, providing add-on therapy, etc.)? What type of mitigation strategy is proposed? Postmarket data Are the probabilities of effectiveness and the rates of harmful events for similar devices similar to what Continued on page 32


is expected for the device under review? Is there reason to believe that long-term device performance, effectiveness of provider training programs, safety and/or efficacy of the device in subgroups or rare adverse events should be evaluated in the postmarket setting? Is there a reason to expect a significant difference between “real world” performance of the device and the performance found in premarket trials? Are there any data that would be provided to support approval that could be deferred to the postmarket setting? Novel technology addressing unmet medical need How well is the medical need this device addresses being met by currently available therapies? How desirable is this device to patients? Appendix B of the final guidance includes a worksheet that clearly summarizes the abovelisted factors that reviewers will use in making benefit-risk determinations as part of the PMA or de novo classification process. Appendix C provides useful examples of how review-

ers might utilize the worksheet in the review of products. As such, these appendices provide a clear roadmap for device manufacturers to follow and may facilitate smoother approval of innovative devices.

Implications In issuing this helpful final guidance, the FDA indicates a commendable willingness to undertake a more flexible and transparent approach to benefit-risk determinations, at least as to devices subject to PMA and de novo review. The multi-factor approach to benefit-risk assessment described in the final guidance, if appropriately implemented, will enable the FDA to conduct an individualized assessment of each medical device subject to PMA or de novo classification. Moreover, by explicitly stating the criteria the FDA will use to assess the above-referenced submissions, device manufacturers should be better able to anticipate the types of data they will need to submit to support a PMA or de novo petition. In particular, the final guidance

is notable in that it indicates that the FDA is willing to consider a patient’s informed request to utilize a device as evidence that such device should be made publicly available—even in situations where the agency might otherwise consider such device to be too risky. In recent years, the FDA has been the subject of some criticism for declining to approve products intended to treat serious or chronic conditions when it deems them to raise issues relative to their risk. Although it remains to be seen whether the FDA will consider patient risk tolerance data to be persuasive, the final guidance represents, at minimum, a nominal step toward embracing broader benefit-risk factors and potentially increasing patient access to innovative medical devices.  * Previously published by McDermott, Will & Emery

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By the numbers... NPI and DEA numbers

What you need to know about the National Provider Identifier and the Drug Enforcement Administration numbers

National Provider Identifier A National Provider Identifier (NPI) is a 10-digit identification number issued to health care providers in the United States. The number is issued by Centers for Medicare and Medicaid Services (CMS). The NPI began replacing the unique provider identification number (UPIN) in 2006 as the required identifier for Medicare services and other payers, including commercial health care insurers. The change to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the first numbers were issued in October of 2006. The NPI was proposed as an eight-position alphanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit in the last position to help detect keying errors. The NPI contains no embedded intelligence; that is it contains no information about the health care provider, such as the type or location. All individual HIPAA covered health care providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapist, athletic trainers, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes. More information regarding NPI numbers can be found at

DEA Number The Drug Enforcement Administration (DEA) is a U.S. Department of Justice law enforcement agency tasked with enforcing the Controlled Substances Act of 1970. It shares concurrent jurisdiction with the Federal Bureau of Investigation (FBI) in narcotics enforcement matters. A DEA number is a series of numbers assigned to a health care provider allowing them to write prescriptions for controlled substances. Legally the DEA number is supposed to only be used for tracking controlled substances, however, the DEA number is often used by the industry as a general “prescriber” number that is a unique identifier for anyone who can prescribe medication. A valid DEA number consists of two letters, six numbers and a one check digit. More information regarding DEA numbers can be found at  MEDMONTHLY.COM |33





ccording to the Office of National Drug Control Policy and the most recent survey of drug use among young people, prescription drugs are the second-most abused category of drugs after marijuana. In addition, the latest National Survey on Drug Use and Health shows that over 70 percent of people who abused prescription pain relievers got them from friends or relatives, while only 5 percent got them from a drug dealer or over the Internet. This practice of “drug diversion” occurs daily when a drug that has been prescribed by a physician is “diverted” in some way by the person for which it was originally prescribed, either intentionally or unintentionally. Either way, doctors are now being held increasingly responsible for the diversion of the drugs they prescribe. “Where the historical attitude toward prescription opioids was that the doctor prescribed and then the patient was responsible for the use of the prescription has changed,” explains Robert Saenz, a national expert in the area of drug Misuse, Addiction and Diversion (MAD). “Now, doctors can be held just as liable for what happens with the medications they prescribe.” Saenz manages, coaches and advises physicians across the country on the very necessary elements of safeguarding medical practices from MAD situations. Saenz tries to get the doctors in the middle of the spectrum – there are docs who are prescribing too many drugs or not prescribing at all - there is a happy medium. Saenz teaches physicians how to monitor their patients. Saenz says

that the vast majority of doctors losing their licenses are in the older spectrum because prescribing opiods has never been an issue before... but it is now and they are going to prison for their involvement. For example Texas physician was recently indicted for his part in an “illegal pain management operation” involving three clinics and four pharmacies. The Drug Enforcement Agency (DEA) charged 76-year-old Gerald Ratinov, MD, with allegedly running the pain pill operation. Ratinov at


practices (when it comes to drug diversion) can be avoided successfully without a reduction in quality of care,” says Saenz. Saenz is also the CEO of Tulsa Pain Consultants in Tulsa, O.K. Tulsa Pain Consultants is a group of four pain management experts who believe in the safe and responsible management of pain on an ongoing basis with their patients and referring physicians. Oklahoma is one of the first states to implement a statewide database that keeps track of prescrip-

The historical attitude toward prescription opioids was that the doctor prescribed and then the patient was responsible for the use of the prescription has changed. Now, doctors can be held just as liable for what happens with the medications they prescribe.

one time served as medical director for three Houston pain clinics that were targeted in several other DEA raids. “I am not surprised by the recent arrest,” Saenz said. “Doctors need to guard themselves against these types of liabilities and threats.” So what are doctors to do? Saenz believes there is plenty of room to both help patients while avoiding the potential for prescription drug abuse. “By implementing a functional based treatment plan, where compliance auditors carefully review treatment plans which include functional goals alongside the medical professional, the risk for medical

tion history so if there is a question about a particular patient’s propensity toward drug-seeking behavior, it can be included or ruled out as a factor in a higher risk scenario. Due to the profound success rate of this system, the state of Oklahoma recently asked Saenz to write legislation for the State of Oklahoma on the subject of drug diversion. The following are a few safeguards that Tulsa Pain Consultants have implemented to keep patients and doctors safe: • Conducting background checks on all new patients to ensure that no prescriptions are given Continued on page 36 MEDMONTHLY.COM |35

Saenz is a national expert on drug diversion and teaches his prevention methods to physicians across the U.S.

to patients with a history of unlawful distribution prior to prescribing them with opioids. • Using urine drug screens prior to and after prescribing opioids to ensure the meds are being taken and not sold or diverted. • Checking all patients in the Oklahoma Bureau of Narcotics database to insure they're not already receiving prescription opioids from another doctor (to prevent doctor pill shopping). • Providing other treatment modalities coupled with appropriate medications to reduce a patient's chances of dependency such as steroid injections for pain, spinal cord implants for chronic pain and even acupuncture. • Meeting with patients individually and having them sign a medication contract outlining specifics of their responsibilities as a patient while taking and securing their prescribed opioids. While some of these measures 36| MAY 2012

may seem strict, the question a physician must concern themselves with is whether or not there is an inherent potential for harm to the particular patient. “Often times this question of harm must be assessed based on various indicators, Saenz says. “If markers point to the potential abuse of the prescriptions, then patients not only run the risk of harming themselves with recreational drug usage, but also from not taking the medication as prescribed. Ultimately we must stand by the physician’s first responsibility, which is to “do no harm.” Saenz says that patients should also be educated with regard to the medicine they are being prescribed; they cannot and should not completely rely on their physician alone. To find more information on Tulsa Pain Consultants please visit: 

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Steps for ICD-10 Orthopedic Coding How and why you must be more specific when coding muscle and connective tissue disorders

By Suzanne Leder, BA, M.Phil., CPC, COBGC, certified ICD-10 trainer and Torrey Kim, MA, CPC, CGSC, editor-in-chief of Part B Insider


ractices seeing patients with orthopedic conditions may have the toughest challenges, when it comes to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM). The reason is that when you’re coding for ligament disorders, palmar fascia contracture, foreign body granulomas, and muscle spasm, your ICD-10 code choices will expand substantially. Follow these practical training steps to learn about how to handle — and when to not worry too much about — coding common connective tissue conditions.

Step 1: Get clinical staff used to be more specific To prep doctors for this level of detail, start training now. “Before the ICD-10 implementation date, coders will need to educate their physicians on the need for a much higher degree of specificity in their diagnostic statements,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, 38 | MAY 2012

Inc., Milltown, N.J. and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, Cali.

Step 2: Identify discrete codes for paraplegia, fibromatoses The International Classification of Diseases, Ninth Revision (ICD-9) codes for specific muscle disorders like 728.3 (other specific muscle disorders) which includes disorders like athrogryposis and immobility syndrome (paraplegic) translate to two different codes in ICD-10. The ICD-10 code for immobility syndrome is M62.3 (immobility syndrome [paraplegic]) and that for other specific disorders is M62.89 (other specified disorders of muscle). “Immobility syndrome has been awarded a specific code for ICD-10, while ‘other specified disorders of the muscle’ has been left undefined to capture the remainder of the unspecified muscle disorders,” says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior

orthopedic coder & auditor, The Coding Network, Washington. The ICD-9 code for fibrosis in muscle ligaments, 728.79 (other fibromatoses of muscle ligament and fascia), extends to two ICD-10 codes as below:  M72.1 (knuckle pads)  M72.4 (pseudosarcomatous fibromatosis)

Step 3: Narrow down to a common code for ligament disorders The ligament disorder code in ICD-10 is more generalized to include a wider array of ligament disorders. Whereas the ICD-9 code 728.4 (laxity of ligament) was solely descriptive of ligament laxity, the ICD-10 code category M24.2 – (disorder of ligament …) describes “disorder of ligament.” This implies that disorders other than a lax ligament can be reported with this code. Remember: You need to identify the anatomic location where this condition Continued on page 40

Orthopedic practices might face the toughest coding challenges so following all the steps is important.

occurs with the fifth and sixth digits.

Step 4: Determine scopes of “other” and “unspecified” muscle disorders You’ll find a broader scope for M62.89 (other specified disorders of muscle). The disorder can be in muscle tendons, fascia, ligament, or aponeurosis. The ICD-9 code 728.89 (other disorders of muscle ligament and fascia), in contrast, is more specific for ligament and fascia. For the unspecified disorders of the connective tissues, you have code 728.9 (unspecified disorder of muscle ligament and fascia) in ICD-9. In ICD-10, you will opt for code M62.9 (disorder of muscle, unspecified). “ICD10 has listed a code specific to the muscle alone. There is also a specific code for disorder of ligament. The ligamentous disorder code is broken down by location, right side (RT) versus left side (LT), with an unspecified code for each body area when RT and LT are not listed. Coders can now be more specific on the actual tissue affected,” says Stumpf.

Step 5: Get more specific for various other conditions The ICD-10 code for Dupuytren’s contracture in the palm is more specific and inclusive of the condition. The ICD-9 code 728.6 (contracture of palmar fascia) includes Dupuytren’s contracture though the same does not appear in the descriptor. On the contrary, the ICD-10 code for the same is M72.0 (palmar fascial fibromatosis [Dupuytren]) which aptly specifies the condition in the descriptor. “M72.0 is very specific to palmar fibromatosis, whereas ICD-9 code 728.6 can be utilized for any contracture of the palmar fascia. Although ICD-9 code 728.6 is used for Dupuytren’s contracture, it 40| MAY 2012

would also apply to any other pathology resulting in palmar contracture,” says Stumpf. “Dupuytren’s contracture is by far the most common cause of palmar fibromatosis,” says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C. The ICD-9 code 728.82 (foreign body granuloma of muscle) for foreign body granuloma of muscle will become inclusive of foreign body granulomas in other soft tissues once ICD-10 rolls out. Code M60.20 (foreign body granuloma of soft tissue, not elsewhere classified, unspecified site) includes foreign body granulomas in soft tissues other than the muscles. For example, you will report subcutaneous tissue foreign body granulomas using the code M60.20. You will find a single code for muscle spasm in ICD-9. The code 728.85 (spasm of muscle) includes a spasm of any type, including those due to injury and stroke, and due to conditions in which the brain or the spinal cord are destroyed, example cerebral palsy or multiple sclerosis. “In ICD-9, the default code for muscle contracture was 728.85, for lack of a more specific code choice,” says Stumpf. However, going further in once ICD-10 implementation date hits, you will have an option of two codes for such conditions. These include M62.40 (contracture of muscle, unspecified site) and M62.838 (other muscle spasm). The catch: You’ll need to know the potential reversibility of the muscle contraction. If the muscle has contracted, become shortened, and fixes the limb permanently in one position, you would use code M62.40. However, if it is a contraction that has some potential of reversibility, you report code M62.838. “ICD-10 is supplying a very specific code for muscle contracture,”

says Stumpf. “ICD-10 has supplied 24 codes from M62.40 through M62.49 to specify specific locations, RT versus LT, an unspecified code for each body location for use when RT/LT has not been clarified, and for ‘other site’ and ‘multiple sites’.”

Step 6: Don’t worry about other changes Don’t worry, however. You’ll find other codes that do not reflect any change in descriptors in ICD-10. The descriptors for 728.5 (hypermobility syndrome) in ICD-9 and M35.7 (hypermobility syndrome) in ICD-10 are similar. The same is true of code 728.71 (plantar fascial fibromatosis) in ICD-9 and code M72.2 (plantar fascial fibromatosis) in ICD-10 for the fibrosis of the plantar fascia. Another such example are the codes for necrotizing fasciitis in ICD9, 728.86 (necrotizing fasciitis) and M72.6 (necrotizing fasciitis) in ICD-10 and for generalized muscle weakness in ICD-9, 728.87 (muscle weakness [generalized]), and M62.81 (muscle weakness [generalized]) in ICD-10. The codes for rhabdomyolysis in ICD-9 (728.88 [rhabdomyolysis]) and ICD-10 (M62.82 [rhabdomyolysis]) have common descriptors. Another important condition that you may frequently report is the Ehlers-Danlos syndrome. “This commonly described condition may manifest as hypermobility and may present with ligamentous hyperlaxity,” says Mallon. You report code 756.83 (Ehlers-Danlos syndrome) for this specific condition. Once the ICD-10 implementation date rolls around, you shall report Q79.6 (Ehlers-Danlos syndrome). 



Childhood Trauma: History isn't Destiny Pediatric intervention can prevent lifelong impairments By Lloyd Sederer, MD


nce again, the American Academy of Pediatrics is demonstrating its clinical leadership. Two recent, groundbreaking reports – "The Lifelong Effects of Early Childhood Adversity and Toxic Stress" and "Early

42| MAY 2012

Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health" – by the Academy boldly declare what has been known but too hidden from sight: Namely, that brain and emotional de-

velopment are profoundly disrupted by childhood adversity and trauma. The pediatric academy quotes Frederick Douglass who said, "It is easier to build strong children than to repair broken men." Toxic stress, or early environmental trauma, has been proven to disrupt normal brain development and trigger genetically predisposed diseases. The tragic results include impairments in the ability to regulate emotions and learn, to adapt socially with others and produce, in adolescence and adulthood, lifelong physical and mental disorders, including heart disease, asthma, arthritis, obesity, diabetes, cancer, depression, substance abuse and post traumatic stress disorder (PTSD). Trouble staying and succeeding in school are also common, as are brushes with the law. Adverse childhood events (ACE) were initially studied by Kaiser Health of Southern California and then by the World Health Organization (WHO) World Mental Health Survey Initiative. ACEs include:  Direct psychological abuse  Direct sexual abuse  Direct physical abuse  Substance abuse in household  Mental illness in household  Mother treated violently  Criminal behavior in household The more ACEs that a child experiences, the greater the risk of them developing a chronic disease, or multiple chronic diseases. From post-traumatic disorder research we know the greater the severity and frequency of the trauma the more likely it will burn itself into the brains neural circuitry. The mechanisms by which early childhood adversity lays its toxic roots are numerous and complex. The manifestations are as specific as youth engaging in impulsive and danger-

ous behaviors (well beyond normal adolescent risk taking), including reckless (and drunk) driving and unprotected sexual behaviors, which can result in sexually transmitted diseases and teenage pregnancies. The mechanisms are as fundamental as the unregulated and ongoing release of stress hormones, including cortisol and adrenaline, which weaken body defenses (compromising the immune system's ability to protect from infection and cancer or


risk for emotional problems (e.g., Dr. David Olds' Nurse Home Visiting Program).  Primary care screening and early intervention for depression in moms.  Pediatric screening and early intervention for depression and addictive disorders in youth.  Parental skills training programs (e.g., Positive Parenting, The Incredible Years, Bright Futures, About Our Kids).

Toxic stress, or early environmental trauma, has been proven to disrupt normal brain development and trigger genetically predisposed diseases.

to turn our immune systems against us in the form of autoimmune diseases), raise blood pressure, promote plaque formation in arteries and are linked, neurologically, to depressive and post-traumatic stress illnesses. The specialty of pediatrics was first to develop "medical homes" (popularized today with federal enabling legislation) designed initially for the young with serious and chronic illnesses whose proper care needs to be monitored and clinically managed by one responsible (accountable) doctor and clinic. Pediatricians have long used screening tools to track childhood development and recently many have introduced depression screening (and treatment paths) as basic tenets of quality care. Their declaration, through these recent reports, of the impact of childhood trauma is a rallying call for what was (until now) another example of "don't ask, don't tell." There are many proven approaches to these problems. Among them are:  Home visits from nurses to mothers identified as being high

 Youth support programs (e.g., Big Sister, Big Brother, after school programs).  Pediatric medical homes that comprehensively support child development and deliver medical, mental health and wellness services.  Trauma-focused mental health programs (for youth already affected). The health of our youth, today and into their futures, can be protected. We can prevent the diseases and disabilities that result from childhood adversity and trauma. State and national budgets can be protected from decades of preventable health, correctional and social welfare expenditures. By following the wise counsel of the American Academy of Pediatrics, and other professional and policy groups, early experience need not be destiny for countless children, their families and their communities. * Article was previously published in the Huffington Post 


When Medicine and Drug Abuse Collide

Exposing the dangers of temptation that many anesthesiologists face

By Jared More


rug abuse in the workplace can be a big concern in any occupation, but what about when the addict is a doctor, or more specifically, an anesthesiologist? Some may think that this group of employees should understand the risks and dangers of controlled substances better than anyone. After all, they deal with these drugs everyday and have studied them in depth. However, this may be the exact reason some doctors are able to successfully support a drug habit without getting caught. Their easy access to the powerful drugs they are exposed to every day may lead to curiosity and cravings for the drug. In addition, these physicians see the

positive results that patients experience with the drugs, and because they know the symptoms of drug abuse and how to hide them, they can reduce their risk of getting caught.

Anesthesiologists and drug abuse A recent study examined the risk of anesthesiologists being exposed to low levels of drugs through patients exhaling them or through the skin. While more research is being done on this subject, it could be argued that a doctor’s the constant exposure to such substances could easily drive them to try it. Many anesthesiologists who are addicts started using drugs when they

were under the stress of their residency training period and were not experienced enough with their profession to say “no” to the temptation. It’s easy to become addicted to such powerful drugs as these vulnerable doctors seldom “just try them once.” Even though the number of anesthesiologist residents who are drug abusers is low – as few as 2 percent – the drugs they use some of the most powerful intravenous drugs available and are potentially lethal because of their addictive nature. Additional problems may result from anesthesiologists' drug abuse because they are so educated about the controlled substances that they are taking, they may be able to cheat on drug tests to keep from getting caught. The chances of an anesthesiologist making it through treatment and going back to their work are not very good; 1 out of 9 will end up dying from relapse and subsequent addiction. In addition, the public safety issue is very concerning – how do we ensure that those responsible for our lives are sober when treating us?

Solutions for hospitals Some hospitals have taken measures to detect drug abuse among staff, including urine drug tests and strict monitoring of controlled substances being taken out of stock. While these may be useful tools to help keep people honest, some critics argue that hospitals should focus more on drug abuse prevention instead of punishment − suggesting that staff training should include drug addiction awareness and that stress reduction practices should be taught. Perhaps if we focus on the well-being of individuals before they feel the need to turn to substances we can prevent the abuse in the first place.  MEDMONTHLY.COM |45


The Recovering Physician

A true success story of the Physicians Health Program By Jane Colley


hat happens when a doctor needs recovery from drug addiction or mental illness? They once had to face their problems alone, but now physicians have a place to turn when their lives seem to have gone in an unfortunate direction. The Physicians Health Program helps identify, treat, monitor the recovery, and endorse the safety of health care practitioners who have a condition, mental or physical, which could affect their ability to practice with reasonable skill and safety. In this true story "Dr. Brown" speaks out about his alcoholism and how the PHP helped him achieve sobriety and regain his medical license. He went six years without a medical license, repeatedly trying to break his twin addictions to opioids and alcohol. By 2000 he was drinking a half gallon of vodka every two days and working as a grocery store clerk. “I was very concerned whether I would live through my alcoholism,” he said. “It’s worse than most chronic diseases. It’s hard for someone who’s not an alcoholic to understand, but there is this profound loss of control. When you are addicted to alcohol the brain malfunctions and causes a constant compulsive and obsessive behavior, which eliminates the ability to control what you’re doing.” His turning point came on a morning at home when he walked down the hall and noticed his young daughter sitting alone in front of the TV watching Sesame Street. He said, “It was an incredible feeling that came over me, that I would never be the kind

of father she deserved unless I could get into recovery.” Within a few days Dr. Brown checked into treatment. Even though he did not want to drink anymore he found it very difficult to get through the cravings and the compulsions that accompany the


encouraged him to apply for a license. He filled out the application, including details of his history of drug addiction. “I figured at least I’d have to go down and stand before the Medical Quality Assurance Commission (MQAC) and

My whole reason for living now is serving humanity. It makes practicing medicine so much better and now that I am sober I am equipped to make a huge difference.

physiological process of becoming sober. He feared that the cravings would eventually overwhelm him and that he would leave. However, after a month, the compulsions lessened, and within three months, they diminished even more significantly. He asked the Physicians Health Program for help with his aftercare, although he was outside PHP’s usual purview since he did not have an active medical license. PHP staff, who had tried to help him years earlier without success, told him they would take him on as a client if he could remain sober for a year and undergo regular counseling. At one year of sobriety, they admitted him into their program but, he said, “I didn’t know if I was ever going to practice medicine.” After three years of sobriety, Dr. Brown began to miss medical practice, and PHP officials

maybe have all these stipulations on my license for many years,” he said. “PHP went before MQAC and talked about me. On the strength of their recommendation and the documentation of my several years of sobriety they gave me a license. It was an incredible thing! I took the license to my PHP recovering doctors’ meeting.” Now practicing again, Dr. Brown finds medicine more satisfying than ever before. “Helping other people is key—that’s part of the 12step program," he says. "My whole reason for living now is serving humanity. It makes practicing medicine so much better and now that I am sober I am equipped to make a huge difference.” 


the arts

A World of Emotion Expressing nature through art By Leigh Ann Simpson


ia De Girolamo, MD, has spent her life collecting inspiration from her travels all over the world, internalizing them to create stunning abstract paintings that convey her emotional responses to the experience. Unlike most children, De Girolamo wasn’t limited to the neighborhood playground; beginning at the tender age of four, she spent every summer with her grandmother in Italy. De Girolamo says that is was during this time that her artistic seeds were sewn. “Even at that young age I was affected by the beauty of the landscape and by the art and architecture of the cities,” De Girolamo recalls. “I think that by drawing and painting I felt I could capture and continue to feel some of that beauty.” De Girolamo also traveled extensively with her parents to exotic destinations such as Greece, Egypt, France, China and Thailand which also provided her with artistic inspiration for her paintings. De Girolamo’s parents nurtured her creativity and instilled virtues that affected her career decisions. Her mother recognized her extreme interest and natural abilities at a young age and arranged for De Girolamo and her sisters to take art classes. Her father, an Italian born immigrant, was a family physician and also worked with the Eastern airline, which provided the family with an affordable means of travel. De Girolamo greatly admired her father’s work as a physician because of the way that he was beloved by his patients. Her admiration, fueled by her love and respect for the objectivity of science, ultimately led her to pursue a career as an internal medicine physician. “I wanted to specialize but did not want to limit myself to one organ system. Infectious disease was one specialty that encompassed the whole body,” she explains. “In addition there was a lot of 'detective work' involved and I like puzzles and mysteries.”

De Girolamo enjoyed helping people, but after 12 years in private practice, she began to feel overwhelmed by the day-to-day operations and administrative stresses associated with running a medical practice. Like so many physicians, she was consumed with her work and had little time to spend with her family or entertaining her own interest. These feeling of discontent began to awaken her inner artist and she began to feel strong desires to paint again, but she considered this merely wishful thinking. However, her feelings drastically changed after the devastating events in New York City on Sept. 11, 2001. In the midst of her hometown tragedy she found inner strength and began to believe that her dream of becoming a professional artist could be real. “At first, it actually seemed a futile and useless desire and then it turned into what seemed the only rational response,” she says. She began spending hours in her studio releasing all of the emotion that had been building inside of her for so

many years. “Making art was energizing and I got such a feeling of joy. I was 'off-balance' after I left medicine and art restored that balance," she says. As an artist, De Girolamo has learned to paint abstract, emotional responses to the natural landscapes that she encounters. She prefers to work with acrylic paint, incorporating other mixed media such as pumice, molding paste, shredded papers and plastics and hand pulled prints. The intensity of the emotions felt in her painting can become quite forceful and moving. “There is a sense of motion in the lines and brushstrokes,” says De Girolamo. “I can get really physical when I work and that comes through in many of my paintings. The marks come intuitively, fast and furious.” For more information on Pia De Girolamo and her art, please visit: 


What’s your practice worth? When most doctors are asked what their practice is worth, the answer is usually, “I don’t know.” Doctors can tell you what their practices made or lost last year, but few actually know what it’s worth. In today’s world, expenses are rising and profits are being squeezed. A BizScore Performance Review will provide details regarding liquidity, profits & profit margins, sales, borrowing and assets. Out three signature sections include:  Performance review  Valuation  Projections

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


the kitchen

By Ashley Acornley, MS, RD, LDN


pring is finally here and it’s time to enjoy all of the fresh and flavorful produce of the season. These include strawberries, a variety of lettuces, asparagus, peas, potatoes and so much more! I am excited to share this protein, antioxidant and omega-3 rich recipe with you to celebrate the warm, beautiful weather. Salmon is filled with omega-3 which is crucial to help maintain mental clarity and focus, and also helps improve skin, eyes and nails. Plus the potatoes, asparagus and fresh vegetables are filled with vitamins, minerals and fiber galore!

Oven-Roasted Salmon with Asparagus & New Potatoes Prep time: 10 minutes | Cook time: 30-35 minutes | Yields: 4 Ingredients: 1 pound small new potatoes, cleaned & halved 2 tablespoons olive oil 1/2 pound medium asparagus, trimmed and sliced on the diagonal, 1-inch long pieces 1 tablespoon fresh dill, chopped 1 strip of lemon zest Preparation:


1 small garlic clove, coarsely chopped 1/2 teaspoon salt 1/2 teaspoon freshly ground pepper 2 (8-to-10 ounce) salmon fillets, or steaks cut about 1-inch thick 1 lemon, cut into large wedges

dish (not glass, as it might 1. Preheat oven to 400 degrees Fahrenheit. In a large, shallow baking in the baking dish cut side es break) coat the potatoes with olive oil and salt. Arrange the potato . Turn the potatoes bottom the on down and roast for 10-12 minutes or until they begin to brown dish from the oven. baking the e over and roast another 10 minutes until browned on top. Remov lemon zest, garlic, salt and a little 2. In a medium bowl, toss the asparagus with the chopped dill, ne. olive oil, and add the asparagus mixture to the potatoes; stir to combi for the salmon. (If you are 3 Push the vegetables to the side of the baking dish to make room return the baking dish to the using fillets, put them skin side down). Salt the salmon well and the fish is just cooked through. If oven. Roast the salmon and asparagus for 10 minutes, or until , and arrange on individual you want, remove the skin and center bones (if you are using steaks) s. plates before serving. Garnish with fresh dill and lemon wedge

SOMETIMES, THE GAME THEY LOVE DOESN’T LOVE THEM BACK. More and more, young athletes are focusing on a single sport and training for that sport year-round — a practice that’s led to an increase in Overuse Injuries. Left untreated, overuse trauma to young shoulders, elbows, knees and wrists may require surgery and have lifelong consequences. For information on preventing and treating Overuse Injuries, visit these sites:

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54 | APRIL 2012

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56 | APRIL 2012

Idaho Idaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720 (208)327-7000 Illinois 320 West Washington St. Springfield, IL 62786 (217)785 -0820 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

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Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 (402)471-3121

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

Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220

Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 (971)673-2700

Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400

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

Pennsylvania P.O. Box 2649 Harrisburg, PA 17105  (717)787-8503 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

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 asp?linkid=6&locid=0 Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053


medical resource guide

ACCOUNTING Boyle CPA, PLLC 3716 National Drive, Suite 206 Raleigh, NC 27612 (919) 720-4970

ADVERTISING 1-800-Urgent-Care

6881 Maple Creek Blvd, Suite 100 West Bloomfield, MI 48322-4559 (248)819-6838

Find Urgent Care

PO Box 15130 Scottsdale, AZ 85267 (602)370-0303

Ring Ring LLC

6881 Maple Creek Blvd, Suite 100 West Bloomfield, MI 48322-4559 (248)819-6838

ANSWERING SERVICES Corridor Medical Answering Service

3088 Route 27, Suite 7 Kendall Park, NJ 08824 (866)447-5154

Docs on Hold

14849 West 95th St. Lenexa, KS 66285 (913)559-3666

BILLING & COLLECTION Advanced Physician Billing, LLC

PO Box 730 Fishers, IN 46038 (866)459-4579 58| APRIL 2012

3562 Habersham at Northlake, Bldg J Tucker, GA 30084 (866)473-0011

Applied Medical Services

Sweans Technologies 501 Silverside Rd. Wilmington, DE 19809 (302)351-3690

VIP Billing

4220 NC Hwy 55, Suite 130B Durham, NC 27713 (919)477-5152

PO Box 1350 Forney, TX 75126 (214)499-3440

Axiom Business Solutions


4704 E. Trindle Rd. Mechanicsburg, PA 17050 (866)517-0466

Frost Arnett 480 James Robertson Parkway Nashville, TN 37219 (800)264-7156

Gold Key Credit, Inc. PO Box 15670 Brooksville, FL 34604 888-717-9615


PO Box 98313 Raleigh, NC 27624 (919)747-9031

Ajishra Technology Support

Horizon Billing Specialists 4635 44th St., Suite C150 Kentwood, MI 49512 (800)378-9991

Management Services On-Call 200 Timber Hill Place, Suite 221 Chapel Hill, NC 27514 (866)347-0001

SEAK Non-Clinical Careers Conference Oct. 21-22, 2012 in Chicago, IL (508)457-1111

Doctor’s Crossing 4107 Medical Parkway, Suite 104 Austin, Texas 78756 (512)517-8545

CODING SPECIALISTS The Coding Institute LLC 2222 Sedwick Drive Durham, NC 27713 (800)508-2582


Marina Medical Billing Service 18000 Studebaker Road 4th Floor Cerritos, CA 90703 (800)287-8166

American Medical Software



6451 Brentwood Stair Rd. Ft. Worth, TX 76112 (800)378-4134

Practice Velocity 1673 Belvidere Road Belvidere, IL 61008 (888)357-4209

1180 Illinois 157 Edwardsville, IL 62025 (618) 692-1300 300 N. Milwaukee Ave Vernon Hills, IL 60061 (866)782-4239

Instant Medical History

4840 Forest Drive #349 Columbia, SC 29206 (803)796-7980

medical resource guide


103 Carpenter Brook Dr. Cary, NC 27519 (919)370-0504

24 Cherry Lane Doylestown, PA 18901 (888)348-1170

Urgent Care America

17595 S. Tamiami Trail Fort Meyers, FL 33908 (239)415-3222

PO Box 101430 Pittsburgh, PA 15237 (412)364-8712

Dentistry’s Business Secrets

9016 Phoenix Parkway O’Fallon, MO 63368 (636)561-5445

Modern Dental Marketing Practices

504 N. Oak St. #6 Roanoke, TX 76262 (940)395-5115


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

1207 Delaware Ave. #433 Buffalo, NY 14209 (800)267-2235

Acentec, Inc

Utilization Solutions (919) 289-9126

(800) 4-THRIVE

Synapse Medical Management

18436 Hawthorne Blvd. #201 Torrance, CA 90504 (310)895-7143

DENTAL Biomet 3i

17815 Sky Park Circle , Suite J Irvine, CA 92614 (949)474-7774

AdvanceMD 10011 S. Centennial Pkwy Sandy, UT 84070 (800) 825-0224

CollaborateMD 201 E. Pine St. #1310 Orlando, FL 32801 (888)348-8457


4555 Riverside Dr. Palm Beach Gardens, FL 33410 (800)342-5454

4701 W. Research Dr. #102 Sioux Falls, SD 57107-1312 (877)697-4696

Dental Management Club

Integritas, Inc.

4924 Balboa Blvd #460 Encino, CA 91316

FINANCIAL CONSULTANTS Sigmon Daknis Wealth Management 701 Town Center Dr. , Ste. #104 Newport News, VA 23606 (757)223-5902 Sigmon & Daknis Williamsburg, VA Office 325 McLaws Circle, Suite 2 Williamsburg, VA 23185 (757)258-1063



Medical Practice Listings

Medical Credentialing

The Dental Box Company, Inc.

820 Benson Rd. Garner, North Carolina 27529 (919) 772-0233

Medical Protective 5814 Reed Rd. Fort Wayne, In 46835 (800)463-3776

MGIS, Inc.

1849 W. North Temple Salt Lake City, UT 84116 (800)969-6447

Professional Medical Insurance Services

16800 Greenspoint Park Drive Houston, TX 77060 (877)583-5510

Wood Insurance Group

4835 East Cactus Rd., #440 Scottsdale, AZ 85254-3544 (602)230-8200

LOCUM TENENS Physician Solutions

2600 Garden Rd. #112 Monterey, CA 93940 (800)458-2486

PO Box 98313 Raleigh, NC 27624 (919)845-0054 MEDMONTHLY.COM |59

medical resource guide LOCUM TENENS (CONT.) Simply Locums, Inc. Your direct, simple & comprehensive source for locum tenens and permanent positions for physicians and other healthcare professionals. Simply Locums was developed to provide a source for both healthcare providers and healthcare facilities to efficiently and directly manage and negotiate their locum tenens and permanent assignments. We’ve streamlined the process, eliminated the costly middleman, and directly link highly qualified healthcare professionals to healthcare facilities. By prohibiting 3rd party recruiter access to our site, we provide cost savings to healthcare facilities and maximize your income. 3949 Hester Lane Salem, IL 62881

Marianne Mitchell (215)704-3188 Nicholas Down Barry Hanshaw 18 Bay Path Drive Boylston MA 01505 508 - 869 - 6038 Pia De Girolamo


ALLPRO Imaging

1295 Walt Whitman Road Melville, NY 11747 (888)862-4050

Biosite, Inc

9975 Summers Ridge Road San Diego, CA 92121 (858)805-8378


Martha Petty 316 Burlage Circle Chapel Hill, NC 27514 (919)933-4920 Julie Jennings (678)772-0889 Eduardo Lapetina 318 North Estes Drive Chapel Hill, NC 27514 (919)960-3400

60| APRIL 2012

800 Shoreline, #900 Corpus Christi, TX 78401 (888)246-3928

Carolina Liquid Chemistries, Inc.

391 Technology Way Winston Salem, NC 27101 (336)722-8910

Dicom Solutions

MedMedia9 PO Box 98313 Raleigh, NC 27624 (919)747-9031 WhiteCoat Designs Web, Print & Marketing Solutions for Doctors (919)714-9885

MEDICAL PRACTICE SALES Medical Practice Listings

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



Deborah Brenner 877 Island Ave #315 San Diego, CA 92101 (619)818-4714


548 Wald Irvine, CA 92618 (800)377-2617

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

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

MEDICAL RESEARCH Arup Laboratories

500 Chipeta Way Salt Lake City, UT 84108 (800)242-2787

Chimerix, Inc. 2505 Meridian Parkway, Suite 340 Durham, NC 27713 (919) 806-1074 Clinical Reference Laboratory 8433 Quivira Rd. Lenexa, KS 66215 (800)445-6917

medical resource guide Peters Medical Research

Sanofi US 55 Corporate Drive Bridgewater, NJ 08807 (800) 981-2491

Dermabond Ethicon, Route 22 West Somerville, NJ 08876 (877)984-4266


507 N. Lindsay St., 2nd Floor High Point, NC 27262

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

DJO 1430 Decision St. Vista, CA 92081 (760)727-1280


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

NUTRITION THERAPIST Triangle Nutrition Therapy 6200 Falls of Neuse Road, Suite 200 Raleigh, NC 27609 (919)876-9779

ExpertMed 31778 Enterprise Dr. Livonia, MI 48150 (800)447-5050

BSN Medical 5825 Carnegie Boulevard Charlotte, NC 28209 (800)552-1157

Gebauer Company

4444 East 153rd St. Cleveland, OH 44128-2955 (216)581-3030

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


15 Barstow Rd. Great Neck, NY 11021 (877)566-5935

Manage My Practice is the go-to online source of technology, information and resources for practice management professionals, and it is visited by over 20,000 medical-practice managers and medical providers each month.

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Careers | Customer Service | Day-to-Day Operations | Electronic Medical Records | Finance | Human Resources | Innovation | Leadership | Marketing | Medicare & Reimbursement | Social Media MEDMONTHLY.COM |61

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A Philip Driver Company

classified listings

Classified To place a classified ad, call 919.747.9031

Physicians needed

Physicians needed

North Carolina

North Carolina (cont.)

Occupational Health Care Practice in Fayetteville North Carolina has two to five days of locums work per week. 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, and PH: (919) 8450054, email: Occupation Health Care Practice located in Greensboro, NC has an immediate opening for a primary care physician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability insurance and an excellent CME, vacation and sick leave package. Send copies of your CV, 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, and PH: (919) 845-0054, email: Family Practice physician opportunity in Raleigh, NC This is a locum’s position with three to four shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from one year of age to geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. Send copies of your CV, 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, and PH: (919) 845-0054, email: Methadone Treatment Center located near Charlotte, NC has an opening for an experienced physician. You must be comfortable in the evaluation and treatment within the guidelines of a highly regulated environment. Practice operating hours are 6 a.m. till 3 p.m. Monday through Friday. Send copies of your CV, 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, and PH: (919) 845-0054,email: Immediate Full-Time Opportunity for Board Certified occupational health care MD in Greensboro, NC. Excellent working environment, wage and professional liability insurance provided. Send copies of your CV, 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, and PH: (919) 845-0054, email:

Cardiology Practice located in High Point, NC has an opening for a board certified cardiovascular physician. This established and beautiful facility offers the ideal setting for an enhanced lifestyle. There is no hospital call or invasive procedures. Look into joining this three physician facility and live the good life in one of North Carolina’s most beautiful cities. 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, and PH: (919) 845-0054, email: Board Certified Internal Medicine physician position is available in the Greensboro, NC area. This is an out-patient opportunity within a large established practice. The employment package contains salary plus incentives. Please send a copy of your current CV, NC medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. email: or phone with any questions, PH: (919) 845-0054. Family Practice physician is needed to cover several shifts per week in Rocky Mount, NC. This high profile practice treats pediatrics, women’s health and primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. Send copies of your CV, NC medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, N.C. 27624, and PH: (919) 845-0054, email: Locum Tenens opportunity for primary care MD in the Triad Area NC. This is a 40 hour per week on-going assignment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wages, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, NC medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. email: or phone with any questions, PH: (919) 845-0054. MEDMONTHLY.COM |63

Ophthalmic and Neuro-Ophthalmic Practice for Sale Raleigh, North Carolina This is a great opportunity to purchase an established ophthalmic practice in the heart of Raleigh. Located on a major road with established clients and plenty of room for growth; you will appreciate the upside this practice offers. This practice performs comprehensive ophthalmic and neuro-ophthalmic exams with diagnosis and treatment of eye disease of all ages. Surgical procedures include no stitch cataract surgery, laser treatment for glaucoma and diabetic eye disease. This practice offers state-of-the-art equipment and the finest quality optical products with contact lens fitting and follow-up care & frames for all ages. List Price: $75,000 | Gross Yearly Income: $310,000

Contact Cara or Philip 919-848-4202 for more information or visit

Primary Care Practice for Sale Hickory, North Carolina Established primary care practice in the beautiful foothills of North Carolina The owning physician is retiring, creating an excellent opportunity for a progressive buyer. There are two full-time physician assistants that see the majority of the patients which averages between 45 to 65 per day. There is lots of room to grow this already solid practice that has a yearly gross of $1,500,00. You will be impressed with this modern and highly visible practice. Listed Price: $325,000

Call Medical Practice Listings at (919) 848-4202 for details and to view our other listings vist

A simple question can reveal as much as a test. “WHAT ARE OUR GOALS FOR TODAY?” Ask your patients about their health priorities at each visit. When you do, both you and your patient can make the most out of the time you have together, and they’ll feel more invested in their own care. Not only does that improve efficiencies, but it also helps improve health outcomes.

For tools and tips to share with your patients, visit

EXCELLENT FAMILY PRACTICE FOR SALE North Carolina family practice located 30 miles from Lake Norman has everything going for it.

Medical Practice Listings For more information call (919) 848-4202. To view other practice listings visit


Physician Solutions has immediate opportunities for psychiatrists throughout NC. Top wages, professional liability insurance and accommodations provided.

Gross revenues in 2010 were 1.5 million, and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established.

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

Excellent medical equipment, staff and hospital nearby, you will be hard-pressed to find a family practice achieving these numbers.

For more information about Physician Solutions or to see all of our locums and permanent listings, please visit

Listing price is $625,000.


compound noun: 1. The action of calling attention to medical goods or services for sale. Exclusively refers to advertising in Med Monthly.

Come see why we’re not your father’s medical journal Scan this code with your smartphone or visit

Med Monthly 919.747.9031 | |

Hospice Practice Wanted Hospice Practice wanted in Raleigh/ Durham area of North Carolina. Medical Practice Listings has a qualified physician buyer that is ready to purchase. If you are considering your hospice practice options, contact us for a confidential discussion regarding your practice.

To find out more information call 919-848-4202 or e-mail

Practice for Sale in Raleigh, NC Primary care practice specializing in women’s care

Med Monthly Med Monthly is the premier health care magazine for medical professionals.

By placing an ad in Med Monthly you’ll reach: family medicine, internal medicine, physician assistants and more!

Call us today to place your classified!


Also available online 24/7

Wanted: Urgent Care Practice

Raleigh, North Carolina The owning physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however, that could double with a second provider.  Exceptional cash flow and profit will surprise even the most optimistic practice seeker.  This is a remarkable opportunity to purchase a well-established woman’s practice.  Spacious practice with several well-appointed exam rooms and beautifully decorated throughout.  New computers and medical management software add to this modern front desk environment.   

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.

List price: $435,000

Medical Practice Listings Buying and selling made easy

Call Medical Practice Listings at (919) 848-4202 for details and to view our other listings visit

Call 919-848-4202 or e-mail MEDMONTHLY.COM |67


OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina Well-established practice serving the Greensboro and High Point areas for over 15 years. Five exam rooms that are fully equipped, plus digital X-Ray. Extensive corporate accounts as well as walk-in traffic. Lab equipment includes CBC. The owning MD is retiring, creating an excellent opportunity for a MD to take over an existing patient base and treat 25 plus patients per day from day one. The practice space is 2,375 sq. feet. This is an exceptionally opportunity. Leased equipment includes: X-Ray $835 per month, copier $127 per month, and CBC $200 per month. Call Medical Practice Listings at (919) 848-4202 for more information.

Asking price: $385,000

To view more listings visit us online at

Pediatrics Practice Wanted Pediatrics practice wanted in NC Considering your options regarding your pediatric practice? We can help. Medical Practice Listings has a well qualified buyer for a pediatric practice anywhere in central North Carolina. Contact us today to discuss your options confidentially. Medical Practice Listings Call 919-848-4202 or e-mail

MODERN MED SPA AVAILABLE Located in beautiful coastal North Carolina

Modern, well-appointed med spa is available in a picturesque part of the state. This practice is positioned in a highly traveled area with positive demographics adding to the business appeal and revenue stream. A sampling of the services and procedures offered are: BOTOX, facial therapy and treatments, laser hair removal, eye lash extensions and body waxing as well as a menu of anti-aging options. If you are currently a med spa owner and looking to expand or considering this high profile med business, this is the perfect opportunity. Highly profitable and organized, you will find this spa poised for success. The qualified buyer can obtain detailed information by contacting Medical Practice Listings at 919-848-4202. | | 919.848.4202 68| APRIL 2012


To place a classified ad, call 919.747.9031

Physicians needed

Physicians needed

North Carolina (cont.)


Internal Medicine Practice located in High Point, NC, has two full-time positions available. This wellestablished practice treats private pay as well as Medicare/Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your NC medical license to - View this and other exceptional physician opportunities at www.physiciansolutions. com or call (919) 845-0054 to discuss your availability and options.

Pediatric Locums Physician needed in Harrisonburg, Danville and Lynchburg, VA. These locum positions require 30 to 40 hours per week, on-going. If you are seeking a beautiful climate and flexibility with your schedule, please consider one of these opportunities. Send copies of your CV, VA. medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email:

Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in NC and VA. Call today to discuss your options and see why Physician Solutions has been the premier physician staffing company on the eastern seaboard. Call (919) 845-0054 or review our corporate capabilities at Pediatricians Needed Well established Pediatric office in Harnett County & Wake County, North Carolina seeks ongoing coverage for locum tenen opportunity. Pediatrician will see about 20 patients daily, hours are 9 a.m. - 5 p.m. No call or hospital duties. Please send a current CV to or call (919) 845-0054 for details on this and other opportunities across the state. Physicians Needed Immediately We have several immediate needs for physician coverage for various facilities in North Carolina for addiction medicine. For immediate consideration please call or email us at or call (919) 8450054. We can put you to work tomorrow! We have very competitive salaries, we pay for mileage, your accommodations if necessary. We look forward to hearing back from you.

Urgent Care opportunities throughout Virginia. We have contracts with numerous facilities and eight to 14-hour shifts are available. If you have experience treating patients from pediatrics to geriatrics, we welcome your inquires. Send copies of your CV, VA medical license, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail:

Practice wanted Pediatric Practice Wanted in Raleigh, NC Medical Practice Listings has a qualified buyer for a pediatric practice in Raleigh, Cary or surrounding area. If you are retiring, relocating or considering your options as a pediatric practice owner, contact us and review your options. Medical Practice Listings is the leading seller of practices in the US. When you list with us, your practice receives exceptional national, regional and local exposure. Contact us today at (919) 848-4202.

MEDICAL PRACTICE LISTINGS Are you looking to sell or buy a practice?

View national practice listings by visiting our website or contact us for a confidential discussion regarding your practice options. We are always ready to assist you.

919.848.4202 | We have in-house practice experts and an attorney ready to assist. MEDMONTHLY.COM | 69

Classified To place a classified ad, call 919.747.9031

Practice for sale

Practice for sale

North Carolina

North Carolina (con't)

Family Practice located in Hickory, NC. Well-established and a solid 40 to 55 patients split between an MD and physician assistant. Experienced staff and outstanding medical equipment. Gross revenues average $1,500,000 with strong profits. Monthly practice rent is only $3,000 and the utilities are very reasonable. The practice with all equipment, charts and good will are priced at $625,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or email:

Internal Medicine Practice located just outside Fayetteville, NC is now being offered. The owning physician is retiring and is willing to continue working for the new owner for a month or two assisting with a smooth transaction. The practice treats patients four and a half days per week with no call or hospital rounds. The schedule accommodates 35 patients per day. You will be hard pressed to find a more beautiful practice that is modern, tastefully decorated and well appointed with vibrant art work. The practice, patient charts, equipment and good will is being offered for $415,000 while the free standing building is being offered for $635,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or email:

Impressive Internal Medicine Practice in Durham, NC: The City of Medicine. Over 20 years serving the community, this practice is now listed for sale. There are four well-equipped exam rooms, new computer equipment and a solid patient following. The owner is retiring and willing to continue with the new owner for a few months to assist with a smooth transition. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at: Modern Vein Care Practice located in the mountains of NC. Booking seven to 10 procedures per day, you will find this impressive vein practice attractive in many ways. Housed in the same practice building with an internal medicine, you will enjoy the referrals from this as well as other primary care and specialties in the community. We have this practice listed for $295,000 which includes charts, equipment and good will. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at Primary Care Practice specializing in women’s care. The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider.  Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several wellappointed exam rooms throughout. New computers and medical management software add to this modern front desk environment. This practice is being offered for $435,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or send an email to

70| MAY 2012

South Carolina Lucrative ENT Practice with room for growth, located three miles from the beach. Physician’s assistant, audiologist, esthetician and well-trained staff. Electronic medical records, mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing allergy, cosmetics, laryngology and trans-nasal esophagoscopy. All the organization is done; walk into a ready-made practice as your own boss and make the changes you want, when you want. Physician will to stay on for a smooth transition. Hospital support is also an option for up to a year. The listing price is $395,000 for the practice, charts, equipment and good will. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or email:

Washington Family Practice located in Bainbridge Island, WA has recently been listed. Solid patient following and cash flow makes this 17-year-old practice very attractive. Contact Medical Practice Listings for more details. email: or (919) 848-4202.

: d e t n Wa Ho

in Da e c i t c a r P spice

MD STAFFING AGENCY FOR SALE Great opportunity for anyone who wants to purchase an established business.

llas, TX

We have a qualified buyer that is looking for an established hospice practice in the Dallas,Texas area. To review your hospice practice options confidentially, contact Medical Practice Listings at 919-848-4202 or e-mail us at

To view our national listings visit

 One of the oldest Locums companies  Large client list  Dozens of MDs under contract  Executive office setting  Modern computers and equipment  Revenue over a million per year  Owner retiring  List price is over $2 million

Please direct all correspondence to Only serious, qualified inquirers.

FAMILY PRACTICE FOR SALE A beautiful practice located in Seattle, Washington This upscale primary care practice has a boutique look and feel while realizing consistent revenues and patient flow. You will be impressed with the well appointed layout, functionality as well as the organization of this true gem of a practice. Currently accepting over 20 insurance carriers including Aetna, Blue Cross and Blue Shield, Cigna, City of Seattle, Great West and United Healthcare. The astute physician considering this practice will be impressed with the comprehensive collection of computers, office furniture and medical equipment such as Welch Allyn Otoscope, Ritter Autoclave, Spirometer and Moore Medical Exam table. Physician compensation is consistently in the $200,000 range with upside as you wish. Do not procrastinate; this practice will not be available for long. List price: $255,000 | Year Established: 2007 | Gross Yearly Income: $380,000

Medical Practice Listings Selling and buying made easy | | 919.848.4202 MEDMONTHLY.COM |71


Exceptional North Carolina Primary Care Practice for Sale Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 1 hour from Raleigh, 15 minutes from Lumberton and about an hour from Wilmington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff. The gross revenue for 2010 is $856,000, and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building. Our Services: • Primary Health • Well Child Health Exams • Sport Physical • Adult Health Exams • Women’s Health Exams • Management of Contraception • DOT Health Exam • Treatment & Management of Medical Conditions • Counseling on Prevention of Preventable Diseases • Counseling on Mental Health • Minor surgical Procedures

By placing a professional ad in Med Monthly, you're spending smart money and directing your marketing efforts toward qualified clients. Contact one of our advertising agents and find out how inexpensive yet powerful your ad in Med Monthly can be. | 919.747.9031

For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit

Private Medical and Mental Health Care Practice for Sale Coastal North Carolina, minutes from Atlantic Beach

Established private internal medicine practice treating general as well as adolescent patients and licensed clinical psychologist’s combine for a high profile multi-disciplinary practice. The staff includes a medical doctor, physician assistant, three licensed clinical psychologists, and a complement of nurses and administrators. The internal medicine practice also uses locum physicians to treat primary care patients as needed. Excellent gross income with solid profits are enjoyed in this evergrowing practice located in a bustling community with handsome demographics. Two all brick condominiums house these practices which are offered for lease or purchase. This expanded services private health care facility has a solid following and all the tools necessary for enhanced services, income and expansion. For more details which include a BizScore Practice Valuation, financial statements, patient demographics and furniture and equipment details, contact one of our professionals.

Medical Practice Listings PH: (919) 848-4202 Email: 72| MAY 2012

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

Practice for Sale in South Denver Neurofeedback and Psychological Practice Located in South Denver, Colorado, this practice features high patient volume and high visibility on the internet. Established referral sources, owner (psychologist) has excellent reputation based on 30 years experience in Denver. Private pay and insurances, high-density traffic, beautifully decorated and furnished offices, 378 active and inactive clients, corporate clients, $14,000 physical assets, good parking, near bus and rapid transit housed in a well-maintained medical building. Live and work in one of the most healthy cities in the U.S. List Price: $150,000 | Established: 2007 | Location: Colorado For more information contact Dr. Jack McInroy at 303-929-2598 or

Primary Care Practice For Sale

Practice at the beach Plastic Surgery practice for sale with lucrative ENT specialty Myrtle Beach, South Carolina Practice for sale with room for growth, located only three miles from the beach. Physician’s assistant, audiologist, esthetician and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of Otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing allergy, cosmetics, laryngology & trans-nasal esophagoscopy. Walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000. For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit

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 | MEDMONTHLY.COM |73

the top May's Top 9 recognizes the nation's most exceptional rehab centers for their dedication to helping patients get through the difficult process of overcoming addiction.

The Canyon Malibu, Cali. This 240-acre serene escape on the California coastline offers experimental therapies such as hiking adventures and meditation sessions.


Vista Taos Renewal Center El Prado, N.M. Patients at this center enjoy spiritual excursions, massage therapy, yoga and a stateof-the-art spa and health club during their transition into sobriety.



Fairwinds Treatment Center Clearwater, Fla. Located near the beautiful gulf beaches, Fairwinds is a leader in the treatment of dual diagnosis.

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Cirque Lodge Sundance, Utah. Nestled in the Rocky Mountains this facility treats individuals and their families. Their luxury amenities such as in-room jacuzzis and saunas cater to their high-end clientele. www.

Compiled by Leigh Ann Simpson

Brighton Center for Recovery Brighton, Mich. Opened in the 1950’s, the Brighton Center for Recovery is the second oldest, and one of the most renowned drug and alcohol rehabilitation program in the country.

Substance abuse treatment centers in the country

Mountain Side Canaan, Conn. Mountain Side offers an innovated and affordable alcohol and drug rehab program that has yielded significantly greater success than traditional treatment models. Each patient’s addiction recovery plan is custom tailored to fit the individual needs of each patient.

The Meadows Wickenburg, Ariz. In addition to drug and alcohol rehabilitation, this facility caters to those who suffer from other addictions such as gambling, sex and work.


La Hacienda Treatment Center Hunt, Texas This facility offers medically supervised detoxification services and individualized treatment programs for collegiate patients, recovering professionals, relapse, family therapy.


La Paloma Treatment Center Memphis, Tenn. This unique model integrates and treats substance abuse and mental illness as co-occuring disorders,(as they are most often linked), which decreases the risks of relapse by addressing addiction at its source.

Save a life. Don’t Drive HoMe buzzeD. BUZZED DRIVING IS DRUNK DRIVING.

Med Monthly May 2012  

Mental health and substance abuse