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o c t o b e r 2 0 11

Imaging Subspecialists of North Jersey, LLC Advanced Imaging Technology, Subspecialty-Trained Physicians and a Mission to Reach Out to the Community Also in this Issue

• Special Feature: Tricore Reduces Group Health Insurance Costs-Here’s How • Overview of the Medicare Shared Savings Program • Vitale Sponsors Bill Creating Physician Loan Redemption Program • To Survive, Medical Companies in New Jersey Are Building New Hospitals

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Publisher’s Letter Dear Readers, Welcome to the October issue of New Jersey Physician, the voice of the state medical community. There is much going on both locally and federally we need

Published by Montdor Medical Media, LLC

to know.

Co-Publisher and Managing Editors Iris and Michael Goldberg

There is much interest in the recent Federal Supreme Court decision to review

Contributing Writers Iris Goldberg Kevin M. Lastorino, Esq Carol Grelecki, Esq Joseph M. Gorrell, Esq Todd C. Brewer, Esq Mark E. Manigan, Esq Ronda Kaysen (NY Times) Deirdre Hartmann, CPA Marina Solo, Esq

the mandatory health coverage bill. Currently slated for Spring, 2012, the court will hear arguments regarding this bill, however it may very well be too late for certain aspects of the bill, already in place, to be repealed. Stay tuned for developments as they arise. A recent ruling gives hospital patients the right to choose who may visit them during their inpatient stay, and gives deference to patients’ wishes, regardless of whether the visitor is a family member, spouse, domestic partner or another type of visitor. The intent of the Medicare Shared Savings Program is to promote accountability

New Jersey Physician is published monthly by Montdor Medical Media, LLC., PO Box 257 Livingston NJ 07039 Tel: 973.994.0068 Fax: 973.994.2063

for a population of Medicare beneficiaries, improve the coordination of FFS items and services, encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery and incent higher value care. As it applies to ACO’s, they will only share in savings if they meet both the quality performance standards and generate shareable savings.

For Information on Advertising in New Jersey Physician, please contact Iris Goldberg at 973.994.0068 or at Send Press Releases and all other information related to this publication to

There is a plethora of new hospitals being built in New Jersey. These are not new

entities to compete in the healthcare market, but new facilities built to replace

Although every precaution is taken to ensure

older buildings. Hospital administrators hope these new facilities will better

accuracy of published materials, New Jersey

position them to attract insured patients and lure top doctors with advanced

Physician cannot be held responsible for opinions

technologies into their medical centers. These hospitals hope their new facilities will prevent them from being dragged down by an outdated structure in a

expressed or facts supplied by its authors. All rights reserved, Reproduction in whole or in part without written permission is prohibited.

community that does not have enough paying patients to support it. No part of this publication may be reproduced or

Our cover story this month is on Imaging Subspecialists of North Jersey. With an impressive team of 20 subspecialty-trained certified radiologists, this is

transmitted in any form or by any means without the written permission from Montdor Medical Media. Copyright 2010.

one of the largest and most comprehensive radiology practices in the state. They are also one of the most charitable practices we have ever encountered. With participation in programs designed to check the cardiac health of first responders, and to assist in the well care and treatment of former professional athletes whose insurance doesn’t cover their needed medical care, they are constantly on the look out on how to best benefit the communities they serve. With warm regards,

Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request New Jersey Physician magazine is an independent publication for the medical community of our state and is not a publication of NJ Physicians Association

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Imaging Subspecialists of North Jersey, LLC

Advanced Imaging Technology, Subspecialty-Trained Physicians and a Mission to Reach Out to the Community CONTENTS

9 10 12

Health Law Update


Hospital Rounds

To Survive, Medical Companies in New Jersey Are Building New Hospitals



Your Assets and Malpractice Claims Protected? Or Risking it All?

16 18

Special Feature

Tricore Reduces Group Health Insurance Costs

Food for Thought

IL Ripasso

Livingston, New Jersey


New Jersey Physician



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September 2011


Cover Story

Imaging Subspecialists of North Jersey, LLC Advanced Imaging Technology, Subspecialty-Trained Physicians and a Mission to Reach Out to the Community By Iris Goldberg

With locations in Paterson, Clifton, Montclair and Wayne as well as an

it offers. At Mountainside Hospital ISNJ has instituted state-of the-art breast

impressive team of 20 subspecialty-trained American Board of Radiology

imaging and intervention as part of a multidisciplinary breast disease

(ABR) certified radiologists, Imaging Subspecialists of North Jersey, LLC

program. Madelyn Danoff, MD is Chief of Women’s Breast Services. She

(ISNJ) is one of the largest and most comprehensive radiology practices

along with Kalavathy Balakumar, MD and Marianne T. Centanni, MD

in the state (see Table 1 on page 5). ISNJ prides itself on offering its

were instrumental in developing the breast services program and perform

patients the most advanced imaging technologies in order to provide the

more than 35 interventional breast procedures collectively at all ISNJ sites

highest level of diagnostic and treatment services.

each week.

For example, Matthew P. Forte, MD, who serves as Chief of Interventional

Frank Yuppa, MD, RVT is President of ISNJ. He also serves as Chairman

Radiology at all ISNJ sites, has brought a new dimension into the

of Radiology at St. Joseph’s Regional Medical Center and Mountainside

interventional lab. Originally trained as a surgeon before choosing to

Hospital. Dr. Yuppa specializes in cardiovascular computed tomography

practice radiology, Dr. Forte is capable of utilizing the most innovative

(CCT), oncological radiology and interventional radiology. He is board-

technology in the interventional procedures that he performs for the

certified in diagnostic radiology, neuroradiology and vascular technology.

patients who are treated at ISNJ. Additionally, Dr. Forte oversees ISNJ’s

Also, Dr. Yuppa is Level 3, board-certified in cardiovascular CT and holds

Vascular Access Center which is right on site where patients receive

certifications in body, neurologic and orthopedic magnetic resonance

dialysis, allowing them to be treated immediately and get back on dialysis

imaging (MRI) and in mammography. He shares some additional exciting

as soon as possible.

technology that he and his colleagues at ISNJ are employing to enhance their imaging capabilities.

Women’s imaging is another area in which ISNJ excels as is demonstrated by the impressive array of diagnostic and interventional radiology services

It has been discovered recently that MRI can be used to map changes in brain hemodynamics that correspond to mental operations, which extends traditional anatomical imaging to include maps of human brain function. This ability to observe the structures and also observe which structures participate in specific functions is made possible by a new technique called functional MRI (fMRI). Dr. Yuppa reports that this ability to directly observe brain function opens up an array of new opportunities to advance our understanding of brain organization, as well as a standard for assessing neurological status and risk. “Functional MRI can be used to determine the proximity of eloquent or very functional centers prior to surgery. It can be used for lateralization of speech function and functional MRI may also help in determining

p Dr. Yuppa is reviewing a functional MRI of the brain showing speech centers illuminated


New Jersey Physician

the prognosis for patients who have suffered a stroke or who have been

Table 1: Radiology Services Offered at ISNJ • Cardiovascular/Heart: Two Level 3-certified and Cardiovascular Board Certified radiologists interpret cardiac/coronary artery CT angiograms performed on 64 slice CT scanners. • Women’s Imaging: Full spectrum of women’s imaging including digital mammography, ultrasound (breast, abdomen and pelvis), hysterosalpinography (HSG) and breast MRI. Highly trained mammographers perform ultrasound-guided, stereotactic-guided and MRI-guided biopsies of the breast. Musculoskeletal: Three fellowship-trained musculoskeletal radiologists perform all MSK services including: MRI and CT, including 3D images (all joints: finger, wrist, hand, elbow, shoulder, hip, knee, ankle, foot, toes, spine, SI joints, etc), X-ray, MRI arthrograms, joint pain management/injection (shoulder, hip, knee, ankle, wrist, thumb, sacroiliac, acromioclavicular, etc). Biopsies of bone and spine are performed at St. Joseph’s and Mountainside Hospital. Hip ultrasound (US) and US-guided procedures are performed at Clifton office, St. Joseph’s Hospital and Mountainside Hospital. Dynamic patellar tracking study/patellofemoral dysplasia is also performed. ISNJ holds Clinical Magnetic Resonance Imaging Society (CMRS) certifications in MRI of brain/neck, orthopedics, and spine and body. ISNJ administers more than 600 joint injections yearly, including steroid injections and contrast injections for CT and MR arthrography. • Neuroradiology: Three radiologists with Certification of Added Qualification (CAQ) in neuroradiology, in addition to American Board of Radiology (ABR) certification. MRI and CT of the brain, neck, spine, peripheral nerves. MRI spectroscopy, perfusion and functional MRI. Advanced neuroimaging of brain, internal acoustic canal (IAC), pituitary, seizure, neck, brachial plexus and spine imaging. Advanced stroke imaging, including CT perfusion, MR angiogram and venogram (MRA/ MRV) of the carotid, subclavian, vertebral and intracranial vessels. • Interventional: Four fellowship-trained interventional radiologists perform all interventional procedures including vascular access and full dialysis related procedures as well as CT, US and fluoroscopy image-guided procedures and biopsies.

p Dr. Yuppa and Dr. Aluri-Vallabhaneni review functional MRI of the brain

diagnosed with a brain tumor,” Dr. Yuppa

an uncertain function such as association


cortices or language-related processes.

He is pleased to share that with the installation

In fact, some have reported fMRI results

of upgraded software now completed, the

consistent with electrophysiology, PET, cortical

radiologists of ISNJ are performing fMRI at St.

stimulation and magneto-encephalography.

Joseph’s Regional Medical Center on a wide

“While in many places functional MRI does

scale basis. As one of only a few facilities in

not replace electrical cortical mapping, it

the tri-state area capable of performing fMRI,

does save doctor time,” Dr. Yuppa elaborates,

ISNJ will undoubtedly continue to receive

indicating a reduction in the amount of

referrals from various locations within New

procedure time when the neurosurgeon does

Jersey, as well as from neighboring states.

not need to search for the affected area.

In order for fMRI to accomplished, the

Bhanu Aluri-Vallabhaneni, MD and other

patient must be capable of cooperating by

neuroradiologists at ISNJ are taking part in

responding to visual or auditory signals.

clinical trials at St. Joseph’s Medical Center

During a typical functional imaging series

that are focusing on therapies for stroke

for speech localization, there are hundreds

victims. Specifically, the “Attack Program”

of images running continuously for three to

is investigating therapies for inter-cerebral

four minutes. In one particular paradigm, the

hemorrhage and another trial looks at a

patient will be shown a series of objects for 30

clot-buster called desmoteplase which is an

seconds and asked to name them silently. This

alternative to TPA.

is followed by a thirty second control where

• Pediatrics: Full pediatric diagnostic imaging is performed by a fellowship-trained radiologist. US, MRI, CT with radiation dose reduction, fluoroscopy, GI and GU diagnostic procedures, x-rays. MRI and CT procedures performed with sedation are monitored by board-certified anesthesiologists at St. Joseph’s Hospital. ISNJ performs congenital pediatric cardiac/chest MRI and MR angiogram imaging.

the patient’s eyes are fixated on a control

Desmoteplase is a chemical found in the

object such as a geometric shape. This will

saliva of vampire bats that has the effect of

preferentially enhance Broca’s speech area.

catalyzing the conversion of plasminogen to

There are many other paradigms available for

plasmin, which is the enzyme responsible for

language and motor function.

breaking down fibrin blood clots. TPA must

The potential role of fMRI in neurosurgical

stroke symptoms, while desmoteplase offers a

• Body Imaging: Fellowship-trained radiologists perform MRI, CT, barium/fluoroscopic studies, virtual colonoscopy, CT enterography, US (including gallbladder, biliary tree, liver, spleen, kidneys, prostate, bladder).

planning, which relies on precise delineation

window of 3 to 9 hours.

• Nuclear Medicine: All aspects of nuclear medicine are performed including PET/CT, thyroid, bone, body, neuroendicrine, thyroid nuclear medicine treatment.

be administered within 3 hours of the onset of

of the structural and functional aspects of the brain, cannot be overstated. The need

For treating stroke victims Dr. Yuppa sees the

for individualized maps of brain function is

tremendous potential of following up with

crucial when the presence of a tumor alters

fMRI to determine prognosis and duration of

the expected location of a function, or when

therapy. He discusses neuroplasticity, which

the location of the tumor is in an area with

is the re-formation and re-distribution of October 2011


neurons as a result of an abnormality. Therapy

Particularly worrisome for this group is that

can enhance the process and this can be

many are unaware of the silent danger they

documented with fMRI. Although Dr. Yuppa

face beyond the actual threat imposed by the

cautions that reporting on this is still very early

disaster to which they are responding. Soft

in the literature, he does foresee the possibility

plaque that is undetectable by ECG or stress test

that fMRI can play a significant role in post-

may be accumulating on arterial walls, even in

stroke rehabilitation.

those who are relatively young. For emergency responders with undetected coronary artery

After traumatic brain injury a type of fMRI called

disease, the high intensity stress they face while

tractography is helpful in diagnosing deficits

on the job can be the catalyst for a serious, if

from major and minor trauma, including those

not deadly heart attack.

in athletes, when other studies are normal or

p CTA Angiography can look directly inside the coronary vessels to identify the presence of soft plaque

and where it is attached. This information is

equivocal. Dr. Yuppa is actively involved in

Dr. Yuppa and the cardiac imaging team

used to plan the ensuing surgery in the most

determining the significance of this technology

at ISNJ have been involved in an ongoing

safe and efficient way possible.

in terms of prognosis and treatment for those

program to educate firefighters and other

who have sustained injury to the brain.

first responders by traveling throughout the

Another way in which ISNJ reaches out to

state to speak at firehouses, police stations,

the community is through its participation

In fact, the potential future applications of fMRI

conventions and other events. For those who

in PAST which stands for Pain Alternatives,

are numerous. Besides neurosurgical planning

wish to undergo screening, the radiologists at

Solutions and Treatments for the Retired

and improved assessment risk for patients and

ISNJ perform cardiac calcium scanning, which

Professional Athlete’s Group. PAST is made

treatment for stroke and brain trauma, possible

is the most accurate technology to predict

up of a prominent group of medical professions

future directions include improved assessment

subsequent coronary events. Then, for those

from many specialties donating their time and

and strategies for the treatment of chronic pain,

who have a calcium score that is concerning,

services to treat aging former professional

improved seizure localization and improved

the radiologists at ISNJ can perform ultra-fast

athletes who find themselves without health

physiology of neurological disorders.

cardiac CT angiography to look directly inside

insurance or funds to cover their much needed

the coronary vessels in order to see if and how

health care.






much dangerous soft plaque is present. Once

technology to improve quality of life and also to

a problem has been identified, aggressive

Edward Milman, MD is the Medical Director

save lives goes beyond treating those patients

treatment can be initiated and a major cardiac

of ISNJ at Wayne Valley Imaging, Director of

who are referred for imaging studies by their

event can be prevented.

MRI at all ISNJ locations and Section Chief

physicians. Compassionate care is also a top

Diagnostic and Interventional Musculoskeletal

priority at ISNJ as is the commitment to initiate

Radiology at St. Joseph’s Regional Medical

community outreach programs that support

Center. Dr. Milman is certified by the American

various timely and worthwhile causes. The

Board of Radiology and holds Clinical Magnetic

radiologists at ISNJ are committed to reaching

Resonance Society Certification in body MRI,

out in order to help those in need of medical

orthopedic MRI and neuroradiology MRI. Like

care. Perhaps the most compelling example

Dr. Yuppa, he is one of a handful of New Jersey

is the work ISNJ has done, especially in the

radiologists who are recognized as Level 3

aftermath of 9/11, to offer its Cardiac Outreach

Coronary CTA certified and Cardiovascular CT

to First Responders, in order to identify those


who are at increased risk of suffering a deadly heart attack while on the job of saving the lives of others.


New Jersey Physician

It was through Dr. Milman’s ongoing relationship One of ISNJ’s proudest accomplishments is the

with many of New Jersey’s leading orthopedic

Sergio Award presented back in 2000 to two of

surgeons that ISNJ became the exclusive

its radiologists for their work with “Healing

provider of radiologic services to PAST. He

the Children.” Dr. Yuppa and Robin Frank-

explains that many of the retired athletes suffer

Gerszberg, MD, who is one of the few board-

the effects of injuries they sustained during

certified pediatric radiologists in northern

their careers. They require joint replacements,

New Jersey, were instrumental in providing

spine surgeries, etc. “We are their radiology

the imaging for surgery to separate conjoined

connection. Whether they need MRI, CT scan

twins. It is the imaging that allows surgeons to

– whatever, we donate those services,” Dr.

see which anatomy the twins share and how

Milman shares.

the contrast material these injections contain steroids and numbing agents. Some areas that can be injected under fluoroscopy for resolution of pain include but are not limited to: • AC joints (acromioclavicular) • SI joints • Thumb • Elbow • Hip Dr. Milman discusses why it is crucial to employ fluoroscopic guidance when administering therapeutic injections. He actually participated in a study, working with an orthopedic resident at St. Joseph’s Medical Center, comparing the accuracy of “blind” injections to the AC joint,

p Dr. MIlman looks at hip arthrogram

done merely by palpation vs. those performed Going forward, Dr. Milman is most excited

within the joint with much more clarity than

with the help of fluoroscopy. “In the AC joint,

about utilizing fMRI to examine the brains of

with MRI alone. MRI contrast material contains

because the anatomy is so variable, injections

the PAST athletes who have suffered numerous

gadolinium, which affects the local magnetic

administered in a physician’s office can miss

concussions during their careers. “Many of

field, outlining the structures, thereby allowing

the target 20 to 30% of the time,” Dr. Milman

these former NFL players that I see have some

them to be evaluated.


sort of cognitive impairment with completely

In addition to gadolinium, Dr. Milman also

normal anatomical MRI and CT scan. There is

injects CT contrast (lohexol), which permits

In fact, in his study group consisting of

some functional brain injury that results from

fluoroscopic guidance, letting him know that

consenting patients, Dr. Milman was inaccurate

continuous head trauma,” Dr. Milman asserts.

he is where he needs to be inside the joint.

in 12 out of 20 patients when he injected blindly.

Also, if for some reason it is not possible

Those patients were then re-injected with


to perform an MRI, if perhaps the patient is

contrast added to confirm proper placement

compassionate care and treatment beyond the

extremely claustrophobic or if there is another

within the AC joint. “I don’t inject medicine

charitable services provided. He emphasizes

contra-indication, Dr. Milman can perform a CT

unless I have fluoroscopically proven that I’m

the importance everyone associated with ISNJ

scan instead.

in the joint,” Dr. Milman emphatically states.






places on treating each patient seen with the utmost kindness and consideration. “My stand

Besides for imaging purposes, Dr. Milman

For this reason, many orthopedists refer their

on this is ‘patient first’ and we started this



patients to ISNJ for therapeutic injections so

approach from day one,” Dr. Milman states.

joint injections to alleviate pain. Along with

they can be certain that their patients are


A very large part of the musculoskeletal work done at ISNJ is procedural. Working with Dr. Milman, Romulo Baltazar, MD also performs interventional musculoskeletal procedures. These include: • Bone biopsy • Spine biopsy • Imaging-guided advanced biopsy of tumors • Joint injections • MR arthrography MR arthrography is an MRI of a joint (usually shoulder, hip, wrist or elbow) with an injection of contrast and saline directly into the joint prior to the imaging. This distends the joint and permits visualization of the smallest structures

p Dr. Milman is administering a fluoroscopically guided injection into the hip October 2011


Frank Yuppa, MD, RVT – President Imaging Subspecialists of North Jersey, LLC

Edward Milman, MD – Medical Director

Bhanu Aluri-Vallabhaneni, MD – Section Chief of Neuroradiology

Kalavathy Balakumar, MD

Romulo Baltazar, MD

Vidor Bernstien, MD

Marianne T. Centanni, MD

Patrick J. Conte, MD

Madelyn Danoff, MD – Section Chief of Breast Imaging

Matthew P. Forte, MD – Section Chief of Vascular and Interventional Radiology

Robin Frank-Gerzberg, MD

Warren Barry Freitag, MD

Michael A. Kessler, MD

Stephen Sang Kwon, MD

Prashant Parashurama, MD, MS – Vice Chairman of Diagnostic Radiology at Mountainside Hospital

p Fluoroscopic guidance guarantees that the injection is placed properly inside the joint

definitely getting the medication delivered

appropriate follow-up care. Dr. Milman and

correctly. Hopefully, this will serve to alleviate

the other interventional radiologists at ISNJ

the problem. If, however, a patient returns to

see their role as one of working with the

the orthopedist after a guided injection and is

referring physician to provide supportive

still complaining of pain, then the physician

diagnostic and treatment capabilities with the

would be fairly certain that another source

highest level of patient care as the ultimate

of the pain or a more aggressive treatment


would need to be investigated. Whether incorporating advanced imaging At ISNJ Dr. Milman also provides ultrasound-

technology for diagnosis and/or minimally

guided aspirations of baker cysts in the knee,

invasive interventional care for patients who

ganglion cysts, as well as paralabral cysts in

are referred by their physicians, or reaching

the shoulder. Additionally, he now performs

out to the community at large, all of the



subspecialized radiologists of ISNJ pride

tendinopathy. This disorder is characterized



themselves on the significant contribution

by deposits of a crystalline calcium phosphate

they have been able to make towards

called hydroxyapatite, which can accumulate

exemplary health care in New Jersey. Looking

in any tendon in the body but occur most often

towards the future, ISNJ will continue to

in the tendons of the rotator cuff, causing pain

explore innovative developments within

and inflammation. In many cases ultrasound-

radiology in order to best serve referring

guided aspiration can avoid surgery for

physicians and patients.

debridement. By aspirating with a needle and at the same time, injecting steroids, Dr.

Please visit Imaging Subspecialists of North

Milman relates that even in the most severe

Jersey at Orestes Sanchez, MD

cases, many patients obtain immediate and permanent relief. Image-guided intervention at ISNJ is a valuable tool for area orthopedists, therefore, allowing them to refer patients for treatment that is definitely on-target. Patients then return to the orthopedist and he or she now has concrete feedback to use in order to deliver the most


New Jersey Physician


David H. Thierman, MD

Frederick N. Cushmore, MD Vijay Hiremath, MD Valery Kalika, MD

Locations for Imaging Subspecialists of New Jersey, LLC are: Wayne Valley Imaging 504 Valley Road Wayne NJ 07470 973-317-5780 St. Joseph’s Regional Medical Center 703 Main Street Paterson, NJ 07503 973-569-6300

St. Joseph’s Ambulatory Imaging Center 1135 Broad Street Clifton NJ 07013 973-569-6300 Mountainside Hospital 1 Bay Avenue Montclair NJ 07042 973-429-6100

St. Joseph’s Vascular Access Center Building 275 11 Getty Avenue Paterson NJ 07503 973-754-2999

Health Law

Health Law Update


Provided by Brach Eichler LLC, Counselors at Law

ASFs Added to List of Facilities under Proposed Amendments to Health Care Facility Infection Reporting Regulations

On September 6, 2011, The New Jersey De-

data, which is information and data relating to

ables comparison between ASFs. The amend-

partment of Health and Senior Services

major site categories, such as medication as-

ments to the regulations implement these

(DHSS) published proposed amendments to

sociated sites, surgical site infections and oth-

statutory requirements.

the Health Care Facility Infection Reporting

er categories identified by the CDC and “CMS

regulations. Presently, the regulations require

HAI” data, which is information relating to the

The amendments would also authorize DHSS

hospitals to report “healthcare-associated

process quality measures associated with the

to access “CDC HAI” data with patient-iden-

infections” or “HAI” to the department. The

prevention of HAI.

tifying information submitted by hospitals. DHSS would only be authorized to access

proposed amendments would add licensed ambulatory surgery facilities (ASFs) as addi-

The amendments to the regulations are neces-

CDC HAI data without patient-identifying infor-

tional health care facilities that are required to

sary because the Health Care Facilities Plan-

mation submitted by ASFs. This amendment

report HAI data.

ning Act, N.J.S.A. 26:H-1 et seq., was amended

also provides that any HIA data retrieved by

effective July 1, 2011, to require ASFs to report

DHSS would not be considered “government

HAI is defined as a localized or systemic con-

HAI. The new amendment to the act states

records” and would not be subject to public

dition resulting from an adverse reaction to the

that infection related data that does not iden-

access or inspection.

associated presence of an infectious agent(s)

tify the patient must be transmitted by ASFs

or its toxin(s) that meet classification criteria

to the DHSS on a quarterly basis and that the

DHSS is accepting comments to the proposed

defined by the Centers for Disease Control

department must make infection-related data

amendments until November 5, 2011.

(CDC). HAI data is categorized as “CDC HAI”

available on its website in a format that en-

OIG Issues Favorable Telemedicine Advisory Opinion The U.S. Department of Health & Human

tions, (iii) acceptance of neuro emergency

that it would not impose administrative sanc-

Services Office of Inspector General (OIG)

transfers from the community hospitals, and

tions for the following reasons:

recently issued an advisory opinion (11-12)

(iv) neuro emergency clinical protocols, train-

• The transfer of neuro emergency patients to

addressing a specialty hospital’s request to

ing and medical education. The parties would

the specialty hospital from the community

provide neurosurgery clinical protocols and

also agree to use each other’s trademarks and

hospitals was unlikely to generate appre-

immediate consultations with stroke neurolo-

service marks for certain marketing activities

ciable referrals between the parties

gists via telemedicine technology to certain

in connection with the program.

community hospitals.

• Although the parties might benefit from the proposed arrangement, the primary benefi-

Although finding that the proposed arrange-

ciaries would be stroke patients, who, with

The specialty hospital sought to provide, at

ment could potentially generate prohibited

the program’s support, could be treated at

its expense and on an exclusive basis, certain

remuneration under the federal anti-kickback

participating community hospitals’ emer-

community hospitals in its service area with

statute if the requisite intent to induce or re-

gency departments

(i) neuro emergency telemedicine technol-

ward referrals of federal health care program

• Despite the parties having the opportunity

ogy, (ii) neuro emergency clinical consulta-

business were present, the OIG concluded

to engage in marketing activities using each October 2011


Health Law Update other’s marks, neither party would be re-

would provide would be billable to Medi-

es the public benefit of promoting timely ac-

quired to do so, and each would be respon-

care; federal health care programs would

cess to specialty care for acute stroke patients

sible for the costs associated with its own

be likely to benefit from the decreased costs

and that it contains sufficient safeguards to re-

marketing activities

associated with timely treatment of stroke

duce the risk that it would result in improper


payments for referrals of federal health care

• The proposed arrangement would be unlikely to result in increased costs to federal

program business.

health care programs because few, if any,

In rendering a favorable advisory opinion, the

of the consultations the specialty hospital

OIG concluded that the arrangement advanc-

Guidance Announced Supporting the Enforcement of Equal Protection and Representation Rights in Hospitals New guidance announced by the Department

promulgated last November by the Centers

to patients’ wishes, regardless of whether the

of Health & Human Services aims to support

for Medicare & Medicaid Services (CMS), up-

visitor is a family member, spouse, domestic

the enforcement of rules to protect hospital

dated the Conditions of Participation, which

partner or another type of visitor or whether

patients’ right to choose their own visitors dur-

all Medicare and Medicaid participating hos-

expressed in writing, orally or through other

ing a hospital stay and the right of patients to

pitals and critical access hospitals must meet.

evidence. State survey agencies have already

designate the person of their choice to make

been directed to be aware of this guidance

medical decisions on their behalf should they

The rules require hospitals to explain to pa-

when they conduct on-site inspections of hos-

become incapacitated, including the selection

tients their right to choose who may visit them

pitals on behalf of CMS.

of a same-sex domestic partner. These rules,

during their inpatient stay, and give deference


New Jersey Statehouse Overview of the Medicare Shared Savings Program The intent of the Shared Savings Program is

redesigned care processes for high quality

share a percentage of the achieved savings

to promote accountability for a population

and efficient service delivery, and incent

with the ACO. Under the Shared Savings

of Medicare beneficiaries, improve the

higher value care. As an incentive to ACOs

Program, ACOs will only share in savings

coordination of FFS items and services,

that successfully meet quality and savings

if they meet both the quality performance

encourage investment in infrastructure and

requirements, the Medicare Program can

standards and generate shareable savings. In


New Jersey Physician

Statehouse order to fulfill the intent of the Shared Savings

rule with comment period published

period for those starting in 2012;

Program as established by the Affordable

elsewhere in this issue of the Federal

(4) greater flexibility in the governance

Care Act, we stated in the proposed rule that

Register entitled Medicare Program;

and legal structure of an ACO;

we will focus on achieving the three-part aim

Final Waivers in Connection With the

(5) simpler and more streamlined

Shared Savings Program;

quality performance standards;

consisting of:

(2)  IRS CMS-1345-F 10 Notice 2011-20 and

(1) better care for individuals;

(6) adjustments to the financial model

(2) better health for populations; and

other applicable IRS guidance viewable

to increase financial incentives to

(3) lower growth in expenditures.

on; and


(3)  a Statement of Antitrust Enforcement

(7) increased sharing caps;

In developing the Shared Savings Program,

Policy Regarding Accountable Care

(8) no down-side risk and first-dollar

and in response to stakeholder suggestions,


sharing in Track 1;

we have worked very closely with agencies

Shared Savings Program issued by the

(9) removal of the 25 percent withhold

across the Federal government to develop

FTC and DOJ (collectively, the Antitrust

of shared savings;

policies to encourage participation and

Agencies). In this final rule we have

(10) greater flexibility in timing for the

ensure a coordinated and aligned inter- and

made significant modifications to reduce

evaluation of sharing savings (claims

intra-agency program implementation. The

burden and cost for participating ACOs.

run-out reduced to 3 months);

result of this effort is the release of several

These modifications include:

(11) greater flexibility in antitrust review;








(1) greater flexibility in eligibility to

(12) greater flexibility in timing for

are strongly encouraged to review. These

participate in the Shared Savings

repayment of losses; and (13) additional

documents are described in more detail in


options for participation of FQHCs and

section II.C.5. of this final rule, and include:

(2) multiple start dates in 2012;


(1) a joint CMS and DHHS OIG interim final

(3) establishment of a longer agreement

Vitale Sponsors Bill Creating Physician Loan Redemption Program Program will address shortage of doctors in underserved areas TRENTON – In an effort to address a current

physicians should not stand in the way of

agree to participate in a full-time clinical

and worsening physician shortage in New

New Jerseyans getting the medical attention

practice in the State for the first four of the

Jersey, a bill sponsored by Senator Joseph

they need.”

ten-year commitment at an approved site in an underserved area.

F. Vitale which would establish a Physician Loan Redemption Program for both primary

This bill would create the Physician Loan

care and specialty physicians who pledge to

Redemption Program which would pay off

“New Jersey has great medical programs

work in underserved and physician shortage

the cost of student loans for doctors working

and produces world-class physicians, but

areas was approved by the Senate Education

in underserved areas. Under the bill, doctors

many are leaving the state after graduation

Committee by a vote of 5 to 0.

would receive a graduated percentage of

and their residencies,” Senator Vitale added.

the cost of their loans for each of ten years

“Loan forgiveness is one of the top factors

The bill (S-1774) is in direct response to the

of which they commit to working in an

medical residents look for in determining

New Jersey Council of Teaching Hospitals

underserved area. If a doctor continues to

a location to practice. This program would

report that within 10 years New Jersey

work in the community for ten years, their

incentivize these physicians to stay here in

will have a shortage of more than 2,800

student loans would be 100 percent forgiven.

New Jersey, serving our communities.”

physicians and specialists. The program would require participants

The bill now heads to the Senate Budget and

“It is necessary that all New Jersey citizens

to be a New Jersey resident; graduate from

Appropriations Committee before going to

have access to qualified doctors no matter

a medical school approved by the State

the full Senate for review.

where they live in the state,” Senator

Board of Medical Examiners; complete an

Vitale (D-Middlesex) said. “A shortage of

accredited residency training program; and October 2011


Hospital Rounds

To Survive, Medical Companies in New Jersey Are Building New Hospitals By By Ronda Kaysen, NY Times

The dazzling new hospital that will open here

“It was a matter of survival,” said Al Maghazehe,

six hospitals have filed for bankruptcy. (The

on Sunday looks more like a five-star resort than

the chief executive of Capital Health. “It was

new hospitals do not add a significant number

a medical center. It may also be the best hope

either this or we would have had to close down

of beds to the existing stock because they are

for survival of its corporate parent, Capital

one of our hospitals. We would have been

each taking an old hospital out of commission.)

Health, a non-profit company that operates

basically out of luck.” Because hospital revenue is generally based on

three health care facilities in New Jersey. He expects the new medical center to bring

the number of patient visits, the new facilities

The $540 million hospital is set on a pastoral

8,000 more hospital admissions a year, increase

all invested heavily in creature comforts to

campus with a weeping fieldstone wall

emergency department and out-patient visits

attract insured patients who have time to shop

fountain, all private rooms, an Italian limestone

by 30 percent, and deliver $130 million in


staircase and amenities like a spa for cancer

additional revenue. The patients who relied on

rooms, rooftop gardens and comfortable


Mercer will most likely turn to one of the two

waiting areas.

It will replace Capital Health’s

Mercer campus, a 19th century medical center

Typical amenities include private

remaining Trenton hospitals. But all these hospitals are making a risky

in nearby Trenton that has dingy, crowded waiting rooms and triaged gurneys lining the

Central New Jersey is seeing something of

investment, banking on an increase in patient

emergency department hallways.

a hospital building boom. Less than half an

volume at a time when people are delaying

hour to the east in Plainsboro, a $523 million

hospital visits, a trend that is expected to

Hospital administrators say they hope the new

hospital is to open next spring, replacing the

continue in the weak economy.

facility will better position the company to

University Medical Center at Princeton, which

attract insured patients from the area’s wealthy

was built in 1919. An hour south in Voorhees,

“They are trying to position themselves in a

Philadelphia suburbs and lure top physicians

Virtua replaced its 38-year-old hospital with a

market where you’re offering the shiny new

with advanced technologies. In the intensive

$493 million facility that opened in May.

store down the street,” said Farzan Bharucha, a health care specialist with Kurt Salmon, a

care unit, for example, equipment can attach to columns suspended from the ceiling and move

“We’re playing catch-up,” said Elizabeth A.

consulting firm. “You’re offering patients a new

freely around the room.

Ryan, the president of the New Jersey Hospital


Association. “There’s a pent-up need to invest Administrators invested in a costly new hospital

in new physical plants, because we’ve just not

Virtua, which delivers 5,600 babies a year at

because they worried that their organization,

been able to keep up.”

Voorhees, invested heavily in its maternity department, building a neonatal intensive care

which today is in sound financial condition, would eventually been dragged down by

New Jersey has the oldest hospitals in the

unit with private rooms for newborns and a

the burden of sustaining an aging, outdated

country, according to the association. In 2005,

separate entrance for labor and delivery. The

building in a community that does not have

the average age for a hospital here was 13.4

680,000 square foot hospital is on a 125 acre

enough paying patients to support it.

years, a full 30 percent higher than the national

campus with features like healing gardens,

average of 10.2 years, according to a 2008

walking paths and meditation spaces.

In-patient volume at Mercer has dropped 30%

report by the state. “We had a crowded situation at our old

since the company acquired it in a 1997 merger. Hospital administrators attribute the decline to

And there are too many of them. In the last 20

Voorhees in labor and delivery and we needed

Trenton’s own falling population, which is now

years, 25 hospitals have closed in the state, 11

more space,” said Richard P. Miller, the chief

about 85,000 people.

of them since 2007. In the last four years alone,

executive of Virtua, a non-profit company. The


New Jersey Physician

new hospital delivered 45 babies in its first two

HealthCare System, a nonprofit company. “If

HealthCare drew on its pool of wealthy donors,

weeks of operation and was full by July, months

we were not able to keep up with changes in

so far raising $133 million from philanthropy.

ahead of schedule.

technology, people would not have continued “Princeton is unique in that there are a

to come here.” The arrival of three new hospitals is a

significant number of people with wealth in

coincidence of timing. All have been in the

Despite Mr. Rabner’s concerns about his

the area who are very generous,” Mr. Rabner

works for years, but their parent corporations


said. “I don’t know if we would have been as

were facing a similar choice: invest heavily

HealthCare is currently in good financial shape,

in new infrastructure in a difficult economic

with an operating margin of 4.3 percent last

climate or risk failure.

year. Capital Health and Virtua also turned a

Location is a prime reason that hospitals

healthy profit last year, with operating margins

like Princeton’s and Virtua’s have been so

of 4.4 percent and 5.6 percent respectively.

successful. Their local clientele tends to be

New Jersey hospitals have an operating margin




of just 1.7 percent, ranking 43rd in the country

successful if we were somewhere else.”

privately insured – so-called commercial

in 2009, well behind the national average of 4.4

But all three companies saw their aging

patients-and the population is growing.

percent, according to the American Hospital

facilities as liabilities that could eventually

moving just seven miles, Capital Health is now


undermine their long-term stability.

also poised to reach a desirable, privately


their competitors in worse financial shape, they The hospitals struggle here because they must

were in a position to attract investors and raise

keep up with costly technological advances



insured market. “They’re all making plays to reach more

at a time when patients spend less time in

commercial patients by building new facilities,”

hospitals than they used to. Their facilities are

The federal government underwrote Capital

said Mr. Bharucha of Kurt Salmon. “But the

aging and regularly need costly improvements,

Health’s mortgage, which was then sold to

financials only work if you can grow more

draining limited resources. The ranks of the

investors. Virtua turned to the bond market

volume and specifically more commercial

uninsured are leaving bills unpaid, and in New

to finance its project and recouped the $100

patient volume.”

Jersey Medicaid reimbursements are among

million it put up in capital. And Princeton

the lowest in the country, according to the New Jersey Hospital Association. Ambulatory care facilities compete for paying patients, and the state requires that hospitals provide complete care to all patients. So, if a patient is admitted to a hospital and needs major surgery, the hospital must provide it, regardless of his ability to pay. “It’s a very tough environment and hospitals are fighting to survive by investing in their facilities,” said Ms. Ryan of the state hospital

The healthcare business environment continues to be increasingly turbulent.

Is your practice

weathering the storm?

association. Princeton HealthCare is moving from a 92-year-old hospital in a residential Princeton neighborhood to a 171-acre campus less than three miles away along Route 1 in Plainsboro. The 630,000 square- foot building will have computers in every treatment and patient room, the latest radiation therapy equipment and 600-square foot operating suites with

The healthcare experts at Nisivoccia LLP utilize a full breadth of practice management, accounting and tax services to improve efficiency, maximize cash flow and enhance your overall practice. We’ll help you navigate the challenging healthcare climate and set your practice on a course for smooth sailing.

technologies like robotics.

(973) 328-1825

“If we had not built this hospital, at some point in the future we would have had to close,” said Barry Rabner, the chief executive of Princeton Independent Member of BKR International October 2011



Your Assets and Malpractice Claims Protected? Or Risking It All?

By Deirdre Hartmann, CPA and Manager, Nisivoccia LLP and Marina Solo, Esq., Of-Counsel, K&L Gates LLP

Everyone likes to gamble occasionally, lottery tickets, football pools, or a trip to Atlantic City or Vegas. However, when it comes to the assets that you have acquired during your career you need to ask, have the necessary steps been taken to protect your assets from risk? For many physicians, the largest worry is being named in a malpractice claim. These worries are well founded. An August 18, 2011 study published by the New England Journal of Medicine estimates that by the age of 65 years, 75% of physicians in low risk specialties had faced a malpractice claim, as compared with 99% of physicians in highrisk specialties. Although most claims do not result in payments to plaintiffs, they are cause for concern.

of professionals, your attorney, your CPA or financial advisor, and your insurance malpractice professional. Having your team work together should ensure your financial stability and protection of the assets you have worked so hard to acquire. Minimize potential exposure by shifting risk to an insurer.

Insurance coverage against malpractice claims is sold as either a “claims made” policy or an “occurrence” policy. Claims made policies cover claims that are reported during the policy period as opposed to occurrence policies which covers claims that occurred during the policy period.

These statistics should motivate all physicians to take a look at their overall finances and implement an asset protection plan sooner rather than later. Federal and State laws prohibit fraudulent transfers meant to hinder, delay or defraud creditors. Any transfers as part of an asset protection plan must be performed well before any claim is filed and must be part of an overall financial plan, such as estate and legacy planning.

Claims made policies are less expensive than occurrence policies because they leave a period after the policy expires in which claims could be filed. This would require purchasing a policy known as a “tail” policy. Each physician in a practice should be familiar with their own, their partners’ and their employees’ malpractice coverage and limits. If practicing medicine as a group practice, the group practice should obtain malpractice coverage. A malpractice liability of a group practice partner or employee could equal risk to the group’s assets.

There are many strategies available, some more complex than others. We highly recommend that you contact your team

Whether you are just joining a practice or running a practice, be sure to review employment agreements of all partners and


New Jersey Physician

employees to confirm sufficient malpractice coverage either through occurrence based policies or availability of “tail” coverage for a claims made policies as well as the parties responsible for the payment of premiums. Consider the transfer of assets to family members, not only for asset protection but also for estate planning.

The first step to developing an asset protection plan is listing all of assets of a client, determining how they are titled. For married couples, the usual result is that a disproportionate amount lands in either the jointly owned column or in the higher income earner’s column. By having assets titled inappropriately, not only could you circumvent any estate tax planning strategies you may have implemented, but also leave the higher income earner’s assets exposed to creditors. For married couples, consider transferring assets so that the scales are balanced with an equal amount of assets owned by each spouse. The personal residence is usually one of the largest assets held jointly consider transferring this asset into the spouse’s name. But realize once transferred, you expose these assets to your spouse’s personal liabilities. Alternatively, assets can be titled jointly to both spouses as “tenants by the entirety” making them unreachable to all but creditors of both spouses until the death of either spouse.

Whether you are single or married, consider a gifting plan to your children or grandchildren by contributing to a college savings plan, outright gifting to family members, or gifting in trust. The law allows for an annual gift exclusion of $13,000 to each donee recipient. Not only does this reduce your estate for estate tax planning purposes, but it also provides protection for you as these assets are no longer in your name, therefore out of the reach of creditors. Each individual strategy should be evaluated based upon your own individual circumstances, family situation, asset protection and estate planning goals. Maximize your contributions to retirement plans.

As a physician, your most valuable assets are usually your retirement accounts. Under the Federal Employee Retirement Income Security Act, otherwise known as ERISA, assets held in a qualified retirement plan are exempt from the reach of creditors. Qualified retirement plans include defined benefit plans, profit sharing plans, employee stock ownership plans, money purchase pension plans, target benefit plans and 401K plans. Although IRAs are not covered under ERISA, New Jersey and several other states exempt these assets from creditors as long as the assets remain in the IRA trust.

own multiple real estate holdings, a family business (other than your medical practice), or a large investment portfolio, outside of your retirement plan. By transferring assets to either of these vehicles, you could reduce your estate, as well as insulate the assets held within these entities from attachment by creditors. A widely recognized estate planning technique is creation of living trusts (sometimes known as the asset protection trusts) wherein the grantor transfers some or all of his assets into a trust managed by a trustee. Unfortunately, living trusts offer somewhat limited asset protection unless the trust is irrevocable and the grantor is not entitled to any benefits from the trust (either by income or principal distributions). As an alternative, consider transferring your assets into one or more limited liability companies, owned by you individually or with a spouse or other family members. For example, if you own multiple real estate properties you can transfer these properties into separate limited liability companies, thereby isolating liabilities. Even if one property were subject to reach of creditors, the others would be protected.

Consider limited liability companies, family limited partnerships and trusts.

Similarly, limited family partnerships are vehicles which help transfer wealth to future generations. Assets from the senior family members are transferred into the limited family partnership. The limited partnership has both general partners and limited partners. Initially, the general partner would be an entity, either a Corporation or a limited liability company, that was owned by the senior family members, who retain control and the decision making power. Over time, the children and the grandchildren could be gifted interests in the limited family partnership, therefore reducing the senior family member’s estate while also reducing their assets subject to creditors.

These strategies are much more complex and would require more planning and administrative burden, but could be worth the extra effort. Consider these if you

The benefit of property transfers to partnerships and limited liability companies is shielding the underlying assets. A typical

Many physicians have traditional defined contribution plans which limit the annual contribution generally to $49,000 a year. However, high earners would be well advised to consider a defined benefit plan, which could result in contributions significantly in excess of $49,000, therefore increasing the amount exempt from claims of creditors. An analysis of you and your employees would be required to determine if this strategy would benefit you.

creditor would not be able to reach the asset directly but would rather assert a lien on the interest in the entity or receive what’s known as a “charging order’, which would entitle him only to distribution of profits, if any, from the entity. A charging order would not entitle a creditor to force the sale of the assets of the holding entity, cause its dissolution or even participate in management decisions. What’s more, under the current Revenue Rule 77-137 a creditor who obtains a charging order would be responsible for paying taxes on the income of the partnership or a limited liability company even if no actual distributions have been made. Depending on the type and size of a claim, this may discourage creditors from pursuing its remedies.

Deirdre M. Hartmann is CPA and Manager of Nisivoccia LLP, a full service CPA firm with offices in Mt. Arlington and Newton, New Jersey. The firm offers traditional tax, accounting and audit services, and maintains practice specialties in sectors including healthcare, municipal government, and education, nonprofit and financial services. Contact her at (973) 328-1825. Marina Solo, Esq. is an of-counsel with the law firm of K&L Gates LLP, a multinational full service law firm with 38 offices around the world. Ms. Solo is a member of the K&L Gates’ national Health Care Group, which was ranked by Modern Healthcare as one of the 20 largest dedicated health care practices in the United States in May 2010. Contact her at (973) 848-4129


Although this article discusses asset protection relating to malpractice claims, it is possible that your assets could be at risk due to disability, retirement or buyout of partners in your practice. Again, it is highly recommended to conduct a systematic review of the operating documents, shareholders’ agreement, buy-sell agreements, etc. to ensure appropriate funds are available to protect your assets in the event of death, disability and retirement. Purchasing life and disability insurance is probably the least expensive and simplest strategy for asset protection. October 2011


Special Feature

The Surgery Center at Hamilton

reduced employees’ group health insurance costs by more than $100,000 while streamlining administration of payroll and benefits. Here’s how. About SCH

TRICORE was one of the providers interviewed

money and provide the support that the SCH

The Surgery Center at Hamilton (SCH)

by the administrator of the SCH; the first

was seeking. After identifying various areas

provides state-of-the-art technology for surgical

impression captured the SCH’s attention,

for potential savings and increased efficiency

procedures and diagnostic studies that do not

if they transitioned away from their current

require an overnight stay. Their skilled surgeons

PEO and moved to the TRICORE Payroll Cost

and dedicated staff offer a multitude of

Management (PCM) model, TRICORE was

procedures. Areas of specialty include, but are

selected as the new provider of administrative

not limited to, gastroenterology, gynecology,

services and benefits assistance for the SCH.

pediatric care and plastic surgery. The SCH


strives to provide the highest quality care, offering many comforts of home, to put

At the beginning of their partnership,

patients at ease. Their attention to detail

TRICORE team members sat down at

and goal of offering the best possible

length with the SCH administrator, to

patient experience creates a hassle-free


environment for both patients and their

Numerous meetings were held to discuss


the options; representatives were very


their hand, so to speak.




helpful throughout the process, and held One year ago, frustration over high Subsequently,

administrative fees, bulky/clumsy payroll



systems and a lack of confidence in the

meetings with the entire SCH staff, to

Professional Employer Organization (PEO)

introduce the plans and assist in completing

that they were using for these services,

the paperwork. Since that time, TRICORE has

prompted the SCH to look for a new provider.

taken a lot of the paperwork burden off of

At the time, the SCH viewed the benefits

the staff, by streamlining the process. Now,

package as the main strength of the PEO’s

when a new employee is added, the SCH has the comfort of knowing it will be processed

offering, but this was being overshadowed by

correctly and efficiently.

the limited payroll system, exorbitant fees and

and the level of professionalism experienced

lackluster HR services. Desiring a comparable

was unmatched by other providers being

benefits package, with greater overall human

considered. The TRICORE representatives were

Another area where TRICORE improved

resource program efficiency for a lesser cost,

extremely thorough, and left no stone unturned

efficiency was with regard to processing bi-

the SCH initiated its search for an alternative.

as they worked through different ways to save

weekly payroll, which in the past had been


New Jersey Physician

processing by automating the transfer of time

they find themselves contacting Judy less

clock data, direct to TRICORE.

frequently. When questions arise, however, they know that Judy will be fully responsive


and is a great resource of information; if she

Having worked with TRICORE for less than a

doesn’t have an answer for you she will find

year, the SCH does not yet have a year-over-year

someone who does.

comparison, so cannot exactly pinpoint total savings. However, they can say with certainty,

Judy can be reached by phone at 609.918.2668

that they have reduced their overall healthcare

or by email at

expenditures by over $100,000. TRICORE’S HR Director, Bill Potter, was very

Relationship with TRICORE Team Members

helpful in recruiting efforts for the SCH. Not only

At the beginning of the process, the SCH had

filtered their applicants’ resumes and sent the

frequent contact with TRICORE’S Regional

most qualified and relevant applications along

Vice President, Judy Levine. Reflecting upon

to the SCH staff for interviews and selection;

the interaction that the SCH had with Judy,

this saved the SCH a lot of time and frustration.

Administrator Chris Wetzel referred to her as

He also assisted in publishing an employee

very time-consuming for the SCH. TRICORE

simply, “awesome.” She is smart, creative and

manual that reflected current state and FFED

was able to take the SCH’s time and attendance

has a genuine understanding and appreciation

federal regulations.

system and develop a custom script, to have

for fiscal responsibility.

did he provide employee selection insight, he

the data flow directly into the payroll system.

Chris Wetzel, Administrator – “TRICORE Due to the extensive work at the onset of the

is an excellent company; I highly recommend

This streamlining resulted in minimal change

SCH’s partnership, they are now at a stage with

them. I couldn’t even try to find something I

on the SCH’s end, and greatly simplified payroll

the system put in place by TRICORE, where

don’t like.”

Let Brach Eichler’s Health Law Practice Group Help You Chart a Strategic Course For Your Health Care Business Health care providers have long come to rely on the attorneys of Brach Eichler to navigate the regulatory environment at both the state and federal levels. Now that health care reform is being implemented, Brach Eichler is ready to help you make sense of the significant changes, the statutory framework and the ramifications for health care providers in New Jersey. Health Law Practice Group Todd C. Brower Lani M. Dornfeld

John D. Fanburg Joseph M. Gorrell

Richard B. Robins Jenny Carroll Chad D. Ehrenkranz

Carol Grelecki Debra C. Lienhardt Kevin M. Lastorino Mark Manigan

Lauren Fuhrman Eric W. Gross Rita M. Jennings

Leonard Lipsky Isai Senthil Edward J. Yun

101 Eisenhower Parkway • Roseland, New Jersey 07068 • t. 973.228.5700 • f. 973.228.7852 • October 2011


Food for Thought

IL Ripasso

Livingston, New Jersey By Iris Goldberg

It pains me to admit it but I have reached the stage of life that causes one to submit to the temptation of the “Early Bird Special.” I don’t understand how this possibly could have happened. Wasn’t it just yesterday when Michael and I mercilessly teased our parents as they proudly reported on the meals they enjoyed at a significantly reduced price by merely arriving before 6 PM? Nevertheless, when the email arrived that it was once again time for the women to get together for dinner (I’ve written about the joys of bonding with women friends over food and wine) and it questioned whether I would be interested in partaking of the $14.95 four-course dinner that was offered until 6, I responded in the affirmative. I had not eaten at Il Ripasso since it changed ownership in 2004 and as it is local for Michael and me, I was interested to find out if it was the attempt to offer attractive pricing or the cuisine that kept the place so popular. I was told to arrive at 5:45 and did, not wanting to disqualify our group. On the way there, I found myself thinking, “Five forty-five is really not that early. By the time you get seated and order you’re not going to actually eat anything until at least 6:15. Why not take advantage of such a good deal?” Then it hit me. I had officially entered the world of the older adult. Could exercising by walking around the mall and choosing friends to plan evenings with by whether they were capable of driving at night be far behind?

placed the regular menu and the “Early Bird” menu in front of each of us. Il Ripasso offers daily specials such as veal chop, rack of lamb, halibut, snapper and bronzino, to name a few. As an appetizer, Chef/ Owner, Roberto recommends an assortito, which is a cold assortment of salami, prosciutto, fresh mozzarella, provolone, roasted peppers and black olives. All of the pasta served at Il Ripasso is homemade and served al dente. There is a daily ravioli special that could be crab meat, veal, short ribs or mushroom. There is also homemade gnocchi with fresh tomato, basil and mozzarella. Popular main dishes include veal scaloppini with wild mushrooms in a marsala reduction, zuppa di pesce, which is jumbo shrimp, calamari, sea scallops, mussels and clams served over angel hair pasta with fresh tomatoes and pan-seared potato-crusted salmon over spinach. Desserts are homemade as well and include all the favorites like tiramisu, crème brulee, oreo cheesecake and warm chocolate soufflé topped with vanilla ice cream.

I entered to find that the room was quite attractive. Once inside, it was impossible to discern that it was technically late afternoon. I was a bit surprised at how many tables were already filled. I looked around and spotted my friends, sipping wine and already engaged in lively conversation. Now that our foursome was complete, our server

Of course, most of this does not appear on the “Early Bird” but I will say, the choices on that menu are more than ample, including soup or salad, appetizer, main course, dessert and coffee. I began with a lovely salad of baby greens with roasted shallot vinaigrette, followed

p The eggplant rollatini is one of their featured appetizers.

p Chicken parmigiano


New Jersey Physician

by a large portion of eggplant rollatini that was really wellprepared. I especially enjoyed the tomato sauce. For the main course I had a chicken Francaise that was tender with a white wine and lemon sauce that had just the right flavor and texture. It was served with roasted potatoes and broccoli. For dessert, two of the women had a dish of ice cream, while I and another opted to pass on dessert. I had a de-caf coffee and she ordered herbal tea. The total charge for each of us, including tax and tip was $18.00. The food was ample and good. The service was impeccable. The environment was comfortable and visually pleasing. My friends and I shared a wonderful evening. It was a bargain indeed! Whether you go for the “Early Bird,” or splurge and go for the regular menu, I think Il Ripasso is a fine choice for a cozy Italian dinner. If you do decide to take advantage of the “Early Bird Special,” you don’t really need to share that information with your children.

p The chicken picatta features a white wine and lemon sauce, oven browned potatoes and stalks of broccoli.

Il Ripasso is located at 499 So. Livingston Avenue, Livingston, NJ 07039-4327. (866) 480-9686

p The Caprisi appetizer ($9) features tomato slices cut in quarters, roasted red peppers, parmigiano cheese all over a bed of arugula and drizzled with a balsamic vinegar dressing.

p The ricotta cheesecake features creamy smooth ricotta cheese and a soft, flaky dough. October 2011


Diagnosis Food for Thought

D IAGNOSIS Famed Infectious Disease Specialist Leon Smith, MD has suggested we start a contest. He will submit symptoms and the correct diagnosis will win a New Jersey Physician T-Shirt, as well as getting honorable mention in our column. Case I

Case II

17 year old inner city male had chronic urethutis with burning frequency urgency for 6 months. Urinalysis and urine culture negative. Smear of discharge and gram stain negative. PSA normal. Cystoscopy negative-slight redness urethra. Gonorrhea, Clindamycin, LSV cultures all negative.

A 27 year old white female developed Grand Mal seizures following sex with her male partner. A massive work up including brain scans and blood tests were all negative.

Exam negative testicles and penis (slightly edematous). No inguinal nodes. A repeat smear of urethra using a special microscope revealed oil droplets

Past medical history of peptic duodenal ulcer controlled primarily by bicarbonate and Pepcid at night. Exam Normal.

Responses received from last month’s cases: Case 1: Munchausen Syndrome Case 2: Allergic sinusitis, occupational to house dust, mites, consider fungus. Dr Fernando Garip 249 Cedar Ave.. Hackensack NJ 07601


Please send responses to 20

New Jersey Physician

Call for Nominations

New Jersey Physician Magazine invites all medical practices to submit nominations for cover stories. Practices should include a brief description of what makes the practice special. Please contact the publisher Iris Goldberg at igoldberg@NJPhysician.Org October 2011


NJ Physician Magazine October 2011  

New Jersey Physician Magazine

NJ Physician Magazine October 2011  

New Jersey Physician Magazine