Medical Real Estate by alicejenny


									                                                             June 2012

  Medical Real Estate
    The market is evolving – are you ready?

                                                 DOCTORS BEWARE:
                                      The RAC Audits-Time to Prepare
                                         In-House Billing Gone Wrong
Ask Dr. Mitteldorf: Q&A on Practice Management
LIFESTYLE:                                                ‘Round
Surviving a Medical Marriage                          the Region


                   CASH GENERATING PROGRAM?

           877-779-2244 TODAY
                        AND CHIROPRACTIC OFFICES

                                                          We o er Revenue Enhancement (RE)
                                                          programs such as:
                                                           • Urgent Care
                                                           • Primary Care (Patients w/no
                                                           • Weight loss
                                                           • Aesthetics-Spa-Anti Aging
                                                           • Wellness Programs
                                                           • Clinical Drug Trials
                                                           • Stress Test
                                                           • Pain Management (Interventional/
                                                             Medical Management)
                                                             And more……
New Beginnings will do an evaluation on your practice and fully set up the ancillary service of your choice.
Training is provided for the owner and sta on how to maximize your pro t. New Beginnings will also
conduct an evaluation on your practice and educate you on how to decrease your overhead and increase
your pro ts.

New Beginnings will also provide you with a fully trained physician and/or mid level provider for your
practice, which will assist you with the cash generating program that you have selected (if necessary). New
Beginnings will fully train the owner/physician on all of the laws and regulations regarding the ancillary
service of your choice.

Marketing Services o ered to increase your patient volume-optional additional charge

Consulting services o ered on an ongoing basis (employee retention, collections, credentialing with the
managed care panels, compliance assistance, and more) - optional additional charge

            New Beginnings….Leave all of the work up to us!
      2         The RAC: How to Detect Fraud
      4         Marketing Strategies & Good Business for Physicians Part ii
      5         Healthcare law Delivers Free Preventive Services To Over 14 million
      6         Know your liability insurance Options
      7         Physician Self Billing: At What Cost?
      8         How to Develop a Fair Compensation Plan
      10        Medical interpreting and What it Means for you
      11        Medical Providers Could Be Stiffed Millions From PiP Glitch
      12        is your Group Rewarding you For Ancillaries?
      15        Doing Nothing: No longer an Option
      16        Can the Free Market Fix Healthcare?
                Medical Staffs and Conflicts of interest
                The Topsy Turvy World of Medical Real Estate                           pg. 29
      20        Choice of Entity Considerations for a Medical Practice’s Real Estate
                HOLISTIC HALLWAY
      22        Ask Dr. Mitteldorf
      23        The Making of the US injury Centers Network
                TECHNOLOGY TODAY
      24        Mobile Apps: 10,000 Ways to improve your Health … and Counting
      25        iCD-10: Keep Change from Costing you Money
                                                                                       Contributing Writers:
                LIFESTYLE                                                              Chris Seabury, Dr. Bottari,
      29        Travel To Paradise                                                     Anne Tschida, Sandra Greenblatt,
                                                                                       C. Glen Ged, Andrew Eriksen, Brian
      30        Surviving the Medical Marriage                                         Foster, Robert S. Forman, Dr. Daniel J.
      31        Can Money Buy love?                                                    Stone, Daniel M Bernick, Nick Martin,
                                                                                       Tom Adams, Hal C. Scherz MD,
                                                                                       Rafiah Prince, Jeff l. Cohen, May-
      32        Classifieds                                                            eluz Navarro, Dr. Brian Mitteldorf,
      33        Resource Directory                                                     Suzan Zellea, Jerry Quintana, Brian A.
                                                                                       Mendez, Kristen Math
                                                                                       For Ad submission:
                                                                                                        Jennifer Escalante
                                                                                       Circulation Manager:

Look what’s coming in July 2012                                              
                                                                                       Sales Representative:
                                                                                       Alisa Cato
Special Feature:                                                             
                                                                                       Tanisha Kemp
MalpRacticE and                                                              
lEgal dEfEnsE UpdatE                                                                   Traffic/Credit Manager: Patise Dean
Also in this issue: Supreme Court Decision on Affordable Care Act &                    President: Carol Johnson
What OB/GyN’s are facing in Florida.                                         

    J u n e 2 0 12                                                                     w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   1

                                                          The RAC:
                                                     How to Detect Fraud
                                                                                         By Chris Seabury

         ver the last several                                                                                                                 The next step is to go
         years, the issues of                                                                                                            through the different files
         Medicare and Medic-                                                                                                             and see if there is a pattern
aid fraud have been increas-                                                                                                             of possible abuses recur-
ingly brought to the forefront.                                                                                                          ring in a series of patients
This is because these pro-                                                                                                               and procedures. This will
grams have become so large                                                                                                               identify where the fraud is
that many enterprises are                                                                                                                occurring and its frequency.
created to swindle the govern-                                                                                                           Once this takes place is
ment. In fact, this has become                                                                                                           when actuaries can begin
one of the most profitable                                                                                                               to understand the overall
crimes in America (costing                                                         party will collect the funds that                     scope of the problem.
taxpayers $60 billion annually). Com-                                              were overpaid to a provider. During              The third step is to contact the
menting about what is happening is                                                 the last year, this has resulted in         RAC about these possible issues and
Brian Waterman, a Special Agent                                                    $1.03 billion being refunded from           work with them to correct any kind
with FBI who observed, “There’s                                                    these kinds of activities. In the case      of over or underpayment. If this
a healthcare fraud industry where                                                  of private practices, dealing with          approach is utilized, it will allow
people are: recruiting patients, getting                                           these issues can be challenging. As         practices to remain in compliance
patient lists, finding doctors, looking                                            a result, they must have effective          with the law and reduce any kind of
on the Internet and finding different                                              procedures in place for detecting and       negative impact on their business. As
scams. These groups and organiza-                                                  preventing possible Medicare/Medic-         a result, the key to being successful
tions are dedicated to nothing but                                                 aid fraud.                                  with this approach is early detection.
committing fraud and finding a better                                                                                          This means that there must be con-
way to steal from Medicare. That’s                                                 How to dEtEct and                           stant amounts of vigilance for any
why you have companies that can run                                                MitigatE fRaUd                              kind of possible abuses occurring.
for 60 to 90 days and bill for ridicu-                                             The first step when detecting any           Once this takes place is when there
lous things. This is because there are                                             kind of possible scam is to consider        will be a positive change to the firm’s
very few checks and balances to even                                               several different factors when look-        internal billing practices.
determine whether these things were                                                ing at the invoice to include:                   Clearly, the best way to prevent
medically necessary, ever given or                                                 • If these services exceeded what           Medicare and Medicaid fraud is to
even physically possible for a patient                                                 was medically necessary.                work directly with the RAC. At the
with the kind of conditions they have.”                                            • The health provider is accepting a        same time, there must be an empha-
     In response to these challenges                                                   referral fee from another provider      sis on monitoring and detecting pos-
is the Tax Relief and Health Care                                                      for the referral.                       sible abuses that are occurring. This
Act of 2006. This directs the US                                                   • There is a misrepresentation              means watching for obvious warning
Department of Health and Human                                                         of what services are billed to          signs early and quickly respond-
Services to recover funds that were                                                    Medicare.                               ing to these problems when they
overpaid from fraudulent activities.                                               • The provider waives the 20%               are small. In the future, this will
To achieve these objectives, they are                                                  coinsurance or deductibles.             decrease the chances of a firm being
working with Recovery Audit Con-                                                        These areas will give actuaries pos-   scrutinized over possible irregulari-
tractors (RACs). This is when a third                                              sible warnings signs of potential fraud.    ties in these billing practices. 
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J u n e 2 0 12   w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   3

                                                                                   Marketing Strategies & Good
                                                                                   Business for Physicians
                                                                                   By Andrew Eriksen
                                                                                   Part 2 of 2

     n the first part of this series, we dis-                                      poor customer service. Since I covered      be on the first page. Are you listed on
     cussed patient loyalty and how vital                                          customer satisfaction and patient loy-      the local search engines? This will get
     this is to the longevity and growth                                           alty in the first article, I am now going   you to first page faster than anything
of your practice. In this article, I will                                          to focus on ways to get new patients in     else and it doesn’t cost you a dime.
provide you with some simple and effec-                                            your waiting room.                          Commission someone in your office or
tive ways to grow your practice without                                                 Put yourself in the shoes of           do it yourself, but make sure you add
it costing you a fortune. What I am not                                            your patient. How are your current          your practice to Google Local, Angie’s
going to do is tell you to focus on Tweet-                                         patients finding you? Do you know           List, Yahoo Local, Bing Local, Health-
ing and social media, which seems to be                                            where they are coming from? Source          grades, & Vitals. You can simply do
what every other article is telling you to                                         verification should be an integral          a search for each of these and you
do. The last thing you need are a bunch                                            part of your new patient work up.           should be able to figure out how to add
of friends/followers asking you medical                                            This question can be relegated to           your business.
questions or trying to schedule appoint-                                           the front desk, but you should also              Do you have any reviews on the
ments through Facebook and Twitter.                                                consider asking your new patients.          numerous local review sites out there?
      Facebook, and Twitter to a lesser                                            If you are geriatric physician, the         You need them and they need to be good
extent, are primarily utilized in two ways:                                        source of your new patients is going        ones. You can obtain positive reviews by
• Seek reviews/experiences from                                                    to be very different than that of a         making it easier on your patients to give
   friends about a provider they are                                               local plastic surgeon. You want to          feedback. Have a laptop or computer ac-
   considering                                                                     cultivate your current sources before       cessible that has a review site pulled up
• Solicit information from friends                                                 creating new ones. If you have a            and simply ask patients at checkout to
   about good providers in the area                                                consistent referring physician that         leave a comment about their experi-
      Neither one of these require you                                             you have never met, then that is a          ence. You can do a different one each
to be actively involved in Facebook or                                             problem. If a patient is responsible        day to spread the good news. You could
Twitter. What you are required to do                                               for referring a family member or            even have a moderated review area on
is focus on quality patient care and                                               friend, you need to let them know           your website.
excellent customer service. In most                                                you appreciate it by having a staff              Our company starts hundreds of
cases, the totality of the patient expe-                                           member call them or by sending a            practices every year and these strate-
rience is how you as a business will                                               thank you letter.                           gies are an integral part of the success
be graded. This means growing your                                                      Majority of the patients now use       of our clients. I hope that you found
business is not solely reliant on your                                             the Internet to find and research new       this information to be helpful and I
bedside manner and superior skills as                                              providers. One simple and necessary         welcome any feedback regarding these
a physician. An example of this is the                                             thing for you to do is to simply re-        or other marketing strategies.
recent propagation of minute clinics                                               search yourself on the Internet. What
and the like that in most instances are                                            do you find? Is it good, or are you         Andrew Eriksen is founder and executive
                                                                                                                               director of Physician Practice Specialists;
entirely staffed by NPs or PAs. This                                               buried on page six of the search re-        800.406.4796;; www.physi-
is the result of the overall impatience                                            sults? Less than 20% of Internet users

of our society and the intolerance for                                             go to the second page so you need to
4   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                         J u n e 2 0 12

                                              P R E S S                      R E L E A S E

                   Healthcare Law Delivers Free Preventive
                         Services To Over 14 million

        he Centers for Medicare &           by giving them the tools they need                                          Affordable Care Act, preventive
        Medicaid Services (CMS)             to take charge of their own health                                          benefits are offered free of charge
        today announced that the            and prevent health problems                                                 to beneficiaries, with no deductible
Affordable Care Act helped 14.3             before they happen.                                                         or co-pay, so that cost is no longer a
million people with Medicare get                “Thanks to the health-care law,                                         barrier for seniors who want to stay
at least one preventive service             millions of Americans are getting                                           healthy and treat problems early.
at no cost to them during the               cancer screenings, mammograms,                                              The law also added an important
first five months of 2012. This             and other preventive services for                                           new service for people with Medi-
includes 1.1 million who have               free,” said CMS Acting Adminis-                                             care — an annual wellness visit
taken advantage of the Annual               trator Marilyn Tavenner. “These                                             with the doctor of their choice — at
Wellness Visit provided by the              free preventive services are helping                                        no cost to beneficiaries.
Affordable Care Act. In 2011,               people in Medicare stay healthy
32.5 million people in Medicare             and lower their health care costs.”                                         For more information on Medicare-
received one or more preventive                 Prior to 2011, people with                                              covered preventive services, please
benefits free of charge.                    Medicare faced cost-sharing for                                             visit:
    One of the major goals of the           many preventive benefits such                                               features/65-older/medicare-preven-
act is to help people stay healthy          as cancer screenings. Under the                                             tive-services/index.html.

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  J u n e 2 0 12                                                                                                            w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e 5

             Know Your Liability Insurance Options
                                                                                   By Brian A. Menendez

         ver the last decade Florida       was part of the malpractice market                             rising malpractice costs. A majority
         physicians have seen mal-         cycle that led to higher costs during                          accepted the price increases, while
         practice insurance costs spike    the “hard market” and lower costs in                           others assumed the ultimate risk
to all time highs in 2004 and 2005,        today’s “soft market.” Many physicians                         and went “bare.” Conversely, a vast
 Ellis_Ged_MedEx_half_pg_Ellis_Ged_Medx_half_pg 4/25/12 12:16 PM Page 1
before reducing 35% by 2010. This          made a tough decision relating to their                        amount of physicians looked for other
                                                                                                          markets or alternative risk strategies.
                                                                                                               Moreover, cheaper coverage was
                                                                                                          able to be acquired through excess and
                                                                                                          surplus carriers or risk retention groups
                                                                                                          that entered the market as conditions
                                                                                                          eased in the state. Still, some physicians
                                                                                                          were tired of paying malpractice costs
                                                                                                          to insurance carriers and decided to
                                                                                                          form their own RRGs or captive insur-
                                                                                                          ance companies to self insure. Though
                                                                                                          it sounds wonderful to own your own
                                                                                                          captive insurance company, the startup
                                                                                                          costs are steep and yearly operating
                                                                                                          and administrative costs add up quickly
                                                                                                          making it a risky endeavor.
                                                                                                               An alternative to forming your own
                                                                                                          captive is a strategy called “Rent a Cap-
                                                                                                          tive,” which is possible through some risk
                                                                                                          retention groups or captive insurance
                                                                                                          companies. As such, physicians, groups, or
                                                                                                          associations varying in size can self insure
                                                                                                          without the normal start up costs, capital
                                                                                                          infusion, or annual maintenance costs as-
                                                                                                          sociated with a normal captive. For a fee,
                                                                                                          the insured will have access to a segre-
                                                                                                          gated account and its reinsurance. This
                                                                                                          will mitigate the insured’s costs assuming
                                                                                                          they maintain good claims history.
                                                                                                               Some experts predict the soft
                                                                                                          market will end in the next few years
                                                                                                          resulting in higher premiums for all
                                                                                                          physicians in the state. Thus, it is time
                                                                                                          to start evaluating alternative risk
                                                                                                          strategies. Going forward some will
                                                                                                          choose to stay in the standard market,
                                                                                                          while others will explore a different
                                                                                                          avenue, but for a select few an alterna-
                                                                                                          tive risk strategy is quite appealing.

                                                                                                          Brian A. Menendez is Vice President of Business
                                                                                                          Development; 813.290.8282, ext. 225;Brian@lan-

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               Physician Self Billing: At What Cost?
                                                By Jerry Quintana

         ou have had in-house                                                               as a last effort before sending to
         billing since you have                                                             hard collections is now 45.7%.
         been in practice, but                                                              • The average percentage of
these four things are challeng-                                                             total A/R from patients writ-
ing your decision to keep this                                                              ten off as bad debt expense
trend going:                                                                                during the past fiscal year has
 • Industry shift to higher                                                                 reached 11.3%.
     deductibles insurance plans                                                            • For those practices that
     and rising unemployment,                                                               continue to manage their own
     leading to greater numbers                                                             claims processing and revenue
     of uninsured patients                                                                  collections, consider the find-
 • Increasing complexity                                                                    ings from Physicians Practice
     among insurance providers             patients. Practices report that “col-            (Feb. 2010):
 • Changing government regula-             lecting from self-pay, high deductible    • Physicians spend three weeks
     tions (Meaningful Use, 5010,          health plans (HDHP) and/or health             per year on average dealing with
     ICD-10)                               savings account patients” was the             billing issues when they bill
 • Evolving technology to keep up          fourth most challenging issue they            themselves.
     with these changes                    face in managing their practice           • Even worse, their nurses spend
     Although insurance and govern-        today. In fact, 60.1% of respondents          23 weeks a year addressing bill-
ment stipulations have arguably been       in the “2009 MBMA Medical Prac-               ing issues.
made in the name of patient care,          tice Today: What Members Have to          • The average fully-burdened cost of a
the overall effect is that it has forced   Say” research reported that is was “a         certified coder is $53,700 per year.
physicians to spend more time on           considerable or extreme challenge” to         Before you begin your search,
administrative functions and less time     collect patient payments, which is up    get clear about the key functions and
with patients. Moreover, inconsistent      from 30.1% in 2008. In short, “doing     reports your practice needs to effectively
billing rules have created significant     it yourself” has become twice as de-     operate. As the first step in your search,
barriers for physicians to receive full    manding as it was in 2008, causing       ask for a free revenue cycle management
compensation on an ongoing basis.          more and more practices to look to       analysis. And remember your goal is not
     Perhaps the biggest challenge         third party medical billings compa-      necessarily to off load your problems,
to hit the private physician more          nies to handle their patient billing     but to hire a firm to solve your problems.
recently is the problem of collecting      and soft collections.                    For this to happen, you must find a
on patient payments. “Now practices             The end result is a considerable    billing partner you can trust and work
have to contend with collecting $1         net loss of revenue duean increasing     with. Finding the right match for your
of every $4 directly from patients,”       amount of time a practice must spend     culture and needs is what the selection
reports the MGMA in its April 2010         on revenue management. Again, ac-        process is all about.
issue of Connexion magazine, based         cording to MGMA conducted surveys:            Your revenue cycle management
on research results collected in its        • The average percentage of total       partner can help you capture more
Fall 2009 “Practice Perspective on              account receivables (A/R) attrib-   revenue at every step of the claims
Patient Payments” survey. Partici-              utable to patients has increased    processing cycle.
pating practices reported that 23.2%            to 26.3%.
of total patient services revenue           • The percentage of practices that      Jerry Quintana works for Practiceforces; Jerry@
                                                                          ; 866-634-6327.
is attributed to collections from               offer and manage payment plans
    J u n e 2 0 12                                                                  w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   7

                How to Develop a Fair Physician
                     Compensation Plan
                                                                           By Daniel M. Bernick, Esq., M.B.A

            hen I first                                                                                                                  the senior physician) is
            started as a                                                                                                                 no longer an option. All
            health-care                                                                                                                  of these factors typically
attorney and consul-                                                                                                                     conspire to help force a
tant, 20 years ago, my                                                                                                                   choice of compensation
mentor remarked that                                                                                                                     formula within a reason-
compensation planning                                                                                                                    able period of time.
for physician groups                                                                                                                          When the two
was probably the most                                                                                                                    partners add a third or
challenging type of                                                                                                                      fourth partner, inertia
consulting assignment                                                                                                                    and history begin to
that our firm handled.                                                                                                                   play a role. The existing
In the years since, after performing                                               (especially for elective services).      formula becomes the starting point,
many such assignments, I agree.                                                    However, such marketplace fac-           and changes to that formula must
     On its face, choosing a compen-                                               tors can’t be controlled very much,      be justified by some pressing need.
sation formula may appear to be a                                                  and thus are accepted as “life.” By      However, the existing owners likely
simple task. It is not a highly techni-                                            contrast, a change in compensation       still have more leverage than the
cal problem. There are a number of                                                 formula is self-administered. This       new partner, because they hold the
standard formulas (see addendum                                                    makes all the difference. When it        keys to partnership, and because
to this article) and virtually all                                                 comes to a change in formula, each       their production (oftentimes) exceeds
groups use one of these formulas,                                                  shareholder wants — and generally        that of the new partner. This again
or a variant on them. What makes                                                   gets — a say.                            helps force a resolution.
compensation planning challenging                                                      In new group practices (e.g.,             For practices with five or more
are the high stakes involved, i.e.,                                                solo adding first partner), the choice   senior partners, change becomes
W-2 pay. This is the stuff that funds                                              of compensation formula can often        much more difficult. Typically, the
mortgages, vacations, private school,                                              be made without too much angst.          group has become more “democratic,”
and college tuitions, and all other                                                First, the choice of compensation        in that voting rights are no longer
“lifestyle” choices. There aren’t many                                             formula is often overshadowed by the     controlled by a senior “benevolent
more important issues than that,                                                   hugely emotional negotiation of the      dictator” shareholder or small group
from a business perspective.                                                       buy-in amount and terms. Second,         of “founders.” Thus, the senior part-
     It’s true that many factors — not                                             the existing owner holds the keys        ners may no longer have the lever-
just the compensation formula —                                                    to partnership, and therefore typi-      age to impose a resolution on the
affect a doctor’s compensation, such                                               cally has more leverage than the new     younger partners. In addition, time
as cuts in reimbursement, increases                                                partner, when choosing the formula.      has passed; a practice culture has
in overhead, increased competition,                                                Third, some choice must be made;         been established; and there is much
or a general economic recession                                                    the “status quo” (100% of profit to      “history.” By “history” I mean such
8   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                    J u n e 2 0 12

                                         it’s a little bit like an election. You vote,
                                         you have your say, but if the process has
                                         validity, you must abide by and accept
                                         the outcome, which in this case the
                                         consultant’s recommendations.
things as the way people were treat-                                              doctors selected on a non-attributed
ed in the past (“I never got a bonus          A Better Way                        basis, as necessary to support his or
for higher production”), or financial         The better way to approach the      her recommendations to the group.
or work-personal life balancing deci-    process involves the following:               A well drafted report, with
sions or choice-of-practice decisions    • The consultant is provided with        proforma, will serve to get the issues
made by a shareholder in the past in        practice financial information,       “out in the open” in a manner in
reliance on the existing formula and        including profit and loss state-      which they can be discussed and
the compensation that it generated          ments, physician productivity,        resolved with a minimum of hostil-
for him or her. Any change in this es-      and other data.                       ity and negativity. In fact, the core
tablished formula means that there       • Each shareholder provides the          issues underlying the group’s inter-
will be “winners” and “losers.”             consultant with responses to a        nal conflict are already known to the
    For such larger, more mature            confidential questionnaire.           shareholders. It is the proverbial “el-
practices, the impetus for change is     • The consultant visits the practice     ephant in the room.” What is needed
usually one or two physicians who           office and interviews the share-      is the consultant’s experienced,
are outliers in terms of production.        holders individually and privately.   professional evaluation and support
I haven’t done a survey, but my          • The consultant prepares a report       or rejection of these competing view-
educated guess is that 90% of the           outlining a recommended new           points, so that one viewpoint prevails
time, the reason that a consultant          formula, the reasons for same,        and guides the group to selection of a
is specially retained to examine the        and proforma of the new for-          single, agreed formula.
compensation formula is because             mula, as applied to the last year’s        The consultant can also help
the high producer is unhappy, and is        financials.                           correct misunderstandings that have
perhaps threatening to leave.            • The consultant comes back to           created conflict in a group.
    Theoretically, the decision             the office to meet with the group,         For example, in a recent com-
whether to adopt a new formula —            discuss, and hopefully make a         pensation consulting engagement,
and what that new formula should            decision.                             for a group of six-shareholder group,
be — could be made with the help of           What this process does is allow     the high producer — a subspecial-
the consultant in a single sit-down      the individual physicians to express     ist — demanded a new formula with
meeting with all of the sharehold-       their concerns privately. The weaker     greater productivity credit. Other
ers. However, that is not realistic.     members of the group will certainly      shareholders resented this demand
The stakes are too high; there is too    not offer their unvarnished views in     in part because they believed that
much soft information to be gath-        a group meeting, for fear of retalia-    the subspecialist’s allocable overhead
ered; and there is too much finan-       tion by the dominant members. The        was far higher than that of the other
cial information to be processed, to     stronger members of the group may        doctors, thus offsetting the subspe-
make a good decision, or really any      not fear “blow back” to the same         cialist’s higher production.
decision.                                extent, but they too want to main-            In fact, it turned out that the
    In the end, any one physician        tain friendly relationships with their   practice’s financial statements
who thinks that he may be hurt by        partners. No one will be fully candid    presented a distorted picture of the
change will demand a proforma of         in a group setting.                      subspecialist’s allocable overhead,
the new formula, as applied to exist-         The role of the consultant is to    which was higher than that of the
ing financials, so that the potential    privately process all of the confiden-   other doctors, as a percentage of
pay cut can be quantified and consid-    tial information, and then discuss       personal collections, but not by that
ered. This can’t be done on the spot.    the sentiments expressed by the                                                       continued on pg 27

    J u n e 2 0 12                                                                w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   9

             Medical interpreting and What it Means for you:
              An Overview of CLAS and the New Joint
                  Commission Language Standards
                                                                                          By Mayeluz Navarro
                                                                                           Part one of a series

   n accordance with Title VI of                                                      on Culturally and Linguistically Ap-   Standards 4-7. Standard 4 states
   the Civil Rights Act of 1964, the                                                  propriate Services (CLAS) in 2000.     that health-care providers must “pro-
   U.S. Department of Health and                                                      According to CLAS, all health-care     vide language assistance services
Human Services, Office of Minority                                                    organizations and providers that re-   … at no cost to each patient with
Health issued the national standards                                                  ceive federal funds must comply with   limited English proficiency.” Stan-
                                                                                                                             dard 5 mandates that both verbal

        You wouldn’t let your family                                                                                         and written information must be pro-
                                                                                                                             vided to the patient in his preferred

        physician perform your heart                                                                                         language. Furthermore, Standard 6
                                                                                                                             dictates that health-care organiza-

            surgery, would you?                                                                                              tions must offer a competent lan-
                                                                                                                             guage provider instead of using the
      No, you’d look for a Board Certified heart surgeon. If you are a health care                                           patient’s family members and friends
          provider or company, or represent one, you should reach out for a                                                  as interpreters. Standard 7 requires
                        Florida Bar Board Certified Health Lawyer                                                            that health care providers offer
                                  to care for your legal needs in today’s complex,                                           “easily understood patient-related
                                         regulated health care environment.                                                  material”in their own language.
                                                                                                                                 In addition to federal regula-
                                                                                                                             tions, the New Joint Commission
                                                                                                                             Language Services Standards also
                                                                                                                             promotes the right to effective com-
                                                                                                                             munication. Healthcare providers
                                                                                                                             must offer information in a way the
                                                                                                                             patient understands; this includes
                                                                                                                             using interpreting and translating
                                                                                                                             services for limited English profi-
                                                                                                                             ciency (LEP) patients. According to
                                                                                                                             the Joint Commission, “Research
                                                                                                                             shows that patients with communi-
                                                                                                                             cation problems are at an increased
                                                                                                                             risk of experiencing preventable ad-

        Sandra Greenblatt, Esq.,
                                                                                                                             verse events … [and LEP patients] …
                                                                                                                             are more likely to experience adverse
           Board Certified Health Lawyer and                                                                                 events than English speaking pa-
         2010 Top Impact Law Leader Honoree                                                                                  tients.” Therefore, to ensure effective
                                                                                                                             patient-provider communication and
       (305) 577-9995                          or                                                      patient safety it is important to use
                                                                                                                             trained interpreters and translators.
      The hiring of a lawyer is an important decision that should not be                                                         It is crucial to know the differ-
      based solely on advertisement. Before you decide, ask us to send
                                                                                                                             ence between an interpreter and
     you free written information about our qualifications and experience.
                                                                                                                                                  continued on pg 13

10     M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                 J u n e 2 0 12

    Medical Providers Could Be Stiffed Millions
                 From PIP Glitch
                                                    By C. Glen Ged

        he massive Personal Injury Pro-                                               six-month gap to deny legitimate
        tection (PIP) reform heralded                                                 payment, prompting a legal battle to
        by the governor as one of the                                                 recoup the earnings.
2012 session’s major accomplishments                                                       In fact, this is just one aspect of
also has a major problem. A gaping                                                    PIP reform that promises to tie the
hole in this so-called “triumphant”                                                   state’s courts up for a long while.
legislation technically allows insur-                                                 The law comes with lots of hits
ers to skip out on paying health-care                                                 to consumers’ rights: restrictions
providers for treating accident victims                                               that require patients to seek initial
for real injuries.                                                                    diagnosis of their injuries within 14
     This is the much-ballyhooed law,                                                 days of an accident; limits on who
set to take effect in part on July 1,                                                 can diagnose their injuries; bans on
was supposedly designed to target                                                     seeking coverage for massage and
and root out fraud. And yet, it’s                                                     acupuncture therapies; and limita-
legitimate medical providers treating                                                 tions that allow motorists to recoup
legitimate, verifiable injuries who                                                   only $2,500 of their $10,000 man-
could be out millions of dollars based                                                dated coverage unless they sustain
on a reading of the law that troubles       professionals for doing their job that    injuries that require “emergency”
even state officials.                       it is scrambling to find a fix before     treatment. These sweeping changes
     In their hurry to placate the          the law takes effect in July.             leave lots of unanswered constitu-
insurance industry and hand Gov.                 In early May, AHCA released          tionality questions that only the
Rick Scott one of his top priority items,   a three-page memo saying it in-           courts will be able to sort out.
lawmakers left a gap in coverage that       tended to eliminate the loophole. In           Meanwhile, one Miami personal
could end up shorting the health-care       the memo, AHCA’s general coun-            injury attorney has already an-
industry millions in earned income.         sel, Stuart Williams, said he could       nounced that she’s planning to sue to
The highly touted HB 119 contains a         foresee how the eligibility gap “would    have the law overturned as unconsti-
six-month eligibility gap that insiders     place the agency in a conundrum.”         tutional, arguing that it undermines
say could provide insurers cover to         But he said AHCA’s reading of the         a 1974 Florida Supreme Court ruling
avoid paying certain medical provid-        legislation is that the health-care       supporting PIP’s careful balance of
ers, such as doctors, chiropractors,        professionals in question are quali-      motorists’ reduced right to sue with
medical schools, and dentists. Under        fied under the law without a hiccup.      the expectation of swift payment of
one part of the law, these professionals         AHCA’s efforts are a welcome at-     their medical claims.
lose their eligibility on July 1, while     tempt to settle a troubling snafu. But         So PIP reform will soon be the
another part of the act restores their      they very well may not be enough.         law of the land in Florida. But it will
eligibility on Jan. 1, 2013.                Legal experts have gone on record         take some time before we know how
     The state’s Agency for Health          in a number of media reports to say       it really shakes out.
Care Administration (AHCA) is               that an agency memo may help the
so troubled by the potential for            courts decide the intent of the law,      C. Glen Ged is CEO of Ellis, Ged&Bodden, a Boca
                                                                                      Raton-based law firm that specializes in collecting
this glitch to give insurers techni-        but it will not necessarily prevent       delayed or wrongly denied PiP insurance claims
cal legal standing to stiff medical         insurers from using the apparent          for healthcare providers; 561-995-1966.

    J u n e 2 0 12                                                                   w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   11

                                                        Is Your Group Rewarding You
                                                        For Ancillaries?
                                                        By Sandra Greenblatt

         ne important reason physi-                                                 revenues, or if the DHS profits repre-             While dividing DHS profits in pods
         cians form or join group                                                   sent less than 5% of the group’s total       of five is widely recognized and used
         practices is to gain access to                                             revenues and of the total compensation       by group practices nationally to better
the resources not generally available                                               of each physician in the group.              satisfy the different practice patterns of
to solo medical practices to provide an-                                                 Many physicians do not realize          physicians in the groups, the Stark Law
cillary services to their patients, both                                            that the Stark Law allows a group to         requirements (and those of its Florida
to improve patient care and generate                                                distribute its overall profits from DHS      law parallels) are complex and care
additional revenue. The Federal Stark                                               in a manner that may be more equitable       must be taken to comply at all times.
Law offers an exception from its prohi-                                             where utilization of the group’s DHS         Groups should consult with qualified
bition against physician self-referrals                                             facilities is not evenly distributed among   health law counsel and take into consid-
for referrals within group practices for                                            its physicians, causing intra-group          eration many factors in dividing DHS
ancillary services known as “designat-                                              friction. Overall DHS profits may be dis-    profits and paying physician bonuses,
ed health services” (DHS), a list of 11                                             tributed to any component of the group       including the nature and scope of their
services including diagnostic imaging,                                              composed of at least five physicians. In     DHS, their specialties, their business
clinical laboratory, outpatient drugs,                                              the Preamble to the Stark Law, CMS           objectives and how this fits into their
physical therapy, etc.                                                              expressed that when DHS profits are          Compliance Plans.
     But, how is the group permitted to                                             shared among not less than five physi-             Stark compliance is one of the
distribute its profits from DHS to physi-                                           cians within a group, such distributions     most challenging issues for physician
cians in the group? This too is regulated                                           will be considered only indirectly related   group practices, but when done right,
and compliance is mandatory to avoid                                                to referrals and, thus, permissible.         can offer significant opportunities for

while dividing dHs profits in pods of five is widely recognized and used by group
practices nationally to better satisfy the different practice patterns, the stark law
    requirements are complex and care must be taken to comply at all times.
Stark’s draconian penalties of refunding                                                 CMS has not issued further              financial reward that groups today
all DHS revenues, fines and penalties,                                              guidance on how components of five           can ill afford to ignore.
including possible exclusion from Medi-                                             physicians should be selected or paid             This article is offered for informa-
care and False Claims Act exposure.                                                 (so long as not directly based on each       tion only and does not constitute legal
     It is unlawful for a group to                                                  physician’s current DHS referrals),          advice, which can only be provided to
distribute profits to its physicians                                                whether each component of five must          a specific client who has signed an en-
in a manner that is directly related                                                share the group’s entire DHS profits         gagement letter with the law firm for a
to the volume or value of that physi-                                               from all DHS or for separate DHS.            fee and after consideration of the facts
cian’s patient referrals for DHS. Many                                              Among health lawyers, interpreta-            and circumstances analyzed under
groups follow the Stark Law’s “safe                                                 tions differ regarding this issue, but       applicable laws and regulations.
harbors” for DHS profit distributions,                                              consensus is that either approach may             For further information, contact
by sharing them equally or according                                                be legally defensible. The decision may      Sandra Greenblatt, P.A. in Miami,
to the group’s distribution of non-DHS                                              depend on the group’s risk tolerance.        305-577-9995, or
12   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                         J u n e 2 0 12

TRANSLATIONS continued from pg 10        interpreters also abide by the Profes-    treat the condition appropriately and
                                         sional Code of Ethics, which requires     avoid further health complications,
a translator. An interpreter works       confidentiality, accuracy, profession-    which can lead to possible law suits.
with verbal information while a          alism and impartiality. Like medical           To find trained medical interpret-
translator converts the written word     providers, trained interpreters must      ers, providers can visit professional
from the source language to the          keep current with medical terminolo-      associations’ online directories like
target language. On occasions you        gy and innovations in the field. They     the International Medical Interpret-
may find a language specialist, who      are aware and comply with laws such       ers Association (IMIA), the American
is both translator and interpreter,      as the Health Insurance Portability       Translators Association (ATA), and
but not all interpreters translate and   and Accountability Act (HIPAA).           the Association of Translators and
not all translators interpret.                Indeed, medical interpreters are     Interpreters of Florida (ATIF). When
    Medical interpreters are much        part of the health-care team and          contacting interpreters directly or
more than bilinguals who convert         therefore have the responsibility         through agencies, it’s recommended to
the information from one language        to support the patient’s health and       ask for references and credentials. Col-
to another. They are also mes-           safety. The benefits of using trained     lege interpreting courses, continuing
sage and cultural clarifiers. This is    medical interpreters are limitless.       education workshops, membership in
another reason why it is critical to     It saves time, money and resources        professional associations and national
hire a trained medical interpreter.      since effective communication lends       certifications are indications that the
A trained interpreter knows the          the provider the opportunity to find      prospective interpreter has received
nuances of the languages and the         the root cause without ordering           formal training.
cultures. She will step in to clarify    excessive tests and potentially de-
any misunderstandings or explain         creases a patient’s hospital stay. The    Mayeluz Navarro is founder and president of Blue
                                                                                   Diamond Translations; 305-771-2510; mayeluz@
ambiguities that may come up due         right diagnosis allows the provider; www.bluedia-
to cultural differences. Trained         to prescribe the correct medication,

        Look what’s coming
           in July 2012
                     Special Feature:
             lEgal dEfEnsE
            Also in this issue:
       Supreme Court Decision on
  Affordable Care Act & What OB/GyN’s
           are facing in Florida.

    J u n e 2 0 12                                                                w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   13

Across the State:
Reports from the Medical World
By Anne Tschida

statE/nation                                                                        • 31% said ACA didn’t go far enough          collaboration aimed at providing care
pHYsicians not Big on                                                                 and a single-payer system is needed        for oncology patients in South Florida.
HEaltHcaRE law                                                                      • 22% said ACA went too far and              The three organizations are teaming up
A new survey by Jackson Healthcare                                                    impedes a physician’s ability to prac-     to create an Accountable Care Program
finds that a “D” is the mean grade                                                    tice medicine                              specific to the treatment of cancer.
physicians give the health law, despite                                             soUtH floRida                                     The Florida Blue/Baptist Health
its primary intention to reduce the                                                 nEw naME at BRowaRd HEaltH                   South Florida/Advanced Medical Spe-
cost of healthcare and provide cover-                                                           MEdical cEntER                   cialties Accountable Care Program will
age for the uninsured. In addition,                                                                    Vania Vazquez has         build a new delivery of care model that
68% of American physicians disagree                                                                    been named Man-           shifts toward a value-based reimburse-
that the Affordable Care Act (ACA)                                                                     ager of Physician         ment. “In the age of reform, health-care
will have a positive impact on physi-                                                                  Services for Broward      organizations must create new models
cian/patient relationship.                                                                             Health Medical            of care that deliver the highest quality
     Only 12% of physicians said the                                                Center. In her role as manager, she          of care while reducing the cost burden
law provides needed health-care reform.                                             will promote physician relationships         for all stakeholders,” said Pat Geraghty,
A majority of physicians said the ACA                                               aligned with the medical center’s            Chair and CEO of Florida Blue.
would not improve healthcare’s quality,                                             product lines, services, and strate-              Accountable Care programs are meant
rising costs or patients’ control over their                                        gic plans. She will also develop new         to present mechanisms, such as shared
own health care. They also said it would                                            partnerships and affiliations with           savings, that incentivize quality, care coor-
worsen the amount of control physicians                                             members of the medical community.            dination, and total care management. An
have over their practice decisions.                                                      Broward Health has been in the          overall goal of Accountable Care arrange-
     The only positive rating physicians                                            health-care business for more than 50        ments is to decrease medical costs.
gave the ACA was related to access –                                                years, and is one of the 10 largest public        Currently, 12 million people
54% of respondents said the new law                                                 health systems in the nation. It in-         worldwide receive a cancer diagnosis
will increase patients’ access to care.                                             cludes Broward Health Medical Center,        each year, with an associated price
The health law is estimated to drive                                                Broward Health North, Broward Health         tag of $286 billion in medical costs
13 million new Medicaid enrollees                                                   Imperial Point, Broward Health Coral         and lost productivity. By 2030, that
beginning in 2014.                                                                  Springs, Chris Evert Children’s Hospi-       number is estimated to increase to
     Among Jackson’s other key survey                                               tal, Broward Health Weston and more          22 million people each year, with a
findings:                                                                           than 30 facilities of the Community          comparable rise in costs.
• 70% said ACA would not stem rising                                                Health Services and Broward Health                The hope is the program will create
   healthcare costs                                                                 Physician Group.                             a model of quality and service that can
• 66% said ACA would give physi-                                                         Prior to joining BHMC, Vazquez          be replicated throughout the state.
   cians less control over their practice                                           served as manager of administrative          oRlando
   decisions                                                                        services for Broward Health Weston.          Expansion at aRnold palMER
• 61% said ACA would not improve                                                                                                 The Arnold Palmer Hospital for Chil-
   the quality of healthcare                                                        BlUE cRoss, Baptist cREatE aco               dren has opened a new outpatient
• 55% said Congress should scrap                                                    Florida Blue, Florida’s Blue Cross and       rehabilitation center. The approxi-
   ACA and start over                                                               Blue Shield company based in Jackson-        mately 10,000-square-foot center is
• 49% said ACA would give patients                                                  ville, and Baptist Health South Florida      located at 925 South Orange Avenue
   less control over their healthcare                                               along with Advanced Medical Special-         in Orlando. Patients at the new
• 35% said it did nothing to reform                                                 ties, an oncology practice with 17 loca-     rehabilitation center will have access
   healthcare.                                                                      tions in South Florida, announced a new                               continued on pg 22

14   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                           J u n e 2 0 12

   Doing Nothing Is No Longer An Option
                                             By Hal C. Scherz, M.D.

        here is a                                                                                          healthcare dollar.
        truism that                                                                                        That means that
        every phy-                                                                                         88% goes else-
sician needs to                                                                                            where — pharmacy,
constantly remind                                                                                          hospitals, insurance,
themselves of: There                                                                                       management, legal,
is no healthcare                                                                                           etc. In difficult eco-
without doctors. So                                                                                        nomic times, when
why do so many of                                                                                          everyone is getting
us feel so power-                                                                                          squeezed, and when
less and why are so                                                                                        doctors are already
many of us unwill-                                                                                         perceived as push-
ing to do something                                                                                        overs in the business
about it?                                                                                                  world, how do you
     Most of us do                        There is no other business model in                              think that they will
what we do professionally because         existence quite like this. Does anyone      fare? Couple this with the fact that
we enjoy helping people. That is          think that lawyers would allow some-        all of the other players in healthcare
our collective strength but also our      one else to set their fees and wait for     spend billions on lobbyists and are
weakness. What we do is special, but      someone other than the client to pay        well organized, while doctors have es-
other entities have staked out their      them, often having to fight for their       sentially no organized representation.
“turf” in our professional world — the    reimbursement and having to con-            The future looks bleak for doctors if
government, insurance companies,          tinuously resubmit their claims to get      we continue down this same path.
and hospitals. They need doctors to       paid because the payment form was                It is interesting that talks about
remain an active player in this world,    improperly filled out?                      healthcare reform play to packed audi-
but have learned to exploit us in busi-        The healthcare industry is a           toriums. Doctors are eager to get news
ness matters, counting on the fact that   vibrant and booming sector of our           “from the front.” They want to know
our sense of morality and responsi-       economy. Between 2008-2009, when            what is going to happen, and after hear-
bility would supersede our fiduciary      every sector of our economy was in          ing the news of what is in store for them,
capabilities.                             recession and losing jobs, the only part    many will be motivated to act, but most
     For the most part, this is ex-       of our economy (besides the federal         will settle into the ennui that character-
actly what has happened and what          government) that had added jobs was         izes their professional lives these days
said entities are counting on in the      healthcare. It is not the “black hole”      as it relates to their business.
future. Simply look at the model under    that politicians in Washington would             There are basically five groups of doc-
which most of us receive payment          have the public believe. Healthcare         tors that I have encountered: those who
for services rendered to patients. In     is an $800 billion annual part of the       are angry about what they hear and are
almost all cases, someone else pays us,   economy, which accounts for over 25         stirred to action; those who are angry but
whether it is the government or the in-   million jobs. So it should come as no       are convinced that there is nothing that
surance companies. To make matters        surprise that lots of people want in        they can do; those who think that they can
worse, someone else has decided how       on it. Doctors’ professional fees ac-       game the system and what is coming will
much your service is worth, not you.      count for approximately 12% of the                                                        continued on pg 17

    J u n e 2 0 12                                                                   w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   15

                                 Can the Free Market Fix Healthcare?
                                                                                        By Daniel Stone M.D.

           itt Romney marked the                                                    one. I told the pharmacist that I would    but wonder why so many of those
           second anniversary of the                                                refill her current medicine and that we    younger than 65, living in one of the
           Affordable Healthcare Act                                                should recheck in three months to see      world’s richest nations, must avoid
by calling for its repeal. Referring to                                             if the price for the other had dropped.    care or risk financial ruin.
the act as “an unfolding disaster,” he                                              Should doctors really have to follow            Despite Gov. Romney’s optimism,
advocated free market initiatives to                                                drug prices like market analysts in        free markets will never solve the
improve access to care. Yet Romney                                                  order to care for their patients? Wel-     problems Joyce faced. In Los Ange-
never explained how the free market                                                 come to the free market in healthcare.     les, a year of health insurance costs
could help uninsured individuals                                                         Despite her tight finances, Joyce     thousands of dollars. No market
like my long-time patient Joyce.                                                    makes a real effort to get the preven-     approach will make that amount
     Joyce, a diabetic in her sixties,                                              tive care I recommend, including           affordable for people like Joyce. If
works for a church in Los Angeles                                                   mammograms, pap smears, and blood          universal coverage is the goal, there
and spends much of her time doing                                                   tests for her diabetes. Sometimes,         is no alternative to subsidies funded
charitable work in Africa. The church                                               though, cost considerations interfere.     by employers and taxpayers. These
does not offer health insurance. As a                                               As a diabetic, Joyce faces risk of         subsidies — along with an individual
diabetic with high cholesterol, Joyce                                               retinal eye injury that can cause blind-   mandate designed to bring younger,
has been virtually uninsurable for                                                  ness. Although such injury is prevent-     healthier people into the pool — form
most of the time I’ve treated her. With                                             able with routine eye care, Joyce has      the basis for Obama’s health care
her pre-existing conditions, no insur-                                              not visited an eye doctor for more than    plan. Those who call for “repealing
ance company would take her even if                                                 two years. A colonoscopy to prevent        and replacing” it should explain who
she could afford the premium. Insur-                                                colon cancer is now recommended at         would be covered by the “replace-
ers know that diabetics like Joyce are                                              age 50. Joyce remains more than 10         ment” and how the care would be
much more likely to become ill and                                                  years overdue for hers. Why? It would      funded.
generate expensive bills, and the                                                   cost well over $1,000.                          The national debate on health-
free market incentivizes them to                                                         Joyce’s experiences outside my        care will take center stage this
identify high risk individuals and                                                  office have been even worse. When          fall as President Obama squares
exclude them.                                                                       I called to discuss her cholesterol        off against his Republican op-
     Free market advocates seldom                                                   medication, she mentioned to me that       ponent. The country deserves a
focus on the plight of those priced                                                 she recently suffered a bout of chest      frank discussion of the major policy
out of the insurance market. These                                                  pain and visited a small community         questions raised by the plight of the
patients tend not to get care when they                                             hospital near her home. The doctors        country’s many Joyces. We have to
need it, and when they do, their physi-                                             told her she needed overnight observa-     ask ourselves the tough questions:
cians face inevitable conflicts between                                             tion. She went home the next day with      Should healthcare coverage for the
providing quality care and keeping                                                  a hospital bill of more than $19,000,      uninsured be broadly subsidized?
costs down. This week, for example,                                                 plus hundreds more in physicians’          Are we comfortable with millions
I received a reminder from my medi-                                                 charges. Were the services Joyce re-       of Americans continuing to live in
cal group’s pharmacist that Joyce’s                                                 ceived even necessary? She’s not sure.     terror that something serious will
cholesterol is too high despite the                                                      Fortunately for Joyce, her            go wrong with their health? This is
medication she takes to control it. The                                             healthcare nightmare is ending. She        a conversation we need to have as a
pharmacist recommended switching                                                    has just turned 65 and will now be         nation, without the partisan political
her to a more potent drug. But when                                                 eligible for Medicare. Soon she will       posturing and gamesmanship that so
I checked online, the cheapest local                                                be able to get the basic tests and         often cloud the issues.
pharmacy I could find was charging                                                  medications that she needs after
$120 for a month’s worth of the recom-                                              years of devoting herself to the im-       Dr. Daniel Stone, practices internal medicine and
                                                                                                                               geriatrics in Beverly Hills.
mended drug versus $6 for her current                                               poverished in Africa. But I can’t help
16   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                             J u n e 2 0 12
DOING NOTHING continued from pg 15           from insurance companies, or the           the newest iteration of HMOs, the
                                             constant threat of Medicare cuts to        Accountable Care Organization,
not affect them; those who are looking for   physicians (a new round of across the      which is a group of doctors who get
an exit strategy; and those who welcome      board cuts goes into effect in October,    together to manage care and make it
the change that is coming (for whatever      separate from the SGR postponement         better by coordinating care, shar-
reason that may be).                         or “doc fix” due to expire in January      ing information and driving the cost
     The average doctor spends less          2012) are now facing further finan-        curve down. Payment is delivered in
than $100 annually on advocacy for           cial burdens. The mandate requiring        a lump sum for an episode of care,
themselves, whether it is on a PAC,          health information systems in their        left to be divided by the ACO; fre-
or some other group that is trying to        offices means that doctors who have        quently controlled by a hospital. The
defend their interests. Contrast this        not implemented such a system will         reality is that this is an attempt to
with trial lawyers who spend 100             get lower levels of reimbursement from     have doctors manage risk, get paid
times that amount. Most doctors will         the government, if they get anything       less, take on liability, and allow in-
become defensive when confronted             at all. Thus doctors are forced to         surance companies and hospitals to
with this fact, claiming that they           divert money that could be spent on        reap the financial rewards.
already give to their specialty societies    new staff or on salary increases for            As bleak as this may appear, the
and state medical associations. Unfor-       existing employees, and instead spend      solution is closer than we may think.
tunately, that has failed to protect us
from the sharks that constantly swim
around us. The American Medical              The average doctor spends less than $100
Association is perceived by the public
as the lobby for doctors, but they have
                                             annually on advocacy for themselves —
become part of the problem, looking          contrast this with trial lawyers who spend
out for their own special interests, and     100 times that amount.
have failed doctors in general.
     We are a profession at a cross-
road. The massive federal expansion          it on technology which is not currently    Doctors still control healthcare, and
over control of our healthcare system,       configured to improve medical care,        they are still the most respected profes-
and quite frankly, over doctors, is          but to comply with government regula-      sion in the eyes of the general public:
beginning to show cracks in the wall.        tions. In fact, in many situations,        89% rate their doctors favorably in a
Beginning with a shaky foundation,           these systems may negatively impact        Gallup poll in 2010, compared to 11% for
it fails to support the massive su-          care. The new law contains provisions      politicians. Doctors need to consolidate
perstructure on which it rests. The          that favor special interests such as       their power into a single, strong uni-
mandate to purchase health insurance         hospitals, who lobbied to get restric-     fied voice that can deliver the message
is being challenged in court and the         tions placed on physicians who own         that things are not working well under
entire law is at risk of being thrown        surgery centers, hospitals, and imag-      this model. We need to begin to take
out. The new majority in the House of        ing centers, which limit or restrict       personal responsibility for our profession
Representatives is vowing not to fund        physician ownership in these entities.     because it has been, and continues to be,
portions of the law that require new                                                    under attack. Doctors need to open up
agencies and expanded bureaucracies          doctoRs REsponsE to                        their pocket books and understand that
to function. However, there are parts        difficUltiEs                               it will take money to keep our profession
of the law that will remain in effect.       And how are doctors responding to          safe from all of the intruders who want
These provisions threaten to place           all of this? Too often, in fear and        what we have. If we do not act soon, pri-
more burdens on doctors and will limit       desperation, they are selling their        vate practice medicine will be a distant
our ability to remain economically           practices to hospitals and relinquish-     memory and we will all be federal, state
solvent. Doing nothing and just hoping       ing financial and professional control     or hospital employees. There will be no
that this will go away or be acceptable      to entities whose only concern is the      one to blame but ourselves. Doing noth-
is simply no longer an option.               bottom line. These organizations           ing is not an option.
     Doctors who are already strug-          have proven over the years that they
gling to keep their practices open           desire to work with doctors, but only      Hal C. Scherz is the founder, president and CEO of
                                                                                        Docs 4 Patient Care;
because of decreasing reimbursement          on their terms. We are now seeing
    J u n e 2 0 12                                                                     w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   17

                           Medical Staffs and Conflicts of Interest
                                                                                         By Jeffrey L. Cohen

           edical staffs                                                                                                                 with a COI. First, the
           are increas-                                                                                                                  COI must be disclosed.
           ingly frus-                                                                                                                   This ought to be done an-
trated with the financial                                                                                                                nually and at each MEC
relationships their                                                                                                                      meeting. Second, on any
medical executive com-                                                                                                                   matter where the COI
mittee (MEC) members                                                                                                                     is implicated, the MEC
have with the hospitals                                                                                                                  member ought to recuse
where they work. These                                                                                                                   himself or herself from a
financial relationships                                                                                                                  vote on the matter. They
can be the cause of trou-                                                                                                                can participate in the
bling conflicts of inter-                                                                                                                MEC consideration, but
est (COI). Medical staffs need to be                                                    Intertwined financial relation-     should leave the room when the vote
proactive about the issue.                                                          ships between hospitals and physi-      is taken.
     A hospital-based physician’s                                                   cian are on the rise. The complexity         There is a third option, a poison
livelihood (and the economic                                                        of an ever-evolving business model      pill of sorts. If an MEC member
welfare of his/her family) depends                                                  brings hospitals and physicians         finds that the COI has him or her
in part on having a good relation-                                                  closer and closer, which creates        bouncing in and out of the MEC
ship with the administration of the                                                 significant COIs. MECs must take a      meeting room regularly, there ought
hospital where he or she works. It                                                  good look at what circumstances con-    to be consideration given to the per-
is easy, therefore, to see how the                                                  stitute a COI and develop methods to    son’s resignation.
physician would be hard pressed to                                                  counteract them.                             At the very least, medical staffs
go against the hospital on contro-                                                      A COI basically exists for an       must develop policies and procedures
versial matters. The same goes                                                      MEC member when the member has          regarding COIs. COIs ought to be
for a full-time employed physician                                                  a relationship with a party which       defined and handled on a prede-
of a hospital and even a medical                                                    causes the member to place his or       termined basis. Moreover, medical
director, who may derive signifi-                                                   her personal interests before those     staffs should give serious consid-
cant compensation from his or her                                                   interests of the medical staff as a     eration to ensuring that at least a
relationship with the hospital.                                                     whole. A classic COI is a financial     majority of the MEC members do
     Looked at another way, what                                                    relationship with the hospital. If an   not have a COI that would prevent
about a physician who staffs a                                                      MEC member receives money from          them from doing their job, which is
hospital-based department at hospi-                                                 a hospital for providing a service      to ensure the integrity and proper
tal #1 who wants to get on staff of                                                 to or on behalf of a hospital, a COI    functioning of the medical staff.
competing hospital #2? What about                                                   exists. But the inquiry does not stop
the physician who is employed by                                                    there. Simply having a COI is not       Jeffrey l. Cohen, with over 25 years of healthcare
                                                                                                                            law experience following his experience as legal
hospital #1 becoming a member                                                       dispositive. The question is what to
                                                                                                                            counsel for the Florida Medical Association, spe-
of hospital #2 and who wants to                                                     do about it.                            cializes in transactional healthcare and corporate
become president of hospital #2’s                                                       There is essentially a two-step     matters at Florida Healthcare law Firm; www.
                                                                                                                  ; 888-455-7702.
medical staff?                                                                      process involved for an MEC member
18   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                          J u n e 2 0 12

 The Topsy Turvy World of Medical Real Estate
                                                    By Tom Adams

        he Florida medi-                                                                         their rent roll. Their story
        cal office markets                                                                       is not unique in the current
        are going through                                                                        environment.
interesting changes that                                                                              The challenges described
are having a significant                                                                         above are viewed as opportu-
impact on property owners                                                                        nities by forward thinking,
and market dynamics                                                                              business-minded health-care
throughout the state. On                                                                         providers and real estate
one hand, the large hospi-                                                                       market participants. Physi-
tal networks and physician                                                                       cian groups and hospitals
groups are very active as they vie for      immediate area? Who controls the           are partnering with developers and
market share and consolidate opera-         primary care market? What are the          medical real estate specialists to
tions. On the other hand, the solo          patient referral patterns and how          develop delivery models that can adapt
practitioners are facing increased          does that impact the medical office        as the future comes into focus. One
pressure to grow, merge, or risk            properties that support the health-        can look to Bethesda Healthcare’s new
being squeezed to the point where           care providers?                            hospital under construction in western
it doesn’t make sense to continue to             Whether it’s a physician who          Boynton Beach, the planned research
practice medicine.                          owns a small office condo, or a na-        hospital in Jupiter by Scripps and
     As a whole, Florida’s medical office   tional investor who owns a portfolio       Tenet Healthcare, the approved HCA
buildings are experiencing the highest      of Florida medical office buildings,       hospital on the west side of Jackson-
vacancy rates in recent memory. The         the criteria involved in operating a       ville and the continued growth of the
factors contributing to the increased       successful medical office building are     Lake Nona region of Orlando as prime
vacancies include the protracted            becoming more complex than simply          examples of hospitals leading the way,
economic malaise, whereby patients          ascribing to the notion that the baby      or protecting their turf. 2012 will
are rationing their own healthcare,         boomer’s demand for health-care ser-       be a year in which significant physi-
and the mergers and acquisitions of         vices will keep the medical buildings      cian practice mergers and new ACOs
physician practices that often creates      filled with physicians who will gladly     are announced. The medical office
holes in buildings and the relocation of    pay ever increasing rents. A prime         markets will absorb the impacts of the
doctors into consolidated space.            example of this is the South Florida       current state of flux. As the economy
     In the new era of ACOs and med-        medical office portfolio owned by          improves and physicians gain confi-
ical homes, the provision of health-        LaSalle Partners, a national owner         dence in their future business pros-
care will become more centralized. It       of healthcare facilities. Their Florida    pects, the softer real estate markets
is yet to be determined who will be         assets are averaging the highest va-       should rebound beginning in 2013.
the winners and losers, but inves-          cancy rates across their portfolio and
tors in the medical real estate sector      there is downward pressure on rents.       Tom Adams is president and CEO of Florida Medical
                                                                                       Space and Medical Development Partners, a Florida
would be well advised to understand         Fortunately, their projects are well
                                                                                       provider of health-care real estate brokerage and
the dynamics within the submarket           capitalized and strategically located      development solutions to doctors and hospitals
in which they invest. What hospi-           on or adjacent to leading hospitals.       throughout the State of Florida; 954- 346-8200, x201.
tal networks have facilities in the         As the economy improves, so should
    J u n e 2 0 12                                                                    w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   19

           Choice of Entity Considerations for a Medical
                       Practice’s Real Estate
                                                                                       By: Robert S. Forman

         enerally, a medical prac-                                                  office and operating premises are      coverage, there is still too great a
         tice will lease the practice’s                                             located. The chief reason for this     risk of individual liability for claims
         office space and associated                                                separation is to limit the medical     against the real estate.
real estate either from an unrelated                                                practice’s liability. If the medical   B. Sub-Chapter S Corporations.
landlord, or from a separate entity                                                 practice’s operations are provided     Although less common than before
owned by either some or all of the                                                  through the same entity that owns      the advent of limited liability
physicians who also are the owners                                                  the practice’s real estate, then the   companies, the subchapter S form
of the medical practice. This article                                               real estate assets are subject to      of ownership is still common for
discusses some of the basic issues                                                  claims by creditors of the medical     many medical practices. Thus, a
pertaining to the legal structure of                                                practice, and vice-versa, which is     temptation may exist to hold medi-
the associated real estate where at                                                 an obviously undesirable situation.    cal real estate also in a subchapter
least some of the medical practice’s                                                                                       S corporation (“S corporation”).
owners also own the medical prac-                                                   potEntial foRMs of REal                An S corporation is commonly
tice’s real estate.                                                                 EstatE ownERsHip                       referred to as a “pass-through”
                                                                                    a. Individual Ownership. The most      entity because income and losses
gEnERal liaBilitY                                                                   rudimentary form of real estate        are passed through to the owners
considERations                                                                      ownership is directly by the indi-     of the S corporation for reporting
As the introductory paragraph                                                       vidual. Although a convenient and      on the owner’s individual income
notes, the legal entity of the medi-                                                easy approach, it is never advisable   tax return; and the S corporation
cal practice will often be separate                                                 to own medical real estate in an in-   itself will not, except in very rare
from the legal entity that holds the                                                dividual capacity. Even if the owner   circumstances, be subject to a sepa-
real estate on which the practice’s                                                 has purchased substantial insurance    rate income tax.
20   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                  J u n e 2 0 12

     Although often a favorable vehi-    attorney. The hiring of a lawyer is an    Robert S. Forman is an attorney at Henderson,
                                                                                   Franklin, Starnes & Holt, P.A. in Fort Myers,
cle from the standpoint of business      important decision that should not        Florida, and concentrates his practice areas of
operations, holding medical real         be based solely upon advertisements.      personal service organizations, acquisitions and
                                                                                   mergers, corporate law, partnership law, limited
estate through an S corporation is       Before you decide, ask us to send you     liability company law, taxation and business plan-
not advisable. Any losses from an        free written information about our        ning, and retirement plans; 239-344-1239; robert.
S corporation can only be taken to       qualifications and experience.
the extent of the S corporation’s
shareholder’s “basis” (“basis” is
a tax-related term which essen-
tially means the acquisition cost
with certain adjustments). Debts
and liabilities of the S corporation
usually do not count towards the
basis calculations, and thus can
result in a disadvantageous limita-
tion of the pass-through of losses
to the individual S corporation’s
c. Limited Liability Compa-
nies. Limited liability companies
(“LLC(s)”) have become an increas-
ingly common form of ownership
of medical real estate. An LLC
will possess the general, limita-
tion of liability feature of corporate
ownership. In addition, similar
to an S corporation, the LLC is a
“pass-through” entity for income tax
purposes, with no entity-level taxa-
tion applicable. Furthermore, if the
LLC has only one owner, it can be
treated as a “disregarded entity” for
federal income tax purposes, thereby
eliminating the need to prepare a
separate federal income tax return.
Unlike the S corporation, however,
the LLC will usually not have the
same potential loss limitations
as were discussed above for an S
corporation. Finally, if the LLC has
more than one owner, there are often
creditor protection advantages to the
owners of the LLC.
     The contents of this article do
not constitute legal advice, nor do
they create an attorney-client rela-
tionship. Should you have any legal
questions you should consult with your
    J u n e 2 0 12                                                                w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   21
H O L I S T I C h A L L W AY Q & A

                                                               Ask Dr. Mitteldorf
                                                                                          By Brian Mitteldorf
Q: How do you see the new PIP                                                       patients seeing the employee turnover?        with a medical doctor. The benefit of
reform affecting chiropractic offices                                               a: The best employee to have is one           offering medical services to your patients
that have massage therapist and acu-                                                that is trustworthy and is willing to         and getting involved with primary care
puncturist on site?                                                                 learn. if an employee has impressed           can make your office a one stop treat-
a: i see the new PiP reform laws af-                                                and makes a daily impact to your office       ment center for all types of injuries and
fecting all chiropractic offices in some                                            and patients let them know it! Show-          illnesses, which will increase your patient
way. At this point chiropractors along                                              ing gratitude and thanking them goes          volume and expose patients to chiro-
with attorneys still do not have a clear                                            a long way. Giving an employee goals          practic care to those who would not
answer as to what constitutes an                                                    on a monthly or quarterly basis giving        usually think of it as main stream type of
emergency medical condition under                                                   them a bonus to obtain is a great             treatment.
the new PiP law and what amount of                                                  motivator. With every office there will
care certain patients will be entitled to.                                          be turnover of staff. Remember, you           Q: I am a new graduate in South
Offices that offered massage therapy                                                can never penalize someone for trying         Florida. What asset tips can you give
care or acupuncture treatment to help                                               to find a better opportunity for them to      me for my new business adventure?
auto accident victims with their injuries                                           better themselves or their families.          a: Start working with another chiroprac-
will no longer be covered service by                                                                                              tor. Earn a salary and if possible ask for
the Florida auto insurance industry as                                              Q: I have two offices one in New York         a percentage of what patients you can
of January 2013 . if patients want those                                            and another one in South Florida. I would     bring into the office. Save your funds. if
services they will have to pay cash for                                             like to integrate with an M.D. in New         you can not bring in patients to an office
them. This is a great loss to the many                                              York. How would I go about doing that         you do not own , why would you think
injured car accident victims that have                                              and how would it be beneficial for me?        you would be able to bring in patients to
been helped for years by these treat-                                               a: i am not a licensed provider in the        an office you do own?
ments and a gain for the insurance                                                  state of New york. However the first
                                                                                                                                  Brian Mitteldorf D.C. has been in active practice
companies to save money.                                                            place you may want to start is by contact-    for over 25 years. He has owned and operated
                                                                                    ing a health-care attorney in the state. As   multiple chiropractic offices in Florida and Geor-
                                                                                                                                  gia. He has provided expert testimony for plaintiff
Q: I have a problem with employee re-                                               each state is different you need to know      attorneys as well as lecturing to attorney groups
tention in the office and this is prohibit-                                         as a chiropractor if you can employee a       on “Traumatic effects of Whiplash” as well as the
                                                                                                                                  AMA Guides 6th edition of Physical impairment.
ing from growing the practice. How                                                  medical doctor or if you will need to set     He is also an Owner of USiC Network, a national
can I overcome this issue without my                                                up another arrangement or corporation         Chiropractic injury Network.

WRAP UP continued from pg 14                                                        and therapists,” said John Dimino,            in May. More than 60,000 practicing
                                                                                    manager of pediatric rehabilitation at        pharmacists, pharmaceutical scien-
to two separate waiting rooms,                                                      Arnold Palmer Hospital.                       tists, student pharmacists, pharmacy
including one for patients requir-                                                       Arnold Palmer is a 158-bed facil-        technicians and others advancing
ing low stimulation, three large                                                    ity dedicated exclusively to the needs        the profession are members. Its
gyms, a rock-climbing wall, and a                                                   of children.                                  House of Delegates is represented by
wheelchair seating and positioning                                                  noRtH floRida                                 more than 450 elected members from
clinic. It is staffed by a number of                                                Uf dEan gEts national post                    50 state associations.
specialists, including a pediatric                                                  The University of Florida dean of the              Drug supply shortages and their
physiatrist, six physical therapists,                                               College of Pharmacy is becoming a             impact on patient care, standardiza-
six occupational therapists, six                                                    delegate for patient care in the larg-        tion of pharmacy practice descriptions,
speech-language pathologists, and                                                   est U.S. association of pharmacists.          and recognition as health-care provid-
certified translators.                                                              The American Pharmacists Asso-                ers, and controlled substances regu-
    “The design and floor plan for this                                             ciation elected William H. Riffee,            lation are some of the issues Riffee
new rehab center were developed with                                                Ph.D. as speaker-elect to its House           expects to weigh in on as a delegate on
a great deal of input from our doctors                                              of Delegates at its annual meeting            the national level. 
22   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                                J u n e 2 0 12
H O L I S T I C h A L L W AY

                                          P R E S S       R E L E A S E

   The Making of the US Injury Centers Network

        he three princi-                                                                        multifaceted market-
        pal shareholders                                                                        ing campaigns were
        of the US injury                                                                        embarked upon
 Centers Network are                                                                            utilizing masterfully
 licensed health-care                                                                           conceived and de-
 professionals who                                                                              signed promotional
 have been partners                                                                             information, adver-
 for the better part of                                                                         tising pieces, and
 the last 30 years. Over                                                                        collateral materials.
 this span of time, they                                                                        Armed with a strong
 have built a network of                                                                        national brand and
 chiropractically based                                                                         an arsenal of well
 injury centers from the                                                                        integrated market-
 ground up, which are                                                                           ing systems, USiC
 currently thriving in                                                                          instituted campaigns
 many states. While many chiroprac-       a week, from all of the accident       designed to attract patients to its
 tors seek to establish diversified       victims (and their legal representa-   offices both directly and indi-
 practices, the principals of the USiC    tives) seeking treatment. Further-     rectly through referral sources,
 Network sought to develop stable,        more, the principals wanted USiC       including attorneys, medical doc-
 self-sustaining chiropractic practices   to be the first thought in the minds   tors, and businesses. Television
 that provide quality care exclusively    of people seeking treatment for        and radio campaigns, print cam-
 to individuals injured in automo-        accident related injuries.             paigns, direct mail campaigns,
 bile, slip and fall, and work-related        Numerous strategic steps           email campaigns, community
 accidents.                               were taken to accomplish these         based campaigns targeting pa-
      After many years of operating       goals. First, to differentiate         trons of local businesses, and in-
 injury centers, the principals con-      and distance itself from other         ternet campaigns were launched
 cluded that if their practices were      chiropractors in the personal          in both English and Spanish.
 going to achieve long-term pro-          injury space, a strong national        Campaigns were directed toward
 fessional and financial success, by      brand was built and promoted.          mainstream, urban, and Hispanic
 being self-reliant and being able to     Experts in the fields of advertis-     markets.
 weather the ups and downs of eco-        ing, general marketing, internet           Having achieved great success
 nomic cycles, several aspects of the     marketing, Web design, comput-         with its strong national brand de-
 practice needed to be addressed.         er programming, search engine          velopment and proprietary mar-
 They recognized that proficiently        optimization, media planning,          keting systems, USiC has entered
 assessing, diagnosing, and treating      media buying, television produc-       the next phase of growth. Through
 personal injury patients (see www.       tion, radio production, and law        membership in the USiC Network, was        were enlisted for assistance. As       we are offering the same opportu-
 necessary, but not enough, in build-     a result of this colossal undertak-    nity for professional and financial
 ing a personal injury practice. it was   ing, a national brand, US injury       stability to other chiropractors and
 not enough to be proficient in the       Centers, was forged that is omni-      healthcare professionals.
 provision of care to personal injury     present throughout the country             Find out more about becom-
 patients. A proficient practice will     on the Web and very prominent          ing a USIC network member
 die if no one knows it exists.           off the web in targeted states.        and adding a personal injury
      USiC wanted to attract at-              To promote the US injury           component to your practice;
 tention, 24 hours a day, 7 days          Centers brand, robust, and             800-397-1990.

   J u n e 2 0 12                                                                w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   23
          T E C H N O L O G Y T O D AY

            ICD-10: Keep Change from Costing You Money
                                                                                            By Brian Foster

            ost experts agree that the                                                   Both CMS and the American            Then there are the insurance
            switch to ICD-10, now                                                   Healthcare Information Manage-            companies that have vast informa-
            scheduled for Oct. 1, 2014,                                             ment Association (AHIMA) are              tion systems built around the use
is long overdue. But depending on                                                   trying not to sound any alarms. Both      of ICD-9 codes to support payments
whose study you read, the costs of                                                  organizations say using ICD-10 will       and justify denials.
switching could be significant.                                                     remove ambiguities and decrease the            And let’s not forget the hundreds
     It is impossible to deny that                                                  need to include supporting documen-       of vendors — from developers of
medicine and the nature of diag-                                                    tation when submitting claims. For        practice management software and
noses have changed dramatically                                                     doctors’ offices, this increased speci-   electronic medical records to the
over the past three decades. Physi-                                                 ficity is supposed to make it easier to   many billing services and revenue
cians, their staffs and their billing                                               assign codes correctly, which in turn     cycle management firms — that are
services need to be well-educated                                                   should result in fewer errors, fewer      all knee-deep in ICD-9 on a daily
and well-prepared so that the new                                                   unpaid claims and therefore fewer         basis. For software companies,
code set is used not to delay or deny                                               requests to resubmit claims with          ICD-9 codes are typically part of the
reimbursement, but to help improve                                                  supporting documentation. Sounds          logic used in various system com-
patient care.                                                                       logical, right?                           ponents or billing modules. Patient
     ICD-10 will force physicians                                                        But at least one study predicts      problem lists, appointment systems,
to be more specific than ever with                                                  claims using the new codes will           reports and more will be impacted.
how they code their patients’ diag-                                                 require more documentation, not                It also won’t be cheap for medical
noses. In some cases, there will be                                                 less, at a cost of tens of thousands of   offices to switch to ICD-10, accord-
dozens of new diagnosis codes to                                                    dollars.                                  ing to a study commissioned by a
choose from where there used to be                                                       Will Payers Need More or Less        coalition of national medical trade
only a few (ICD-9 has about 13,000                                                  Documentation?                            groups, including the American
total codes, version ten has 68,000).                                                    The current set of codes, the In-    Medical Association. Cost esti-
The new codes are now primarily                                                     ternational Classification of Diseas-     mates range from nearly $84,000
alphanumeric and contain seven                                                      es, Version 9, has been in place for      for a small practice to just under
characters, plus they are organized                                                 more than 30 years, and the U.S. is       $300,000 for a practice with 10
differently. For example, injuries are                                              actually years behind other countries     doctors. The study, performed by
grouped by anatomical site rather                                                   in adopting ICD-10. For example,          Nachimson Advisors LLC, points to
than injury category.                                                               the United Kingdom, France, and           typical factors contributing to these
     Why the added complex-                                                         Australia have all been using the         costs: staff training, superbill revi-
ity? According to the Centers for                                                   new version since the 1990s. ICD-10       sion, IT system changes, and cash
Medicare and Medicaid Services                                                      consists of two parts, but physicians     flow disruptions.
(CMS), ICD-9 is woefully outdated                                                   will only use ICD-10-CM, developed             But the study also predicts that
and ICD-10 better reflects modern                                                   by the Centers for Disease Control        analyzing payer contracts, dealing
medicine. The new codes will give                                                   and Prevention.                           with coverage determinations and
payers, regulators and analysts                                                          It won’t be easy shedding ICD-9.     “increased documentation costs” will
the ability to refine reimburse-                                                    Physicians use (and frequently            be significant challenges, warning
ment methodologies and conduct                                                      struggle with) these codes daily.         that “additional documentation could
public health surveillance more                                                     Technical schools across the country      be required to support a patient’s
effectively.                                                                        train and certify professional coders     treatment plan.”
     But what exactly does “refine re-                                              to work in medical offices, consul-            Out of all the factors cited by
imbursement methodologies” mean?                                                    tants have built valuable businesses      Nachimson, the costs of increased
The fear is that ICD-10 will give                                                   to help refine the codes chosen by        documentation contribute more than
payers new tools to delay and deny                                                  doctors, and there is even an associa-    50% of the predicted additional costs
reimbursements.                                                                     tion of certified coders (the AAPCC).                          continued on pg 27

24   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                     J u n e 2 0 12

                   Mobile Apps:
 10,000 Ways to Improve Your Health … and Counting
                                                  By Nick Martin

            obile “apps,” which may                                                          OptumizeMe makes it fun for
            have started as produc-                                                     users to achieve fitness, nutrition
            tivity tools – such as                                                      and lifestyle goals. It also provides
for email, calendar and database                                                        positive reinforcement by reward-
management – now include games,                                                         ing users with competitive chal-
GPS services, order tracking,                                                           lenge “badges” and capitalizes on
weight management and more.                                                             the proven benefits of peer support
Why? Apps make it easier to start,                                                      by encouraging users to network
track and accomplish tasks by                                                           with friends, family members and
reaching people on devices they                                                         co-workers. A July 2007 report in
enjoy using and integrating those                                                       the New England Journal of Medi-
tasks seamlessly into their daily                                                       cine demonstrated that healthy
routines. So, it is no wonder that                                                      behavior (as well as not-so-healthy
health and medical apps, one of                                                         behavior) spreads through social
the fastest-growing segments in                                                         connections – a key component of
app development, have enormous                                                          OptumizeMe.
potential benefits for consumers                                                             Other mobile apps such as
and the overall health system.            company is using apps to forge excit-       Health4Me can also help simplify
     According to Float Mobile Re-        ing new paths to engage consumers           how consumers access their health
search, Apple’s iTunes App Store cur-     in healthy behaviors in ways that are       information. Among the app’s many
rently offers more than 10,000 medical    as convenient as they are fun, and as       features is an “Easy Connect” option.
and health care apps. Nearly 80           educational as they are effective.          Users select the type of question they
percent of U.S. consumers are inter-           Some of the most popular health        have about their claims and benefits,
ested in mobile health solutions, and     apps today focus on empowering              and then request a callback on their
40 percent of physicians believe that     consumers to take a more active role        mobile device from a UnitedHealth-
mobile health technologies can reduce     in their personal health and health         care customer service representative.
office visits.                            outcomes. They can count calories,          The app also provides users with 24/7
     Health apps help engage con-         monitor migraine symptoms, track            access to a registered nurse; enables
sumers in their health and well-          exercise activity or send a medication      them to locate a nearby in-network
being. They take a targeted and           reminder. The common thread: these          physician, hospital or other medical
personalized approach to addressing       apps put consumers in charge of when        facility; and provides access to their
health issues and helping consumers       and how they manage their health.           personal health benefits information.
monitor and stay focused on their              For example, OptumizeMe, one                Mobile technology holds end-
progress. Apps can also help provide      of the first health challenge apps, en-     less possibilities to improve peo-
a complete and accurate snapshot          ables people to use their smartphones       ple’s health and make the health
of the users’ health and wellness,        to challenge others to health and fit-      care system more efficient and
giving users the power to make            ness goals, track their fitness progress    cost-effective.
more informed decisions about their       and post results on their Facebook®              So, the next time you wonder
health, and giving health profession-     page. Users can compete with co-            how you might improve your health,
als the ability to provide better care.   workers to eat five servings of fruits      remember: there’s an app for that!
     UnitedHealth Group supports          and vegetables each day or challenge a
use of technology to improve care         friend who lives across the country to      Nick Martin, Vice President of innovation, Re-
                                                                                      search and Development at UnitedHealth Group
quality and efficiency. Today, the        run 10 miles a week.
    J u n e 2 0 12                                                                   w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   25
26   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z   J u n e 2 0 12
IDC 10 continued from pg 24               services, doctors are warned not to           or your billing service will still be
                                          contract with companies whose sys-            dealing with the obsolete code set for
— an ominous warning and certain-         tems will soon be obsolete.                   several weeks, if not months. “That’s
ly contrary to one of the advantages          “What if you purchase new soft-           because the claims you filed before
that CMS says the new code set is         ware today, but in 2014 the vendor            the deadline used ICD-9, and you’ll
supposed to deliver.                      demands a huge fee to ‘upgrade’ to            still need to track those claims and
                                          ICD-10? And what if you refused to            be sure they are paid appropriately,”
wHat to BE waRY of                        pay that fee, what then?” warned              he said.
With a deadline more than two years       Chris Acevedo, owner of Acev-                       Between now and October of 2014,
away, physicians, administrators and      edo Consulting, a Delray Beach, a             it’s important that you prepare your
their staffs are taking baby steps to     Florida-based firm that specializes           practice for the ICD-10 switch and
prepare for ICD-10. The American          in compliance and coding. “Same               make the right decisions to be pro-
Association of Professional Coders        question for billing services — if they       tected from overpaying for the change.
(AAPC) only recently started offer-       are providing your practice software,         The code set transition likely won’t
ing “ICD-10 Bootcamps.”                   don’t contract with them unless they          be easy, but by educating yourself on
    But consultants are warning of a      are prepared to adopt ICD-10 with-            what to expect, you can make to move
turbulent switch to the new system.       out any additional costs to you. Get it       to ICD-10 a little less painful.
And because many practices are            in writing.”
adopting new technologies today,              Acevedo also warns that even              Brian Foster is a director of Client Solutions
                                                                                        at CareCloud, with over 20-plus years in the
such as electronic medical records or     though payers will stop accepting             healthcare industry; BFoster@carecloud.
upgraded revenue cycle management         ICD-9 on 9/30/14, your practice               com or 786-879-9200.

COMPENSATION continued from pg 9          group that has become paralyzed by            help convert a “win-lose” change in
                                          the compensation-related conflict.            the formula to a “win-and-stay even”
much. A longstanding misperception             By allowing expressions of individ-      outcome, or even (hopefully) a “win-
was corrected. This discovery helped      ual views, in confidential interviews         win” (total compensation pool grows,
lower the level of resentment towards     and questionnaires, there is a greater        so that all members of the group make
the high producer’s demands, and          chance that the new formula will have         more money).
helped facilitate a resolution.           “buy-in” by each shareholder. It’s a              By educating the consultant on
     Other important aspects of the       little bit like an election. You vote, you    your practice dynamics and inter-
process described above are:              have your say, but if the process has         nal workings, you will have a ready
     * The individual interviews,         validity, you must abide by and accept        resource to help with any problems
followed by discussion of the key         the outcome, which in this case the           that may arise in the future, without
internal dynamics of the group, on a      consultant’s recommendations.                 the time and expense of repeating
non-attributed basis, in the consul-           The consultant, having been              the process described above.
tant’s report, all serve to allow the     educated on the inner workings of                 In the end, the challenge of
shareholders to “vent” their frustra-     the practice, can suggest remedial            compensation planning is not devis-
tions and concerns (at first privately,   measures that the “loser” under the           ing an intricate formula with lots of
and then, in the group setting, on        new formula can take to improve his           bells and whistles. This is not rocket
a more limited basis) and are thus        financial outcome under the new for-          science. A good formula will be easy
“therapeutic.”                            mula. This can include financial sup-         to understand and implement. The
     * The proforma quantifies the        port from the group. For instance, if         challenge is determining which of
new formula’s impact on each share-       the new formula introduces a greater          the basic formulas is best suited to
holder. A pay cut which is quantified     production component, perhaps the             the group’s unique history, current
— even if the cut is significant — is     low producer needs additional outside         situation, and physician personali-
often less threatening than a pay cut     training to enable him to do a new            ties, and getting everyone to truly
whose dimensions are unknown.             lucrative procedure. Perhaps he needs         “buy-into” this new formula.
     The perspective and credibility      a greater marketing budget, to develop
of an experienced outsider, who has       a stronger flow of patients. Perhaps he       Daniel M. Bernick is an attorney, consultant, and
                                                                                        principal of The Health Care Group and Health
been involved with other medical          is being shorted in terms of technical        Care law Associates, P.C. in Plymouth Meeting,
groups, can help tip the scale to-        staff support. The consultant can eval-       PA. This article originally appeared in “Physicians
                                                                                        News Digest.”
wards one approach or another, for a      uate these various possibilities and
    J u n e 2 0 12                                                                     w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   27
A more personable approach on healthcare

                       Travel To Paradise
                                                         Surviving the Medical Marriage pg. 30
                                                                  Can Money Buy Love? pg. 31

28   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z        J u n e 2 0 12

                                 Travel To Paradise
                                                 By Susan Zellea

    f you are looking for a getaway                                                 the world’s most beautiful beaches?
    that offers the finer things in                                                 They can arrange that too. Getting
    life, there are many destinations                                               there is easy, as it is just a 15-minute
that would fit the bill. This article                                               ride from Providenciales Airport and
will give a few suggestions of resorts                                              luxury transports can be provided to
that might be just what you have                                                    the resort.
been searching for.                                                                      For those of you who are travel-
     One of these choices would be                                                  ling with a family and want a mind-
the Dominican Republic’s wonder-                                                    less vacation experience, head to the
ful resort known as Casa de Campo.                                                  newest hot spot in Mexico, the Riv-
This 7,000-acre resort caters to                                                    iera Maya which consists of 86 miles
those seeking adventure while still                                                 of gorgeous coastline. Flying into
having opportunities for R&R. It is                                                 Cancun (which is not in the Riviera
located on the southeastern coast                                                   Maya, but the main airport of the
of the island and offers numerous                                                   area) is available from most larger
categories of accommodations. There                                                 airports. The Paradisius and Dream
are guest rooms, suites, and villas                                                 Hotel choices are 4- to 5-star rated,
that are provided with its own four                                                 all inclusive and have great kids pro-
passenger touring cart to give you                                                  grams. The historical sights (Tulum)
the independence to zip around the                                                  and adventure opportunities (such as
expansive grounds. Guests such                                                      swimming with the dolphins) make
as Jay-Z and Beyonce, Alicia Keys                                                   it a great destination for families.
and LeBron James, frequent this                                                     These hotels offer family suites, as
resort and enjoy the activities, such                                               well as, standard hotel rooms with
as golf, hour long horseback tours,                                                 luxury amenities and wonderful all

For those of you who are travelling with a family and want a mind-
 less vacation experience, head to the newest hot spot in Mexico,
the Riviera Maya which consists of 86 miles of gorgeous coastline.
skeet-shooting, kayaking, tennis and      suites are the penthouses, which are      inclusive dining experiences. Your
excursions to nearby Santo Domingo        available in one, two, or three bed-      drinks, meals, gratuities and taxes
or Catalina Island. There are a           room options and range from 3,422         and fees are included in your pricing.
number of excellent restaurants on        to 3,791 square feet. The Regent Spa          There are many more destina-
the property including The Beach          is the resort’s “crown jewel,” with 17    tions that can be mentioned, but
Club by Le Cirque, an outpost of the      treatment rooms and the 90-minute         space does not allow. Don’t get
Maccioni family’s famous New York         Zareeba, indigenous island herbal         caught up with “cookie cutter” type
Restaurant. Getting to this resort by     steam cleansing, and detoxification       vacations. Speak with a travel pro-
air is easy, as many major airlines       being the most requested treatment.       fessional and find the right place for
fly to this island.                       The concierge team can arrange a pri-     your “dream” vacation.
     For luxury on a piece of paradise,   vate sunset sailing charter for VIP’s
the Regent Palms in Turks and Caicos      or arrange a day visiting uninhabited     Susan Zellea is owner and manager of Travel
                                                                                    with Sue-Z;;
just might be for you. Here, the best     cays. Want a romantic meal on one of      561-683-0044.

    J u n e 2 0 12                                                                 w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   29

                 Surviving the Medical Marriage
                                                                                           By Kristen Math

        he only thing that is certain                                               Many of the spouses are working          spend quality time with him. He was
        about the medical lifestyle                                                 through adjustments like yours, so it    tired and needed some downtime
        is change. Moves for medi-                                                  is easy to find an understanding ear.    (especially if he was post-call) and I
cal school, residency, and attend-                                                  2. Join a plaYgRoUp.                     ended up disappointed. Establishing
ing positions dominate a landscape                                                  If you have made the choice to stay      a group of friends that I could go to
peppered with call schedules, pagers,                                               at home with your children, then you     the movies with or going to an auxil-
and licensing exams. As my husband                                                  know how wonderful and stressful         iary meeting once a month gave me
prepared to finish a fellowship and                                                 this can be. Joining a playgroup is      time to get out and enjoy being with
move on to his first post-training                                                  the perfect way to meet other stay-at-   people. I felt more fulfilled and was
job, I remember trying to soak up                                                   home moms.                               less needy when my husband arrived
every last memory that I could of the                                               3. cREatE a nicHE foR YoURsElf.          home exhausted and headed for bed.
years that we had spent preparing                                                   One of the things that I found diffi-    7. spEaking of tHE BEd…
for this time. I wanted to memorize                                                 cult during my husband’s training is     Don’t forget to nurture your rela-
the landscape of the life that we had                                               that the focus seemed to be complete-    tionship with your spouse there.
been creating.                                                                      ly on the resident and their life and    Enough said.
     We brought three children into                                                 accomplishments. I sometimes found       8. co-op witH a fRiEnd.
the world during training and had                                                   myself feeling envious and resentful.    I found it difficult to find a sitter for
somehow managed to survive the                                                      We make a lot of sacrifices for our      my children when I had an appoint-
grueling pre-80 hour work week                                                      spouses to accomplish their goals        ment or an errand to run. A friend
residency and fellowship with our                                                   and sometimes it can be frustrating.     and I came up with a wonderful
marriage intact. We had reached the                                                 I decided to go back to school part-     child-swapping solution — you watch
end of training … passed the goal                                                   time. This gave me something im-         mine, I’ll watch yours. It worked out
line … and the paradox was that                                                     portant that I was doing for myself.     great and it was free! The best part
even though I thought I had been so                                                 It really helped to bring me out of a    of all, was knowing that my children
miserable, saying good-bye to friends                                               slump and give me some direction as      were with someone that I trusted.
and moving on to the next step was                                                  we settled into our new lives.           9. BUdgEt.
harder than I had ever imagined.                                                    4. coMMUnicatE.                          The biggest adjustment that we
If anyone would have told me that                                                   Talk with your spouse about how          made after training ended was
the end of training would bring on                                                  they are managing all of the chang-      financial. I think we had an idea
nostalgia and sadness, I wouldn’t                                                   es. Share your feelings too. This is     in our minds that the first attend-
have believed them. This was part of                                                a stressful time for both of you and     ing paycheck would solve all of our
the journey of our lives and I wasn’t                                               working through it together will help    problems. It took some time for us
ready to let it go.                                                                 keep your relationship strong.           to come up with a reasonable work-
     As I settled in to the post-train-                                             5. go oUt togEtHER.                      ing budget that allowed us to pay off
ing life, I found that the tools that                                               Make time to go out alone with your      student loans, make a modest house
had gotten me through residency and                                                 spouse once a week if you can. Hire      payment, and still have a little left
fellowship still applied. Adjusting to                                              a babysitter if you need one, but take   over each month. Don’t forget to keep
change can be challenging. Here are                                                 time out for yourselves.                 budgeting when training ends.
some of the things that helped me                                                   6. go oUt on YoUR own.                   10. ExploRE YoUR coMMUnitY.
along the way.                                                                      This was a hard one for me. Initially,   When my husband was finishing his
1. gEt involvEd in YoUR local                                                       I found that I wanted to spend any       fellowship in Florida, getting out
MEdical spoUsE gUild.                                                               moment where my husband was              and discovering new beaches to take
I can’t emphasize this enough. The                                                  home with him. What ended up             the kids to was a favorite pastime
auxiliary is an excellent place to                                                  happening is that I would wait for       of mine. There were so many fun
meet people from all walks of life.                                                 him to get home and then expect to                             continued on pg 33

30   M e d i c a l E x c h a n g e | w w w. m e d i c a l e x c h a n g e . b i z                                                                     J u n e 2 0 12

                                   Can Money Buy Love?
   When Working Parents Pay for the love of Their Children
                                                    By Rafiah H. Prince

         fter graduating from                                                                        family. This means setting up a
         the Ivory Towers we                                                                         work schedule that is conducive
         start our careers. The                                                                      with maintaining quality of
old saying says “hard work                                                                           life. This includes taking a day
pays off.” While many of us                                                                          off to see your son or daughter’s
may shine at work it means                                                                           soccer game or surprising them
long hours, travel, and time                                                                         by picking them up after school
away from the people that                                                                            for a bike ride. These moments
we love. The main reason                                                                             may seem small, but they are
why many of us get up in                                                                             priceless and may stay with
the mornings and tackle the                                                                          your children as they grow up.
daily grind is to ensure that                                                                        For some professions where this
we provide the basic needs                                                                           is more difficult, you may need
for our families and live a                                                                          to step out of the box and be
lifestyle that affords us happiness.           In addition, it manifests the idea that       creative with your time. We are lucky
The balance between work and family            materialistic objects bring happiness,        to live in a time where communica-
at times can get complicated and this          and that the importance of the rela-          tion comes in many forms. You want
idea of happiness can become fleeting.         tionship between the parent and child         to create a presence in your children’s
The very things that bring us the most         can be equated to a monetary value. It        lives. They need to know that you
happiness like spending time with our          becomes easy to get stuck in a cycle of       care, so checking in with your child
children are limited to brief encoun-          spending more to show that you care           can be helpful. This can be done by
ters. The more we become consumed              that much more; or the extra a parent         text, call, email, Skype, and facetime
with our businesses and careers the            works, the more they have to spend to         when you cannot be there.
more distant we may feel from our              show that they care. In this cycle the
children. It is common to feel guilty.         very act or noble intent gets lost —          conclUsion
We fear that our children will not love        which is the care and love for your child.    While the routine of compensating
us the same or see us as bad parents.          While you may spend and buy many              your children with money instead of
Because of this many, parents fall into        gifts for your children, memories and         time may feel like a wild animal that
using money to compensate for the              quality time spent is priceless.              cannot be tamed you can close your
lack of time with their children.                                                            wallet and start to open your arms.
                                               How to cHangE it                              As a parent, you take the lead in your
wHat tHis MEans foR faMiliEs                   The first step in changing this be-           household. Your primary job is to
Many working parents use money                 havior is to admit that it is going on.       teach and provide for your children,
to make up for the time that they do           Be mindful of your role as a parent           so that they become productive adults.
not spend with their children. Work-           and tell yourself that you are ready to       This means it important to be mindful
ing parents may buy expensive gifts,           change it. It’s important that you open       of one’s roles as parents and how we
cash, video games, expensive cars, and         up the lines of communication with            set the foundation for positive relation-
designer clothing. While these things          your children and establish realistic         ships for our children.
bring instant happiness to a child and         goals towards building a healthy rela-
allow for the parent who is giving the         tionship. It is important to establish        Rafiah H. Prince is a marriage and family therapist;
gifts to feel relief, it can be short lived.   a healthy balance between work and
     J u n e 2 0 12                                                                         w w w. m e d i c a l e x c h a n g e . b i z | M e d i c a l E x c h a n g e   31
Classifieds                                                                         To place a classified ad please contact the classified department
                                                                                    305-820-1119 or email

Medical Recruitment:                                          Medical practice for sale/ lease         chiropractor Recruitment                percentage based pay. if you want
                                                                                                                                               to practice in a beautiful, estab-
Director of Nursing for Home                                  Medical Practice-Primary Care            Seeking a full time Chiroprac-          lished office without the financial
Health Agency                                                 with Weight Loss program                 tor for office in Ponte Vedra           obligations of rent/payroll/utilities,
Growing HOME HEAlTH AGENCy                                    located in Town of 15,000                Beach, Florida 32082. We have           etc., this is the ideal position for
in MiAMi-DADE has an immediate                                residents northwest of Gainesville,      a wellness based office treating        you. Must already have Fl license.
position available for a DON Direc-                           Florida. One of only two prac-           mostly families. Practice is patient    Call (813) 659.2694
tor of Nursing. Experienced DON                               tices in the area. Five mins from        referral driven. We use primar-
Director of Nursing full time, part                           county hospital. Full qualified staff    ily diversified technique. We are
time or per-diem. We seek a de-
pendable, caring and self-motivated
                                                              in place. Major payers are BCBS
                                                              and Medicare. Facility has been
                                                                                                       located about 30 Miles south of
                                                                                                       Jacksonville, Fl.
                                                                                                                                                   Recruit a
professional to join our staff and                            completely renovated. 6 fully                                                      provider, sell
                                                                                                       Brian Torchin send resume
provide the highest quality home
health care to our community. you
                                                              equipped exam rooms, one set
                                                              up for minor surgical procedures,        to 800.263.1547 or call me at             your Medical
must have a current Florida State li-                         4 prvt offices, waiting/file rooms,      267.251.5275                              Equipment or
cense for at least one year. We pride                         lab and kitchen. Seller is offering
ourselves in offering flexible hours                          extraordinary seller terms for this      Great opportunity to join an              practice with
and very competitive pay.                                     successful practice. Practice gross
                                                              of $774K. Contact David Greene
                                                                                                       established, busy chiroprac-
                                                                                                       tic practice in Plant City, FL
                                                                                                                                                  a classified
Please e-mail us or fax your                                  (719) 487-9973                           (suburb of Tampa).                        Ad in Medical
resume to 305-826-5075. In-
clude your phone number and                                   Medical Equipment for sale
                                                                                                       Owner/DC stays booked and has
                                                                                                       outstanding reputation in area.
the best time for us to call you.                                                                      Friendly staff and beautiful 4000
We will try to accommodate                                    Vital Signs monitors for sale
your specific work preferences.                               BP, SPO2, TEMP, EKG, EtCo2 start-
                                                                                                       sq ft clinic in great location. Eight
                                                                                                       treatment rooms, lab, huge waiting
                                                                                                                                                Medical Exchange
You may also call Ana at 305-                                 ing at $1000 Call 727-455-8160           room, 3 restrooms, etc. Fully fur-        reach over 80,000
824-3777 if you have questions                                                                         nished & equipped except iC must            physicians, top
                                                              Therapy Equipment                        provide his/her own table. New           hospital executives,
Health Care Workers                                           low volt galvanic muscle stimu-          iC/associate needs to be skillful,
Seeking Home Health workers in                                lator, like new 500, Full spine          possess a great patient-dr manner
                                                                                                                                                 midlevel provides,
South Broward area, with one year                             Xray viewbox 125, Shoulder               and be hard-working, dedicated,              chiropractors
minimum experience required for                               ladder 75, Shoulder rehab                outgoing and energetic. you will            and more in the
all applicants. Spanish Speaking a                            wheel 200, Dumbells 1- 10 w              be building your practice within
                                                                                                                                                  State of Florida.
plus. Applicant can send resume to                            wall rack 125 Call Dr. Schleter          a practice, so networking skills a
954-578-1772                                                  (954)294-4420                            must. independent contractor/

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MARRIAGE continued from pg 30                           too. Looking in the local papers and          through the ups and downs that are
                                                        asking new friends and neighbors for          inherent to the medical lifestyle.
playgrounds and family activities to                    suggestions helped me to find the fun         Good luck on your journey!
enjoy. The hardest part about him                       family activities that I was craving.
accepting a post-training job in Min-                       It has been eleven years since we         Kristen Math is the founder of the international
                                                                                                      Medical Spouse Network (www.medicalspouse.
nesota was saying good-bye to those                     traded in the beaches of Florida for          com) and author of the book “Surviving Resi-
beaches and parks. As I began to                        the ice and snow of Minnesota win-            dency: A medical spouse guide to embracing the
                                                                                                      training years.” She earned her MS in Molecular
explore Minnesota though, I dis-                        ters. The transition took time, but           Biology from the University of Florida, and she is a
covered that there are beaches here                     we still use the 10 tools to navigate         “stay” at home mom to five busy children.

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                                                                                     18520 NW 67th Ave., Suite 278

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                                                                                     Hialeah, FL 33015

                                          18 52 0 N W 67 t h Ave., S ui te 278 Hiale ah, FL 3 3 015
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