Member Matters v o l u m e
In this issue: Business of Medicine - Timeshares: Not just for vacations
Why Social Media? - Why Not?
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About
the
Cover Photo
State Rep. Mark Veasey and Val Gibson, MD, of Metropolitan Anesthesiology Consultants, at a physician fundraiser for Veasey’s congressional campaign.
Dallas County Medical Society PO Box 4680, Dallas, TX 75208-0680 Phone: 214-948-3622, FAX: 214-946-5805 www.dallas-cms.org Email: lauren@dallas-cms.org
DCMS Communications Committee Roger S. Khetan, MD.............................................. Chair Robert Beard, MD Gene Beisert, MD Suzanne Corrigan, MD Seemal R. Desai, MD Daniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MD C. Turner Lewis III, MD David Scott Miller, MD
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Pr es i de nt’s Pa ge The “R” Word
DCMS Board of Directors Richard W. Snyder II, MD.................................. President Cynthia Sherry, MD..................................President-Elect Jeffrey E. Janis, MD..........................Secretary/Treasurer Shelton G. Hopkins, MD.......... Immediate Past President Mark A. Casanova, MD Wendy Chung, MD R. Garret Cynar, MD Sarah L. Helfand, MD Michael R. Hicks, MD Rainer A. Khetan, MD Todd A. Pollock, MD Kim Rice, MD Christian Royer, MD
DCMS Staff Michael J. Darrouzet................... Chief Executive Officer Lauren N. Cowling................................ Managing Editor Mary Katherine Allen........................... Advertising Sales Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS
According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Michael J. Darrouzet, Executive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.
Dallas Medical Journal (ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.
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DCMS Ne twor ki ng S oci al Photo s
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Why S oci al Medi a ? Why Not?
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Bus i ne s s of Medi ci ne Timeshares: Not Just for Vacation
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Communi ty The Tragedy of Unmanaged Commons
Subscription rates $12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.
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submit letters to the editor to lauren@dallas-cms. org visit us online at www.dallas-cms.org • November 2012 •
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The “R” Word
President’s Page
No, not Radical or Republican. Not Redistribution or Realignment. Not the Rich, Romney or Ryan. Not even Readmissions, Re-credentialing or Re-certification (although don’t get me started; I could write a whole President’s Page on that one). The R word I am talking about is Rationing! There, I said it! So far, so good. I haven’t broken out in a rash, cold sweat or started to wheeze, but we’ll see how this goes. In healthcare reform, the Rationing R word is so devastatingly toxic, so nuclear that it has tanked many political careers and many attempts at healthcare reform. Hillary Clinton’s efforts at healthcare reform in the early ’90s initially come to mind. Thunderous echoes of “Death Panels” are still fresh and reverberate across the spectrum of digital media discourse. Perhaps no issue in American politics so polarizes our nation. Yet it is exactly this divide that we must cross if we ever are to have meaningful reform. As I write this President’s Page, we are just two weeks away from the US Presidential election, an inflection point that will decide which direction our on going healthcare reform will follow. Both parties agree that change is a must. However, irrespective of the the divergent political rheotoric or even the outcome of the election, the establishment of limits to what is paid for by government funded health plans is an inevitable, un-welcome truth. Effective health system reform never will manifest unless rationing (or whatever one wants to call the concept) is a key element, be it legislative or regulatory. Now, many of you know me to be fairly conservative in my political outlook, so you know I don’t make that statement lightly! A veritable economic tsunami of crushing costs of medical care is crashing toward us. The numbers speak for themselves and are very sobering. Total healthcare spending in the United States is between 18 percent and 19 percent GDP. That equates to $2.6 trillion, or roughly $8,000 per person. Some have estimated that, conservatively, total healthcare spending could grow to 30 percent of GDP by 2030. The federal government’s spending on health care consumes 4.8 percent of the nation’s economic production and is expected to eat up 9.2 percent in 25 years, according to estimates from the Congressional Budget Office. All this is before the advent of Obamacare and Medicaid expansion. This growth rate clearly is not sustainable. Our modern word “rationing” is derived from the Latin “rationem,” meaning a “reckoning, calculation or proportion.” In 1550, it meant “reasoning.” In 1666, it began also to be used as the relation of one number to another, as in ratio. In 1702, the French used the word as a “fixed allowance of food.” All these examples and derivative meanings refer to something finite and limited. Today, “rationing” is defined as the controlled distribution of scarce resources, goods or services. Health care is a scarce resource and all scarce resources are rationed in one way or another. Our current system of health care is no different. Rationing is alive and well in the US healthcare system in 2012. Those who feel that rationing is absent in our country are just kidding themselves. It is an illusion that many so desperately try to protect. Rationing is so commonplace and familiar that we don’t recognize it as such. Rationing of health care occurs because we have limited resources, be it providers, money, supplies, or hospitals.. The most obvious example is transplantation, which has faced rationing for decades. In cardiac transplantation, for example, 2,000 to 2,200 hearts are transplanted each year in the United States, although the actual potential recipient pool of endstage heart failure patients dwarfs this number at a conservatively estimated 100,000. Each week around the country, transplant teams of physicians, nurses and coordinators present potential
candidates for listing in an exquisitely regulated organ rationing system. This process is in place because of the obvious limitation of a scarce healthcare resource (the donor heart); similar processes are in place for other solid organs. Even if an organ is available, candidates for this waiting list must pass financial muster. Transplant committees must consider the short- and long-term financial scenario of the candidate. It is routine for the patient’s financial status to be presented along with the clinical information in making the decision whether to list. If the insurance plan fails to cover the full costs of the expensive long-term immunosuppressive meds, transplant committees must take this into consideration and limit (i.e., ration) the availability to this list, so as not to waste the full potential of transplants. Under rare occasions of enhanced need, hospitals and blood bank systems ration the availability of certain blood types to the most ill. When hospital beds are full, bed availability informally is rationed through curbside communication among the intensivist, admitting physician, ED physician, on-call nursing supervisor, and bed control. Similarly, many communities have mass casualty plans in place should a disaster such as an H1N1 epidemic, a Katrina or a dirty bomb strike, and limited ICU beds have to be rationed among victims. The well-recognized tradition of triage is a formal process of rationing that is performed in almost all urgent and emergency care settings. Through triage, clinicians ration patient treatment efficiently when resources are insufficient for all to be treated immediately. Clearly, medical rationing (the controlled distribution of a scarce resource) is firmly embedded in what we do on a daily basis. We also cannot ignore other limited resources — specifically, money and doctors — that are required to deliver health care. As indicated previously, our current trajectory of healthcare spending clearly is not sustainable. Our financial resources are finite. We also have a physician shortage of 50,000 in this country, and the American Association of Medical Colleges predicts that by 2025, that number will swell to 130,000. The most common examples of rationing in US healthcare however are implicit, and, as such, are not readily recognized. Or perhaps more realistically, the truth is that we don’t want to consciously and publically acknowledge that rationing is occurring. To borrow a quote from the movie “A Few Good Men,” “You don’t want the truth because deep down in places you don’t talk about at parties,...” Prior-authorizations and co-payments are rationing tools designed to discourage and limit the delivery of care. Rationing takes place whenever an insurance company denies a treatment. Self-rationing occurs when a patient chooses an over-the-counter remedy for symptoms instead of going to the doctor where they will have to pay a co-pay. Access to our broader healthcare network is rationed under the guise of money and time. We’re all familiar with the expression, “Time is money.” That is exactly how we pay for the health care we receive — by spending our money and our time — and often-in combinations in inverse proportions. Those who have money (or access to money through insurance) receive health care, while those who don’t go without or must wait a long time to access the system. And the more money you have, the more healthcare services you can consume, and faster. Those who have no money or are covered by poorly paying insurance plans must pay for their care with their time, be it a long wait in an ED or a long wait for an appointment to see a private physician or one in a charity clinic. Many physicians limit the number of patients they see from poorly paying plans such as Medicaid, with openings for new patients available only months in the future. According to a 2009 Merritt Hawkins report, the average wait time is 2 months for a new patient primary care visit in Massachusetts, which, ironically, is the only state that offers universal health coverage. In the rest of the country, the wait averages 3 weeks. As I have said many times, coverage is not
Richard W. Snyder II, MD
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President’s Page the same as access, and access to a waiting list is not access to health care. In Texas, only 19 percent of primary care physicians in Dallas County accept new Medicaid patients, and that number is in a free fall, even before a possible Medicaid expansion. In a few years, how long will a patient have to wait to see a PCP under a Medicaid plan in Dallas? The current mantra in the political healthcare world is “the right patient, for the right treatment at the right time.” Timeliness of health care is getting as much attention as the quality, and appropriately so. The time element in health care is definitely a quality factor. The longer one has to wait to access the system, the greater the chance for a poor outcome. On the other end of the spectrum, an extreme form of rationing that is increasingly prevalent for those who can afford it is the concierge system. For on average $1,500 to $2,000 a year, individuals can eliminate the time component in the healthcare payment system and have almost immediate access to physicians, either through a same-day office visit, or digitally via e-mail or phone. The problem with this system is that instead of carrying the typical 2,500 patient caseload for the average PCP, concierge physicians limit their patients to around 750 patients. This worsens the physician shortage, creating even longer wait lists for those whose lack of funds limits their access to the system. Again, that same law of healthcare economics is preserved: money and/or time. Total access to health care over the short term is a fairly fixed dynamic, and is more or less a zero sum game. Increasing access to one group through a concierge system decreases access to another group with traditional insurance. We do ration health care in this country, and we must come to grips with that reality. We must acknowledge that our system of rationing is one of the most unfair and most inefficient in the world. “Fairness” arguments are made from both sides of the consumer spectrum. We all are familiar with arguments of how “unfair” it is that some people have limited access to health care and others do not. But passionate arguments also can be made about how “unfair” it is to spend 30 percent of our limited healthcare financial resources (Medicare) on patients in the last year of life, and that these dollars could be spent more “fairly” and “efficiently.” Another type of inefficiency in healthcare rationing in the United States is the ubiquitous “prior authorization” song and dance that we physicians must go through for most any diagnostic or therapeutic procedure we want to do for our patients, just short of blowing their nose. Every day, my fax machine is filled with medication pre-auth form requests that drive me crazy. These “processes” are put in place to serve as barriers that limit (ration) the diagnostic and therapeutic services that we provide for our patients. Our time is much better spent providing care as opposed to dealing with this inefficient rationing exercise. As I like to say, “more patient, less paper.” The real question I pose for society, politicians and physician providers is, are we going to keep our head buried in the sand, ignore the facts and accept this underground system of implicit rationing with all its issues of fairness and inefficiency? Truly, American-style medical rationing is the dirty little secret of US healthcare, our own medical version of “don’t ask, don’t tell.” Or are we going to drag this issue out of the closet and face reality that we do ration care in the US, albeit implicitly? We must address this problem openly and directly by replacing our current system of implicit rationing with a system of explicit rationing through government funded health plans which would set limits on what would be paid for that is more efficient, transparent, and dare I say more fair. How would we do this? Many look abroad for models of health system reform that our country should adopt. The secret to these systems is that they openly address and embrace a system of organized rationing (controlled distribution of a scarce resource) at a societal level. Economic tools such as the Quality Adjusted Life Year have been developed to assist in this
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direct and active system of rationing. These rationing decisions are made by weighing the cost of the treatment against the potential improvement in the insured’s health. The problem is this parameter incorporates a societal value element into the calculation, and that can vary by culture, country, state, and even time, and can be very subjective. For example, The United Kingdom has NICE, the National Institute of Clinical Excellence. (Gotta love that acronym especially when dealing with a subject such as rationing!) The UK has established cost-effectiveness limits using the QALY metric for therapies beyond which its publically funded government health system, National Health Service, will not venture. For NICE, in dollars, that limit is $50,000 for QALY. To put this in perspective, in the United States, annual PAP smears for low-risk women have a QALY value of $700,000; yearly mammograms for women aged 40– 49 roughly is $150,000, and dialysis is $50,000. Another example is the booming surgical therapy for endstage heart failure: left ventricular assist devices. In 2011, the QALY figure for this device is roughly $170,000. Remember, there is a conservatively estimated 100,000 patient yearly market for this device just in the US. Using the NICE guideline, the procedure would found not to be cost-effective compared to medical therapy and would not be paid for, even though it clearly is life saving. Is this appropriate, or, dare I ask, moral? Would this be right for our country? And how and who would make these decisions? I don’t know, but at least the Brits acknowledge the limits of their resources and are addressing them. Let’s admit it; we physicians at times shake our heads with exasperation when considering the appropriateness of offering expensive life-extending therapies to terminal patients who have limited duration and quality of life. Our recent Affordable Care Act directly implemented a fairly profound mechanism of rationing, although many will deny that is indeed what it is. The Independent Payment Advisory Board (or IPAB — think MedPAC on steroids) will use comparative effectiveness research to help determine payment levels for various interventions. Labeled a “death panel,” the IPAB has been a political hot potato. Say what you may about Obamacare, at least the authors recognized the necessity of incorporating an element of rationing into the reform effort. Is this the right path to institutionalized rationing for our country? Can society accept the controlled distribution of scarce medical resources provided by government funded health plans? This is not a simple subject to address. We as a society do not do well with government control, always fanatically clinging to an entitled sense of choice. For physicians it will have to involve acceptance in more equal measure a sense of duty not only to the patient, but also to society as a whole. The patient-physician relationship cannot exist in a vacuum. However, I firmly believe it is a discourse that physicians should be at the forefront at both the national and individual patient level. Nonetheless, it is difficult to have a comprehensive discussion on this topic if we cannot even accept that we have limits to what we can provide as a society in regard to health care. We must be able to wrap our arms around the fact that we cannot provide everything to everyone all the time. It is even more difficult to envision effective healthcare reform if we cannot openly and transparently discuss the controlled distribution of ever scarcer medical resources — rationing — without being demonized. It doesn’t matter if you are an R, or a D, meaningful health system reform will not be realized until we as a society, and especially we physicians, accept the idea of rationing the very precious and limited resource that is health care. The discussion must begin with the de-stigmatization of a reality, of an unwelcome truth. We first have to be able to use the entire word — not just one letter. (See, that wasn’t so bad. I didn’t implode or spontaneously combust!) Follow Dr. Snyder on Twitter @DCMSPres!
My Medical Society. My savings.
My Member benefits.
THE HEART HOSPITAL Baylor Plano:
Innovative Heart Care at Its Highest Rating
THE HEART HOSPITAL’s Cardiac Surgery Program has earned the highest national ranking – three stars – from The Society of Thoracic Surgeons (STS), an honor that puts us at the forefront in clinical quality. Our cardiac surgery program is ranked in the top 3% in the country for aortic valve replacement procedures and the top 14% nationwide for coronary artery bypass graft procedures. At THE HEART HOSPITAL Baylor Plano, we are patient-centered and quality driven. Earning the three star rating is a true testament of our commitment to medical excellence and positive patient outcomes. Thanks to our highly-skilled and dedicated heart team, we continue to be one of the top 10 largest cardiothoracic surgery programs in the country.*
For more information, call 1.800.4BAYLOR or visit TheHeartHospitalBaylor.com. 1100 Allied Drive • Plano, TX 75093
*Source: TRG Health Care Solutions, Denver, Colorado; based on patient volume The Society of Thoracic Surgeons developed a comprehensive rating system for the quality of cardiac surgery among hospitals across the country. Approximately 12-15% of hospitals received the “3 star” rating, which denotes the highest category of quality. In the current analysis of national data covering the period from January 1, 2011 through December 31, 2011, the cardiac surgery performance of the hospital is established in the highest quality tier, thereby receiving an STS three star rating. The STS National Cardiac Database measures outcomes on over 95% of the 1,100 cardiac surgery programs in the U.S. Notice Regarding Physician Ownership: THE HEART HOSPITAL Baylor Plano is a hospital in which physicians have an ownership or investment interest. The list of the physician owners or investors is available to you upon request. Physicians are members of the medical staff at one of Baylor Health Care System’s subsidiary, community or affiliated medical centers and are neither employees nor agents of those medical centers, THE HEART HOSPITAL Baylor Plano or Baylor Health Care System. ©2012 Baylor Health Care System BID_THHBP_390 9.12
D C M S It was a
N e t w o r k i n g house at Gordon Biersch
S o c i a l on Sept. 27.
full The conversation was flowing and business cards were shared among the 60 DCMS members who attended the DCMS Networking Social.
visit us online at www.dallas-cms.org • November 2012 •
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Accountant (CPA) / Tax Services
Legal Services
Paula Allgood, CPA……Beaird Harris & Co, P.C. 972.503.1040……PaulaA@bh-co.com
Michael H. Saks……Wright, Ginsberg, Brusilow, PC 972.788.1600……msaks@wgblawfirm.com
Lori A. Eads, CPA……Bland, Garvey, Eads, Medlock + Deppe, P.C. 972.231.2503……leads@taxsmart.com
W. Darrell Armer*……Looper, Reed & McGraw, PC 214.922.8923……darmer@lrmlaw.com *Board Certified-Health Law by The Texas Board of Legal Specialization
Design / Build Medical & Dental Contractor Grady Herzog……Structures & Interiors Inc. 817.329.4241……gherzog@structures-interiors.com
Electronic Medical Records Leslie Warren……EMR Advisory Group 972.898.5671……lwarren@emradvisorygroup.com
Employee Benefits Amy Rickman……Lockton Dunning Benefits 940.384.2720……ARickman@lockton.com
Financing / Banking Gary West……BB&T 469.791.4502……GMWest@BBandT.com
Marketing / Public Relations Barbara Steckler……Concepts in Medical Marketing 972.490.7636……barbarasteckler@yahoo.com
Medical Malpractice / Commercial Insurance James Patterson, CIC, AAI……Agapé Healthcare Partners Metro 817.329.4200……jim@agapeins.com
OSHA Compliance Jessica James 469.360.1367……jsscjames@aol.com
Personnel Recruitment
Financial / Estate / Insurance Planning
Jan Harris, CPC……J. Harris Co. Personnel Services Inc. 214.369.9545……j.harrisco@verizon.net
Mark A. Trewitt, CFP®, CLU, ChFC, AEP Integrated Financial Solutions Group 972.312.1337……mark@ifsgllc.com
Practice Management / Billing / Consulting David Loomis……The Health Group 972.792.5700……dloomis@thehealthgroup.org
Healthcare Furnishings
Promotional Products / Wearables / Filing Systems
Lisa Locke……bkm Total Office of Texas, LLC 214.902.7215……llocke@bkmtexas.com
Nance Lindstrom……Safeguard Business Systems & Promotional Products 972.596.8282……rich.nance@verizon.net
Healthcare Interior Designer Laura Ginsberg……Medical Space Design, Inc. 972.566.6771…….lauraginsberg@msddallas.com
Real Estate (Healthcare) M.W. (Hugh) Resnick……Pizel & Assoc. Commercial Real Estate 972.404.0008……hugh@pizel.com
Telecommunications Charlie Hubbard, PMP……HUBCO Communications, Inc. 469.293.3081……chubbard@gohubco.com
Power Up Your Practice. Contact the professionals behind the professionals.
w w w. d o c t o r s r e f e r ra l s e r v i c e . c o m
why social media? In November 2009, the Dallas Medical Journal published an article titled, “Social Media and Medicine.” At the time, Twitter was in its infant stages and Facebook had not gone public. Today, Twitter and Facebook are two of the most visited Web sites across every age bracket and demographic group. This begs the question: Are you on Facebook? Are you a blogger? Do you tweet? Are you linked in? Do you click on QR codes? Do you know what all this means? Social media (or even “new” media to some) usually is defined as the online tools that people use to share content, profiles, opinion, insights, experiences, perspectives, and media, thus facilitating conversations and interaction online among groups of people. The two main participants in social media are the sender of information and the recipient of information. The commercial market has recognized the value of engaging customers through social media. Are you and your practice reaping the same benefits? Most people first turn to the Internet when seeking information. One could assume that the first place people turn when seeking information about health care or healthcare providers also is the Internet. If you don’t have an online presence, you risk someone else creating that presence for you. The most common excuse for not being active on a social media site is, “I don’t have anything to say.” But you don’t have to “say” anything to create an online presence. Information from trusted news sources, your county medical society, and even your patients could be helpful to your audience. Using social media enables you to capture and engage patients you might otherwise miss. The proliferation of social media is not simply a phase; it’s here to stay. Follow DCMS on Twitter @DallasCMS. Follow the DCMS President on Twitter @DCMSPres “Like” us on Facebook at www.facebook.com/DallasCMS
FIRST TUESDAYS Join physicians from across the at the CAPITOL state for First Tuesdays during the 2013 legislative session. YOU can Tuesday, Feb. 5 Tuesday, March 5 Tuesday, April 2 Tuesday, May 7 www.texmed.org/firsttuesdays
lobby legislators on issues important to medicine and your practice. YOU can make a difference.
For more information or to sign up, contact Tracy Casto, director of legislative affairs and advocacy, at 214.413.1427 or tracy@dallas-cms.org.
visit us online at www.dallas-cms.org • November 2012 •
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Business of Medicine
Timeshares
n o t j u s t fo r v a c a t ion s
By Rebecca Harrell
The process of leasing a medical office can be complicated and fraught with issues that result in longlasting and expensive mistakes. One way to avoid this? Lease a timeshare. Medical timeshares, where physicians share space on a short-term basis, have been around for years. Declining reimbursements and economic pressures are leading physicians to seek ways to reduce fixed costs. As physicians look for ways to expand their practices and save money, timeshares have become more popular. Their appeal is that vacant space can be leased on a short-term basis — by the hour, the day, the week, or the month. Some large multitenant buildings have built out an entire floor to be leased as a timeshare space, much like an executive suite (but without the staff). The landlord provides access to a private mailbox, faxing, photocopying, conference rooms, and other support services as part of the package. As with executive suites, timeshares can help project the image of a professional operation at a more affordable cost. Timeshares may be attractive to newly employed physicians who have time remaining on their office leases, and to a group practice if extra space is available because one or more physicians retires or leaves the practice. The transition to electronic medical records is leaving empty rooms where paper charts were stored. Lessee Benefits For physicians who are looking for space to rent, timeshares are attractive to “test the water” before signing a long-term lease and funding the associated capital costs. Physicians who would benefit from this arrangement are those who are: • Considering opening a satellite office in a new market • Relocating to a new city • One to 2 years out of residency and want to ensure the practice will be successful before committing to an area for the long term Physicians whose income growth rate is unpredictable because they are unsure how much their practice will grow and how frequently they will get referrals would benefit from a short-term lease arrangement. Physicians unsure of local market conditions may want to test the best combination of practice elements in order to maximize growth. These would include: • Trying out different locations • Varying office space plans and layouts to obtain greater efficiencies • Hiring the personnel they think they need • Selecting the laboratories that will perform their tests • Setting office hours and fees specific to location Solo- or small-group practice physicians who need to establish long-term relationships with patients, such
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• November 2012 • Dallas Medical Journal
as primary care physicians, internists, pediatricians, and obstetricians/ gynecologists, may not be the most appropriate candidates for this type of arrangement. Lessor Benefits If a practice is not fully utilizing the space it occupies, subletting or leasing the space to physicians. This will help both the lessor and lessee cut overhead costs. Subleasing to other physicians also can aid with referrals. Physicians who refer patients to subtenants are not required to offer information about the arrangement, but, because of regulations governing referrals, one should avoid the appearance of impropriety. Cross-coverage can be another benefit of timeshares. If the physician leases to others in the same specialty, physicians in the lease arrangement can agree to see each others’ patients when needed. Physicians in this arrangement can increase their patient load. For physicians who need to expand their practice, subleasing part of the office for a few hours or days each week may offer additional revenue and help with expenses until new members are on board. Other ancillary benefits William Abramovits,MD, a Dallas dermatologist, considers subleasing as a first step in his process to find a future partner. He’d like to find a younger physician with whom to partner and who could take over his practice when he retires. Some physicians who have expressed interest in subleasing have shown the potential to become partners. “Besides the financial gain, subletting assists me with finding the right physician,” he says. “With subletting I have the ability to find a good fit over a period of time rather than relying on only interviews. If an appropriate candidate came along, my preference would be for them to join the practice, but to start out, they would be subletting.” Choose subtenants wisely The lessor should consider whether subtenants are complementary to his medical practice. When patient populations are complementary, the arrangement can provide a financial boost to the practice and make it easier for patients to access recommended care. For example, a neurologist could gain by renting space to a physical therapist, but having a psychiatrist renting space next to a urologist may not provide the referral gains. Such arrangements do not violate anti-kickback statutes as long as the rent paid is comparable to that for similar spaces in the area, and a lease of at least one year is signed. Physicians are allowed to charge a subtenant for the cost of the office space and use of the common areas, but the size of the space and the time allotted need to be fixed. For example, an arrangement that allows a physician to use an office every Wednesday for eight hours, paying the same rent no matter how many patients are seen, is within safe harbor guidelines as long as the lease is in writing with a term of one year or more and the rental rate is fair market value. An arrangement in which the hours vary
widely or the rent is well above or below the cost of similar spaces violates the guidelines. Experts who understand physician needs should be able to facilitate matches. Commercial real estate brokers who specialize in working with medical practices can conduct a search for office mates. Once a connection has been made, due diligence is important. Both parties should check references and research professional reputations. Contractual considerations The first step for physicians who want to sublease space is to read the original (master) lease agreement and determine if subleasing is allowed. Some contracts prohibit the practice; most require the property owner or landlord’s permission. The lease also may specify who can sublease the space. If a medical office building is on land that is ground leased from a hospital, the hospital lease may specify the type of healthcare professionals allowed in the building. The structure of the subtenant arrangement is important. Will the subtenant have access to a specific room 24 hours a day, seven days a week? Or will use be limited to predetermined hours and days? Prospective renters should consider other services that will be provided. What equipment will subtenants be allowed to use? Will staff be shared? Can the waiting room accommodate additional patientswhom a new physician may bring in? One Dallas orthopaedic surgeon is in his office only when his subtenant is not. His subtenant, an endocrinology practice, occupies the same office on different times and days. The staff is only in the office when he is there. Subtenants handle their own appointment schedules and billing with their own staff. Agreements should be very clear about what is included in the arrangement. Also consider the type of healthcare practitioners who will work well together. For example, Brad Sellers, MD, an ER/urgent care physician, is considering sharing a location with a physical therapist. “Having another healthcare provider close by makes it convenient for some of my patients to access other necessary medical care,” he says. Physicians should engage both professional and legal counsel to negotiate those agreements and determine whether federal Stark laws and federal or state antikickback statues apply. According to the AMA, most physicians who sublease their space charge a one-month security deposit and collect rent from their tenants monthly. Subleases should not be written for a longer term than the original lease. In addition to defining what the rent includes, the sublease should state details regarding contract termination. A oneto four-month notice allows for a fairly easy exit. A timeshare sublease must comply with all of the terms and conditions of the original (master) lease and typically must be approved in advance by the landlord/owner. Expectations should be clearly outlined in a sublease agreement. In a sublease, unless the subtenant assumes the obligations of the master lease, there is no legal relationship between the subtenant and the landlord, so the subtenant doesn’t have to pay the landlord rent and the landlord doesn’t have to respond to the subtenant’s requests or demands for repairs. The sublease should delineate how various problems reported by the subtenant will be handled. In addition to outlining the sharing of resources, hours and rooms used, the lease should address any referral and cross-coverage relationship. A real estate professional can be of great assistance in determining the best use of the space. Medical office configurations vary, but all timeshares should cover these basic functions: • Administrative: includes reception, waiting area, business office, medical records, copy, and
conference area. • HIPAA considerations: medical records housed in lockable storage closets, orientation of computer screens, patient registration and checkout, and sound attenuation in patient rooms • Patient Care: exam room, procedure rooms and consultation rooms • Support Services: nurse station, laboratory room, X-ray/imaging room, break room, rest rooms, and file and storage areas Know the fair market value Errors can occur in the determination of fair market values. According to Jon Henderson, a shareholder in Polsinelli Shugart’s Dallas office who specializes in healthcare transactional and related regulatory matters, “There are a lot of regulatory compliance issues to consider with any referral relationship. A referral relationship does not mean the business arrangement is improper, but it may mean that the arrangement must satisfy an exception or safe harbor to be compliant. In real property leases, an important factor is that the rent for the space has to be at fair-market value. You cannot underpay. You cannot overpay.” Physicians should be aware of these common pitfalls in order to avoid compliance violations: • Gross vs triple net lease documentation to support lease amount • Incorrect square footage for leased space • Hospital/lessor losing money on real estate holdings when most real estate leasing companies in market are generating profit/margin • Not charging for increases in operating expenses or annual escalations in rental rate when the lease contemplated such increases • Enhanced tenant improvements not factored into lease rate • Not accounting for “vacancy” in timeshare arrangement • Use of staff, supplies or specialized equipment not factored into timeshare compensation arrangement • Not increasing the rent as more space is being used, what brokers call “space creep” Timeshare arrangements accommodate physicians who want a cost-effective lease and a short-term commitment to the space. For physicians interested in leasing out their space, a model agreement will provide cost-effective space to their subtenants plus other ancillary practice benefits. When an ideal arrangement can be made, the physicians involved not only will benefit but ultimately will increase patients’ access to care.
Sources: American
Medical News. Sharing your consider when looking for an office mate. amednews/2010/02/01/bisa0201.htm.
space: Things to www.ama-assn.org/
aker & Daniels LLP and HealthCare Appraisers, Inc. Avoiding Fair B Market Value Pitfalls. www.healthcareappraisers.com/presentations/ HCCA_2010_FMV_Pitfalls_TS.pdf. xecutive Suites. www.entrepreneur.com/encyclopedia/term/82390. E html#
Rebecca Harrell is a DCMS Circle of Friends member and provides commercial real estate brokerage services exclusively to medical professionals considering leasing, buying, selling, or building a facility. She can be reached at rharrell@henrysmiller.com or at 972.386.1475.
visit us online at www.dallas-cms.org • November 2012 •
215
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• November 2012 • Dallas Medical Journal
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Community
The Tragedy of the Unmanaged Commons Jim Walton, DO, MBA, PAD Medical Directory
“ F reedo m is t h e rec ogn ition of n ec essity .” Over the last 4 years, PAD has worked on a project to improve care for diabetics. Charity clinic physicians have worked with Community Health Workers to coordinate care and manage this chronic disease in 1,200 patients. Our outcomes have been sterling, with sustained HgbA1c reductions for uninsured working poor patients who were seen at five Dallas-area clinics. Most clinicians know the evidence that for every 1-percent reduction in HgA1c (i.e., blood sugar control), the risk of developing eye, kidney and nerve disease drops by 40 percent and the risk for heart attack falls by 14 percent.1 Although our data isn’t a randomized controlled trial, it suggests that we have developed a promising solution for improving health outcomes for uninsured diabetics. The Legislature will face a difficult decision in the upcoming session (Spring 2013). As part of the Patient Protection and Affordable Care Act, states can elect to work with the federal government to expand Medicaid eligibility to include adults and children whose annual family income is <133 percent of federal poverty guidelines. For Dallas County, it is estimated that expanded Medicaid eligibility could decrease our rate of uninsured from 25.4 percent to 14.1 percent (adding 267,433 people with health insurance). This would increase our county’s share of Medicaid dollars by an estimated $580 million over four years (2014–2017), and support 8,590 RNs and 3,185 family physicians.2 These numbers represent an unprecedented opportunity to care for more people. Imagine the decrease in diabetes in Dallas County if the influx of Medicaid funds could: • Expand primary care physician practices. • Expand diabetes projects to improve control while reducing avoidable complications. • Expand the number of chronically ill uninsured people who have a medical home. The risks for Dallas are great if our state leaders make the wrong decision, and those risks cause me to wonder if this dilemma illustrates the “tragedy of the commons.” This economic theory, defined by Garrett Hardin in 1968, suggests that the depletion of shared resources by individuals, who are exercising their personal freedoms, may adversely affect the community by depleting the shared resource over the long term.3 Will the expansion of Medicaid adversely affect the community’s shared resources over the long term, i.e., a reduction in access to primary care physicians as a
Hemoglobin A1c Mean (%)
— Garrett Hardin, Science, 1968 13.0 12.0 11.0 10.0 9.0 8.0 7.0 6.0 5.0 Visit1 (N=824)
Visit4
Visit5
Visit6
Visit7
Endpoint
(N=754)
(N=691)
(N=579)
(N=481)
(N=870)
VISIT
result of an excess of people with Medicaid seeking care? Or, will the avoidance of Medicaid expansion adversely affect the community’s shared resources, i.e., a reduction in access to emergency room care from excess people seeking care, but who are without insurance and with chronic medical conditions? Hardin was forced to respond to the criticisms of his original article. In a later Science article, he noted his largest mistake “was the omission of the adjective ‘unmanaged.’” In conclusion he suggests that all shared resources require management, believing that humans can and should work toward preserving them. Applied to our current question, the Dallas medical community should have much to say about the best course of action to preserve our shared resources. It is both a privilege and a responsibility to shed light on the best course to manage the shared resources of healthcare access. As the numbers demonstrate, thousands of our neighbors (many without a voice in the process) are waiting for us to represent them while also protecting the commons for the long term. Sources 1 UK Prospective Diabetes Study (1998), Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 Diabetes. Lancet 1998: 837–853. 2 Cline M, Murdock S (2012), Estimates of the Impact of the Affordable Care Act on Counties in Texas, conducted for Methodist Healthcare Ministries of South Texas, Hobby Center for the Study of Texas at Rice University; http://cppp.org/ research.php?aid=1231. 3 Hardin, G. (1968), The Tragedy of the Commons, Science 162 (3859): 1243-1248.
visit us online at www.dallas-cms.org • November 2012 •
217
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DCMS Holiday Social Sunday, Dec. 9
Meyerson Symphony Center 2301 Flora St., Dallas, 75201
1:30 p.m. – Cocktails and light hors d’oeuvres 2:30 p.m. – Christmas Celebration
The DSO’s beloved holiday concert tradition returns with an all-new concert of dazzling seasonal favorites that’s perfect for the entire family! Enjoy an unforgettable Christmas concert at the Meyerson Symphony Center, compliments of DCMS!
RSVP required; limited seats available. Cost is $25/person. Only ONE guest per DCMS member.
2012 DCMS Holiday Social RSVP Form
DCMS Member Name:
1 Ticket ($25)
Spouse/Guest Name: (Limit one per DCMS member)
Phone:
E-mail:
Credit Card Number: Card Type:
VISA MC AMEX DISC
Exp. Date:
Security Code:
Fax credit card payments to 214.946.5805 or mail checks payable to DCMS, PO Box 4680, Dallas, TX 75208. Reservations must be received by Friday, Nov. 30. Questions? Contact Cara at 214.413.1423 or cara@dallas-cms.org.
Event is sponsored by:
2 Tickets ($50)
BE A MEMBER
MEMBERSHIP MATTERS
W hy Be i n g a M e m be r i s i mp ort ant f or Brad M cGowan , MD
220
Because my practice does not exist in a
and has become the hub of my “professional
vacuum. I’m a neurosurgeon in Dallas and a
society” life. It has become a home base, of
member of a larger collection of physicians in
sorts.
the community. Membership in DCMS provides
My choice to become active in DCMS partly
an avenue of communication among physicians
was based on the benefits it offers. First and
across specialties and locales who share a goal:
foremost has been the ability to meet physicians
To improve the medical community and the
in the community outside my specialty and
health of the population it serves.
practice area. Through my membership my
I
have
been
a
member
of
DCMS
for
referral base has grown. Also, I now have more
approximately one year. During my inaugural
detailed answers when posed the inevitable,
year, I have been involved in the Legislative
“Who do you recommend?” at neighborhood
Affairs Committee and HealthPAC. Through
barbecues and parties.
my work on these committees, I have gained
I look forward to increasing my involvement
a better understanding of the public policy
in DCMS. I anticipate continuing to be involved
issues that affect physicians and patients. I also
in the Legislative Affairs Committee and
better understand the legislative and judicial
HealthPAC, as it seems new issues rise faster
bodies that influence the practice of medicine.
than the old ones can be put to rest. Becoming
I have met many candidates for public office
involved in the TMA through DCMS is another
and gained insight into how the local political
avenue by which I can explore and grow my
process works. I also have gained exposure
interests in political advocacy. As I have a
to innumerable differing points of view, some
2-year-old daughter and another on the way, I
of which with I agree, and others I don’t.
have the feeling that DCMS picnics and movie
Regardless, the result is a better understanding
events will become more frequent. As an
of the public policies influencing my daily
alumnus of UT Southwestern Medical School
professional life.
and Parkland residency, I remember the DCMS
DCMS was the first medical society I joined
dinners I attended. I intend to contribute to
upon completion of residency. After all, if I
similar memories for future medical students.
cannot be an involved society member at a
DCMS offers me multiple areas of opportunity
local level, what benefit would membership in
to become involved in the community. Whether
regional or national groups offer me beyond
through philanthropy, political action, social
providing the always-needed CME? One year
networking, or practice growth, DCMS continues
and multiple society memberships later, DCMS
to offer new opportunities for me to make a
membership has been the most rewarding
positive impact in my community.
• November 2012 • Dallas Medical Journal
Call for Nominees
2013 PAD Physician Volunteers of the Year Award
Purpose of the Award is to: • Recognize and reward leadership/involvement in volunteerism and community service in relation to Project Access Dallas and other DCMS Foundation community service projects. • Encourage a culture of citizenship and service in our community. • Recognize a PAD physician who demonstrates compassionate care for the uninsured.
Selection Criteria: Utilization: Diagnostic and medical home referrals will considered. Data from the PAD database will
determine which physicians have the most diagnostic and medical home referrals. Time in the PAD program: A physician should have served as a PAD volunteer for at least one year. Community Service: Consideration will be given to participation in other DCMS Foundation community service projects. This will be determined by DCMS staff and other physicians involved in the community service aspects of the DCMS Foundation. Advocacy for PAD will be considered. This includes helping to build the PAD network, volunteering as a physician champion, and speaking at hospital functions and/or other events.
Nomination and Selection Process:
Nominations will be accepted from PAD physicians who volunteer, the charitable clinics where PAD physicians volunteer, and DCMS staff who work with PAD physicians. Nominations are due by Nov. 14. The winner will be announced at the Installation and Awards Dinner in January. Have questions or want to nominate someone?
DOES YOUR PRACTICE HAVE A HEALTHY FINANCIAL PROGNOSIS? You’ve got to manage the finances for both you and your busy practice. Bank of Texas has special services for both—plus someone dedicated to your financial needs. And that means better health for you, your practice and your patients. Personal Solutions Residential mortgage, including 100% financing Life and disability insurance services Investment management Estate and retirement planning Specialized healthcare deposit products
Practice Solutions Term financing for partnership buy-ins Equipment financing and lines of credit Real estate financing Healthcare remittance automation Deposit solutions
Private Banking | Fiduciary Services | Investment Management | Wealth Advisory Services | Specialty Asset Management Bob White: 214.987.8882 | Bernie Blaschke: 214.346.3911 | www.bankoftexas.com
©2012 Bank of Texas, a division of BOKF, NA. Member FDIC. Broker/Dealer Services and Securities offered by BOSC, Inc., an SEC registered investment adviser, a registered broker/dealer, a subsidiary of BOK Financial Corporation, an affiliate of BOKF, NA dba Bank of Texas, member FINRA/SIPC. SEC registration does not imply a certain level of skill or training. Insurance offered by BOSC Agency, Inc., an affiliated agency. Investments and insurance are not insured by FDIC, are not deposits or other obligations of, and are not guaranteed by, any bank or bank affiliate. Investments are subject to risks, including possible loss of principal amount invested.
visit us online at www.dallas-cms.org • November 2012 •
221
State Rep. Angie Chen Button (R-Garland) and Lisa Swanson, MD, catch up at a fundraiser lunch at the home of DCMS President Richard W. Snyder II, MD.
On the eve of the Texas/OU football game, Scott Holliday, DO, and his son, Dylan, join DCMS President Richard W. Snyder, MD (center), at a fundraiser for State Rep. Dan Branch (R-Dallas) at the Old Parkland building
Meet the Candidates DCMS members organized and attended a slew of candidate interviews and fundraisers in October, just a few weeks before the Nov. 6 general election. DCMS President Richard W. Snyder II, MD, and his wife, Shelley Hall, MD, hosted a reception at their home, and Tillmann Hein, MD, put together a physicianonly fundraiser at the home of Michael Allison, MD. Candidates took advantage of the Texas/OU weekend to thank their supporters at breakfast, lunch and dinner functions.
Tillmann Hein, MD, meets with Pat Fallon, candidate for state representative, in HD-106 (Denton County) at a dinner in Grapevine.
Drs.John Geiser and Val Gibson talk politics at a fundraiser for Mark Veasey, Democratic candidate for CD 33, a new district.
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At a morning reception in October, State Rep. Rafael Anchia (D-Dallas) tells TEXPAC board member Lee Ann Pearse, MD, that he appreciates TEXPAC’s support
Michael Allison, MD, hosts a reception at his home for congressional candidate Mark Veasey. Judge Susan Hawk, spouse of John Geiser, MD, was among Veasey’s supporters who attended.
• November 2012 • Dallas Medical Journal
State Rep. Kenneth Sheets (R-Dallas) talks with TEXPAC Director David Reynolds and John Gilmore, MD, after Sheets’ interview with DCMS physicians.
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• November 2012 • Dallas Medical Journal
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