Med Monthly December 2014

Med Monthly December 2014

FLY WHERE FOR MEDICAL CARE? Medical Tourism is a Growing Industry pg. 38

What Drives Frequent Pediatric Acute Care Visits for Minor Illnesses? pg. 40

Will You Recognize the Ebola Threat Facing You? pg. 34

the

Bag, Doctor ’s Open Writers’ Forum issue

contents

features

34 WILL YOU RECOGNIZE THE EBOLA THREAT FACING YOU? 38 FLY WHERE FOR MEDICAL CARE? Medical Tourism is a Growing Industry 40 WHAT DRIVES FREQUENT PEDIATRIC ACUTE CARE VISITS FOR MINOR ILLNESSES?

14

insight

HOW TO INCREASE PATIENTS WITH A PROFESSIONAL WEBSITE

6 NATIONAL DIABETES EDUCATION PROGRAM RELEASES GUIDING PRINCIPLES FOR DIABETES CARE 8 COMPASSION CAN HELP PHYSICIAN BURNOUT 10 TOPLESS CRUISE IN BELMONT: Neighbors in Deed Helping Neighbors in Need

research and technology

practice tips

22 CYPHER: TAKING THE STRESS OUT OF ICD10 STRESS SYNDROME

14 HOW TO INCREASE PATIENTS WITH A PROFESSIONAL WEBSITE 16 2 COLLECTION TIPS TO INCREASE PRACTICE REVENUE WILL YOU RECOGNIZE THE EBOLA THREAT FACING YOU?

34

18 PROMISING ROLE OF MINDFULNESS MEDITATION IN TREATMENT FOR SMOKING

26 MILLIONS OF US WOMEN ARE NOT GETTING SCREENED FOR CERVICAL CANCER

legal 28 MOBILE HEALTH APPS ARE IN A BOOM PHASE: Why is it so Hard for Pharmaceutical Companies to Find Users?

30 IRS PUTS THE KIBOSH ON HEALTH PLANS THAT FAIL TO COVER HOSPITAL OR PHYSICIAN SERVICES

the arts 42 2014 MED MONTHLY COVER REVIEW

healthy living 44 QUINOA CHOCOLATE CHIP COOKIES

January 1, 2014 begins the attestation period for Stage 2 Meaningful Use. If you are a member of the North Carolina Medical Society, you have access to the resources provided for our members to help your practice achieve Meaningful Use in 2014.

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Providing Jobs, Services, Vendors, and CME www.ncmedsoc.org

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Med Monthly December 2014 Publisher Creative Director Contributors

Philip Driver Thomas Hibbard Ashley Acornley, MS, RD, LDN. Naren Arulrajah Vinay Bhupathy Scott A. Cardin, Ph.D. Taylor Anne D’Ilio Nicole EInhorn, M.D. Barbara Hales, M.D. Laura E. Marusinec, M.D. Carrie A. Noriega, M.D. Denise Price Thomas Nicole C. Rushing, Ph.D. Emily L. Smith Lauren M. Smith, Ph.D. Julia Solooki, MBA Vikas Vij

Med Monthly is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices.

We are currently accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at medmonthly.com/writers-guidelines P.O. Box 99488 Raleigh, NC 27624 medmedia9@gmail.com Online 24/7 at medmonthly.com

contributors Starla Fitch, M.D.

is a board certified practicing oculoplastic surgeon in Atlanta and is the creator of lovemedicineagain. com, an online community and other health care professionals who want to reconnect with their passion for the practice. Dr. Fitch’s new book, Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine, has been named #1 Amazon International Bestseller, #1 Hottest Release, and Amazon Editors’ Best Books for 2014.

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

Laura E. Marusinec, MD is a board-certified pediatrician at Children’s Hospital of Wisconsin Urgent Care with experience in general pediatrics, pediatric dermatology, and pediatric urgent care. She has supported an electronic health record implementation and optimization and is pursuing further medical writing education and opportunities.

Carrie Noriega, MD is a board certified obstetrician/ gynecologist who has worked in both private practice in the US and a socialized medical system.

As an adventure racer and endurance mountain bike racer, she has developed a special interest in promoting health and wellness through science and medicine.

Julia Solooki, MBA is a 10 year veteran to the Healthcare IT/Services sector and is the Director of Business Development and Marketing for ClinicSpectrum, Inc., www.clinicspectrum.com a healthcare services company providing outsourcing and back office solutions for medical billing companies, medical offices, hospital billing departments, and hospital medical records departments. Contact Julia at julia@clinicspectrum.com.

WWW.MEDMONTHLY.COM |5

insight

National Diabetes Education Program Releases Guiding Principles for Diabetes Care

A newly published set of 10 guiding principles highlights areas of agreement for diabetes care that could be clinically useful in diabetes management and prevention. Presented by the National Diabetes Education Program (NDEP), Guiding Principles for the Care of People With or at Risk for Diabetes is aimed at assisting with identification and management of the disease, self-management support for patients, physical activity and blood glucose control, among other topics. More than a dozen federal agencies and professional organizations support the document.

“There are a lot of diabetes guidelines out there, and practitioners and patients can get confused about which 6

| DECEMBER 2014

they should follow,” said Judith Fradkin, M.D., director of the Division of Diabetes, Endocrinology and Metabolic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health. “With these Guiding Principles, we aren’t creating new guidelines, but clarifying where there is general agreement across myriad diabetes guidelines. Guiding Principles represents a set of sound practices. Our goal in developing this resource is to help clinicians help their patients with diabetes.”

“Guiding Principles is the result of a major collaborative effort from a varied group of experts who are committed to

improving the care for people with or at risk for diabetes,” said NIDDK Director Griffin P. Rodgers, M.D. “These principles represent the cornerstone of diabetes management and prevention.”

The National Diabetes Education Program’s newly released Guiding Principles outlines 10 clinically useful principles for health care professionals that highlight areas of agreement in diabetes management and prevention and is supported by more than a dozen federal agencies and professional organizations.

Diabetes has placed a health care and financial burden on Americans. More than 29 million Americans have diabetes and another 86 million – over one in three adults – have prediabetes. Diabetes costs the country $245 billion annually, estimates the American Diabetes Association.

NDEP is a partnership between the NIH and the Centers for Disease Control and Prevention. The following organizations and U.S. agencies support Guiding Principles: • • • • • • • • • • • • • • • • •

Academy of Nutrition and Dietetics Agency for Healthcare Research and Quality American Academy of Ophthalmology American Academy of Physician Assistants American Association of Clinical Endocrinologists American Association of Diabetes Educators American Association of Nurse Practitioners American College of Obstetricians and Gynecologists American Diabetes Association American Heart Association American Optometric Association American Podiatric Medical Association Department of Defense Endocrine Society Health Resources and Services Administration Indian Health Service National Council of Asian Pacific Islander Physicians and AANPHI Diabetes Coalition • Office of Minority Health The NDEP works with more than 200 partners and offers materials and resources to the public, people diagnosed with diabetes, health care professionals and business professionals. To view or download NDEP resources, visit www.YourDiabetesInfo.org .

The NIDDK, a component of the National Institutes of Health (NIH), conducts and supports research on diabetes and other endocrine and metabolic diseases; digestive diseases, nutrition and obesity; and kidney, urologic and hematologic diseases. Spanning the full spectrum of medicine and afflicting people of all ages and ethnic groups, these diseases encompass some of the most common, severe, and disabling conditions affecting Americans. For more information about the NIDDK and its programs, see wwww.niddk.nih.gov.  About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Source: http://www.nih.gov/news/health/nov2014/niddk-12.htm

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insight

COMPASSION CAN HELP PHYSICIAN BURNOUT

By Starla Fitch, M.D.

I believe compassion is one of the most important qualities doctors can share with their patients.

One of the honors I’m most proud of is being selected for the past three years as one of the Most Compassionate Doctors of the Year, according to annual patient surveys.

I think I’ve just been lucky, as I know many doctors who seem way more compassionate than me.

I don’t believe it’s enough to simply recognize that compassion has its place in our world. It must be shared, demonstrated, with everyone we meet. We must embrace it with open arms and say, “Hello, old friend. Hang out with me for awhile.”

In Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine compassion is one of the recommended prescriptions.

While compassion is a crucial quality for doctors to share, I believe it can get you into trouble. It can blur the line between doctor-patient, doctor-nurse, doctortechnician. Sometimes that’s a good thing; you know when it’s not. ‘Nuff said.

Of course, I’m talking about compassion in the best sense. The kind of compassion that helps you push back your fatigue, your hunger, and your aches when you need to get the job done. The kind that brings you up short when you have a visceral reaction to your patient’s bad pathology report.

This kind of compassion makes us more human and more approachable to the patients who trust us with their well beings.

In our world of hurry-up, push forward, and keep 8 | DECEMBER 2014

a-going, compassion doesn’t always come easy—especially for busy doctors with more to-do’s on their lists than time in a day.

I’m often asked what’s the best way to bring out compassion on those days when you’re not sure you have any left to give. Here are some ideas that have helped me: 1. Go back to basics. Treat each patient like family—not like your aggravating Uncle Ned, but like your sweet Aunt Agnes. Reach deep.

2. Stop and breathe. As you wash your hands at the sink in between patients, picture washing away any negative energy from the previous patient and sudsing in the positive energy for the next patient. A clean slate every time. Aaaaah.

3. Listen. Listen to what your patient says in between the lines. We all are rushed, no doubt. But in thirty seconds, you may hear something special. It may be the key to your patient’s new problem (could that new puppy be causing allergies?) or it may unlock the listlessness you sense (a granddaughter just got diagnosed with diabetes at the age of seven).

4. Pass the compassion all around. Don’t save it for your family or a few select patients. Spread it like warm butter on biscuits. Yum. We’d love to have you come on over to www.lovemedicineagain.com and share in the compassion our online community provides. We’re all in this together, my friends. 

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insight

2nd Annual

Topless Cruise in Belmont Neighbors in Deed Helping Neighbors in Need

By Denise Price Thomas Founder & Creator, Topless Cruise and Contributing Writer for Med Monthly www.denisepricethomas.com

10 | DECEMBER 2014

‘‘

“I feel honored to be a part of the Topless Cruise. Only being diagnosed with breast cancer a few weeks earlier, I was amazed at all of the support I received from other breast cancer survivors. People I had never met hugged me, gave me words of encouragement and their phone numbers “just in case I wanted to talk.” My daughter rode along beside me and my family was huddled on the corner downtown cheering me on with pink posters, balloons and their hearts filled with love & encouragement for me. It was a wonderful day!” Susie Parker

W

ho in the world would drive down Main Street with their TOP DOWN?!? Me, that’s who...along with lots of friends. It began as a dream (literally) in October, Breast Cancer Awareness Month, 2013. I awoke and began making my notes, determined to make my dream come true. I met with a friend for lunch, told her of my dream and she was instantly ready to take her top down too! CONVERTIBLE TOP, that is...and the “wheels” kept rolling on from there.

After receiving approval and the blessing from the town... the date was set for the first Saturday in November for the Topless Cruise in Belmont, adding the slogan “It’s never too late to take your top down for a mammogram!” We were on a roll...and in just 2 and a half weeks, we were cruising!

Number 1 rule - 100% of every donated dollar would stay in our community, helping local patients who have cancer. Mission accomplished. A Facebook page was built by a friend, which was our only means of advertising along with word of mouth. Before you knew it, we had 20 convertibles signed up, ready to take their top down for a great cause. Sponsors stepped up to help... knowing their names wouldn’t be “up in lights” but they didn’t hesitate to give from their hearts to assist patients right here in their neighborhood.

Thus, our first annual Topless Cruise in Belmont was born! It was a beautiful sunny day, 75 degrees and what fun we had! My friend, an RN and a breast cancer survivor of 10 1/2 years rode with me as our Pink Princess. Another friend, a radiologist, specializing in breast care called to ride shotgun in my topless car. Smiles, tears of joy, hugs, support, testimonies, stories shared...what a GREAT DAY it was and raising over $3800.00! We referred to that as the “38DD Topless Cruise” Other than my leading the cruise “too fast” (so they said), everything was perfect!

We all enjoyed time together following the cruise, offering support, encouragement and more.

This year, when the date was announced on Facebook for the 2nd Annual Topless Cruise in Belmont, we had over 1600 views that day on our Facebook page! Of course I

don’t know what may have gotten their attention but hey, it worked!

Excitement was building, we “flocked” the town with Pink Flamingoes, recognizing downtown businesses that were supportive. A local BBQ hotspot called to donate BBQ sandwiches for all participants and sponsors as did our local bakery, donating pink cupcakes (size A & B) and the local coffee shop donated coffee. Our beautiful venue was graciously offered at no charge, along with beautiful decor and a DJ volunteered his time & talent. A friend designed our flyers that were posted on Facebook, available for sharing or printing. Two great local car dealerships stepped up again this year, excited about participating and being “charter sponsors” along with our well respected radiology group and our talented photographer. Two local female breast surgeons had heard all about it and asked

‘‘

“It is really inspiring to see so many members of our community gathering in support for this great cause.

We had such a day of fun & fellowship while raising awareness for breast cancer and the needs within our community. Having the CaroMont mobile mammography van as our “caboose” was a great way to remind everyone that early detection is the best prevention.”

Annamarie Collier, MD continued on page 12 WWW.MEDMONTHLY.COM | 11

continued from page 11

to be sponsors this year. Thanks to the suggestion by a dedicated mammography technician, our local hospital entered the mobile mammography unit this year, allowing people to have their mammograms right after the Topless Cruise. The Mammo Bus was the caboose in the cruise.

What fun it was!

A friend called me in tears the week of the cruise. She had recently been diagnosed with breast cancer. She said, “I want to come but I’m afraid all I’ll do is cry.” My reply, “wear your sunglasses and come on. You will find a support system like none other. You will see what life looks like AFTER cancer. You will be surrounded by survivors and support.” She came, she cried, she participated and she is thankful. She was our newest Pink Princess. Another friend had just completed her final round of chemotherapy.

She, along with her husband and two small children enjoyed their topless ride. My cousin, a 2 year survivor was escorted by another cousin. Two friends, both RNs are 11 1/2 year survivors, were cruising together in a brand new 2014 Camaro with their top down. Another flock of friends wore pink TuTus with signs to save the TaTas for their surviving friend, all enjoyed cruising topless.

They were decorated and so were their topless rides with balloons, bras of all shapes and sizes, pink wigs, boas & bling. All stages, all ages....the “Pink Princesses” embraced each other sharing laughter, tears and joy...along with exchanging phone numbers to help each other through their journeys each day. I almost forgot to mention, this year the weather was “an arctic blast” (per the weather man) with high winds, low temperatures, rains, clouds and you name it. I was asked if we should reschedule and after giving some thought, I remembered I had invited Faith and Hope so I made the statement that “these survivors have survived MUCH GREATER STORMS than this so let’s roll”...and we did. After music, photos, registration & shout outs to our sponsors, our Sheriff announced our route and his plans to lead the way. At that very moment, the clouds rolled back and the TOPS CAME DOWN! Once again, we were cruising for a cause....TOPLESS! What began as a dream, ignited wheels to turn, excited the community and the Pink Princesses were connected.

Our promise is to “Keep it Rolling” each year as the Annual Topless Cruise in Belmont comes together. We’re cruising for a cause as “Neighbors in Deed are Helping Neighbors in Need”.

This year we raised $5230.00 to help our neighbors who have cancer. 100% of every donated dollar helps with nutrition, co-pays and other related medical expenses.

It is my desire to see this Topless Cruise roll into other cities and states. What a wonderful feeling it is when the community sees a need, comes together, and makes a positive difference.  12 | DECEMBER 2014

‘‘

“As a pre-op nurse and an 11 1/2 year breast cancer survivor myself, it is an honor to participate in the Topless Cruise. When I was diagnosed, I knew no one well enough to reach out to ask advice. I would be at work, go to another room and cry, pull myself together and go help another patient. I was tearful and fearful. I want people to know that they have my support, love and friendship. I want them to know this is just a bump in the road. They will get through this and be stronger. I know I am. My life is even better after having breast cancer because of the blessings I’ve received.

There is life after cancer!”

Robin Cudd, RN

“Training Wheels in Heels” Denise Price Thomas Trainer for Health Care Professionals Focusing on Exceptional Customer Service, Effective Communication & Exemplary Compassion 34+ year career in health care and certified in health care management Undercover Patient Providing Insight to Your Practice Through the “Eyes of a Patient” Conference Speaker Presenting also as “Gladys Friday”, Health Care Comedienne

Home Grown/Nationally Known www.denisepricethomas.com denisepricethomas@gmail.com 704-747-8699

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practice tips

How to Increase Patients with a Professional Website

By Naren Arulrajah with Vikas Vij

A search engine optimized website is the most potent as well as most cost-effective tool, which you can use to promote your medical practice to your local target audience. According to Pew Research data, 72 percent of all Internet users look online for health information. Therefore, if your medical website ranks high in search results for the most relevant localized keywords that local patients are searching for, it will drive a lot of new potential patients to your website.

14 | DECEMBER 2014

Once the patients are on your site, your content should be convincing and compelling enough to encourage them to consider visiting your practice for a consultation. In other words, your website content should play two critical roles. First, it should be search engine optimized effectively to bring patients to your website. Second, it should engage and interest them in a way that they choose to seek an appointment with your office.

Develop Effective Website Content

To build strong content for your medical website, consider the following guidelines: l

l

l

l

l

l

Make sure that your content is directed at your average potential patient and adequately satisfies their need for information. Instead of worrying about marketing your practice through your content, your primary goal should be to create a comprehensive, information and educational online resource for your patients.

Stay focused on the areas of your expertise, and the procedures and treatments that you provide through your practice. Use your actual experience with previous patients, explain about the medical technologies and techniques that you actually employ during procedures, and provide real, valuable information to the patients to resolve their queries, concerns and doubts as best as possible.

Use patient-friendly language, present the content in interesting ways interspersed with tips, guidelines, Q&As, How-to’s, real-life examples and anecdotes.

Enrich the content with supportive images, infographics, videos, slideshares, webinars, PowerPoint presentations, and other such tools.

Make sure the content is original, creative and engaging enough to prompt the readers to respond by way of comments, feedback, or sharing the content on their social networks or other blogs and websites.

Provide social media ‘share’ buttons alongside your content wherever possible to make it easy for the readers to share it.

Update the content regularly to build ‘reader loyalty’ for your website. The best way to do it is to have a unique blog section on your website where you can periodically add new pieces of content to inform, educate and advise potential patients about various procedures and treatments related to your practice.

Last, but not the least, make sure that your medical website design and content are developed in accordance with Google’s official search engine optimization (SEO) guidelines. You can review the “Google Search Engine Optimization Starter Guide,” which is freely accessible online once you create a Google+ account. Follow the guidelines of Google carefully to achieve higher search rankings, and

ultimately higher online traffic and an increased number of new patients to your practice.

Driving Targeted Traffic to your Site

Consider the following quintessential and proven strategies to drive the targeted traffic of localized patients to your medical website:

Localized Keyword Optimization

Make use of Google AdWords Keyword Planner, which is a free AdWords tool to provide you useful insights about a variety of keywords related to your field and how commonly the users are employing these keywords to search for relevant information. Wherever possible, add the names of local areas from where you expect to receive patients to your practice. The keywords should be added judiciously to the headlines of each page, anchor text, titles and tags, URLs as well as the body of the content.

Mobile Screen Compatibility

The explosive growth and popularity of mobile devices have made it imperative that you make your website mobile device compatible. It will allow mobile users to achieve a wholesome viewing experience when they access your website through their mobile device screens. At the same time, a mobile-friendly website will enhance your chances of ranking higher in the search results.

List your Practice on ‘Google My Business’

Google commands more than 80 percent of the entire web search traffic. It officially recommends businesses and professionals to list their business or practice on Google My Business. According to Google, when you provide appropriate information in this tool, it will increase your chances to rank higher in locally relevant results in both web search and Google Maps. Add your practice to just one or two most representative categories to achieve the best impact.

With a patient-centric website created within the legitimate SEO parameters to help the search engines choose your website in their search results, you can significantly improve the local exposure for your medical practice. Consistent website development and SEO efforts will eventually translate into an increased traffic of new patients for your practice.  About the Author: Naren Arulrajah is the President and CEO of Ekwa Marketing, a complete Internet marketing company that focuses on website development, SEO, social media marketing, and the online reputations of medical professionals. Vikas Vij is the marketing manager for Ekwa Marketing. Visit Ekwa Marketing at www.ekwa.com.

WWW.MEDMONTHLY.COM | 15

practice tips

2 Collection Tips to Increase Practice Revenue

By Julia Solooki, MBA Director of Business Development/Marketing

16

| DECEMBER 2014

Tip #1 - Outsourcing Accounts Receivable Tracking down past-due balances and claim denials from insurance companies and patients is tedious work and consumes precious time that many physician practices simply don’t have no matter if you have two or ten people on staff for front and back office work. This is also an area that can become incredibly costly for practices. We don’t have to tell you twice that if money isn’t coming in the door exactly when balances are due, the likelihood of capturing those balances lessens as time goes on.

Among other time-consuming areas physician and clinical practices must handle on a daily and weekly basis, this is an area of a practice that is especially ideal for outsourcing. Specialized organizations can devote the proper time to the process and have the expertise to maximize collections.

An outsourced accounts receivable collections process begins after the physician’s billing staff creates and sends insurance claims (electronic/paper claims or manual HCFA forms) to various insurance companies. Follow up on electronic claims should begin 10 days after submission, and paper/ Health Care Financing Administration (HCFA) claims follow up should begin 20 to 45 days after submission.

The follow-up process is divided into three methods: 1. Online Claims Follow-Up – Using various insurance company websites and internet payer portals, the service provider checks on the status of outstanding claims.

2. Automated Claims Follow-Up – By calling insurance companies directly, an interactive voice response system (IVR) will give the status of unpaid claims.

3. Insurance Company Representative – If necessary, calling a “live” insurance company representative can provide a more detailed reason for claim denials when such information is not available from either websites or automated phone systems.

These outsourced services can help practices delegate specific time-consuming tasks and maximize their collections to boost the bottom line and get money flowing in the door today.

Tip #2 - Quit ‘Leaving Money on the Table’ With Automated Collection Software At what point should practices “leave money on the table” and abandon their collection efforts on patient-owed balances? It’s a difficult decision that today’s practices are being forced to make more often than they’d like.

Collecting past-due balances from patients is an important component of the revenue cycle that physician practices must actively manage, but it’s costly, time-consuming and labor-intensive. Only a relatively small percentage of efforts result in successful collection. For the remaining patients who fail to respond, practices are forced to report debts to credit bureaus or take legal action to collect past-due balances. In the end, every dollar invested in the collection process is one less dollar of profit for the practice.

But it gets worse. The cost of collecting on small-dollar accounts can easily exceed the past-due balance. The result is that many practices choose to “leave money on the table” rather than pursue advanced collection efforts. Over the course of years, these ignored accounts add up to a substantial sum of money.

Perhaps now, with the assistance of technology, practices will no longer have to make the decision to forego collecting past-due balances. A new breed of automated collection software eases the burden of patient collections. These solutions reduce the time and costs associated with standard mail delivery and costly representative phone calls.

Automated collection software can be installed and managed by practices to relentlessly – within regulations – contact debtors to increase collection rates. Practices that are considering the implementation of this software should look for the following capabilities: Messaging Options – These allow practices to tailor how the patient will be contacted. Options include text, secure text, email, secure email, push notifications to smart phones, and automated calls. These options allow practice to contact debtors via multiple methods to increase collections. l Decision Rules – These allow practices to configure when and how often the debtor is contacted. Options include setting the date, time, hour and frequency of contact. l

Practices employing automated collection software can reduce their collection costs and increase the chances of collecting balances by eliminating representative involvement and automating the process. Most importantly, practices can quit “leaving money on the table.”  WWW.MEDMONTHLY.COM | 17

research & technology

Promising Role of Mindfulness Meditation in Treatment for Smoking

By Nicole C. Rushing, Ph.D., Lauren M. Smith, Ph.D., Emily L. Smith, Taylor Anne D’Ilio, and Scott A. Cardin, Ph.D.

18 | DECEMBER 2014

T

obacco use is the number one cause of preventable death in the United States, affecting nearly every organ of the body.1 Despite the wellknown health consequences of tobacco use and increases in tobacco prevention policies, still about 20% of adults in the United States are current smokers. Furthermore, use of alternative nicotine products such as e-cigarettes is on the rise. These alternatives remain potentially addictive and are not currently regulated by the Food and Drug Administration.

The good news is that most tobacco users are interested in quitting. In 2010, 69% of adult smokers said they want to quit, and 52% had tried to quit during the preceding year.1 Quitting has benefits regardless of age or smoking history. Even among those who have used tobacco for several decades, cessation is associated with significant improvements in health.

In spite of their interest in quitting, many tobacco users find it hard to permanently quit. Not only is nicotine highly addictive, but quitting may also be difficult because most smokers in the US who try to quit using tobacco do so without taking advantage of empirically tested, effective methods.1 There are numerous successful tobacco dependence treatments and medications, which are generally categorized into behavioral therapies, nicotine replacement products, and non-nicotine medications such as bupropion SR (Zyban®) and varenicline tartrate (Chantix®). Standard behavioral therapy programs, whether delivered in group or individual format, often include the following components: increasing self-awareness of tobacco use, enhancing motivation to quit, preparing for quitting, and providing strategies to maintain abstinence and prevent relapse. More effective than employing either counseling or medication alone, however, is the utilization of both together.1 Even among “gold standard” approaches, relapse remains a problem. When interviewed, only about 4–6% of smokers succeeded in quitting in the past year.1 To address the problem of relapse, novel practices such as acupuncture, “workplace challenges,” text messaging and cell phone “app” support, and others are beginning to be included in cessation programs in order to increase chances of long-term success. Mindfulness meditation is one adjunctive practice that is beginning to show promise in treatment of tobacco use disorders.

With roots in Buddhism, mindfulness is an active process, which involves paying attention in the present moment, non-judgmentally, without commentary or decision-making. Mindfulness is about being compassionate with yourself. Further, mindfulness is not a religion, does not take a lot of time, and is not complicated, making it a skill that is feasible to include in tobacco cessation programs.

All mindfulness techniques are considered forms of meditation, and there is more than one way to practice

mindfulness. Here we describe one example of a mindfulness exercise, which involves sitting quietly and focusing on your breathing. Notice all the sensations in the abdomen as the breath moves in and out of the body.

If you notice your mind wandering while you do this, simply notice where it went, and then gently escort it to the present moment and back to the breath. Mind-wandering will happen often, and there is no need to judge yourself.

When you register that your mind has wandered, just bring your attention back to the breath. This technique can be practiced twice daily for 10-15 minutes.

Mindfulness training has been shown to significantly aid in improvement of physical health, mental health, and overall well-being. For example, it has been successfully applied to treatment of psychological disorders including anxiety and depression. The practice of mindfulness meditation is also associated with improved immune system functioning, enhanced learning and memory, increased psychological hardiness, and reduced pain.

Mindfulness is thought to work by reducing anxiety and negative affect, decreasing rumination, improving coping strategies, assisting in the development of self-observation, and improving attention. Indeed, participants undergoing mindfulness training exhibit increased levels of activity in areas of the brain associated with attentional deployment, learning and memory, and self-control.2 Importantly, mindfulness training has shown early effectiveness in treating addictions, including nicotine dependence. It is thought to work by addressing common barriers to successful long-term cessation, namely cravings, also called smoking urges, and stress. Studies have shown that suppression of thoughts related to substance abuse may increase unwanted thoughts and even counteract attempts in smoking cessation, activating brain networks related to craving. Mindfulness meditation practice emphasizes acknowledgement and acceptance, rather than suppression, of unwanted thoughts. Therefore, it does not force participants to resist craving, but instead, allows tobacco users to identify and understand cues, improve self-control and increase capacity to handle craving, thereby reducing the likelihood of relapse. Some have suggested the training may help to bring automatic reactions and habits under more conscious, cognitive control. In this regard, mindfulness meditation may help tobacco users engage in “urge surfing,” or coping with cravings and allowing them to pass without returning to smoking. One mindfulness technique now taught as part of tobacco use interventions is to recognize a craving is arising, accept this moment, notice how your body feels as the craving enters and to replace the wish for the craving to go away with the knowledge that it will subside. In essence, smokers try to “ride out” the uncomfortable sensations without acting on them. In a study of smokers trained to continued on page 20 WWW.MEDMONTHLY.COM | 19

continued from page 19

practice mindfulness meditation, brain scans show altered activity in areas related to self-awareness and self-control.3 Stress and resulting negative emotions are also predictors of relapse that may be addressed through mindfulness practice. In fact, many tobacco users report that they smoke to alleviate stress and to regulate their mood. Thus, when encountering anxiety and irritability, which are common symptoms of nicotine withdrawal, tobacco users may be likely to relapse. The rehearsal of present-focused attention, rather than past or futureoriented attention, may address these barriers by allowing the individual to observe negative states, but not react to them, thus aiding in stress reduction and improving mood. Mindfulness may also work by allowing individuals to better adhere to tobacco cessation treatment in the moment and use coping skills when faced with triggers.

With regards to smoking, mindfulness training has shown preliminary utility in reducing negative emotions, craving, withdrawal symptoms, number of cigarettes smoked, and nicotine dependence. For example, in a study comparing the American Lung Association’s Freedom from Smoking treatment and mindfulness training over 8 weeks, participants randomized to the mindfulness condition smoked fewer cigarettes and were more likely to be abstinent from smoking four months after the treatment ended.4 In a second study comparing these two behavioral treatments, smokers in the mindfulness condition showed decreases in intensity of cravings and stress.5 Based on the research findings to date, mindfulness meditation shows promise as a strategy for reducing cravings and negative emotions which tend to accompany smoking cessation and predict relapse. Adjunctive mindfulness exercises that are quick and straightforward are now being included alongside standard interventions or used in conjunction with tobacco replacements with promising results. With additional research, mindfulness meditation may be considered a cost-effective method to enhance treatment-as-usual in addressing tobacco use disorders.  References 1. U.S. Department of Health and Human Services [DHHS]. (2014). The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

2. Brewer, J. A., Elwafi, H. M., & Davis, J. H. (2013).

Craving to quit: Psychological models and neurobiological mechanisms of mindfulness training as treatments for addictions. Psychology of Addictive Behaviors, 27, 366379.

20 | DECEMBER 2014

3. Tang, Y.-Y., Tang, R. Posner M. I. (2013). Brief meditation training induces smoking reduction.

Proceedings of the National Academy of Sciences, 110, 13971–13975.

4. Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C. Johnson, H. E., Deleone, C. M…, Rounsaville, B. J. (2011).

Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol dependence, 119, 72-80.

5. Davis, J. M., Manley, A. R., Goldberg, S. B., Smith, S. S., Jorenby, D. E. (2014). Randomized trial comparing mindfulness training for smokers to a matched control.

Journal of Substance Abuse Treatment, 47, 213-221.

“This material is based upon work supported by the Department of Veterans Affairs. This reflects the authors’ personal views and in no way represents the official view of the Department of Veterans Affairs of the U.S. Government.”

Author Biography The authors comprise a research team which includes a licensed psychologist, two pre-doctoral psychology interns, and two undergraduate psychology students at the Gulf Coast Veterans Health Care System in Biloxi, MS. They are currently conducting a longitudinal study examining the effectiveness of a tobacco cessation intervention for Veterans.

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research & technology

Cypher: Taking the Stress Out of ICD10 Stress Syndrome

By Nicole EInhorn MD Chief Clinical Content Officer (CCCO) ICDLogic

Great controversy surround the planned transition from ICD9 to ICD10 and Clinical Documentation Improvement (CDI) initiatives, arousing strong emotions earning the moniker: ICD10 stress syndrome.

By introducing new concepts and definitions, ICD10 greatly expanded its lexicon and alphanumeric codes from 18,400 in ICD9 to almost 145,000 in ICD10.

The impacts of ICD10 and CDI will be profound: both will majorly challenge an already stressed health care system, but can also produce profound benefits.

Proponents emphasize its potential benefits in harnessing big data for better, more cost-effective, evidence-based population health management paid according to a value-based reimbursement model.

Kathleen Sebelius, secretary of Health and Human services was quoted from her November 2013 letter to Senator Jeff Sessions that: ”ICD10 is foundational for building a modernized health care system that will facilitate broader access to high quality care”. (New York Times, front page business/financial section, 12-30-2013).

22 | DECEMBER 2014

Opponents emphasize the direct and indirect costs, cash flow disruptions, and implementation challenges which rely heavily on new and often untested technologies.

The AMA Wire, in an article entitled: ICD10 financially disastrous for Physicians, AMA tells HSS, estimated the cost of implementation to range from $56,639 to $226,105 for small practices. (AMA Wire 2/12/14 ICD10 financially disastrous for Physicians AMA tells HSS).

Each side predicts opposing consequences on access and care: supporters predict improvements, whereas opponents predict the opposite at an overly burdensome cost.

With health care costing over 30% of the federal budget, and almost 18% of GDP, both sides do agree that the US cannot afford the escalating cost of health care.

Caught firmly in the conflicts’ battleground, are small and middle-sized providers; and critical access hospitals.

Squeezed by declining reimbursements, small profit margins and limited financial reserves, patronized by “insurance-challenged” and aging populations, these groups bear a disproportionate share of these burdens.

Tricia Maddrey Baker, executive officer of the Pitt County Medical Society, responding to criticisms directed at MD’s resistance to ICD10, wrote that the MD’s she serves are professionals passionate about medicine. “They see the plan as competing with time with their patients as well as costing them real money in lost income as well as new expenses”. Her county’s medical facilities and 865 providers—many of whom are small providers-- serve a much broader area of mostly poor and rural communities, where any challenges to resources will have serious repercussions. Her concerns are echoed across the nation.

Consequently, Congress in April 2014 again delayed ICD10 implementation; in July 2014, CMS set the final deadline as October 1, 2015. Ostensibly, delay provides time to fully prepare and test, and likely too, to prevent a repeat like the much troubled ACA rollout.

The EMR’s themselves struggle with regulation, market consolidation, and ICD10 transition. Almost 750 vendors supplying proprietary, MU certified products, compete for clients. For some, their ICD10 solutions are simple ICD10

“flat files” where diagnosing a single condition condition— such as femur fracture—requires sorting through over 2600 codes. As the EHR market consolidates--a vast majority use one of 10 EHR vendors—options become increasingly limited.

Many EHRs are criticized as expensive, unwieldy, and reducing productivity. The AMA Wire reported this month that physicians reported spending 46 more minutes a day documenting using an EMR; a burden likely to increase as documentation requirements do as well.

What the market lacked was an inexpensive, nimble, clinical workflow tool that is simple, elegant and harnesses the power of information technology.

Cypher@ by ICDLogic was created to meet that critical need. Cypher is not just a coding tool. It is a Computer Assisted Clinical Documentation Improvement (CACDI) clinical workflow and educational tool that is quick, easy, accurate and intuitive. The entire clinical and continued on page 24 WWW.MEDMONTHLY.COM | 23

continued from page 23

administrative team can use it. In three easy steps, and in less than a minute for most patient records, Cypher accurately generates ICD9, ICD10, and SnoMed codes while also teaching CDI and ICD10 concurrent with care.

Cypher is cloud-based, compatible with most mobile devices, HIPAA compliant, ready to use now, and costs about $1/day! Built on API platforms, Cypher has the potential to integrate with any EHR. Cypher is feature-rich: It uses intelligent search, proprietary guided navigation and sophisticated filtering.

Special prompts allow capture of additional factors, etiologies, and co-morbidities—all which help define the severity of illness—as well as the much maligned cause and location codes. Importantly, Its ICD10 guidance panels are written in clinical terms not ‘code speak’.

Accurate clinical documentation, concurrent with care, yields better outcomes for patients and the bottom line.

But few clinicians have the time to make CDI a frontline workflow priority. Cypher prompts users to document thoroughly while learning the fundamentals of ICD-10 and CDI before it becomes mandatory.

To best illustrate how Cypher works, consider this.

Traditional coding and documentation analysis occur at the “back end”, sometimes days after a patient encounter.

The opportunity to capture important information is often lost because it was not adequately documented, resulting in queries and denials.

Many EHR’s promote extensive dashboard features that track queries and denials. Cypher instead helps accurately document the care provided in ICD10 compliant fashion to minimize those queries and denials, and maximize reimbursement.

Cypher’s approach starts at the “front end” with the clinical team and the patient, capturing details on condition, etiologies and co-morbidities. That process integrates into routine workflow; better documentation is produced. At the “back-end”, the administrative team uses the resultant Cypher summary to complete billing.

Cypher captures details on condition and severity of illness providing real value to hospitals and third party payers to use in risk management and resource allocation.

Physicians who best document and code are likely to improve their negotiating position, and their physician profiling: a key component in performance-based reimbursement.

Cypher educates differently too. Traditional methods train clinicians on code sets, going chapter by chapter, expecting them to retain information that can’t be learned in a classroom. Seminars are expensive, tedious, and often occur remote in time and place to the workflow, and likely unsupported by easy or accessible workflow tools. Without reinforcement, recall degrades drastically over time.

24 | DECEMBER 2014

Remember: Implementing ICD-10 is not about coding, it’s about improving clinical documentation.

Cypher is the flagship product of ICDLogic, an innovative health information technology start-up company, co-founded by Monique Fayad (CEO), Jackie Morey (CM&SO), and Yigal Ron (CTO) in March 2013 specifically to address the unmet needs created by ICD10 and CDI. Combined, the founders have over four decades of experience in health information technologies, successfully developing and launching multiple information-driven, healthcare e-solutions across clinical, revenue cycle and regulatory sectors. Supporting them is our Physician Advisory Board, including this author, and our CDI Expert Advisory Board.

To introduce myself, I am Nicole Einhorn MD, an orthopedic surgeon specializing in upper extremity surgery. I practiced for 15 years in a 6 person orthopedic group in northwest Indiana. While co-managing partner, I helped select and implement my group’s first EMR. Since leaving clinical practice in September 2013, I have been an investor in, and Chief Clinical Content Officer (CCCO) of ICDLogic.

I understand well how difficult it is to mesh a clinical practice and the business of medicine, and how important good documentation is to both.

While clinicians are taught to document our patients’ histories, exams, diagnosis and care in a way that is clinically relevant, we are not generally taught to language to also satisfy the administrative needs that influence our reimbursement.

My interest in computer assisted workflow and documentation tools began in my first days of clinical practice: in 1997. Confronted by the sheer volume of paperwork, and the unhappy results of a mock audit, I studied E&M coding guidelines, and looked at software solutions to streamline and improve my documentation. I tried to convert my paper templates to computerized ones with drop down menus which might even work on the newly introduced touchscreen technology.

The technologies I wished for 15 years ago ultimately appeared in today’s more sophisticated EHR’s. The features I wish for now in dealing with the complexities of the impending CDI and ICD10 transitions, appear in Cypher: ease, simplicity, elegance, intuitiveness, accuracy, affordability and user-friendliness.

At ICDLogic, we don’t underestimate the challenge of implementing ICD-10, but with we can help you navigate the complexities of that transition, and harness the power of health information technology in an easy, accurate, and inexpensive way. Cypher helps take the stress out of ICD10 stress syndrome.  Go to www.icdlogic.com for more information to request a demonstration.

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research & technology

Millions of US Women Are Not Getting Screened for Cervical Cancer

26 | DECEMBER 2014

D

espite evidence that cervical cancer screening saves lives, about eight million women ages 21 to 65 years have not been screened for cervical cancer in the past five years, according to a new Vital Signs (www.cdc.gov/vitalsigns) report from the Centers for Disease Control and Prevention. More than half of new cervical cancer cases occur among women who have never or rarely been screened.

“Every visit to a provider can be an opportunity to prevent cervical cancer by making sure women are referred for screening appropriately,” said CDC Principal Deputy Director Ileana Arias, Ph.D. “We must increase our efforts to make sure that all women understand the importance of getting screened for cervical cancer. No woman should die from cervical cancer.”

Researchers reviewed data from the 2012 Behavioral Risk Factor Surveillance System to determine women who had not been screened for cervical cancer in the past five years. They analyzed the number of cervical cancer cases that occurred during 2007 to 2011 from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology and End Results Program. Cervical cancer deaths were based on death certificates submitted to the National Vital Statistics System.

Key findings:

• In 2012, 11.4 percent of women reported they had not been screened for cervical cancer in the past five years; the percentage was larger for women without health insurance (23.1 percent) and for those without a regular health care provider (25.5 percent).

• The percentage of women not screened as recommended (www.cdc.gov/cancer/cervical/basic_info/screening. htm) was higher among older women (12.6 percent), Asians/Pacific Islanders (19.7 percent), and American Indians/Alaska Natives (16.5 percent).

• From 2007 to 2011, the cervical cancer incidence rate decreased by 1.9 percent per year while the death rate remained stable.

• The Southern region had the highest rate of cervical cancer (8.5 per 100,000), the highest death rate (2.7 per 100,000), and the largest percentage of women who had not been screened in the past five years (12.3 percent).

Using the human papillomavirus (HPV) vaccine as a primary prevention measure could also help reduce cervical cancer and deaths from cervical cancer. Another recent CDC study showed that the vaccine is underused; only 1 in 3 girls and 1 in 7 boys had received the 3-dose series in 2013. The HPV vaccine is recommended as a routine vaccine for children 11 - 12 years old. Modeling studies have shown that HPV vaccination and cervical cancer screening combined can prevent as many as 93 percent of new cervical cancer cases.

Even with improvements in prevention and early detection methods, most cervical cancers occur in women who are not up-to-date with screening. Addressing financial and non-financial barriers can help increase screening rates and, in turn, reduce new cases of and deaths from this disease.

Efforts to prevent cervical cancer

CDC’s National Breast and Cervical Cancer Early Detection Program (www.cdc.gov/cancer/nbccedp/) provides low-income, uninsured, and underinsured women access to breast and cervical cancer screening and diagnostic services in all 50 states, the District of Columbia, 5 U.S. territories, and 11 American Indian/Alaska Native tribes or tribal organizations.

Through the Affordable Care Act, more Americans can find and choose health care coverage that fits their needs and budget, including important preventive services such as cervical cancer screening and HPV vaccines that can be covered with no additional costs. Visit Healthcare.gov or call 1-800-318-2596 (TTY/TDD 1-855-889-4325) to learn more.

To learn more about recommended ages and tests for cervical cancer screening, visit: www.cdc.gov/cancer/ cervical.

To learn more about HPV vaccine recommendations, visit: www.cdc.gov/vaccines/teens.

Vital Signs (www.cdc.gov/vitalsigns) is a report that appears on the first Tuesday of the month as part of the CDC journal, Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr). The report provides the latest data and information on key health indicators. These are cancer prevention, obesity, tobacco use, motor vehicle passenger safety, prescription drug overdose, HIV/AIDS, alcohol use, health care-associated infections, cardiovascular health, teen pregnancy, food safety, and viral hepatitis.  Source: http://www.cdc.gov/media/releases/2014/p1105-vs-cervical-cancer.html WWW.MEDMONTHLY.COM | 27

legal

MOBILE HEALTH APPS ARE IN A BOOM PHASE

By Vinay Bhupathy, Associate, SheppardMullin

Why is it so Hard for Pharmaceutical Companies to Find Users?

28 | DECEMBER 2014

Mobile medical and health applications have been in a boom phase for the past few years, but despite this trend, one group of entities has had trouble breaking into the mobile medical app sphere, pharmaceutical (i.e., pharma) companies. A recent report published

by Research2Guidance, indicates that most major pharmaceutical companies have had trouble generating downloads for their health-related apps and even when they do, have trouble getting users to continue using their products.1 For example, some of the most successful pharma companies have only a handful of apps and less than 1 million active users.2 By contrast, there are more than a hundred thousand health-related apps on Google’s Play store and Apple’s iTunes store based on recent calculations, and some experts estimate that there could be as many as 500 million users of medical applications by 2015.3 What is the cause of this inability to generate downloads or hang on to users? There are a few possibilities.

First, many pharma company apps are marketed to or focused on assisting current or potential users of the company’s products. Even if a particular medicine developed by a pharma company has a broad user base, that base is only going to be a small fraction of the total number of mobile medical app users. Most successful mobile medical and health app manufacturers are able to target a wide swath of smartphone users and therefore can realize a larger number of downloads per app. The second and related issue is the subject matter of most apps. As mentioned above, if a pharma company makes an app that is only interesting to someone who has a specific disease state that the company’s product targets, the app’s market penetration will be very low. Lastly, the Research2Guidance report indicates that pharma companies do not have a cohesive vision in their apps and therefore users may have difficulty associating a common brand with the various offerings a single company may distribute.4 All of these factors pose significant hurdles to pharma companies that are trying to break into this market.

Are pharma companies headed for failure in the mobile app space? Perhaps, but maybe that is because they are on the wrong side of the fence. Pharma companies have enormous resources that many mobile health application developers would give an arm and a leg, or more realistically the right to co-brand, to get a piece of. Additionally, the Pharma companies could achieve a better reach by broadening their horizons beyond apps that directly promote their products. The pharma companies may also want to partner with large provider entities, to the extent permitted by applicable law such as the federal Anti-Kickback Statute. These types of partnerships could help relieve the distrust many users may have towards a large pharmaceutical company. In other words, patients and lay users are more likely to trust their doctors than the company that makes their medications.

Ultimately, the clear trend over time demonstrates that pharma companies in the mobile app space will need to modify their approach to better serve the desires of mobile app users and achieve success on a larger scale. If the pharma companies can evolve and better address the needs of mobile app users, they may be able to succeed in the future.  _________ 1 Pogorzelska, Zuzanna. “Why Pharma companies fail to have an impact on the mHealth app economy.” Research2Guidance – Mobile Health Economics.

2 Comstock, Jonah. “Report: Pharma companies have many apps, relatively few downloads.”MobiHealth News. Oct. 27, 2014.

3 Kamerow, Douglas. “Regulating medical apps: which ones and how much?” The BMJ. 2013;347:f6009.

4 Id at Note 1.

Vinay Bhupathy is an attorney with Sheppard Mullin Richter & Hampton, LLP in Los Angeles. Mr. Bhupathy works with healthcare clients on a broad range of issues including privacy and security counseling, fraud and abuse and licensure issues, government and private payor risk sharing and mergers and acquisitions. He has a particular focus on population health management and the health information technology industry.

Vinay received his J.D. from Columbia Law School and can be reached at vbhupathy@sheppardmullin.com.

Source: http://www.natlawreview.com/article/mobile-healthapps-are-boom-phase-why-it-so-hard-pharmaceuticalcompanies-to-find-us

legal

IRS PUTS THE KIBOSH ON HEALTH PLANS THAT FAIL TO COVER HOSPITAL OR PHYSICIAN SERVICES

By Alden J. Bianchi Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. 30 | DECEMBER 2014

In a previous post, we described an Affordable Care Act compliance strategy—referred to commercially as a “minimum value plan” or “MVP”— that involves an offer of group health plan coverage that, while similar in most respects to traditional major medical coverage, carves out inpatient hospital services. A subsequent post warned of rumors that regulators were less than thrilled with these arrangements, and that in all likelihood the Treasury Department/ IRS and the Department of Health and Human Services (the “Departments”) would take steps to require that plans purporting to provide minimum value cover such services.

On November 3, 2014, the Departments announced their intent to retroactively revise their respective minimum value regulations so that plans that fail to provide substantial coverage for in-patient hospitalization services (or for physician services) will not qualify as minimum value.

The Departments’ announcement also included some limited transition relief, and imposed some additional notice requirements.

Background An employer may be liable for an “assessable payment” under the Affordable Care Act’s employer shared responsibility (pay-or-play) rules if one or more of its full-time employees receives a premium tax credit from a public exchange or marketplace.

An employee (or family member) who is offered coverage under an eligible employer-sponsored plan that offers affordable coverage providing “minimum value,” however, is barred from receiving a tax credit.

MVPs were intended to facilitate compliance by employers by lowering the cost of affordable, minimum value coverage. The plans hold down costs by carving out in-patient hospitalization services or, in some cases, physician services, while at the same time providing minimum value.

By offering affordable MVP coverage to substantially all their full-time employees, an employer would avoid penalties under the ACA’s employer shared responsibility rules.

The Actuarial Assumptions underlying “minimum value” In general, a plan provides minimum value if the plan’s “share of the total allowed costs of benefits provided under the plan is at least 60 percent of the total allowable cost of benefits”— defined in regulations published by the U.S. Department of Health and Human Services as: 1. The anticipated covered medical spending for a bundle of services referred to as “essential health benefits” (EHBs); 2. Computed in accordance with the plan’s cost-sharing, and 3. Divided by the total anticipated allowed charges for EHB coverage provided to a standard population.

While EHBs include in-patient hospital services and physician services, self-funded and large fullyinsured employer-sponsored group health plans are not required to offer EHBs and thus are not required to provide these services. The regulators worried, however, about the reference in the ACA to coverage offered to a “standard population.” In this context, the standard population that Congress had in mind includes and is generally limited to large employer plans.

According to the Departments: “A plan that fails to provide substantial coverage for these services would fail to offer fundamental benefits that are nearly universally covered, and historically have been considered integral to coverage, under typical employer-sponsored group health plans.”

In May 2013, the IRS published a proposed regulation that looked to the HHS standards to determine minimum value. According to the IRS, if a plan provided minimum value for HHS’s purposes (principally to

determine whether individuals were eligible for a premium tax credit), then the plan was also deemed to provide minimum value for purposes of determining assessable payments under the employer shared responsibility rules. Under the HHS final regulations and the IRS’s proposed rule, plans can determine minimum value by, among other approaches, using an on-line calculator designed and made available by HHS. It did not take long for sponsors and promoters of MVP arrangements to discover that a group health plan could, if properly designed, return a value of 60% from the online calculator even if the plan did not cover inpatient hospital services or physician services.

This design proved particularly attractive since exclusion of inpatient hospital services or physician services reduced the premiums for MVP coverage to less than half of the cost of traditional major medical coverage, making it much easier for employers to offer MVP coverage on an affordable basis.

The Problem with the Calculator Notice 2014-69 states flatly that plans that fail to provide substantial coverage for in-patient hospitalization services should not be permitted to satisfy the requirements for providing minimum value. In so holding, the notice concedes that that there may be a problem under the hood of the online calculator. According to the notice: “Concerns have been raised as to whether the continuance tables underlying the MV Calculator (and thus the MV Calculator) produce valid actuarial results for unconventional plan designs that exclude substantial coverage for in-patient hospitalization services. These concerns include that the standard population and other underlying assumptions used continued on page 32 WWW.MEDMONTHLY.COM | 31

continued from page 31

in developing the MV Calculator and associated continuance tables are based on typical self-insured employer-sponsored plans, essentially all of which historically have included coverage for these services, and that designing a plan to exclude such coverage could substantially affect the composition of the population covered by discouraging enrollment by employees who have, or anticipate that they might have, significant health issues. It has been suggested that these and other effects resulting from excluding substantial coverage of in-patient hospitalization services may not be adequately taken into account by the MV Calculator and its underlying continuance tables.

Similar concerns have been raised regarding the possibility of using the MV calculator to demonstrate that an unconventional plan design that excludes substantial coverage of physician services provides minimum value.”

In plain English, government actuaries have a lot of work ahead of them to figure out exactly how the online calculator should be reconfigured to produce the intended policy result of requiring hospital and physician coverage, and what the scope of that coverage should be.

Treatment of MVP Arrangements in 2015 and Later Years In Notice 2014-69, the Departments announced their intent to revise their respective minimum value regulations so that plans that fail to provide substantial coverage for inpatient hospitalization services or for physician services will not qualify as minimum value. The Departments anticipate that these changes will be finalized in 2015 and will generally apply beginning in 2015, with one important exception.

32 | DECEMBER 2014

Transition Relief Recognizing that many employers have either already adopted or have gone a long way toward adopting MVP-type arrangements, the notice provides a welcome transition rule under which a plan that is adopted before November 4, 2014 and that has a plan year beginning no later than March 1, 2015 will not be subject to the new rules until the following plan year. This transition rule applies to an employer that has either “entered into a binding written commitment to adopt, or has begun enrolling employees in, [an MVP arrangement] prior to November 4, 2014 based on the employer’s reliance on the results of use of the MV Calculator.”

Employers that have at least some written evidence, prior to November 4, 2014 of a binding commitment to adopt an MVP plan should qualify for relief. With respect to starting enrollment, circulation of enrollment materials clearly qualifies. Arguably, notifying employees that the enrollment will commence at some time in the near future also should qualify. Employers unsure of whether they have taken sufficient steps prior to November 4, 2014 to qualify for relief should consult their insurance advisors or legal counsel.

Employer Duty to Inform Employees Irrespective of whether an MVP arrangement qualifies for transition relief, the Departments have determined that employees covered under MVP arrangements will retain their eligibility for premium tax credits even though the employer is protected from assessable payments. Notice 2014-69 imposes on employers that offer coverage under MVP arrangements the obligation to refrain from making certain representations and to make certain affirmative disclosures. Specifically, the employer—

• Must not state or imply in any disclosure that the offer of coverage under the MVP arrangement precludes an employee from obtaining a premium tax credit, if otherwise eligible; and • Must timely correct any prior disclosures that stated or implied that the offer of the MVP arrangement would preclude an otherwise tax-credit-eligible employee from obtaining a premium tax credit.

The notice further clarifies that if an employer also offers an employee another plan that is not an MVP arrangement and that is affordable and provides minimum value, the employer is permitted to advise the employee that the offer of this other plan will or may preclude the employee from obtaining a premium tax credit.

Closing Thoughts Notice 2014-69 appears to impose a benefit mandate—i.e., to cover inpatient hospital services and physician services—on self-funded and large fully-insured group health plans.

The Departments might claim that this is not a benefit requirement, since no plan is required to include inpatient hospital services and physician services. It is rather a predicate for minimum value status. This can only be true, however, if there is a problem under the hood of the calculator. Is it really possible for a plan that fails to cover inpatient hospital services and physician services to deliver a minimum value of 60% or greater? If the answer is yes, then it should not be possible for the Departments to deliver on their promise. While the notice does not say so explicitly, one suspects that they have already determined that an MVP plan cannot get to 60% minimum value.  Source: http://www.natlawreview.com/ article/affordable-care-act-countdownto-compliance-employers-week-7-irsputs-kibosh-health-

WWW.MEDMONTHLY.COM | 35

features

Will You Recognize the Ebola Threat Facing You?

By Barbara Hales, M.D. www.thewritetreatment.com 34 | DECEMBER 2014

There has been a great deal of interest or panic in the news lately regarding Ebola, including an episode that went unrecognized and undiagnosed until many people were exposed and the symptoms became fulminant.

While it’s true that the odds of an Ebola case coming to our practice or hospital in the U.S. are remote, it is conceivable. (As witnessed in Texas in the last month). After all, the world is becoming a smaller place with mobility becoming easier and more affordable.

We are always warned against “chasing zebras” in diagnosis during training but as you and I know, zebras do exist. Will we see them?

The thing is, people will be looking to us, as physicians to thwart a medical threat or disaster and protect them.

The question is: Can you?

Overview Ebola hemorrhagic fever, or simply Ebola as it is known now, is nontreatable and has a very high mortality rate. It can infect all primates. There are five viral strains of Filoviridae Ebolavirus of which 4 attack humans.

First discovered near the Ebola River in the Democratic Republic of the Congo in 1976, outbreaks of this disease have sprung up in several countries of Africa. In 2014, Ebola reached epidemic status.

Signs and Symptoms Symptoms manifest 2-21 days after exposure but typically in 8-10 days. They include: l

Abdominal pain

l Diarrhea l Fatigue l Fever l

Muscle pain Hemorrhagic bleeding or unexplained bruising l Severe headache l Vomiting l Weakness and lethargy l

Diagnosis Because diagnosis is difficult in the early stages of Ebola infection, and can be confused with influenza, we rely on known contact with an exposed person (One who has travelled to a country where an outbreak has occurred). Quarantine should be established and testing initiated.

Laboratory Test l IgM ELISA l ELISA- antigen-capture

Test Initiation enzyme linked

Early stage - when symptoms manifest

immunosorbent assay chain reaction

l PCR- polymerase l Virus isolation l IgM

and IgG antibody detection

l Immunohistochemistry l PCR l Virus isolation

Later stage During autopsy

continued on page 36 WWW.MEDMONTHLY.COM | 35

continued from page 35

Transmission and Prevention Spread It is believed that infection comes from exposure to an infected primates leading to transmission between humans and can become rampant in healthcare sites when protective gear is not donned.

Method of spread involves direct contact through mucous membranes or broken skin and: l Contaminated body fluids- urine, saliva, vomit, ejaculate, breast milk, blood l Infected animals- apes, monkeys, gorillas, fruit bats l Contaminated fomites- needles, syringes The virus isn’t air-born or contracted from water but can be spread from handling infected meat.

Though viral spread does not occur from a recovered individual, it can exist in semen for 3 months. Condoms are advised but abstinence is a better avoidance plan.

Inhibition Since there is no FDA-approved Ebola vaccine available yet, take the following precautions: l Avoid contact with body fluids from contaminated patients l Defer body handling in funerals l Avoid hospitals where Ebola patients are cared for l Take sterilization measures l Wear appropriate PPE gear l Isolate infected patients from others l Monitor your health for 21 days after possible exposure l Get immediate medical attention if Ebola symptoms appear l Notify health officials if direct contact with the virus occurred

Why Worry About Ebola in the U.S.?

There are seven reasons why you need to be vigilant and “on your game”.

1) A new survey reported in the Association for Professionals in Infection Control and Epidemiology reveals that only 6% of American hospitals are prepared

Katrina Crist, the CEO, stated “the results of the poll paint a disturbing picture and point to an urgent need to bolster infection prevention resources in healthcare facilities”.

2) Ebola can conceivably mutate to an airborne variantin 1989, the Ebola0Reston strain was seen to do this.

36 | DECEMBER 2014

3) The spread is rapid among people in crowded living conditions or poor hygiene and can become a pandemic if not contained.

4) Though not airborne technically, the Ebola virus can be spread through droplets transmitted in the air from a contaminated person nearby.

5) A Drexel University study shows that a quarantine of 21 days is insufficient for viral spread in 12% of the cases.

6) The Ebola virus can be viable for 50 days on a fomite.

7) Protective gear does not offer complete protectioneven healthcare professionals using protective equipment (including 16 people in Doctors Without Borders) have become infected despite following established guidelines We cannot be cavalier regarding the threat of Ebola being just “over there”. We have already seen that with travel, it has also gone from there to here!

There is a big difference between wanting to avoid panic and not wanting to face reality. While the chances of your exposure here are minimal or a “shot in the dark”, it behooves you to at least keep it in mind when examining new patients. 

The Write Treatment

Ezines and NewslettersCost Effective Powerful Tools • Drive traffic to your business website • Build relationships between yourself and patients • Get new patients • Announce a new service or product • Give great impact Have you got a newsletter yet or want to spread a message?

Contact Barbara Hales, M.D. for a free consultation.

Barbara@TheWriteTreatment.com 516-647-3002

WWW.MEDMONTHLY.COM | 39

features

FLY WHERE FOR MEDICAL CARE?

Medical Tourism is a Growing Industry

By Carrie A Noriega, MD

About 5 years ago, I had a patient travel to Venezuela for an abdominoplasty and a mastopexy. She had family that lived in Venezuela who helped her find a reputable plastic surgeon and provided her with accommodations after her surgery.

When I asked her why she was traveling so far for her procedure she said it was because the surgery cost 38 | DECEMBER 2014

about 25 percent of what it would cost in the US. Even with the expense of airfare, she said it was still cheaper.

When I saw her after her procedure she said she had a great experience and was ecstatic with her results. I initially thought her traveling outside of the US for medical care was unique, but I have since discovered that she is one of many who are going to the

effort of seeking medical care in other countries.

Medical tourism, which includes anyone traveling to another country to receive medical treatment, is a growing industry. Some predict that 11 million people will travel to another country for medical care in 2014, spending an estimated 38.5-55.5 billion US dollars.

It is expected that 1.2 million of these

travelers will be US citizens who spend between 3,500-5,000 US dollars per visit, including all medically-related costs.1 So what is driving this new industry? As costs for healthcare in the US and other countries continue to rise, many people are looking for more affordable options for healthcare. And it isn’t just individuals who are looking to save on healthcare spending, but also companies that provide self-funded healthcare plans. Some companies are starting to offer overseas medical care to their employees at no cost to the employees. Even when the companies pay for the procedure and all travel related expenses, they are still saving a significant amount of money. One such company paid for an employee to travel to Costa Rica for a knee replacement, which in the US would have cost $59,000 but in Costa Rica cost only $23,531.2 This particular company does not require the employee to pay any out-of pocket expenses and even shares 10% of the cost savings with the employee in the form of a bonus. The employees are happy with the arrangement since they have no out-of-pocket expenses and the companies are happy with their overall cost savings. Traveling for medical care can be a win for everyone.

Currently, the top 5 destinations for medical tourism are Thailand, Hungary, India, Singapore, and Malaysia. The US currently ranks 7th for the number of people traveling here for medical care but it is actively working to improve its rank.3 A recent article in the Washington Business Journal indicates that the US is working to increase the number of travelers to the US seeking health care, particularly to Washington DC. The District health department is planning to not only partner with local hospitals but also area hotels and restaurants to offer a full destination package.4 Las Vegas and Florida already offer medical travel packages, which has made them top medical destinations

in the US for people from all over the world.

The types of procedures people are having done varies just as much as where they are going. Cosmetic surgery, dental procedures, and heart surgery top the list of medical procedures. However, people are also undergoing orthopedic procedures, cancer treatment, weight loss procedures, and invitro fertilization treatments. People also seek alternative treatments with therapies that may not be available or approved in their home countries. These therapies range from non-western treatments with acupuncture to experimental proton bean therapy to treat brain tumors. The procedures available to patients willing to travel are almost endless.

Medical tourism isn’t just for the cost-conscious consumer. There is a whole sector of the industry that targets people looking to combine luxury travel with medical services.

You can travel to South Africa for your rhinoplasty and then go on a five-star African safari. Prince Court Medical Center in Kuala Lumpur offers invitro-fertilization in spacious junior suites. Bumrungrad International hospital in Bangkok offers access to over 200 US-certified surgeons at a facility that offers luxurious 5 star accommodations, a shopping mall, and a Starbucks. Even the Ritz-Carlton Hotel in Seoul Korea now offers an anti-aging clinic and spa where you can have plastic surgery procedures while staying in one of their beautiful suites.

While the cost benefits and access to medical treatments is clear, is this really a safe alternative for medical care? The answer to that is it depends.

Due to the global demand for medical procedures, the US-based Joint Commission launched an international affiliate in 1999 called the Joint Commission International (JCI).

Since 1999, 693 hospitals and clinics worldwide have been accredited by JCI and the number is growing by about 20% per year.1 JCI offers a searchable

website to help find accredited facilities in whichever region you are interested in traveling to for your treatment. There are also companies that are designed to help you find safe, reputable facilities for the treatments you are seeking. They will put together a complete package including all travel arrangements, any necessary visas, and all medical appointments that may be needed. So if you do your research correctly, there are safe, affordable global options available for medical care.

Since the globalization of most other markets has already occurred, it only makes sense that medicine is becoming more global as well. While medical tourism may have originally been for the more adventurous, this is no longer the case. Even organizations like AARP are beginning to offer their members advice on how to seek good quality medical care abroad. As costs for healthcare continue to rise, international medical care will become a viable sector of medical care for more and more people.  References: 1 Patients beyond borders. www. patientsbeyondborders.com/medicaltourism-statistics-facts Published July 2014. Accessed November 9, 2014 Stephano R. No kidding: Overseas medical tourism is well worth trip.

Health Law Gurus. October 27, 2014. www.healthlawgurus.com/2014/10/ no-kidding-overseas-medical-tourismis-well-worth-trip 2

Das R. Medical tourism gets a facelift and perhaps a pacemaker. Forbes.

August 19, 2014. http://www.forbes. com/sites/reenitadas/2014/08/19/ medical-tourism-gets-a-facelift-andperhaps-a-pacemaker 3

Reed T. The White House. The Washington Monument. Surgery? D.C. officials plan to launch new medical tourism program. Washington Business Journal. Oct. 29, 2014 www.bizjournals.com/washington/ blog/2014/10/the-white-house-thewashington-monument-surgery-d.html 4

WWW.MEDMONTHLY.COM | 39

features

What Drives Frequent Pediatric Acute Care Visits for Minor Illnesses?

By Laura E. Marusinec, MD Urgent Care Pediatrician

A

s an urgent care pediatrician, I take care of dozens of sick children each week–and just as many NOT very sick children. It seems we are seeing more children brought in for minor illnesses, such as brief fevers, colds, and diarrhea, which in the past were just taken care of at home. Of course there are many occasions when a child needs to be seen urgently. But many times a little TLC at home would do just as well.

As a child, I rarely went to the doctor; our generation just didn’t go in every time we had a cold. We got our shots and occasionally even a check-up, but rarely did we go in for an illness, and certainly not to an emergency room.

If we did, you can bet we were pretty darn sick. In my practice, however, things have changed. A large number of children seen any given night in urgent care are in for minor illnesses such as fever for less than 24 hours, a few episodes of vomiting or diarrhea, minor aches and pains, rashes, pink eye, and runny noses. Much of my night is spent reassuring parents that nothing is seriously wrong with their child, “it’s just a minor viral infection,” no antibiotics are needed, and they can manage the symptoms at home with some fluids, rest, and occasional acetaminophen or ibuprofen. Meanwhile, the parents are hovering over the child, worried looks on their faces, telling me all of the terrible things that are going on. Often the symptoms began within hours, and the child is brought

40 | DECEMBER 2014

in before even offering treatment at home.

At some of our sites, it is not uncommon to see families in every few months for these minor complaints, with often several children at each visit. Add this to the likely many visits to their own doctor, and often several visits to the ER, and you can see the problem. The already overburdened healthcare system is spending valuable time and resources reassuring worried parents, which could be better spent treating patients who are truly ill or talking with families about issues such as effective home care, preventative medicine, behavioral and learning concerns, safety, and healthy lifestyles. Many of the children seen are significantly overweight or have multiple cavities, issues that deserve much more attention than the minor illnesses that are bringing them in so frequently.

Questions What motivates parents to bring in children frequently for minor concerns? Where is parents’ confidence in taking care of their mildly ill children? Why have they gotten so dependent on doctors, and what are they so worried about? Are primary care providers not educating families on home care of minor illnesses? They probably don’t have time, with the increasing demands put on them in a 15 minute visit. Or, are parents getting the information but not listening or understanding? Is the media to blame–with

dramatic stories of Ebola and Enterovirus D68 causing fear?

Are generational, cultural, financial, or educational factors involved? Do daycares, schools, and employers contribute to the problem? Can improved and more readily available resources and education from doctors or nurses reduce these visits? These questions would be a good starting point for research into this subject. I have a few thoughts on some of the key driving forces:

It’s convenient: Having the convenience of ERs and especially urgent cares likely encourages overuse. Some primary care providers find it easier to “just send them to urgent care” instead of taking the time to talk to the parents to attempt to determine what is going on and provide home care advice when appropriate. Some of my area’s local providers’ phone messages give information on urgent care before providing access to their own nurses or providers for advice. I’ve even actually had parents tell me that they came to our urgent care because they were at the store down the road, so they “might as well come in.” Parents no longer have to miss work to bring in their child. The clinic that has the most visits for minor concerns is one where most patients don’t pay anything for the visit, and often get OTC meds filled at no charge, so there is no disincentive to be seen.

“Can he/she go back to daycare/ school?”

Another likely culprit is the increase in daycares sending kids home with a ‘fever’ of 100, a rash, runny nose, or the slightest concern of pink eye, requiring a note from a physician in order to return. This usually means a visit to the doctor, often after work, which then means a trip to urgent care or the ER. This goes against the AAP guidelines, which say it’s ok to send a child with a minor illness to daycare. In addition, the incentive to come in can also be to obtain an excuse from school for the child or from work for the parent, and many employers make it more difficult for a parent to stay home and care for an ill child. Parents are looking to us to make the child better so that the child may return to daycare or school, and they can return to work.

So, how can we reduce some of these acute care visits?

Reassurance and Education Although it is quicker just to take care of the acute problem and move on, all of us, from primary care to urgent care or ER, need to take the time to reassure parents and instill pride when they are doing the right things, and to reinforce how to do so again at home the NEXT time

their child is ill. Although there are many resources out there, some may be hard to find or navigate, especially online. We need to provide thorough verbal and written instructions on home care, along with resources that are easy to find and understand, and we need to remind parents of the availability of their PCP for follow-up concerns. I help develop patient discharge instructions for my hospital for a variety of common illnesses and injuries, which provide information on home care as well as when the child should be seen, and I have upcoming blog posts on the approach to after-hours care along with information and advice on common minor illnesses, including one of the biggest concerns, “fever phobia”. My number one piece of advice to parents who have questions of what to do for a mildly ill child or when to bring them in is to call their doctor’s office.

The Medical Home Primary care providers should provide education on home care of minor illnesses during sick visits as well as well-checks, and they need to be available by phone to give advice, day or night–and make sure parents are aware of this and feel welcome to call. I can’t count how many times I have asked a parent if they had contacted their child’s doctor about the problem, only to be met with a surprised look–“I can do that?!” That’s what a medical home is all about!

With the recent emphasis on the medical home, including keeping patients in closer contact with their PCPs, we just might reduce these visits. As opposed to the clinics putting urgent care information first on their phone messages, another local clinic posts their availability for same-day and after hours care as well as phone availability clearly on their website and discourages the use of urgent care clinics, preferring to keep their patients in the medical home. Unfortunately, with more frequently changing insurance coverage, many families don’t have a wellestablished or trusted medical home, which makes this a continued challenge.

As an urgent care pediatrician, my job is to diagnose and treat ill children, and that’s what I love to do. I never want to discourage families from seeking care, especially when children are truly ill, but we also need to find the most appropriate and effective ways to help families care for their children at home and avoid some unnecessary visits. With steadily increasing health care costs and burdens on ERs, reducing unnecessary frequent visits could benefit us all.

And, on busy shifts when the waiting room is overflowing, reducing these visits could allow me a little more time to spend with the patients who really need my care.  Laura Marusinec is a board-certified pediatrician and medical writer with experience in general pediatrics, pediatric dermatology, and pediatric urgent care.

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the arts

2014 Med Monthly Cover Review

42

| DECEMBER 2014

It has been another fantastic year at Med Monthly and the cover art has been exceptional. This is a gallery of our covers featured in 2014.

Please feel free to click on the cover art to view to that month’s issue online.

Featured Topics for 2014 January – Your Practice Web Site February – Med Spa’s March – Locum Tenens/Traveling Nurses April – Staging Your Practice for Success May – Physician Salaries/Careers June – Medical Specialties July – Diet & Your Practice August – Concierge Medicine September – Medical Billing October – Urgent Care November – Health Care Reform December – Doctor’s Bag, Writers Open Forum

Upcoming Topics for 2015 January – Coping With Stress February – The Modern Dentist March – The Front Desk April – Developing a Referral Network May – Attracting New Patients June – Practice & Profit July – Your Practice Website August – Doctor-Patient Communication September – The Practice Manager October – Mid Levels and Your Practice November – Increase the Value of Your Practice December – Today’s Practice Models

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healthy living

Quinoa Chocolate Chip Cookies

By Ashley Acornley, MS, RD, LDN Happy holidays! December is the time of year where many tempting treats such as cookies, hot cocoa, and candy are plentiful in our homes, at the workplace, and given as gifts to others. Oftentimes, having an excess amount starches, sugars, and saturated fats in our body can make us feel sluggish and tired. Why not try preparing a healthier cookie alternative this holiday season? Your body will thank you for it.

This quinoa chocolate chip cookie contains natural ingredients and has more protein and less fat than the average chocolate chip cookie. This is a no-bake recipe too - so minimal work in the kitchen is required!

Ingredients:

• 1/2 cup natural peanut butter • 2 tbsp applesauce • 1/4 cup raw honey or agave • 1 tbsp pure vanilla extract • 1/2 tsp sea salt • 1/3 cup almond flour • 1 1/2 cups cooked quinoa

(about 1/2 cup of uncooked

quinoa) or 1/2 cup soaked quinoa • 1/4 to 1/3 cup dark chocolate chips

Preparation: 1. In a small bowl, combine the peanut butter, applesauce, honey, vanilla and salt.

2. Add the rest of the ingredients and mix until combined.

3. Spoon rounded tablespoons of cookies on a cookie sheet lined with parchment or wax paper.

4. Place in the freezer to set, about 20 minutes. Cookies are ready to be enjoyed cold or thawed.

44

| DECEMBER 2014

U.S. OPTICAL BOARDS Alaska P.O. Box 110806 Juneau, AK 99811 (907)465-5470 http://www.dced.state.ak.us/occ/pdop.htm

Idaho 450 W. State St., 10th Floor Boise , ID 83720 (208)334-5500 http://www.ironforidaho.net/

Oregon 3218 Pringle Rd. SE Ste. 270 Salem, OR 97302 (503)373-7721 www.obo.state.or.us

Arizona 1400 W. Washington, Rm. 230 Phoenix, AZ 85007 (602)542-3095 http://www.do.az.gov

Kentucky P.O. Box 1360 Frankfurt, KY 40602 (502)564-3296 http://www.opticiantraining.org/optician-training-kentucky/

Rhode Island 3 Capitol Hill, Rm 104 Providence, RI 02908 (401)222-7883 http://sos.ri.gov/govdirectory/index.php? page=DetailDeptAgency&eid=260

Massachusetts 239 Causeway St. Boston, MA 02114 (617)727-5339 http://1.usa.gov/zbJVt7

South Carolina P.O. Box 11329 Columbia, SC 29211 (803)896-4665 www.llr.state.sc.us

Nevada P.O. Box 70503 Reno, NV 89570 (775)853-1421 http://nvbdo.state.nv.us/

Tennessee Heritage Place Metro Center 227 French Landing, Ste. 300 Nashville, TN 37243 (615)253-6061 http://health.state.tn.us/boards/do/

Arkansas P.O. Box 627 Helena, AR 72342 (870)572-2847 California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 (916)263-2382 http://www.optometry.ca.gov/ Colorado 1560 Broadway St. #1310 Denver, CO 80202 (303)894-7750 http://www.dora.state.co.us/optometry/ Connecticut 410 Capitol Ave., MS #12APP P.O. Box 340308 Hartford, CT 06134 (860)509-7603 ext. 4 http://www.ct.gov/dph/cwp/view. asp?a=3121&q=427586 Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 http://www.pof.org/opticianry-board/ Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 http://sos.ga.gov/index.php/licensing/ plb/20 Hawaii P.O. Box 3469 Honolulu, HI 96801 (808)586-2704 http://hawaii.gov/dcca/pvl/programs/ dispensingoptician/

New Hampshire 129 Pleasant St. Concord, NH 03301 (603)271-5590 www.state.nh.us New Jersey P.O. Box 45011 Newark, NJ 07101 (973)504-6435 http://www.njconsumeraffairs.gov/ ophth/ New York 89 Washington Ave., 2nd Floor W. Albany, NY 12234 (518)402-5944 http://www.op.nysed.gov/prof/od/ North Carolina P.O. Box 25336 Raleigh, NC 27611 (919)733-9321 http://www.ncoptometry.org/ Ohio 77 S. High St. Columbus, OH 43266 (614)466-9707 http://optical.ohio.gov/

Texas P.O. Box 149347 Austin, TX 78714 (512)834-6661 http://www.tob.state.tx.us/ Vermont National Life Bldg N FL. 2 Montpelier, VT 05620 (802)828-2191 http://vtprofessionals.org/opr1/ opticians/ Virginia 3600 W. Broad St. Richmond, VA 23230 (804)367-8500 http://www.dpor.virginia.gov/Boards/ HAS-Opticians/ Washington 300 SE Quince P.O. Box 47870 Olympia, WA 98504 (360)236-4947 http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission. aspx

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

Hawaii DCCA-PVL Att: Dental P.O. Box 3469 Honolulu, HI 96801 (808)586-3000 http://1.usa.gov/s5Ry9i Idaho P.O. Box 83720 Boise, ID 83720 (208)334-2369 http://isbd.idaho.gov/

Arkansas 101 E. Capitol Ave., Suite 111 Little Rock, AR 72201 (501)682-2085 http://www.asbde.org/

Illinois 320 W. Washington St. Springfield, IL 62786 (217)785-0820 http://bit.ly/svi6Od

California 2005 Evergreen Street, Suite 1550Â Sacramento, CA 95815 877-729-7789 http://www.dbc.ca.gov/

Indiana 402 W. Washington St., Room W072 Indianapolis, IN 46204 (317)232-2980 http://www.in.gov/pla/dental.htm

Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7800 http://www.dora.state.co.us/dental/

Iowa 400 SW 8th St. Suite D Des Moines, IA 50309 (515)281-5157 http://www.state.ia.us/dentalboard/

Connecticut 410 Capitol Ave. Hartford, CT 06134 (860)509-8000 http://www.ct.gov/dph/cwp/view. asp?a=3143&q=388884

Kansas 900 SW Jackson Room 564-S Topeka, KS 66612 (785)296-6400 http://www.dental.ks.gov/

Delaware Cannon Building, Suite 203 861 Solver Lake Blvd.

Dover, DE 19904 (302)744-4500 http://1.usa.gov/t0mbWZ

Kentucky 312 Whittington Parkway, Suite 101 Louisville, KY 40222 (502)429-7280 http://dentistry.ky.gov/

Florida 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399 (850)245-4474 http://floridasdentistry.gov/ 46

Georgia 237 Coliseum Drive Macon, GA 31217 (478)207-2440 https://gbd.georgia.gov/

| DECEMBER 2014

Louisiana 365 Canal St., Suite 2680 New Orleans, LA 70130 (504)568-8574 http://www.lsbd.org/

Maine 143 State House Station 161 Capitol St. Augusta, ME 04333 (207)287-3333 http://www.mainedental.org/ Maryland 55 Wade Ave. Catonsville, Maryland 21228 (410)402-8500 http://dhmh.state.md.us/dental/ Massachusetts 1000 Washington St., Suite 710 Boston, MA 02118 (617)727-1944 http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/ dentist/ Michigan P.O. Box 30664 Lansing, MI 48909 (517)241-2650 http://www.michigan.gov/lara/0,4601,7154-35299_28150_27529_27533---,00. html Minnesota 2829 University Ave., SE. Suite 450 Minneapolis, MN 55414 (612)617-2250 http://www.dentalboard.state.mn.us/ Mississippi 600 E. Amite St., Suite 100 Jackson, MS 39201 (601)944-9622 http://bit.ly/uuXKxl Missouri 3605 Missouri Blvd.

P.O. Box 1367 Jefferson City, MO 65102 (573)751-0040 http://pr.mo.gov/dental.asp Montana P.O. Box 200113 Helena, MT 59620 (406)444-2511 http://bsd.dli.mt.gov/license/bsd_ boards/den_board/board_page.asp

Nebraska 301 Centennial Mall South Lincoln, NE 68509 (402)471-3121 http://dhhs.ne.gov/publichealth/Pages/ crl_medical_dent_hygiene_board.aspx

Ohio Riffe Center 77 S. High St.,17th Floor Columbus, OH 43215 (614)466-2580 http://www.dental.ohio.gov/

Nevada 6010 S. Rainbow Blvd. Suite A-1 Las Vegas, NV 89118 (702)486-7044 http://www.nvdentalboard.nv.gov/

Oklahoma 201 N.E. 38th Terr., #2 Oklahoma City, OK 73105 (405)524-9037 http://www.ok.gov/dentistry/

New Hampshire 2 Industrial Park Dr. Concord, NH 03301 (603)271-4561 http://www.nh.gov/dental/

Oregon 1600 SW 4th Ave. Suite 770 Portland, OR 97201 (971)673-3200 http://www.oregon.gov/Dentistry/

New Jersey P.O Box 45005 Newark, NJ 07101 (973)504-6405 http://bit.ly/uO2tLg

Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 (717)783-7162 http://bit.ly/s5oYiS

New Mexico Toney Anaya Building 2550 Cerrillos Rd. Santa Fe, NM 87505 (505)476-4680 http://www.rld.state.nm.us/boards/Dental_Health_Care.aspx

Rhode Island Dept. of Health Three Capitol Hill, Room 104 Providence, RI 02908 (401)222-2828 http://1.usa.gov/u66MaB

New York 89 Washington Ave. Albany, NY 12234 (518)474-3817 http://www.op.nysed.gov/prof/dent/

South Carolina P.O. Box 11329 Columbia, SC 29211 (803)896-4599 http://www.llr.state.sc.us/POL/Dentistry/

North Carolina 507 Airport Blvd., Suite 105 Morrisville, NC 27560 (919)678-8223 http://www.ncdentalboard.org/

South Dakota P.O. Box 1079 105. S. Euclid Ave. Suite C Pierre, SC 57501 (605)224-1282 https://www.sdboardofdentistry.com/

North Dakota P.O. Box 7246 Bismark, ND 58507 (701)258-8600 http://www.nddentalboard.org/

Tennessee 227 French Landing, Suite 300 Nashville, TN 37243 (615)532-3202 http://health.state.tn.us/boards/dentistry/

Texas 333 Guadeloupe St. Suite 3-800 Austin, TX 78701 (512)463-6400 http://www.tsbde.state.tx.us/ Utah 160 E. 300 South Salt Lake City, UT 84111 (801)530-6628 http://1.usa.gov/xMVXWm Vermont National Life Building North FL2 Montpelier, VT 05620 (802)828-1505 http://governor.vermont.gov/boards_ and_commissions/dental_examiners Virginia Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4538 http://www.dhp.virginia.gov/dentistry Washington 310 Israel Rd. SE P.O. Box 47865 Olympia, WA 98504 (360)236-4700 http://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/Dentist.aspx West Virginia 1319 Robert C. Byrd Dr. P.O. Box 1447 Crab Orchard, WV 25827 1-877-914-8266 http://www.wvdentalboard.org/ Wisconsin P.O. Box 8935 Madison, WI 53708 1(877)617-1565 http://dsps.wi.gov/Default. aspx?Page=90c5523f-bab0-4a45-ab943d9f699d4eb5 Wyoming 1800 Carey Ave., 4th Floor Cheyenne, WY 82002 (307)777-6529 http://plboards.state.wy.us/dental/index.asp

WWW.MEDMONTHLY.COM | 47

U.S. MEDICAL BOARDS Alabama P.O. Box 946 Montgomery, AL 36101 (334)242-4116 http://www.albme.org/ Alaska 550 West 7th Ave., Suite 1500 Anchorage, AK 99501 (907)269-8163 http://commerce.alaska.gov/dnn/cbpl/ ProfessionalLicensing/StateMedicalBoard.aspx Arizona 9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258 (480)551-2700 http://www.azmd.gov Arkansas 1401 West Capitol Ave., Suite 340 Little Rock, AR 72201 (501)296-1802 http://www.armedicalboard.org/ California 2005 Evergreen St., Suite 1200 Sacramento, CA 95815 (916)263-2382 http://www.mbc.ca.gov/ Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7690 http://www.dora.state.co.us/medical/ Connecticut 401 Capitol Ave. Hartford, CT 06134 (860)509-8000 http://www.ct.gov/dph/cwp/view. asp?a=3143&q=388902 Delaware Division of Professional Regulation Cannon Building 861 Silver Lake Blvd., Suite 203 Dover, DE 19904 (302)744-4500 http://dpr.delaware.gov/ District of Columbia 899 North Capitol St., NE Washington, DC 20002 (202)442-5955 http://doh.dc.gov/bomed 48 | DECEMBER 2014

Florida 2585 Merchants Row Blvd.

Tallahassee, FL 32399 (850)245-4444 http://www.stateofflorida.com/Portal/ DesktopDefault.aspx?tabid=115

Louisiana LSBME P.O. Box 30250 New Orleans, LA 70190 (504)568-6820 http://www.lsbme.la.gov/

Georgia 2 Peachtree Street NW, 36th Floor Atlanta, GA 30303 (404)656-3913 http://bit.ly/vPJQyG

Maine 161 Capitol Street 137 State House Station Augusta, ME 04333 (207)287-3601 http://bit.ly/hnrzp

Hawaii DCCA-PVL P.O. Box 3469 Honolulu, HI 96801 (808)587-3295 http://hawaii.gov/dcca/pvl/boards/medical/

Maryland 4201 Patterson Ave. Baltimore, MD 21215 (410)764-4777 http://www.mbp.state.md.us/

Idaho Idaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720 (208)327-7000 http://bit.ly/orPmFU

Massachusetts 200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 (781)876-8200 http://www.mass.gov/eohhs/gov/departments/borim/

Illinois 320 West Washington St. Springfield, IL 62786 (217)785 -0820 http://www.idfpr.com/profs/info/Physicians.asp

Michigan Bureau of Health Professions P.O. Box 30670 Lansing, MI 48909 (517)335-0918 http://www.michigan.gov/lara/0,4601,7154-35299_28150_27529_27541-58914-,00.html

Indiana 402 W. Washington St. #W072 Indianapolis, IN 46204 (317)233-0800 http://www.in.gov/pla/ Iowa 400 SW 8th St., Suite C Des Moines, IA 50309 (515)281-6641 http://medicalboard.iowa.gov/ Kansas 800 SW Jackson, Lower Level, Suite A Topeka, KS 66612 (785)296-7413 http://www.ksbha.org/ Kentucky 310 Whittington Pkwy., Suite 1B Louisville, KY 40222 (502)429-7150 http://kbml.ky.gov/Pages/default.aspx

Minnesota University Park Plaza 2829 University Ave. SE, Suite 500 Minneapolis, MN 55414 (612)617-2130 http://bit.ly/pAFXGq Mississippi 1867 Crane Ridge Drive, Suite 200-B Jackson, MS 39216 (601)987-3079 http://www.msbml.state.ms.us/ Missouri Missouri Division of Professional Registration 3605 Missouri Blvd.

P.O. Box 1335 Jefferson City, MO 65102 (573)751-0293 http://pr.mo.gov/healingarts.asp

Montana 301 S. Park Ave. #430 Helena, MT 59601 (406)841-2300 http://bsd.dli.mt.gov/license/bsd_ boards/med_board/board_page.asp Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 (402)471-3121 http://www.mdpreferredservices.com/ state-licensing-boards/nebraska-boardof-medicine-and-surgery Nevada Board of Medical Examiners P.O. Box 7238 Reno, NV 89510 (775)688-2559 http://www.medboard.nv.gov/ New Hampshire New Hampshire State Board of Medicine 2 Industrial Park Dr. #8 Concord, NH 03301 (603)271-1203 http://www.nh.gov/medicine/ New Jersey P. O. Box 360 Trenton, NJ 08625 (609)292-7837 http://bit.ly/w5rc8J New Mexico 2055 S. Pacheco St. Building 400 Santa Fe, NM 87505 (505)476-7220 http://www.nmmb.state.nm.us/ New York Office of the Professions State Education Building, 2nd Floor Albany, NY 12234 (518)474-3817 http://www.op.nysed.gov/ North Carolina P.O. Box 20007 Raleigh, NC 27619 (919)326-1100 http://www.ncmedboard.org/

North Dakota 418 E. Broadway Ave., Suite 12 Bismarck, ND 58501 (701)328-6500 http://www.ndbomex.com/

Texas P.O. Box 2018 Austin, TX 78768 (512)305-7010 http://www.tmb.state.tx.us/

Ohio 30 E. Broad St., 3rd Floor Columbus, OH 43215 (614)466-3934 http://med.ohio.gov/

Utah P.O. Box 146741 Salt Lake City, UT 84114 (801)530-6628 http://www.dopl.utah.gov/licensing/physician_surgeon.html

Oklahoma P.O. Box 18256 Oklahoma City, OK 73154 (405)962-1400 http://www.okmedicalboard.org/ Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 (971)673-2700 http://www.oregon.gov/OMB/ Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 (717)787-8503 http://www.dos.state.pa.us/portal/server. pt/community/state_board_of_medicine/12512 Rhode Island 3 Capitol Hill Providence, RI 02908 (401)222-5960 http://1.usa.gov/xgocXV South Carolina P.O. Box 11289 Columbia, SC 29211 (803)896-4500 http://www.llr.state.sc.us/pol/medical/ South Dakota 101 N. Main Ave. Suite 301 Sioux Falls, SD 57104 (605)367-7781 http://www.sdbmoe.gov/ Tennessee 425 5th Ave. North Cordell Hull Bldg. 3rd Floor Nashville, TN 37243 (615)741-3111 http://health.state.tn.us/boards/me/

Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220 http://1.usa.gov/wMdnxh Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400 http://1.usa.gov/xjfJXK Washington Public Health Systems Development Washington State Department of Health 101 Israel Rd. SE, MS 47890 Tumwater, WA 98501 (360)236-4085 http://www.medlicense.com/washingtonmedicallicense.html West Virginia 101 Dee Dr., Suite 103 Charleston, WV 25311 (304)558-2921 http://www.wvbom.wv.gov/ Wisconsin P.O. Box 8935 Madison, WI 53708 (877)617-1565 http://dsps.wi.gov/Boards-Councils/ Board-Pages/Medical-Examining-BoardMain-Page/ Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053 http://wyomedboard.state.wy.us/

WWW.MEDMONTHLY.COM | 49

medical resource guide ACCOUNTING

Utilization Solutions service@pushpa.biz (919) 289-9126

www.pushpa.biz

Boyle CPA, PLLC 3716 National Drive, Suite 206 Raleigh, NC 27612 (919) 720-4970 www.boyle-cpa.com

BILLING & COLLECTION

DENTAL Biomet 3i

4555 Riverside Dr. Palm Beach Gardens, FL 33410 (800)342-5454 www.biomet3i.com

Dental Management Club Applied Medical Systems, Inc. Billing - Coding - Practice Solutions 4220 NC Hwy 55, Suite 130B Durham, NC 27713 (800) 334-6606 www.ams-nc.com

CODING SPECIALISTS Place Your Ad Here

CONSULTING SERVICES, PRACTICE MANAGEMENT Physician Wellness Services 5000 West 36th Street, Suite 240 Minneapolis, MN 55416 888.892.3861 www.physicianwellnessservices.com

Urgent Care America

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

Urgent Care & Occupational Medicine Consultant Lawrence Earl, MD COO/CMO ASAP Urgentcare Medical Director, NADME.org 908-635-4775 (m) 866-405-4770 (f ) http://www.asap-urgentcare.com/ http://www.UrgentCareMentor.com

50 | DECEMBER 2014

4924 Balboa Blvd #460 Encino, CA 91316 www.dentalmanagementclub.com

The Dental Box Company, Inc.

PO Box 101430 Pittsburgh, PA 15237 (412)364-8712 www.thedentalbox.com

DIETICIAN Triangle Nutrition Therapy 4030 Wake Forest Road, Suite 300 Raleigh, NC 27609 (919)876-9779 http://trianglediet.com/

ELECTRONIC MED. RECORDS

EXECUTIVE ACCOUNTING & FINANCE RECRUITER Accounting Professionals Agency, LLC Adrienne Aldridge, CPA, CGMA, FLMI President 1204 Benoit Place Apex, NC 27502 (919) 924-4476 aaldridge@AccountingProfessioinals Agency.com www.AccountingProfessionalsAgency.com

FINANCIAL CONSULTANTS Sigmon Daknis Wealth Management 701 Town Center Dr. , Ste. #104 Newport News, VA 23606 (757)223-5902 www.sigmondaknis.com

INSURANCE, MED. LIABILITY Jones Insurance 820 Benson Rd. Garner, North Carolina 27529 (919) 772-0233 www.Jones-insurance.com

AdvancedMD 10011 S. Centennial Pkwy Sandy, UT 84070 (800) 825-0224 www.advancedmd.com

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

EQUIPMENT APPRAISER Brumbaugh Appraisals 8601 Six Forks Road, Suite 400, Raleigh, NC 27615 (919) 870-8258 www.brumbaughappraisals.com

LOCUM TENENS Physician Solutions

PO Box 98313 Raleigh, NC 27624 (919)845-0054 www.physiciansolutions.com

MEDICAL ARCHITECTS MMA Medical Architects

520 Sutter Street San Francisco, CA 94115 (415) 346-9990 http://www.mmamedarc.com

medical resource guide MEDICAL ART

MEDICAL PRACTICE SALES

Deborah Brenner

877 Island Ave #315 San Diego, CA 92101 (619)818-4714 www.deborahbrenner.com

Medical Practice Listings

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

MedImagery

Laura Maaske 262-308-1300 Laura@medimagery.com http://www.medimagery.com

MEDICAL EQUIPMENT

MEDICAL PRACTICE VALUATIONS

PO Box 99488 Raleigh, NC 27624 (919)846-4747 www.bizscorevaluation.com

Matthew Hall (704)419-3005 mhall@assuredpharma.com

www.assurepharma.com

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

www.thetps.com

Capri Health

Angela Savitri, OTR/L, RYT, IHC, RCST速 919-673-2813 angela@caprihealth.com www.freedomfromchronicstress.com

REAL ESTATE York Properties, Inc. Headquarters & Property Management 1900 Cameron Street Raleigh, NC 27605 (919) 821-1350

BizScore

Assured Pharmaceuticals

PROFESSIONAL SPEAKER

MEDICAL RESEARCH

Commercial Sales & Leasing (919) 821-7177 www.yorkproperties.com

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

Scynexis, Inc.

3501 C Tricenter Blvd.

Durham, NC 27713 (919) 933-4990 www.scynexis.com

MEDICAL EQUIPMENT FINANCING Bank of America

Mark MacKinnon, Regional Sales Manager 3801 Columbine Circle Charlotte, NC 28211 (704)995-9193 mark.mackinnon@bankofamerica.com www.bankofamerica.com/practicesolutions

SUPPLIES, GENERAL PRACTICE FINANCING Bank of America

Mark MacKinnon, Regional Sales Manager 3801 Columbine Circle Charlotte, NC 28211 (704)995-9193 mark.mackinnon@bankofamerica.com

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

www.bankofamerica.com/practicesolutions

MEDICAL MARKETING WhiteCoat Designs

Web, Print & Marketing Solutions for Doctors (919)714-9885 www.whitecoat-designs.com

WWW.MEDMONTHLY.COM | 51

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

Family Primary Care Practice

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

Family Practice/Primary Care

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

Med Spa

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

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

Practice Type: Internal Medicine

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

Dental Practices Place Your Ad Here

Optical Practices Place Your Ad Here

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

Considering your practice options? Call us today.

52 | DECEMBER 2014

PRIMARY CARE PRACTICE - Hickory, North Carolina This is an outstanding opportunity to acquire one of the most organized and profitable primary care practices in the area. Grossing a million and a half yearly, the principal physician enjoys ordinary practice income of over $300,000 annually.

Hickory is located in the foot-hills of North Carolina and is surrounded by picturesque mountains, lakes, upscale shopping malls and the school systems are excellent. If you are looking for an established practice that runs like a well oiled machine, request more information.

The free standing building that houses this practice is available to purchase or rent with an option. There are 4 exam rooms with a well appointed procedure room. The owning physician works 4 to 5 days per week and there is a full time physician assistant staffed as well.

For the well qualified purchasing physician, the owner may consider some owner-financing. Call us today.

List price: $425,000 | Year Established: 2007 | Gross Yearly Income: $1,500,000

Medical Practice Listings Selling and buying made easy

MedicalPracticeListings.com | medlisting@gmail.com | 919-848-4202

Women’s Health Practice in Morehead City, NC

PEDIATRICIAN

OR FAMILY MEDICINE DOCTOR NEEDED IN

ROANOKE RAPIDS, NC

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

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

Credentialing at the hospital is necessary.

Medical Practice Listings Buying and selling made easy

Call 919-848-4202 or email medlistings@gmail.com www.medicalpracticelistings.com

Call 919- 845-0054 or email: physiciansolutions@gmail.com www.physiciansolutions.com WWW.MEDMONTHLY.COM | 53

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

Wanted: Urgent Care Practice Urgent care practice wanted in North Carolina.

Qualified physician is seeking to purchase an established urgent care within 100 miles of Raleigh, North Carolina.

If you are considering retiring, relocations or closing your practice for personal reasons, contact us for a confidential discussion regarding your urgent care. You will receive cash at closing and not be required to carry a note.

l One

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

Medical Practice Listings Buying and selling made easy

Please direct all correspondence to driverphilip@gmail.com.

Only serious, qualified inquirers.

Call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com

Eastern North Carolina Family Practice Available Well-appointed Eastern North Carolina Family Practice established in 2000 is for sale in Williamston, NC. This organized practice boasts a wide array of diagnostic equipment including a GE DEXA scanner with a new tube, GE case 8000 stress testing treadmill and controller and back up treadmill, Autoclave and full set of operating equipment, EKG-Ez EKG and much more.

The average number of patients seen daily is between 12 to 22.

The building is owned by MD and can be purchased or leased.

The owning physician is retiring and will assist as needed during the transition period. The gross receipts for the past three years are $650,000 and the list price was just reduced to $240,000.

If you are looking to purchase a well equipped primary care practice, please contact us today.

Contact: Cara or Philip at 919-848-4202

medlisting@gmail.com medicalpracticelistings.com

PHYSICIANS NEEDED: Mental health facility in Eastern North Carolina seeks: PA/FT ongoing, start immediately Physician Assistant needed to work with physicians to provide primary care for resident patients. FT ongoing 8a-5p. Limited inpatient call is required. The position is responsible for performing history and physicals of patients on admission, annual physicals, dictate discharge summaries, sick call on unit assigned, suture minor lacerations, prescribe medications and order lab work. Works 8 hour shifts Monday through Friday with some extended work on rotating basis required. It is a 24 hour in-patient facility that serves adolescent, adult and geriatric patients.

FT ongoing Medical Director, start immediately The Director of Medical Services is responsible for ensuring all patients receive quality medical care. The director supervises medical physicians and physician extenders. The Director of Medical Services also provides guidance to the following service areas: Dental Clinic, X-Ray Department, Laboratory Services, Infection Control, Speech/Language Services, Employee Health,

Pharmacy Department, Physical Therapy and Telemedicine. The Medical Director reports directly to the Clinical Director. The position will manage and participate in direct patient care as required; maintain and participate in an on-call schedule ensuring that a physician is always available to hospitalized patients; and maintain privileges of medical staff.

Permanent Psychiatrist needed FT, start immediately An accredited State Psychiatric Hospital serving the eastern region of North Carolina, is recruiting for permanent full-time Psychiatrist. The 24 hour in-patient facility serves adolescent, adult and geriatric patients. The psychiatrist will serve as a team leader for multi-disciplinary team to ensure quality patient care/treatment. Responsibilities include:

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

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

NC OPPORTUNITIES LOCUMS OR PERMANENT

PEDIATRICIAN

or family medicine doctor needed in

FAYETTEVILLE, NC

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

Call us today if you are available for a few days a month, on-going or for permanent placement.

Please contact Physican Solutions at 919-845-0054 or physiciansolutions@gmail.com For more information about Physician Solutions or to see all of our locums and permanent listings, please visit physiciansolutions.com

Comfortable seeing children. Needed immediately.

Call 919- 845-0054 or email: physiciansolutions@gmail.com www.physiciansolutions.com WWW.MEDMONTHLY.COM | 55

NC Opportunities DENTISTS AND HYGIENISTS

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

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

• • • • • •

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

There is a Compounding Pharmacy located in the same suites with a consulting pharmacist working with this Integrative practice. Average Patients per Day: 12-20 Physician Solutions has immediate opportunities for dentists and hygienists throughout NC. Top wages, professional liability insurance and accommodations provided.

Call us today if you are available for a few days a month, on-going or for permanent placement. Please contact Physican Solutions at 919-845-0054 or physiciansolutions@gmail.com

Gross Yearly Income: $335,000+ | List Price: $125,000

Call 919-848-4202 or email medlistings@gmail.com www.medicalpracticelistings.com

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

Medical Practice Listings l 919-848-4202 l medlisting@gmail.com l medicalpracticelistings.com

3 OCCUPATIONAL THERAPISTS POSITIONS IN JACKSONVILLE, NC These positions are 40 hour per week temp status to permanent positions with the following qualifications required: l Have graduated from an accredited Occupational Therapist program with a Masters Degree and 1 year experience or a Bachelors Degree with 3 years experience in Occupational Therapy. Program must be accredited by the Accreditation Council for Occupational Therapy Education (ACOTE). l Possess and maintain a valid license or certificate to practice as an Occupational Therapist in any of the 50 states, District of Columbia, the Commonwealth of Puerto Rico, Guam or the US Virgin Islands. l Possess and Occupational Therapist Registered (OTR) certification by the National Board for Certification of Occupational Therapy (NBCOT). l Possess a minimum of one year experience as an Occupational Therapist, preferably working in the neurological based practice setting and with a familiarity of TBI specific patient care practice needs.

HOW TO APPLY: Send us your Resume/CV along with the following: available date to start, salary history, cover letter, eight hour shifts available per week. We will contact you by Email or phone to discuss our program. Make sure you provide your phone numbers and Email address.

Contact Cara at: physiciansolutions@gmail.com or phone (919) 845-0054 for details

Primary Care Practice For Sale

NC MedSpa For Sale MedSpa Located in North Carolina

Wilmington, NC

We have recently listed a MedSpa in NC

Established primary care on the coast of North Carolina’s beautiful beaches.

Fully staffed with MD’s and PA’s to treat both appointment and walk-in patients.

Excellent exam room layout, equipment and visibility.

This established practice has staff MDs, PAs and nurses to assist patients. Some of the procedures performed include: Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, fractional laser resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing, and we are in the valuation process.

Contact Medical Practice Listings for more information.

Contact Medical Practice Listings today to discuss the practice details.

Medical Practice Listings 919.848.4202 | medlistings@gmail.com www.medicalpracticelistings.com

For more information call Medical Practice Listings at 919-848-4202 or e-mail medlistings@gmail.com

www.medicalpracticelistings.com

Modern Med Spa Available

Located in beautiful coastal North Carolina Modern, well-appointed med spa is available in the eastern part of the state. This Spa specializes in BOTOX, facial therapy and treatments, laser hair removal, eye lash extensions and body waxing as well as a menu of anti-aging options. This impressive practice is perfect as-is and can accommodate additional services like; primary health or dermatology.

The Gross revenue is over $1,500.000 during 2012 with consistent high revenue numbers for the past several years. The average number of patients seen daily is between 26 and 32 with room for improvement. You will find this Med Spa to be in a highly visible location with upscale amenities. The building is leased and the lease can be assigned or restructured. Highly profitable and organized, this spa POISED FOR SUCCESS. 919.848.4202 medlisting@gmail.com medicalpracticelistings.com

Pediatrics Practice Wanted Pediatrics practice wanted in NC Considering your options regarding your pediatric practice? We can help.

Medical Practice Listings has a well qualified buyer for a pediatric practice anywhere in central North Carolina.

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

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

Listing Price: $430,000

Contact us today to discuss your options confidentially.

Medical Practice Listings Call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com

Call 919-848-4202 or email medlistings@gmail.com www.medicalpracticelistings.com

ADVERTISE YOUR PRACTICE BUILDING IN MED MONTHLY

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

List price: $435,000

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

By placing a professional ad in Med Monthly, you're spending smart money and directing your marketing efforts toward qualified clients.

Contact one of our advertising agents and find out how inexpensive yet powerful your ad in Med Monthly can be.

medmonthly.com | 919.747.9031

PRIMARY CARE PRACTICE East of Raleigh, North Carolina We are offering a well established primary care practice only minutes east of Raleigh North Carolina. The retiring physician maintains a 5 day work week and has a solid base of patients that can easily be expanded. There are 6 fully equipped exam rooms, a large private doctor’s office, spacious business office, and patient friendly check in and out while the patient waiting room is generous overlooking manicured flowered grounds. This family practice is open Monday through Friday and treats 8 to a dozen patients per day.

Currently operating on paper charts, there is no EMR in place. The Gross revenue is about $235,000 yearly.

We are offering this practice for $50,000 which includes all the medical equipment and furniture. The building is free standing and can be leased or purchased.

Contact Cara or Philip at 919-848-4202 to receive details and reasonable offers will be presented to the selling physician.

Medical Practice Listings Selling and buying made easy

MedicalPracticeListings.com | medlisting@gmail.com | 919-848-4202

Physician Solutions, Inc. Medical & Dental Staffing

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

Physician Solutions

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

phone: 919-845-0054 fax: 919-845-1947 www.physiciansolutions.com physiciansolutions@gmail.com