Med Monthly January 2013 by MedMedia9

Med Monthly JANUARY 2013

THE DEBATE AROUND THE “MEDICALIZATION” OF FEMALE SEXUALITY pg. 52

ANDROPAUSE AND MALE SEXUALITY pg. 50

THE ISSUE OF SEXUAL HEALTH AND WHY IT IS IMPORTANT TO CLINICIANS pg. 44

the

sex and the practice issue

Talking to Your Health Care Provider About Your Sexual Wellbeing

Questions To Ask

pg. 14

contents

The Art@Hospitals Initiative - Pedro’s Wish

features 44 THE ISSUE OF SEXUAL HEALTH AND WHY IT IS IMPORTANT TO CLINICIANS 48 ALLIED HEALTH CARE COLLABORATION IN SEXUAL MEDICINE 50 ANDROPAUSE AND MALE SEXUALITY 52 THE DEBATE AROUND THE “MEDICALIZATION” OF FEMALE SEXUALITY

practice tips 18 PREGNANCY AND EARLY VISITS FOR YOUR BABY - Role of bonding with a Pediatrician 20 PHYSICIAN ASSISTANT WORKFORCE:

insight

A Noted Shift in Gender Demographics

10 BREAST AUGMENTATION IMPROVES QUALITY OF LIFE 12 WHY DOCTORS MUST HAVE A WEBSITE – and What They Must Have On It

14 TALKING TO YOUR HEALTH CARE PROVIDER ABOUT YOUR SEXUAL WELLBEING: 10 Questions to Ask

international 16 IMMUNOTECH LABORATORIES, INC. com-

pletes clinical trial protocol preparation for it’s HIV/AIDS vaccine drug candidate through Mexican hospitals contracts

Allied Health Care Collaboration In Sexual Medicine

22 12 WAYS TO SUPERCHARGE YOUR PRACTICE

research and technology 28 HEALTH IT – Deciphering Medical And Industry

Associations Comments On Meaningful Use Stage 2

30 CHILDREN’S HEALTHCARE OF ATLANTA DEVELOPS NEW SMART PHONE APP FOR EARLY DETECTION OF HEART DEFECTS IN NEWBORNS 32 YOU IMAGINE - Mobile Health For Women

legal 40 HMA EXEC SAYS PHYSICIANS ‘GROSSLY MISCHARACTERIZED’ ADMISSIONS MANAGEMENT 42 LEGAL ISSUES OF FERTILITY

the arts 56 THE ART@HOSPITALS INITIATIVE - Pedro’s Wish

healthy living 58 HOT ONION SOUP

in every issue 4 editor’s letter 8 news briefs

64 resource guide 80 top 9 list

editor’s letter

“Sex and the Practice” is the titillating theme for the January issue. Med Monthly has articles that answer sexual questions that people might find hard to discuss, even with their doctor. How can issues with sexuality be broached, how wide spread are they, and how can they be ameliorated? Sheryl Kingsberg, PhD, in her feature The Issue of Sexual Health and Why It is Important to Clinicians bluntly states, “If you don’t think your patients are having sexual problems, you are not asking.” Around 43% of women believe they have sexual problems, and 11% have a diagnosed condition. Kingsberg elaborates on how a patient should be secure in the fact that these issues are real, common and treatable. The article Allied Health Care Collaboration in Sexual Medicine by Rebecca Dnistran, MA, also asserts that embarrassment often prevents women from seeking help with problems associated with sex. Dnistran recommends making an appointment with your primary care physician. They are trained both in the psychosocial and biological aspects of sexual issues. A way for physicians to introduce the subject in a non threatening way is to provide a screening checklist for sexual dysfunction along with their intake forms. It is well known that women’s bodies change during menopause. But is male menopause real? Michael Werner, MD, believes it is. In his feature Andropause and Male Sexuality he discusses how there are emotional and physical changes a man goes through as his hormones decrease with age. Unlike the dramatic changes that occur during female menopause, Andropause creates changes such as diminished sexual desire and erectile quality gradually. The occurrence of “male menopause” increases through life – 2-5% of men have this condition in their 40s, while there is an incidence of 91% in males over 80. Though sexual issues can be uncomfortable to discuss, our January issue tries to encourage people to seek medical help and assure them they are not alone. Problems with sex can seriously affect a person physically and emotionally. There are solutions for sexual problems, but both the patient and the doctor have to be open and honest – possibly joining the psycho-sexual with the physiological to make a happier individual.

Ashley Austin Managing Editor

4 | JANUARY 2013

Med Monthly November 2012 Publisher Philip Driver Managing Editor Ashley Austin Creative Director Thomas Hibbard Contributors Ashley Acornley, MS, RD, LDN Melissa B. Brisman, Esq., LLC Rebecca H. Dnistran, MA Philip Driver Satya Jammalamadaka MD Sheryl Kingsberg, PhD Bat Sheva Marcus, LMSW, MPH, PhD Laura Masske Frank J. Rosello Lisa P. Shock, MHS, PA-C Michael A. Werner, M.D., FACS Mary Pat Whaley, FACMPE Jessica Zigmond

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 Rebecca H. Dnistran, MA is a NC Licensed Marriage and Family Therapist, a NC Licensed Professional Counselor and holds a Diplomate in Sex Therapy from AASECT. She is one of six founding members of The Center for Sexual Health, an organization of Sex Therapists, Medical Affiliates and Medical Consultants serving the Triangle and beyond in North Carolina. (www.centerforsexualhealth.com)

Laura Maaske is a medical illustrator with a Master's of Science degree in Biomedical Visualization from the University of Toronto. She launched Medimagery in 1997, specializing in the creation of patient education materials, interactive media, e-books, cellular and molecular illustrations, and design of medical education materials. For more information, please visit Medimagery. com, send a note to Laura@medimagery.com or call 262.308.1300.

Bat Sheva Marcus, LMSW, MPH, PhD is the Clinical Director of the Medical Center for Female Sexuality, located in Manhattan, Purchase and Great Neck. Bat Sheva Marcus wrote her dissertation on women and vibrator use while earning her Doctor of Philosophy in human sexuality from the Institute of Advanced Study of Human Sexuality. She also has a Master’s in public health from the same institution. She is a licensed social worker with a Master’s degree from Columbia University. Dr. Marcus is a founder of the Medical Center for Female Sexuality. For more information, please visit www.centerforfemalesexuality.com or call (646) 839-0700.

Michael A. Werner, M.D., FACS

is a board-certified urologist who received his specialized fellowship training in male infertility and surgery and male sexual dysfunction at Boston University Medical Center. He lectures and writes extensively on these topics in medical journals and books. Dr. Werner completed his Urology residency at Mount Sinai Medical Center in Manhattan and received his medical school training at the University of California at San Francisco. He holds an undergraduate degree in Biology from Harvard College. Dr. Werner’s private practice has locations in Westchester and Manhattan, and is limited to male infertility and male sexual dysfunction. For more information, please visit www.wernermd. com and www.nyandropausecenter.com or call (646) 380-2600.

designer's thoughts From the Drawing Board Bill Gates stated, “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” Several new medical technologies are covered this month in Med Monthly with the intent of making your practice more efficient. “12 Ways to Supercharge Your Practice”, the second part of Mary Pat Whaley’s article, discusses the benefits of using cloud technology to communicate with patients with mobile apps and to store your valuable documents, getting the most out of your SEO (search engine optimization) to drive new patients to your practice, and incorporating EHR (electronic health records) and ePrescribing Incentive Program to maximize your Medicare payments. Laura Maaske’s article “Mobile Health for Women” discusses mobile apps designed with the woman in mind. She covers apps for several female health concerns including predicting women’s cycles, pregnancy, breast cancer information and tests, oncology, finding a doctor, and even a charitable contribution app whose proceeds go to help breast cancer. In keeping with this month’s focus on sex and the practice, there is a light-hearted app, “Your Man Reminder” that has hot-looking shirtless men reminding women to perform their weekly or monthly breast exams and includes “man-o-grams” which can be sent to friends to remind them to do their exams. In the “Research and Technology” section of this month’s magazine, the article “Why Doctors Must Have a Website” addresses the key reasons to have a doctor or practice website and lists what to include on your site. Also in the R&T section is an article on a new Smart Phone app for early detection of heart defects in newborns developed by the Children’s Healthcare of Atlanta called the Pulse Ox Tool. Sun Microsystems co-founder, Scott McNealy, states “Technology has the shelf life of a banana.” Our objective at Med Monthly is to supply you with ripe, fresh bananas in medical technology each month to assist health care practices operate efficiently and profitably.

Thomas Hibbard Creative Director

6 | JANUARY 2013

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news briefs

Infertility Insurance Coverage Leads to More Births, Can Ease Health Disparities Two studies done at Washington University in St. Louis and presented to the 68th Annual Meeting of the American Society for Reproductive Medicine show the impact that having health insurance coverage for infertility can make. The first study compared patients whose health insurance included coverage for infertility with those without insurance coverage for their disease. Tracking medical and billing records of over 1000 patients, the investigators found that patients with insurance coverage were able to seek IVF earlier and ultimately have more children than women lacking such coverage. The second study sought to explore the relationship between insurance, race and outcomes. Again reviewing medical and billing records from over 1000 women they found that insurance coverage in-

creases access to infertility treatments and with that improved coverage, African American women were able to achieve similar pregnancy rates to women of other races. “These studies point out the vital role insurance coverage for infertility can play. As with other diseases, patients with insurance get treated faster, and have better outcomes than those without. It is time that health insurance companies end their discrimination against the infertile, said Glenn Schattman, MD, President of the Society for Assisted Reproductive Technology. Source: American Society for Reproductive Medicine, Press Releases at http://www.asrm.org/Infertility_Insurance_Coverage_Leads_to_More_Births_Can_ Ease_Health_Disparities/

Vitera Healthcare Solutions Study Indicates That the Majority of Health Care Professionals Are Interested in a Mobile EHR Solution Vitera Healthcare Solutions, one of the nation’s largest providers of electronic health records and practice management software and services, announced today the results of its EHR Solutions and Mobile Technologies Study. The Tampa-based Health care IT provider, which serves more than 400,000 health care professionals, surveyed doctors, executives and practice managers to identify how they currently use mobile technologies and how they intend to use them in the future. The Study found that while 72 percent of surveyed health care professionals already use their mobile device for work purposes, only six percent are currently using their devices to connect to their EHR or to e-prescribe. However, the majority of respondents are interested in a mobile EHR solution, with physicians being the most interested (91%), followed by practice administrators (66%) and billing managers (43%). “Health care professionals are embracing the convenience of mobile technology to handle a number of work tasks, but want to expand this ability by having a mobile EHR solution,” said Matthew Hawkins, CEO of Vitera Healthcare Solutions. “In the same manner that other professionals are able to enjoy the benefits of their mobile device as an office on-the-go, practice physicians, executives and managers are looking for the same accessibility to provide more efficient care for their patients.” Survey results showed that the key features respondents are looking for in a mobile EHR solution are the ability to review 8 | JANUARY 2013

(93%) and update (87%) a patient’s chart and order prescriptions (86%). Other key findings include: Respondents presently use their mobile device to email, phone, text or send other communications (55%); perform medical research on the go (20%); and as a remote desktop solution (14%). The ability to document a patient’s encounter (82%) and out-of-office activities (67%) are other essential elements surveyed professionals are looking for in a mobile EHR solution. The most popular mobile devices respondents use are iPhones (60%), an iPads (45%) and Android smartphones (38%) Source: http://www.viterahealthcare.com/company/ Pages/pr_ViteraHealthcareSolutionsStudyIndicatesThattheMajorityofHealthcareProfessionalsAreInterestedinaMobileEHRSolution.aspx

SOON COMING ONTHLY IN MED M

coming In the up , 2013 issue February e m thly’s the Med Mon T will be EN

HealthCare.gov helps same-sex couples find coverage by adding new details Americans are now able to use HealthCare.gov to search specifically for insurance plans that include coverage for domestic partners, HHS Secretary Kathleen Sebelius announced today. The Health Plan Finder tool on HealthCare.gov allows consumers to compare the cost sharing and benefit choices of health plans and choose the best option to meet their needs. As a part of the plan finder update, domestic partners, including samesex couples, can now filter plans that offer coverage for all members of their family. “Last year, as part of our commitment to work with the lesbian, gay, bisexual and transgender community and be more responsive to the needs of these populations, we promised to improve the Health Plan Finder tool to give these individuals the ability to search for health plans that provide same-sex partner benefits.” said Secretary Sebelius. “Today we have delivered on that promise.” Consumers looking for information on same-sex partner coverage can also access HealthCare.gov’s regular features, such as sorting based on enrollment, out-of-pocket expenses or other key categories. The same-sex partner filter is also available for small businesses looking for coverage for their employees. Studies have shown that a portion of the lesbian, gay, bisexual and transgender (LGBT) community is disproportionately uninsured, including those without access to coverage through a spouse, domestic partner or employer. This new filter helps address that issue by linking same-sex couples to carriers that provide benefits for their partners. “In the past, many same-sex couples have faced challenges searching for health coverage that suited their needs,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight. “This tool will eliminate the guesswork, providing an enhanced resource for exploring insurance coverage.” HealthCare.gov, created by the Affordable Care Act, is the first of its kind to bring information and links to health insurance plans to one place, and to make it easy for consumers to learn about and compare their insurance options. The Centers for Medicare and Medicaid Services worked to define and collect detailed benefits and premium rating information from insurers across the country to develop the site. Source: http://www.hhs.gov/news/press/2012pres/02/20120207b.html

Preliminary Results of the FDA-funded Study Suggests 1.5-fold Increase in the Risk of Blood Clots for Women The U.S. Food and Drug Administration (FDA) has informed the public that it has not yet reached a conclusion, but remains concerned, about the potential increased risk of blood clots with the use of drospirenone-containing birth control pills. It is sold under the brand names Yasmin, Yasminelle, Yaz, Beyaz, Ocella, Zarah, and Angeliq. FDA has completed its review of the two 2011 studies that evaluated the risk of blood clots for women who use drospirenone-containing birth control pills and is continuing its review of a separate FDA-funded study that evaluated the risk of blood clots in users of several different hormonal birth control products (contraceptives). Preliminary results of the FDA-funded study suggest an approximately 1.5-fold increase in the risk of blood clots for women who use drospirenone-containing birth control pills compared to users of other hormonal contraceptives. Patients should talk to their health care professional about their risk for blood clots before deciding which birth control pill to use. Known risk factors that increase the risk of a blood clot include smoking, being overweight (obesity), and family history of blood clots, in addition to other factors that contraindicate use of birth control pills. Women currently taking a drospirenonecontaining birth control pill should be informed of the potential risk for blood clots. FDA will continue to communicate any new information to the public as it becomes available. Source: http://www.hhs.gov/opa/ news/news-20110928-pre.html MEDMONTHLY.COM |9 MEDMONTHLY.COM |9

insight

Breast Augmentation Improves Quality of Life Study Reveals Improved Satisfaction, Well-Being and Sexual Functioning

American Society of Plastic Surgeons 10 | JANUARY 2013

Women undergoing breast augmentation surgery report substantial improvement in several key areas of quality of life, reports a study in Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). “Cosmetic breast augmentation can have a significant and profound positive impact on a woman’s satisfaction with her breasts and her psychosocial and sexual wellbeing,” according to the report by ASPS Member Surgeon Colleen M. McCarthy, MD of Memorial SloanKettering Cancer Center, New York, and coauthors.

Questionnaire Shows Benefits After Breast Augmentation The researchers developed and evaluated a questionnaire (BREAST-Q©) to evaluate changes in health-related quality of life after cosmetic breast augmentation. Quality of life is increasingly regarded as an important factor in evaluating the benefits of many types of medical or surgical treatments. The BREAST-Q© questionnaire evaluated changes in six areas: satisfaction with breasts and with overall outcome, psychosocial, sexual, and physical well-being, and satisfaction with care. Fortyone women completed the questionnaire six months before and after undergoing cosmetic breast augmentation surgery with implants. The group results showed significant improvement in three out of the six areas. On a 0-to-100 scale, average scores increased from 27 to 70 for satisfaction with breasts, from 45 to 78 for psychosocial well-being, and from 35 to 72 for sexual well-being. More than 80 percent of women reported “significant improvement” in satisfaction in these three areas. The gains in quality of life were considered very large-similar in magnitude to the

improvement in symptoms after hip replacement surgery. Breast augmentation is the most common cosmetic surgical procedure performed in the United States. According to ASPS statistics, more than 300,000 women underwent cosmetic breast augmentation in 2011. Dissatisfaction with breast size or shape can negatively affect a woman’s quality of life in several ways, including self-perceived attractiveness and sexuality. In recent years, the U.S. Food and Drug Administration has urged ongoing follow-up of women receiving breast implants to document not only the safety but also the effectiveness of breast augmentation. Dr. McCarthy and colleagues write, “This means that, more than ever before, it is vital to provide reliable and valid evidence regarding patient outcomes of breast augmentation, especially...healthrelated quality of life and patient satisfaction.” The new study shows that implantbased breast augmentation can significantly improve a woman’s quality of life in several key areas. It also demonstrates the ability of the BREAST-Q© to “capture the impact of surgery from a patient perspective.” The researchers believe their findings are directly relevant to plastic surgeons working with individual patients. The BREAST-Q© can provide “tangible evidence” of patient satisfaction, improve communication, and help in establishing the expected results of cosmetic breast augmentation. Using the BREAST-Q© in future studies and clinical practice will also be useful in providing “benchmarks” for patient satisfaction and quality of life-especially psychological outcomes.  Source: http://www.plasticsurgery.org/ News-and-Resources/Press-ReleaseArchives/2012-Press-Release-Archives/ Breast-Augmentation-ImprovesQuality-of-Life.html American Society of Plastic Surgeons www.plasticsurgery.org

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insight

Why Doctors Must Have a Website –

And What They Must Have on it You probably spend a good amount of money marketing to prospective and current patients with flyers, postcards, or by running print ads. However, a professional website can be one of the most powerful marketing tools you will ever have. As more and more patients go online to find information about their doctor and medical clinics, it’s in your best interest to have a professional website for them to access. Your website can provide some very detailed information about your practice, your services, and also valuable information about you.

Key Reasons to Have a Practice Website Some of the key reasons to set up a professional website for yourself or your practice include: • Providing a list of procedures and services available for patients at a glance • Showcasing your practice and staff members 12 | JANUARY 2013

• Providing a bio of doctors or medical practitioners at your practice as a brief intro • Including videos or other media to help patients learn more about your practice • Providing links to your social media accounts such as Twitter and Facebook so patients can keep current with your updates • Updating a blog attached to the site regularly to provide interesting content for patients and also for SEO purposes • Being accessible from search engine searches so that interested patients can find you and book a consultation or appointment

What to Include on Your Practice Website Once you realize how powerful having a practice website can be, you’ll need to make sure your site has several key elements. A doctor or practice website needs to include:

• Comprehensive list of services or procedures you offer • Before and After Gallery of your best results (if available) • Contact form for prospective and current patients seeking a consultation or appointment • Online appointment feature • Live chat option (ideal for many practices) for patients who need questions answered immediately • FAQs page • Ask the nurse; Email Q & A • Staff profiles and list of certifications • Photos or video tour of the practice • Interactive map to your location • Practice hours and days of operation • Insurance plans and programs accepted • Pictures of staff and practice Following these suggestions will allow your website to reflect who you are and help you achieve what you want your practice to become. 

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insight

Talking to Your Health Care Provider About Your Sexual Wellbeing: 10 Questions

To Ask

Talking to a health care provider about your sexual health can be intimidating. You might feel embarrassed about the questions that you have; you might not want to admit to certain feelings or fears about your health. However, being able to talk to your health care provider about your physical health as it relates to your sexual health is absolutely crucial.

By the American Social Health Association 14 | JANUARY 2013

If you can’t be totally honest about what’s happening with your body and your feelings about it, you won’t be able to get accurate treatment. Your health care provider should be able to give you straightforward, nonjudgmental feedback and advice about your body and sexual life, but he or she has to start with the whole picture! The first step is to choose a health care provider that you trust. He or she should be someone who is openminded, honest, and very good at listening. Be sure to talk to your health care provider about your own boundaries in terms of what is okay in terms of how he or she deals with your body and health concerns. If you feel uncomfortable with your health care provider for any reason, follow your instincts; ask around for other recommendations. Your good health depends on your ability to communicate and rely on your health care provider! You might have to try more than one before you feel completely comfortable. But when you do, he or she will be an ally as you continue to learn more about how to remain in good health. When thinking about how to discuss your concerns or sexual problems with your health care provider, remember that: • he or she is there to help you • the things you want to talk about are almost certainly not new. • he or she will have dealt with many patients who come to the table with all kinds of questions or conditions.

10 Questions to Ask The questions you may want to ask your health care provider can cover a wide range of topics. from changes in sex drive, dealing with sex during pregnancy, pain during sex, protecting your fertility, what form of contraception would be best, or other issues. There are few topics, however, that any sexually active person should be sure to discuss, including

‘‘

Your health care provider should be able to give you straightforward, nonjudgmental feedback and advice about your body and sexual life, but he or she has to start with the whole picture!

preventing sexually transmitted infections, getting tested, and more. The 10 questions below are a great place to start the conversation with your health care provider. 1. I want to make sure that I’m taking all of the right steps to protect myself from sexually transmitted infections. Where should I start? 2. How can I talk to my partner about STIs? Can you give me some advice? 3. I want to make sure that my partner and I get tested before we have sex. Where should I go? How can I bring up the topic with him/her? 4. Given what we’ve talked about in terms of my relationship history, should I be tested for STDs/STIs? Which ones? 5. How often should I be tested for STIs? Which ones? 6. Are there any vaccines I should consider to protect myself from STIs? Are there vaccines that are recommended for me? 7. What are my options when it comes to birth control? How can I talk to my partner about birth control options? 8. I’ve been feeling differently about sex recently. Can we talk about what might be going on? 9. What screenings* are recommended for someone

my age? (*such as STI tests, mammograms, prostate cancer screening, etc.) 10. I’m not always happy with the way my partner treats me. Can we chat about that? Your provider needs to know some personal information about you so that she or he can help answer your questions and assess your risk and offer the correct advice. You may want to talk to your provider about the following: • Your sexual history • Your current sexual practices • Your condom use • Any symptoms you have • If you could be pregnant

Finding the Right Provider What if you don’t have a regular health care provider? Where do you begin trying to find one? You can start by asking family, friends, or coworkers for referrals. If you have health insurance, your insurance company should offer a list of providers as well. The links below offer another resource, allowing you to search for appropriate providers and health centers in your area: Find a Health Center (from the U.S. Health Resources Services Administration) Search federally-funded health centers that provide care even if you have no health insurance. You pay what you can afford, based on your income. MedlinePlus Directories MedlinePlus (a service of the National Library of Medicine and the National Institutes of Health) provides links to directories to help you find health professionals, services and facilities. Planned Parenthood Find a Planned Parenthood clinic near you.  Courtesy of the American Social Health Association, all rights reserved MEDMONTHLY.COM |15

international subsequently stimulate cytotoxic lymphocytes. These lymphocytes have a prominent role in the host’s immunologic response to HIV infection. Proteins encoded by these pathogens enter the endogenous pathway for antigen presentation and are expressed on the surface of the infected cell as a complex with class l MHC- proteins. IPF appears to present a novel mechanism to reduce viral burden and stimulate immune responses to the virus for patients with significant antiretroviral resistance. Furthermore, the use of IPF with antiretroviral therapy reduces the viral load between two and five log reduction.  Further information can be obtained from www.immunotechlab.com

Mexican Hospital Contracts Assist Immunotech Laboratories, Inc. to Complete Clinical Trial Protocol Preparation for HIV/AIDS Vaccine Drug Candidate

ursuant to significantly positive results with its patient population targeting full blown AIDS patients, Immunotech Laboratories, Inc. has completed numerous clinical contracts with Mexican hospitals to initiate a full blown effort of clinical trial protocol preparation for its HIV/AIDS Vaccine drug candidate. The successful outcome of these efforts will eventually provide the necessary regulatory means for its product’s registration approval in the Republic of Mexico and eventually open a venue to most of the central and South American markets. Resistance to all commercially available antiretroviral (ARV) agents within all classes has been reported. The occurrence of multi-class resistance remains high, with 20% of infected individuals developing resistance to two or more classes within six years of initiating treatment,

16| JANUARY 2013

and 10% of newly diagnosed infections already resistant to at least one class in the U.S. Multi-class resistance is even more prevalent in disenfranchised patient populations, whose rates of successful adherence to even the most simplified regimens available remains prohibitively low. Inactivated Pepsin Fraction (IPF), like other natural autoantibody based fractionated proteins, has an affinity to pathogenic binding and simultaneously produces effects of immune homeostasis. IPF has shown significant antiretroviral activity via immune stimulatory pathways in vitro, notably helper T1 cells elaborate cytokines INFy, IL-2. These cells selectively promote cellmediated immune responses that are disadvantageous to viral replication. IPF appears to modulate helper T1 cells’ expression of elaborate cytokines INFy, IL-2, which selectively promote cell-mediated immune response and

This news release contains forwardlooking statements that involve risks and uncertainties associated with financial projections, budgets, milestone timelines, clinical development, regulatory approvals, and other risks described by Immunotech Laboratories, Inc. from time to time in its periodic reports filed with the SEC. IPF is not approved by the US Food and Drug Administration or by any comparable regulatory agencies elsewhere in the world. While Immunotech Laboratories believes that the forward-looking statements and underlying assumptions contained therein are reasonable, any of the assumptions could be inaccurate, including, but not limited to, the ability of Immunotech Laboratories to establish the efficacy of IPF in the treatment of any disease or health condition, the development of studies and strategies leading to commercialization of IPF in the United States, the obtaining of funding required to carry out the development plan, the completion of studies and tests on time or at all, and the successful outcome of such studies or tests. Therefore, there can be no assurance that the forward-looking statements included in this release will prove to be accurate. In light of the significant uncertainties inherent in the forward-looking statements included herein, Immunotech Laboratories or any other person that the objectives and plans of Immunotech Laboratories will be achieved should not regard the forward-looking statements as a representation.

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practice tips

PREGNANCY AND EARLY VISITS FOR YOUR BABY Role of Bonding With a Pediatrician By Satya Jammalamadaka MD. Pineville Pediatrics 18 | JANUARY 2013

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“There are many pediatricians who provide excellent care but they are all different in their approaches and styles.”

For every woman, pregnancy is a time filled with excitement, anticipation and a lot of preparation for her child. One of the most important and crucial things that many mothers are considering and making part of their routine nowadays is “Pediatrician shopping” along with the Toys R Us shopping. Scheduling interviews with more than one pediatrician might seem to be unnecessary but it is worth taking the less than 10 minutes for a brief interview in order to get a “feel” for his/her personality and approach, and it is well needed and useful. Pediatricians should be well prepared for this as well, whether the visit is for a charge or for free and, mother should be informed of the same. There are many Pediatricians who provide excellent care but they are all different in their approaches and styles. It is extremely important for a family or mother to get the feel of whether their family’s needs and their questions regarding their new baby will be addressed in the way they want it and/or believe in. The ideal time for a mother to look for a Pediatrician locally in her area is in the second trimester of her pregnancy or 28-32 weeks. This gives enough time for a mother to plan everything for her baby. Say for example, some babies are born at full term or at completion of 9 months of pregnancy and some babies might be born earlier or premature and so, second trimester “Pediatrician shopping” is ideal. Asking her OBGYN or midwife

or Nurse Practitioner or Physician Assistant or any of her friends and/ or family is a good way to find some good Pediatricians to meet. Some of the “search media” like Google and reviews and ratings can help when they want to do their own research to find out about good local Pediatricians. A phone call to each of the offices that any mother has considered will start her search – the front desk to the nurse to the doctor will tell her whether she would be comfortable and her needs and her child’s needs will be met as a team by them or not. The maximum visits for a baby will be in the first year and the maximum questions and concerns will also be at the same time. So, a Pediatrician who is approachable and accessible is always a plus. For a mother, to write down the important questions that need to be answered such as whether she prefers a male or female pediatrician or the approximate age of the pediatrician (if it matters) is important. Every mother has her own concerns and questions regarding her pregnancy and delivery of her child, for a Pediatrician, but the most common ones she should and could have are – • What is your educational background and how long have you been practicing? • What are your hours? Do you offer evenings or weekends and same day sick appointments? • What if my baby gets sick when the office is closed? Who covers in an emergency if you aren’t on call? • Is this a solo or group practice? If it’s solo, who covers when you are gone? If it’s a group, how often will we see you, and how often will we see other members? • Do you have separate sick and well waiting rooms? • Do you respond to questions by e-mail and if so, is it PROTECTED? Do you accept calls for routine and non-emergency questions? If I leave a message, how long does it usually take you to return the call?

• Will your initial meeting with my baby be at the hospital or the first checkup? What is your schedule for well baby checkups? • What will be goals of well check visits? • What are your views on such matters as: Bottle feeding? Circumcision? Parenting techniques? Getting babies to sleep? Alternative medicine? Antibiotics? Immunizations? Childhood obesity? • Do you take my insurance? Is there an extra charge for: Advice calls during the day? Advice calls after hours? Medication refills? Filling out forms? Will any other fees apply? • What are your policies for insurance claims, lab policies, payments and billing? • What tests are handled in the office, and what is done elsewhere? Where? A mother should always look for building a relationship with her child’s pediatrician before she needs her services. It reduces her anxiety during the pregnancy as well as after the birth of her baby. If a pediatrician is too busy to provide a prenatal interview, this may be indicative of how busy the practice is and the amount of personal attention the family is likely to receive. No matter how good a pediatrician is reported to be, if she is overworked, a family’s interaction is unlikely to be satisfactory. The bond between the parent and pediatrician is a critical one and so is the bond between the child and a Pediatrician, when he/she grows up. A doctor may be well-qualified, but if a parent doesn’t have confidence in the physician, it may affect the welfare of the child. It’s OK for both parties, Physician and the family to “move on” once such disparity occurs and continue the search to find the “right fit”. As I always believe “A child’s well being should be the priority!”  http://pinevillepediatrics.com MEDMONTHLY.COM |19

practice tips

Physician Assistant Workforce:

A Noted Shift in Gender Demographics

A 2011 article published in

By Lisa P. Shock, MHS, PA-C President/CEO Utilization Solutions in Healthcare, Inc. 20 | JANUARY 2013

HealthLeaders Media comments on the Physician Assistant workforce experiencing a 100% increase in the last 10 years. I am often fond of saying that PAs are like type O blood â&#x20AC;&#x201C; we can practice in every specialty and in every medical practice setting. It is not surprising that practices and health care systems are utilizing us more to deliver high quality, cost effective medical care.

One of the largest trends I have seen over my career is the change in demographics. According to the AAPA, female PAs outnumber male PAs by nearly 20,000 and this is evidenced in the student applicant pool as well. Factors including lifestyle, flexibility, and family planning have all contributed to this shift. My colleague, L. Gail Curtis, MPAS, PA-C, DFAAPA, published a recent article entitled, From “old boys” to “all girls”: Changing PA demographics, highlighting and chronicling the gender shift in PAs since the onset of the profession. Job satisfaction remains high for Physician Assistants. A recent article ranked PAs in the top 7% of all jobs for job satisfaction. Another recent article published in July of 2012 declares that the average female primary care physician would be better off financially if she had become a physician assistant. When examining and comparing the earnings of male and female physicians, male physicians earn

more per hour relative to male PAs than female physicians earn relative to female PAs. The significant difference comes from an hours gap. The vast majority of male physicians under the age of 55 work substantially more than the standard 40 hour work week. In contrast, most female physicians work between 2 to 10 hours fewer than this per week. Even though both male and female physicians both earn higher wages than their PA counterparts, most female doctors don’t work enough hours at those wages to financially justify the costs of doctoral training. My prediction is that the PA profession will continue with another 100% doubling in the next 10 years. Health reform initiatives will increase the number of patients that need care. The only way the US healthcare system can absorb the huge changes we have been talking about is through more efficient utilization of all resources – and when it comes to the actual delivery of care by providers it will have to be through more efficient

teams. The growth in the number and size of PA training programs has been substantial, with more than 5,300 graduates projected in 2010, and although the number of PAs in clinical practice could reach 110,000 by 2015, this remains less than one PA for every five medical and surgical specialists.  References: http://www.myplan.com/ careers/physician-assistants/ summary-29-1071.00.html?sid=018af5 e996d5ae5c7b4218faa8ebd189 http://www.healthleadersmedia. com/page-1/PHY-270712/USPhysician-Assistant-WorkforceDoubles-in-10-Years http://www.theatlantic.com/ health/archive/2012/07/is-medicalschool-a-worthwhile-investment-forwomen/260051/# http://www.jaapa.com/fromold-boys-to-all-girls-changing-pademographics/article/234026/ https://www.aapa.org/the_pa_ profession/quick_facts/resources/item. aspx?id=3850&terms=demographics

practice tips

12 Ways to Supercharge Your Practice Part 2 of 2

By Mary Pat Whaley, FACMPE

There are 12 very actionable ways to make positive improvements in your practice. In this issue weâ&#x20AC;&#x2122;ll present the last 6 ways (the first 6 ways were covered in our December 2012 issue). Read through all twelve ways and rank them in order of importance and priority for your group. Bring them to your strategic planning meetings and discuss ways to implement them, or use them as a springboard for other ideas to improve your practice and gain a competitive edge. 22 | JANUARY 2013

#7 Take Care of Your

Staff So They Can Take of Your Patients “Employees are the most valuable resource in any business.” We hear that statement all the time. I believe it. Most managers would say they believe it. But a lot of managers don’t act as if they believe it. If you take it to heart and realize what the extreme cost of turnover is to your organization, then you are always trying to find new ways to find the very best staff, and once you’ve hired them, to keep them motivated and willing to stick with you. Each of us requires the basics – compensation and benefits must meet baseline needs for anyone to consider a job offer. Survey after survey tells us, however, that it is the needs beyond the basics that close the deal and keep employees satisfied going forward. An article discussing the recent Society for Human Resource Managements (SHRM) Job Satisfaction Survey stated: “…there are more important factors [than money] that contribute to job satisfaction, such as relationships with immediate supervisors, management recognition of employee job performance, and communication between employees and senior management.”

Reason for Poor Job Satisfaction and How to Fix It

Lack of Formal Onboarding/ Training. Have a written plan for new employees that takes at least 2 weeks and includes the new employee sitting in every department and hearing from the staff in that department what they do and how the new employee’s job relates to theirs. Lack of Performance Standards and Incentives. The Fix: Develop a whole incentive plan and tie it into performance. An easier, less costly and more immediate way is to have teams (individual departments or the whole gang) work on specific goals and

earn periodic rewards – a pizza party, leaving early on a Friday, gas cards, a bowling party. Poor Communication. The Fix. Tell all employees (not just some) as much as you possibly can, as soon as you possibly can. Don’t leave out the details. Doom and Gloom. Everything is on fire. The doctors are worried, preoccupied, consumed. The Fix. Realize you are always on stage and you set the tone for the practice. You exude calm, confidence and peace. You smile every morning when you come in and you smile every evening when you leave. This is not to say you are not serious, but, you never let them see you sweat. Lack of One-on-One Time with You. The Fix: Invite employees passing your office to step in your office and sit down for 15 minutes now and then. Sit in a department when things are quiet. Ask how the latest project is going. Ask how their husband’s new job is or how their mother-in-law is doing after her stroke. Then listen. Look at and listen to your most valuable resource.

#8 Leverage the Cloud for Real Results

The technology trend that is creating big opportunities for health care providers and managers to improve their bottom line, drive savings, and empower a mobile workforce is the cloud. The cloud is more than just a fashionable concept – this is a real change in the way people work- and leading organizations are looking past the buzz into the substantive improvements that technology can offer in work flow and cash flow. By relying on offsite computing power and a constant high-speed Internet connection, the cloud has all sorts of advantages over a traditional, onpremise model.

How can the Cloud change your practice today?

The cloud can actually protect things better than you can. For less money. If you have your valuable documents stored in on-site servers, or on personal desktops, you are at risk. Cloud services offer auditability, encryption, and redundancy, and with strong end-user security practices in place, can provide health care organizations with absolute top of the line data security AND put the replacement and maintenance back on the vendor. You pay for access, and pay only for what you need. Moving documents to the cloud not only protects them physically, but keeps them at your fingertips and the fingertips of permissioned users. Separated data facilities, redundant storage, and professional grade encryption are all more secure than the traditional, “server in the closet” model. The cloud can mobilize your practice, but keep everyone on the same page. The modern medical practice employs providers and administrative and clinical staff that bring powerful mobile devices to work everyday – and take them home too. By giving your key decision makers access to their work files outside of the office, you give them the tools of a work computer anywhere they go. Physicians can handle office tasks on their own schedule, and in their own setting. Administrators can access critical documents from a phone, or a home laptop as easily as they would their desktop. The access you pay for is everywhere: if you have a web or wireless connection, you can access your files. Tedious, in-house FTP setups, or VPN’ing into the network can be complex and costly solutions; workarounds like emailing yourself the work files you need, or loading USB flash drives can introduce security risks. And, how can you be sure you remembered to send the latest continued on page 24 MEDMONTHLY.COM |23

continued from page 23

version? If your work data is hosted in the Cloud, the availability of what you are working on is as much of an afterthought as the lights and water at your office. Updates to files are pushed to everyone immediately too, so you know your team always has the latest. With mobile applications and network access, employees can not only work from home – they can work from anywhere they have a mobile device and service. The Cloud turns computing power into a utility. In terms of your practice cash flow, cloud computing enables you to flatten IT spending into a much more predictable outlay. If you own your server, you are very familiar with the “update cycle”. Determining the right time for updates, upgrades, replacements and expansion to keep up with your needs, comply with new regulations, ease pain points for the staff, or improve security can be an endless loop of spending lots of time and money.

#9 Create a Credit Card on File Program

Having a credit-card-on-file program in your practice has the potential to simplify patient collections, as well as improving your cash flow. Let’s take it a step at a time: • Evaluate your patient base to determine if a credit-card on file program will work for you. As of the end of 2011, creditcard.com says there was a total of more than 1 billion credit and debit cards (Visa, M/C and A/E only) in circulation in the U.S., and the average person has 2.7 cards. Almost everyone has a credit or debit card and they routinely use them to pay bills. • Once you decide you want a creditcard-on-file program, decide on a time-frame to implement it. 24 | JANUARY 2013

• Start communicating to patients that you are going to a credit-cardon-file program. • Shop for an online credit card processor that allows you to set up payment plans and process refunds. • Develop your workflow for collecting at time of service, and for using the credit card on file to charge balances and make refunds after the EOBs arrive. • Role play and practice with the staff to make sure they feel confident explaining the credit-card-on-file program to patients. Go Live!

#10 Fix the Phones!

Any time I ask a practice about their pain points, they invariably name “the phones” as one of their toughest problems to solve. Phone calls are escalating as many patients are trying to avoid going to the doctor. That means instead of making an appointment, patients are calling hoping to be given advice or a prescription over the phone. Staffing up to answer the phones is rarely an option for most practices. In many cases, there is no payer compensation for health care for phone services, therefore adding more staff for no additional compensation is not tenable. There is no best practice for number of phone receptionists to number of physicians and non-physician providers. Every practice is different based on the specialty, the practice culture and staffing structure. When the problem is the phones, the issue is complex. Doing a poor job of answering the phones not only causes patient dissatisfaction, it snowballs as patients call back again looking for answers, causing confusion and inefficiency. Poor phone management also has the potential to compromise care if a patient’s question goes unanswered.

Where do you start to tackle the problem with the phones?

Contact your local phone service provider and order a phone study. Make sure you include all primary phone numbers that your main number rolls over to so you get a solid study. Exclude direct numbers that patients have unless it is routinely published. For instance, if each provider assistant takes patient questions directly from provider’s patients via a direct number, that number should be included in the study. If a billing person occasionally gives out their number to a patient having a problem, no need to survey that number. Make sure the week that will be surveyed has no holidays. The survey will probably be scheduled about a month out and may take an additional several weeks to get back to you. Different companies call these studies different things – it could be called a busy study, a volume study or a traffic study. Whichever it is, it should include detailed information about everything that comes through your phone system in aggregate from, and by individual number. Do your own side-by-side study during the same week. Measure the incoming calls for the same week as the service provider so you have comparison data and so you can break your data down into the specifics you need to determine what types of calls you are getting in what volume. Have everyone who is receiving calls on the lines you identified for the service provider document the calls that come in on the those lines in categories. Once the two studies are completed, you’ll have lots of data to review. You will see when and why calls are coming in and will be able to strategize to address your practice’s needs.

Setting Patient Expectations for Callbacks

One of the keys to conquering the phone problem is setting realistic expectations and reinforcing those

expectations. If patient calls are rated as HIGH, MEDIUM, or LOW urgency, staff can let patients know how soon their question will be answered. HIGH urgency might be a 4-hour callback, MEDIUM may be answered by the end of the day and LOW may be answered within 24 hours. If the practice can determine which calls fall into each category, and train the staff to identify the call correctly, patients can be told when their call will be returned. Then these expectations must be met or exceeded.

#11 Get to Know

SEO (Search Engine Optimization) Search Engine Optimization is the way you market your practice so your practice shows up in searches as high on Page One as possible. Wikipedia defines SEO as the process of improving the visibility of a website or a web page in a search engine’s “natural,” or unpaid (“organic” or “algorithmic”), search results.

‘‘

“…there are more important factors (than money) that contribute to job satisfaction, such as relationships with immediate supervisors, management recognition of employee job performance, and communication between employees and senior management.”

Everyone has seen the flesh-colored box at the top of Google search results. These are companies that have paid to be listed in this primo spot. Below the flesh-colored box are the search results that have appeared based on their relevance to the search terms entered. Everyone wants to know how a company arrives in that treasured first page of real estate. You need to know how to get your practice listed on page one. Your website should be one of your primary SEO strategies. Word of mouth and personal recommendations are still a great way for patients to find you, but your website needs to be doing the heavy lifting to: – Drive new patients to the practice. – Drive established patients to return to the practice. – Keep patients attached to you as their provider. Your website should be providing B2C (business to consumer) marketing for you. How does a website accomplish these things? In a web search, being the first or one of the first unpaid results that appears in the search is the way to ensure searchers find your practice. The way to get to page one, even number one on page one, is through SEO. You or your webmaster need to follow tried and true SEO rules. Even if you’ve had your website for years, you can rework your website to make sure you are following these rules: –Optimize your website by making sure it has a strong structure, an easily navigable flow, and that everything is titled and tagged appropriately. Just like a wellorganized cabinet of medical supplies, first-time visitors should be able to figure out how to find the information they want. –Create useful, interesting and highquality content that reflects who your practice is. Good content will positively affect your ranking on SERP (search engine results page.) Your content should be targeted to the interests and concerns of your

patient demographic, as well as giving insights into office activities and news. - Utilize images. Everyone loves images, both to illustrate information and to introduce readers to the people and activities of your practice. – Utilize videos. Everyone really loves videos. – Make it easy for readers to search your website for information by offering a search box. – Make it easy for readers to share information they find on your site with others via email, Twitter, Facebook and Google+. – Make your website available for mobile users. – Keep your website fresh. Adding a blog and posting content (it doesn’t have to be lengthy) is one way to keep readers informed, entertained and coming back for more.

#12 Maximize Your

Medicare Payments

Medicare has so many programs that have the potential to increase or decrease your payments that practices need a list to keep them straight. Here’s your list with information on which programs are mutually exclusive and which can be combined.

1. Electronic Health Records (EHR) Incentive Program

You must be the owner of the certified EHR, although you do not need to have paid for the EHR. You can choose to participate in Medicare (federally administered) or Medicaid (state administered) program. You must attest or document that you have adopted, implemented, upgraded or demonstrate meaningful use. Eligible professionals choosing to participate the Medicare program can each earn up to $44K over 5 years, and eligible professionals choosing to participate in the Medicaid program can each earn up to $63,750 over 6 years. continued on page 26 MEDMONTHLY.COM |25

continued from page 25

2. ePrescribing Incentive Program

Each professional needs to report 10 eRx events for Medicare patients for dates of service before June 30, 2012 OR apply for one of five exclusions or four exemptions before December 31, 2012. Successful e-prescribers can qualify to earn an incentive payment based on a percentage of their total estimated Medicare PFS allowed charges processed not later than 2 months after the end of the reporting period. For reporting year 2012, EPs who are successful e-prescribers can qualify to earn an incentive payment equal to 1.0 percent of allowed charges. For reporting year 2013, EPs can qualify to earn an incentive payment of 0.5 percent of allowed charges. Beginning in 2012, EPs who are not successful e-prescribers in 2011 and do not qualify for a hardship exception will be subject to a payment adjustment equal to 1.0 percent of their Medicare PFS allowed charges. The payment adjustment increases to 1.5 percent in 2013 and 2.0 percent in 2014.

3. PQRS (Physician Quality Reporting System)

Physicians may report individually or practices may choose a set of three measures that relate to the type of patients they see. Measures are performed and modifiers are attached to claims. Bonuses are available until 2014; starting in 2015 practices not participating in PQRS will receive a negative payment adjustment.

4. Medicare Wellness Visits

Many practices are losing money due to the confusion over what Medicare pays for and what Medicare doesn’t pay for. Medicare introduced three new visits in 2010 and many providers continue to have trouble understanding and providing them correctly. The “Welcome to Medicare” visit is technically called the “Initial Patient 26 |JANUARY 2013

Physical Examination” (IPPE), but to everyone’s dismay, it is not a physical examination at all, with the exception of basic visits such as height, weight, BMI, blood pressure and pulse, and the potential for an EKG and an Abdominal Aortic Aneurysm screening. The Annual Wellness Visit (AWV) and the Subsequent Annual Wellness Visit are not physical examinations either, yet almost ALL patients believe that Medicare now gives free annual physicals. Practices must train all staff and physicians to use the correct terminology first. I suggest everyone stop using the phrases “annual physical” or “complete physical” with Medicare patients. Patients can request and receive: • A Welcome to Medicare Visit with no exam (no deductible, no coinsurance) • A first annual Wellness Visit with no exam (no deductible, no coinsurance) • A Subsequent Annual Wellness Visit with no exam every year thereafter (no deductible, no coinsurance) What patients think they want is either a preventive visit, which Medicare will NOT pay for, or a standard Evaluation & Management (E/M) visit, which their deductible and co-insurance will apply to. The only way the practice can win is by driving home to patients what Medicare does pay for and doesn’t pay for and making sure your documentation matches the code you submit to Medicare.

5. The ABN (Advance Beneficiary Notice)

Many practices miss revenue when they provide services to Medicare patients that are statutorily excluded from Medicare benefits. These may be services that do not meet the Medicare definition of medical necessity or are provided at more frequent intervals than Medicare approves. Identifying these non-covered services is the hard

‘‘

“The only way the practice can win is by driving home to patients what Medicare does pay for and doesn’t pay for and making sure your documentation matches the code you submit to Medicare.”

thing, however, unless your EMR can alert you to a service that will not be paid by Medicare, and if the patient requests the service and signs an ABN prior to the provision of the service In this case, the practice may collect the full fee from the patient.

6. Primary Care Incentive Payment Program (PCIP)

Eligible Providers (Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, and Physicians who have their primary specialty designation in family medicine, internal medicine, geriatric medicine or pediatric medicine) can receive a 10% incentive payment for services under Part B. The PCIP program, which was created by the Patient Protection and Affordable Care Act, requires Medicare to pay primary care providers, whose primary care billings comprise at least 60 percent of their total Medicare allowed charges, a quarterly 10-percent bonus from Jan. 1, 2011, until the end of December 2015. Eligible primary care physicians furnishing a primary care service in a Health Professional Shortage Area (HPSA) area may receive both a HPSA and a PCIP payment.

7. HPSA (Health Professional Shortage Area)

Medicare makes bonus payments annually of 10% to physicians who provide medical care services in

geographic areas that lack sufficient health care providers to meet the needs of the population. Payments are automatic; there is no need to register or report anything on the claim to receive it. If services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

8. HPSA (Health Professional Shortage Area ) Surgical Incentive Payment (HSIP) The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs. Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period. Payments are automatic; there is no need to register or report anything on the claim form. –If services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

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research & technology

Health IT â&#x20AC;&#x201C;

Deciphering Medical And Industry Associations Comments On Meaningful Use Stage 2 by Frank J. Rosello, CEO, Environmental Intelligence LL

The window for submitting comments on the Centers for Medicare and Medicaid Services (CMS) Notice of Proposed Rule-Making (NPRM) for Meaningful Use Stage 2 has officially closed. CMS now begins the arduous task of reviewing the multitude of comments submitted and face the challenge of how to best incorporate the feedback in the Meaningful Use Stage 2 Final Rule. Based on the comments submitted by two key medical and industry associations alone, to say that CMS have their hands full is an understatement. 28 | JANUARY 2013

he Healthcare Information and Management Systems Society (HIMSS) Electronic Health Records (EHR) Association, the most influential EHR industry group with its membership comprised of the top forty-two EHR companies in the U.S., submitted their comments directly to CMS Acting Administrator, Marilyn Tavenner. The American Medical Association (AMA), the largest and most influential medical organization in the U.S. representing over two hundred and sixteen thousand physicians, followed by also submitting their comments directly to CMS Acting Administrator Tavenner. It is important to note that the AMA collaborated with ninetynine specialty and state level provider organizations and societies for the purpose of drafting their comments to CMS on the NPRM for Meaningful Use Stage 2. Both organizations noted, on their respective submissions, that they support CMS’ proposed one-year extension of Stage 1 of Meaningful Use along with the recommendation to delay the start of Stage 2 for eligible providers (EPs) to January 2014. The comments both organizations submitted to CMS reveals that there is some common ground shared between providers and the EHR industry however, within the common ground different concerns are revealed. The HIMSS EHR Association is urging CMS to expedite the release of the final rule for Stage 2 of Meaningful Use due to the development and operational implications associated with the proposed rule. The rationale is due to the immaturity of the proposed clinical quality measures (CQM), certification criteria, and that all providers will be required to upgrade to the 2014 edition of their EHR regardless of their stage of meaningful use. The HIMSS EHR Association concluded that the EHR upgrade requirement and the tight timeline would increase the number of upgrades required in a very short

period of time for EP’s who attested in 2011and 2012 and those who will attest in 2013 and 2014. As a result of their conclusion, they are encouraging CMS to consider allowing eligible providers who are still in Stage 1 in 2014 to continue to use 2011 certified EHR technology at their discretion. The AMA’s comments to CMS also recognizes the importance to expedite the release of the final rule for Stage 2 citing that physicians need to be assured that their EHR systems will be able to support Stage 2 measures well in advance of 2014. However, the AMA does not share the same view with industry that physicians that are still in Stage 1 in 2014 be allowed to use 2011 certified EHR technology. The AMA recognizes that physicians and their support staff need adequate training and have to adjust workflows in order to meet Stage 2 measures prior to the 2014 date. What the AMA is bringing to light is the proposed timeline in the NPRM for Stage 2 is so tight that there is very little confidence shared by physicians that industry will be ready for the start of Stage 2 despite the delay to January 2014. Furthermore, allowing physicians who are still in Stage 1 in 2014 to continue to use 2011 certified EHR technology is not the right answer. The AMA was very articulate in their comments to CMS on the NRPM for Stage 2 that while they share the Administration’s goal of widespread EHR adoption, they are concerned that the proposed meaningful use criteria for Stage 2 will actually discourage physician participation in the EHR incentive program rather that encourage it. The AMA cites that physicians face significant barriers with adopting EHR technology and attesting to meaningful use Stage 1 measures. The AMA referenced an April 2012 Health Affairs survey that revealed that while about half of all eligible office-based physicians intended to apply for either the Medicare or Medicaid meaningful

use incentives, only eleven percent of physicians surveyed intended to apply for incentives and had EHR systems capable of meeting two-thirds of the Stage 1 core meaningful use measures. The survey highlights that physicians are facing technological and other challenges in meeting all of the required Stage 1 meaningful use program measures and are not adequately prepared to take on Stage 2. The AMA, in an effort to increase physician participation rates, recommends to CMS to survey physicians who elected to participate and those who elected not to participate during Stage 1 of the incentive program and identify barriers to and solutions for physician participation prior to finalizing Stage 2 requirements. In addition, the AMA recommends that prior to moving a measure from the Stage 1 menu set to the core set for Stage 2, or prior to adding new core measures for Stage 2, the expected impact, the expected value, the clinical and administrative risks, administrative burden, costs to physicians, and technological standards of the move should be thoroughly assessed. CMS should seriously consider the AMA’s recommendation to survey physicians and perhaps take it one step further by including industry in the discussion and analysis of the findings. The key to attaining CMS’s goal of widespread meaningful use of EHR technology by physicians that will improve quality of care delivery, enhance patient safety, and support practice efficiencies is effective collaboration between providers and industry. Only through effective collaboration will CMS move closer to achieving the desired outcome for the Medicare and Medicaid EHR Incentive Program which is to accelerate the adoption and meaningful use of EHR technology by physicians and other clinicians to improve the U.S. healthcare system and patient outcomes.  MEDMONTHLY.COM |29

research & technology

Children’s Healthcare of Atlanta Develops New Smart Phone App For Early Detection of Heart Defects in Newborns Pediatric cardiologists at Children’s Sibley Heart Center lead the development of new protocols that save infants’ live Pulse Oximetry Screening is a life-saving test that can detect critical congenital heart defects (CCHD) in newborn babies before an infant is discharged from the hospital. The test is easy to perform, however, appropriate interpretation of the results can be challenging. In order to aid health care providers in interpreting the results of the screening, Children’s Healthcare of Atlanta has created the Pulse Ox Tool, a ground-breaking app for smart phones that automates the Pulse Oximetry Screening test and improves 30 | JANUARY 2013

the accuracy of detecting children with possible CCHD. “Research shows that this simple screening test for newborn babies can help prevent the delay of diagnosis of critical congenital heart defects in infants,” says Dr. Matt Oster, M.D., M.P.H., a pediatric cardiologist at Children’s Sibley Heart Center who led the development of the digital tool. “We are thrilled to premiere this revolutionary tool to newborn nurseries and pediatric hospitals across the country. The convenience of downloading the app for free to

your smart phone makes increased precision of care available to all providers.” In 2011, the Secretary of Health and Human Services committee, led by Dr. William Mahle, M.D., a pediatric cardiologist at Children’s Sibley Heart Center, recommended that pulse oximetry screening be added to the routine uniform screening panel that every newborn baby receives after birth. Dr. Mahle led a team that developed the methods for implementing the screening, which includes an algorithm that uses pulse oximetry readings to determine whether patients need immediate further testing for CCHD. Without this test, many babies with heart defects show no symptoms at birth but go into heart failure a few weeks later. While not a difficult equation, the mathematics required to manually compute the algorithm sometimes produces user error. To remedy this, Dr.Oster led a team to create the Pulse Ox Tool, an app for smart phones that automates the calculation of the algorithm, thereby decreasing the chance for errors. Upon testing the web-based pulse ox tool at Children’s, it was determined that the computerbased algorithm’s error rate was significantly lower than when the algorithm was manually computed by providers. Pulse Ox Tool is now available for free download on iTunes, Google Play and Windows, as well as in a webbased version at www.pulseoxtool. com. Research efforts for this application are being conducted under the Children’s Center for Cardiovascular Biology. This effort is part of the Emory+Children’s Pediatric Research Center led by Children’s Healthcare of Atlanta and Emory University, including partnerships with the Georgia Institute of Technology and Morehouse School of Medicine.  Source: www.choa.org

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research & technology

YOU IMAGINE Mobile Health for Women By

32| JANUARY 2013

In my earlier comments about mobile health, the most remarkable changes taking place are simply to be putting such powerful devices in the hands of a great number of people. With this month’s focus on women’s health care, and as women own more than half the smartphones in the U.S.1, I’d like to offer that perspective. Smartphones offer great promise and potential, only some of which may be fully realized. Recently, it was the vision of young woman to reveal that power. Brittany Wenger, from Florida showed the world, when she won Google’s Science Fair.2 Using three commercial cloud networks, Wenger combined their strengths at pattern detecting to develop a Java program. This program uses fine needle aspiration samples, which is a minimally invasive test that has not traditionally led to very accurate test results, diagnosing correctly 94% of the time, and identifying cancer types with 99% accuracy.3 Find her tool at http://cloud4cancer.appspot.com/.

In the developing world

While people like Brittany focus on the cutting edge, other mobile health efforts focus on basic health needs. Smartphones are not only changing how Americans use health, they are offering great promise in the world at large, applied differently in different regions. Twenty years after cell phones were invented, there were a billion in use.4 Four years later there were two billion. Two years after that there were three billion. In 2012, 80% of the world’s population lives within range of a cellular network, which is double the level in 2000. There are more than 3.3 billion mobile phone subscriptions over the world. Most of these subscriptions are in the developing world.5 Some regions, struck by devastating infant hunger and infant death rates, are utilizing cell phones for communication to save lives. In other regions, sex workers are using cell phones to move more freely and independently. This has not always translated to health

benefits, as this makes women more mobile and difficult to find. In another effort, the Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) is helping women who are suffering from fistulas. It is a fistula ambassadors’ network, intended to locate and help women with fistulas, which has been implemented throughout Tanzania. Charitable donations allow these women to benefit from free surgery. But even the travel costs are prohibitive. CCBRT uses a mobile banking system called Vodafone M-PESA6 to send patients money for bus travel. The money is sent by SMS to fistula volunteer ambassadors whose job it is to identify and refer women who need the treatment. Local Vodafone M-PESA agents send money to the volunteer, who buys bus tickets for the patient. Ambassadors receive some financial compensation when patients reach the hospital. In 2010, 54 ambassadors referred 129 women for fistula repair.7 India suffers some of the greatest child hunger rates in the world.8 Sometimes the problem is simply that new mothers are not aware of the availability of resources for their infants. University of Sydney researchers are working to bring cell phones to rural women in Maharashtra State, Nagpur, in partnership with The South Asian Feeding Network. The women are kept in text communication as they care for their newborns.9

Available for your patients…

In my exploration of the apps loved by women, not just in developing regions, but in developed as well, I found that the apps generally fit into categories intended for women in specific stages of life. There are apps for girls who are experience their period for the first time. There are apps for women planning pregnancy. There are apps for women who are pregnant. And there are apps for women to proactively address breast cancer risks. And there are apps for women with cancer. The list goes on, but these were the major areas of development.

Perhaps the most general feature app for women to understand their health questions is the “52 Weeks for Women’s Health” app. It approaches women’s health from many different angles and is a way for women who want to practice good preventative health to explore questions. 52 Weeks for Women’s Health

Based on Primer for Women’s Health: Learn about Your Body in 52 Weeks By the Office of Research on Women’s Health (ORWH) at the National Institutes of Health. http://52weeks4women.nih.gov/. This is a general app offering women answers to questions about women’s health, health risks, screening information, definitions of health terms, a goal setting feature, a journal feature, password protection, and a variety of skins. Cost: Free MEDMONTHLY.COM |33

Apps for predicting women’s cycles One convenience that many women have begun to use are apps to predict their periods and their ovulation schedule. For the young women, prediction is simply helpful. And for women wanting to become pregnant, the apps offer vital predictive features. The strength of the ovulation apps in particular is that they offer sophisticated metrics, combined in one, often simple interface that is fun, personalized, and conveneient. Period Pace: menstrual cycle log By Aesop

http://www.aesopapps.com/contractionscounter/ Well loved by consumers. Easy to use. Allows adjustment of calendar cycle when clicking on the “I”. Cost: Free

OvuView - Period Tracker By Sleekbit

http://www.sleekbit.com/ OvuView tracks and predicts menstruation, ovulation and fertility, using sympto-thermal methods (STM). It also tracks weight, headaches, appetite, PMS and other symptoms, temperature (with automatic morning notifications to record this data), data backup and restore, and offers personal notes. It also offers guiding hints and cycle statistics. The Pro features are more extensive, including data import from ‘My Days’, ‘WomanLog Calendar’ and ‘Fertility Friend’, mode to email data, demo mode for a glimpse of the capabilities, password protection, 2 widgets, colot themes, user-defined custom symptoms, and pregnancy mode. OvuView evaluates and charts fertility using 14 different methods, which brings many complicated parameters into a single, simple interface. Android only - Available on Google Play.

While on the subject of young women and the changes with puberty, “Girl Facts 300” addresses some of the questions young women might be facing. But it is very limited in its reach and seems to be the only app available to offer tips to girls and young women. Girl Facts 500

By Michael Quach Cost: Free

34 | JANUARY 2013

Pregnancy apps These are not only fun but informative apps, offering a glimpse into the baby’s development, and what to be expecting at various stages of pregnancy. Pregnancy Progress: baby journal and medical info By Aesop

http://www.aesopapps.com/contractionscounter/ Log your own pregnancy milestones and memories; track medical appointments, pregnancy questions, and symptoms; view calendars with calculator, view baby reports week by week, and medical charts to track your pregnancy progress; share on social networks; monitor water and vitamin intake. Cost: $1.99

Contractions Counter By Aesop

http://www.aesopapps.com/contractionscounter/ A simple interface which makes timing contractions more convenient. Cost: $1.99

I’m Expecting - Pregnancy App

By MedHelp, in partnership with GE Healthymagination http://www.aesopapps.com/contractionscounter/ Tracks symptoms and compares them with thousands of other women; allows note sharing; offers tips for alleviating symptoms; offers weekly updates of baby’s growth; add doctor appointments; upload photos of your baby bump for slideshow (on phone enabled devices); send birth announcements; post questions; store doctor information. Cost: Free

MEDMONTHLY.COM |35

Breast cancer information and prevention apps Breast cancer apps focus on three strategies: (1) prevention and detection, (2) support for those diagnosed and for their loved ones, and (3) contribution to the cause itself. Prevention and Detection apps are designed to help women with self-exams, teach about the tests, find local doctors, find local mammogram facilities, offer videos, and all general teaching. The National Breast Cancer Foundation offers a prevention app called Early Detection Plan. Early Detection Plan: Breast Cancer (EDP) By National Breast Cancer Foundation http://www.nationalbreastcancer.org/ The app offers breast cancer prevention strategies, with instructions for breast self-exams, details about tests, breast cancer facts, and mammograms reminders. It bases these reminders on your age and health history. Cost: Free

Keep A Breast

By The Keep A Breast Foundation http://www.keep-a-breast.org/ Developed with an intuitive layout by the Keep a Breast Foundation, the app offers support, instructions about self-exams, reminder notifications, methods of early detection, and prevention tips. Cost: Free

iBreastCheck

By Breakthrough Breast Cancer http://www.ibreastcheck.com/ This award-winning app features a video to teach breast self-exam, reminders, risk reports, and health tips for breast cancer. It also offers suggestions for getting involved in the search for a cure. Winner of the New Media Age Effectiveness Awards 2011 Finalist in the Technology4Good Awards 2011; Marketing Week Engage Awards 2011 CIPR Excellence Awards 2011 Third Sector Excellence Awards 2011 PR Week Awards 2011 Charity Times Awards 2011 Cost: Free

36 | JANUARY 2013

For those who like need some encouragement to do their breast self-exams, “Your Man Reminder” makes the task more fun. Rethink Breast Cancer is a charity in Toronto, Canada, with an app that features hot-looking shirtless men. The men remind women to do weekly or monthly exams. The app even offers “man-o-grams”, which can be sent to friends to remind them to check their breasts, as well. The app also offers tips and a tool to schedule doctor’s appointments. Your Man Reminder

By Rethink Breast Cancer http://rethinkbreastcancer.com/ A variety of men provide encouraging remarks to women for regular breast self-exams. Cost: Free

Other oncology apps “HysterSisters” offers more than informative videos for women who are undergoing hysterectomy, it also connects users to the wider world of women who are are undergoing similar diagnoses and procedures, for greater social support. HysterSisters Hysterectomy Support By HysterSisters, Inc.

http://www.hystersisters.com/ When a woman downloads the app, it prompts her for the date of her hysterectomy. From then on it creates a personalized schedule of articles, videos, suggested doctor visits and questions, and other resources tailored to her point in the surgery timeline. It also includes a tracking component, encouraging women to track their symptoms in a log they can later print out and give to their doctor. Cost: Free

This ovarian cancer app, “Ovarian Cancer V1”, released just this month, offers illustrations to show the pathways involved, and detailed explanations with signs and symptoms. This app is the only one available on iTunes under this important topic of women’s health. It can be found in the medical section of iTunes, and as it is intended mainly for information, it does not offer the patient support that an app found in the health section of iTunes would offer. Ovarian Cancer V1 By Jose Barrientos

Detailed illustrations and explanations provide information and details about symptoms of ovarian cancer. Cost: $0.99

MEDMONTHLY.COM |37

Breast cancer tests, support, and treatment apps “My Breast Cancer Diagnosis Guide” is an app developed by Breastcancer.org. It evaluates pathology report to help users understand their cancer staging; it lists treatment options and lifestyle adjustments. “Beyond the Shock” is a video-based app. It is a particularly beautiful and artistic app for those who have been diagnosed with breast cancer, or for their loved ones. It offers videos to put cancer in perspective, illustrated information, and guidance about cancer and treatments. Breast Cancer Diagnosis Guide By Breastcancer.org

This app is designed for a woman who has been diagnosed with cancer, or someone close to someone with breast cancer. It offers a glossary of terms with explanations, medical illustrations, interpretations of your pathology reports and diagnostic tests, and personalized research articles. This app is a 2011 Webby Awards Official Honoree. Cost: Free

Breast Cancer: Beyond The Shock

By National Breast Cancer Foundation http://beyondtheshock.com/ Beyond The Shock is a comprehensive online guide to understanding breast cancer. It is a resource for women who have been diagnosed with breast cancer, and a tool for loved ones to gain a better understanding of the disease. Rated well by users Cost: Free

Finding doctors and testing sites Apps like this “Breast Health GPS” locate nearby facilities so women can schedule to their convenience. Breast Health GPS

By Breast Health & Healing Foundation http://www.breasthealthandhealing.org/ Locates the nearest certified mammogram screening center and allows users to upload photos to post to the Theresa Quilt for breast cancer, which is a free online and virtual quilt dedicated to breast cancer survivors. Cost: Free

38 | JANUARY 2013

Charitable contribution How wonderful that apps can be both fun and useful in fighting good causes. “Bliss HD” is an app which donates half its proceeds to The Beautiful Day Foundation. Bliss HD+

By Mobile Deluxe http://www.mobiledeluxe.com/games/bliss-hd/ This app isn’t for information, it’s for fun. Buy the game and proceeds help breast cancer. Cost: $1.99

This list is a starting point for women’s health apps, with new apps being released every day. New visions for women’s needs and women’s health change rapidly. For those of you who see a need that is not being met, I would love to have your insights and feedback.  In U.S., Slightly More Women Than Men Are Using Smartphones http://allthingsd.com/20120507/slightly-more-women-than-men-in-u-s-usingsmartphones/ 2 Brittany Wenger, 17, Wins Google Science Fair Grand Prize For Breast Cancer Diagnosis App The Huffington Post. By Dino Grandoni Posted: 07/25/2012. http://www.huffingtonpost.com/2012/07/25/brittany-wenger-googlescience-fair-breast-cancer_n_1703012.html 3 How Teen’s App Can Diagnose Breast Cancer. By Sandy Fitzgerald. July 27, 2012. http:// www.mobiledia.com/news/157404.html 4 Can the Cellphone Help End Global Poverty? By Sara Corbett. 2008. http://www. nytimes.com/2008/04/13/magazine/13anthropology-t.html?pagewanted=all 5 European Travel Commission NewMedia TrendWatch. 06 November 2012. http://www. newmediatrendwatch.com/world-overview/98-mobile-devices?showall=1 6 Wikipedia article. http://en.wikipedia.org/wiki/M-Pesa 7 Mobile phones advance third world health care http://www.healthcarecommunication. com/Main/Articles/Mobile_phones_advance_third_world_health_care_6895.aspx 8 World Hunger Index. http://en.wikipedia.org/wiki/Global_Hunger_Index 9 Sydney University researchers use mobile phone technology to tackle disease, malnutrition in India. http://www.newstrackindia.com/newsdetails/2012/11/27/298Sydney-University-researchers-use-mobile-phone-technology-to-tackle-diseasemalnutrition-in-India-.html 1

Medimagery Medical Illustration & Design info@medimagery.com http://www.medimagery.com/ http://www.linkedin.com/in/lauramaaske http://twitter.com/#!/Medimagery http://www.facebook.com/Medimagery http://www.facebook.com/laura.maaske http://medillsb.com/ArtistPortfolioThumbs.aspx?AID=4115 MEDMONTHLY.COM |39

legal

HMA Exec Says Physicians

‘Grossly Mischaracterized’ Admissions Management

By Jessica Zigmond www.ModernHealthcare.com

40 | JANUARY 2013

‘‘

“I’ve been in these trenches,” Levine told Modern Healthcare. “I know the difference between fraud and people trying to act appropriately in an impossible maze of rules which is what hospitals are dealing with now.”

hysicians interviewed for a “60 Minutes” investigation into Health Management Associates’ admissions practices “grossly mischaracterized” what goes on at the for-profit hospital chain’s facilities, a top executive for the company said after the segment aired Sunday, December 2. Alan Levine, senior vice president at HMA and president of its Florida group, said some of the doctors who spoke to reporter Steve Kroft had reasons for doing so, including ongoing litigation with the company. Levine said HMA provided an incredible amount of information to “60 Minutes” suggesting the core issue is not about inpatient admission goals or quotas, but rather about the challenge hospitals face in managing patients between observation stays and inpatient admissions. The CBS program did not explore that topic. The “60 Minutes” investigation of HMA found the nation’s fourth-largest for-profit hospital chain pressured physicians to admit patients to its hospitals by setting admission quotas. “Hospitals throughout the United States are struggling with how to manage the issues specifically related to RAC (recovery audit contractor) audits with how to manage these patients between observation and inpatient admission,” Levine said. “Because we are heavily engaged in this, it’s easy for people to mischaracterize admission rates.” Levine also emphasized that a company called Opera Solutions conducted an independent analysis of HMA’s admission percentages and found no difference from the rest of the industry. A significant part of the program focused on allegations from the company’s former compliance director, Paul Meyer, who said HMA’s admission practices were profitdriven and represented Medicare fraud. Meyer, a former employee with the FBI, brought his concerns to top management. Levine said Gary Newsome, HMA’s president and CEO, took Meyer’s concerns very seriously and hired an outside law firm to investigation. The firm’s monthslong probe found no evidence of wrongdoing, according to Levine, who served as the secretary of health and hospitals for Louisiana from January 2008 until August 2010 and as Florida’s secretary of healthcare administration from

2004 to 2006. “I’ve been in these trenches,” Levine told Modern Healthcare. “I know the difference between fraud and people trying to act appropriately in an impossible maze of rules—which is what hospitals are dealing with now.” Reporter Kroft noted that “60 Minutes” interviewed 100 current and past employees at the company and reviewed documents, including company e-mails. The segment also included a clip of a deposition last summer by former HMA Executive Vice President Jon Vollmer, who said the push to boost admissions came from straight from the top—specifically from Newsome. “Mr. Newsome’s thought was that an average of 16% was accomplishable at all hospitals or more and we should seek to do that and make that happen,” Vollmer said in the deposition. Kroft said Vollmer has since been fired from the company. Although the news program had tried to secure an interview with Newsome, it was instead directed to talk with Levine. In an interview, Kroft presented Levine with a document “60 Minutes” received from a physician at one of the company’s Oklahoma hospitals that clearly showed an admission goal of 20%. “That’s not from our company; I don’t know where that came from,” Levine said. “We don’t have any kind of goals. I don’t know what the percent admissions are in that hospital—maybe they’re actually 20%,” he continued. “But the admissions goal at any hospital is driven only by what the normal trend is for that hospital.” Kroft said the news team heard of no complaints about quality at HMA facilities. He ended the segment by saying the Justice Department is investigating the hospital chain and has subpoenaed records pertaining to the management of its hospital emergency rooms admissions and software from ProMed Clinical Systems, which HMA has stopped using. The company is cooperating with the investigation, Kroft said. The company anticipated the negative report on Friday with an investor call.  Source: http://www.modernhealthcare.com/ article/20121202/NEWS/312029989/60-minutes-says-hmaset-admission-quotas MEDMONTHLY.COM |41

legal

Legal Issues of

Fertility

By Melissa B. Brisman, Esq., LLC

The advances in fertility technology have created a legal challenge in this country and abroad. At present, the law is playing â&#x20AC;&#x153;catch-upâ&#x20AC;? with science and, as a result, reproductive law has emerged. In the United States most reproductive law is governed by the individual states and, to date, very few states have begun to tackle the current issues. Everyday we are finding an ever increasing need for clarity and consistency in the area of reproductive law in order to keep up with these scientific advances. Previously, traditional surrogacy, whereby the carrier uses her own egg to conceive a child for the intended parents, was the only other viable alternative to adoption to aid individual(s) in creating their family. However, over the years, embryo, sperm and egg donations, 42| JANUARY 2013

and gestational carrier arrangements have become viable alternatives. The gestational carrier arrangement is one of the more complex options. Today, with the breakthrough of in vitro fertilization, the process by which ova is fertilized by sperm outside of the womb, it is possible for individual(s) who are unable to conceive and/or carry their own child(ren) to utilize a gestational carrier in order to have a child(ren) who are genetically related to the prospective parent(s) and not genetically related to the carrier. This opportunity to create families using the method of in vitro fertilization has become increasing popular and preferred by prospective parents. However, it has also created interesting legal questions and ethical ramifications in the legal community and society at large.

Until quite recently, it was standard to name the woman who physically delivered the child(ren) as the mother on the birth certificate(s) and, prior to recent scientific advancements, this made perfect sense. With the increasing advances and availability of infertility treatments, these laws are becoming more and more archaic and obsolete. In the past, an adoption proceeding was the only recourse for parents. Imagine having to adopt your own child! Unbelievable as it may sound, this is currently the law in some of the United States and the only option available to individual(s) who choose to use a gestational carrier to assist them in creating their family. However, many individual states and lower courts are starting to set precedent in cases where a gestational carrier is being used to

assist individual(s) in having their own biological children. Pennsylvania, Massachusetts, Connecticut and New Jersey are the forerunners in adapting the law to the current landscape of infertility treatment. These states, albeit currently at the county level, are allowing prospective parents to pursue a “birth order” thereby allowing doctors and hospitals to name the child(ren)’s genetic and/or intended parents on the birth certificates at the time of delivery and eliminating the need to amend the certificates later. However, for the individual(s) who choose this path to build their families, the legal work begins well before the child(ren) is even in the womb. In order to protect the interests of the prospective parents, gestational carriers, and donors, it is imperative that a legal contract be drafted and agreed to by all parties involved which outlines, in detail, the intentions of the parties involved. This is particularly important regarding issues of custody and responsibility for the child(ren) once born. When prospective parents embark on the exciting journey towards parenthood, it is easy to overlook and/or sometimes disregard the legal ramifications of the unique relationships in these reproductive arrangements. Don’t be fooled into thinking that the law does not play a role in these relationships. It is of the utmost importance that prospective parents, carriers and donors seek legal advice from a seasoned law practitioner who is well versed in reproductive law. It is a very exciting time for prospective parents taking advantage of the advances in fertility treatment as well as the attorneys establishing the foundation on which the future of reproductive law will grow.  Melissa B. Brisman, Esq., LLC One Paragon Drive, Suite 158 Montvale, NJ 07645 201-505-0099 201-505-0097 Fax www.reproductivelawyer.com Source: http://www.fertilitytoday.org/ fertility_law_ethics.html

features

The Issue of Sexual Health and Why It is Important to Clinicians An Interview with Sheryl A. Kingsberg, PhD by Philip Driver 44| JANUARY 2013

Sexual Health

and How to Recognize a Problem

If you don’t think your patients are having sexual problems, you are not asking. There are high instances of sexual dysfunction in women, especially those going through menopause. About 43% report having problems and about 11% have a diagnosed condition. Patients tend to be hesitant to bring these issues up, and they often don’t know where to turn. A good place to start is with their primary care provider or their GYN, but in reality, patients should discuss their problem with whichever HCP they are comfortable with and discuss their issues at a minimum on a yearly basis. Patients want you, the provider, to open the door. Make sure your patients know you are willing to talk about their issues and try to put them at ease. There are many ways to make your patient more comfortable when discussing their sexual problems, such as placing literature in the waiting room and informing your patients through your web site that you treat sexual related problems. Doctors can have links to informational web sites like menopause.org, which has a whole module on sexuality and menopause, and ARHP.org . It is important to assure your patient that their sexual problems are treatable and they are not alone. Hopefully this will normalize their problem. If the issue is beyond your expertise, it is still very helpful to

‘‘

simply acknowledge your patient’s right to her sexual health and to normalize her sexual concerns. From there it is helpful to have a network set up so you can make an informed referral. Often general practitioners don’t know where to send patients. They can refer to North American Menopause Society (NAMS) and menopause.org or www.ISSWSH.org (Find a Practitioner section) which can help practitioners become more comfortable with diagnosing women’s sexual health. Doctors should not assume that younger women in their 30’s and 40’s do not have sexual problems—the prevalence is still over 10% regardless of age However menopause is a time when problems can develop or be exacerbated Estrogen deficiency has a significant impact on vulvovaginal tissue and many women and many HCPS don’t realize that vulvo-vagina atrophy (VVA) is a common disorder, affecting 25-50% of postmenpausal women, which needs to be addressed. There are several female sexual disorders including hypoactive sexual desire disorder (HSDD), female orgasmic disorder and arousal disorder. The most prevalent sexual disorder is HSDD but you should also be aware that 25% of women will experience some form of vulvovaginal pain in their lives and this is particularly true in postmenopausal

A good place to start is with their primary care provider or their GYN, but in reality, patients should discuss their problem with whichever HCP they are comfortable with and discuss their issues at a minimum on a yearly basis.

women. As noted before, 25-50% of postmenopausal women have VVA and yet many have never discussed this with their HCPS and only 7% are currently being treated with prescription therapy. Over time, postmenopausal women may not have hot flashes anymore, but VVA can occur years after menopause is over and progresses with time. The treatment for VVA Typically follows a 3 tiered approach - If a woman is experiencing pain during sex (dyspareunia) that is due primarily to dryness, you may advise that she try using a water based lubricant during sex; it won’t reduce atrophy (which causes a change in the tissue that becomes thinner) but it will help with the dryness induced pain - Long acting moisturizers can help with Ph balance and dryness, but often won’t be enough to resolve atrophy - Local estrogen in the form a tablet, cream or longacting ring can be applied which improves vaginal cytomorphology and reduces atrophic vaginal symptoms of dyspareunia, vaginal itching and dryness. Although it is a normal function of menopause that atrophy occurs without estrogen, it is preventable and treatable. While local estrogens are generally safe since they don’t create a systemic absorption, women are often fearful of taking a hormone. Often cancer survivors are candidates for local estrogen therapy, and the HCP and the woman should talk with oncologists with that in mind. It should not automatically be ruled out. Women often don’t have enough knowledge about the changes that occur during menopause and the vaginal changes that take place. continued on page 46 MEDMONTHLY.COM |45

continued from page 45

Women may be embarrassed to even bring the topic up with HCPs. The REVEAL survey (revealsurvey.com), a market research survey sponsored by Pfizer, asked 1000 postmenopausal women questions about their beliefs about menopause, aging and society’s perceptions and confirmed that they are uncomfortable to talk about vulvovaginal symptoms of menopause or don’t know that they are symptoms so don’t ask.

Essential questions to include in a sexual assessment are: l Are there problems in desire,

arousal, orgasm or is she experiencing dyspareunia and can the patient determine the primary problem?

l How does the patient see/describe

the problem?

l How long has the problem been

present (also specify if life-long or occurred after a period of normal function)?

l Was the onset sudden or gradual? l Is the problem specific to

a situation/partner or is it generalized?

l Where there likely precipitating

events (biologic or situational)?

l Are there problems in the patient’s

primary sexual relationship (or any relationship in which the sexual problem is occurring)?

l Are there current life stressors that

might be contributing to sexual problems and if so how are they perceived and managed?

l Is there a history of physical,

emotional or sexual abuse that may be contributing?

l Does the partner have any sexual

problems? 

46 | JANUARY 2013

Meet Dr. Kingsberg Dr. Sheryl Kingsberg is the chief of behavioral medicine at University Hospitals Case Medical Center and professor in Reproductive Biology and Psychiatry at Case Western Reserve University. Dr. Kingsberg received her PhD from the University of South Florida in Tampa and completed her fellowship in sexual medicine at University Hospitals Case Medical Center. Her areas of clinical specialization include sexual medicine, female sexual disorders, cognitive behavioral psychotherapy, menopause, pregnancy and postpartum mood disorders, psychological aspects of infertility, and psychological and sexual aspects of cancer. Dr. Kingsberg’s primary research interests are in treatments for female sexual disorders and the psychological aspects of infertility and menopause. She has numerous publications in many national and international journals, sits on the editorial board of Menopause and has authored numerous chapters on topics including perimenopause and sexuality, oocyte donation, infertility and aging, the treatment of psychogenic erectile dysfunction and sexuality after cancer. Dr. Kingsberg is an active member in a number of national and international organizations. She currently sits on the North American Menopause Society’s Board of Trustees and is the Treasurer of the Society for Reproductive Technologies (SART). She is a past president of The International Society for the Study of Women’s Sexual Health and has served in numerous leadership roles within the American Society for Reproductive Medicine including as the Chairman of the Sexuality Special Interest Group.

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features

Allied Health Care Collaboration in Sexual Medicine By Rebecca H. Dnistran, MA

egina and Joe have a problem. They met on a dating site and over the past two years they have grown together as a couple. For the most part, the blending of their lives was easy and they considered themselves fortunate to have found each other. But, something was happening that neither of them wanted to talk about with each other and certainly not with their friends. They were sure everyone was having more sex than they were. Their sexual relationship had stalled six months into the relationship. Intercourse was feeling physically uncomfortable for Regina. They had a wedding date set for the following summer and they both felt pressure to resolve the problem. Regina silently blamed herself and won-

48 | JANUARY 2013

dered if something was wrong with her “down there.” It was a depressing and anxiety provoking situation for both of them. Joe didn’t know what to do. He tried flowers and a weekend getaway. He read somewhere that “Acts of service” might help, so he took out the garbage and mopped the kitchen floor. Regina thought about seeing a physician or a psychologist but her primary care doc had never asked her about sex in the past and she couldn’t imagine talking to a therapist without euphemisms for fear of embarrassing herself and the therapist. The fact is, many patients are reluctant to talk about sex if their Dr. doesn’t ask. People are better adept at discussing sexual prowess than sexual problems. It is important for physicians to put

‘‘

Primary care physicians are trained in the psychosocial as well as the biochemical causes of disease placing them in a great position to assess patients with sexual dysfunction.

their patients at ease in order to get an accurate history of their symptoms. Primary care physicians are trained in the psychosocial as well as the biochemical causes of disease placing them in a great position to assess patients with sexual dysfunction.

Practical aspects in a medical evaluation for a reported sexual dysfunction would include assessing the integrity of the hormonal milieu, nerves and blood flow combined with a good medical history of overall health. A careful review of current medications, supplements, alcohol use and recreational drugs is important because of their potential impact on sexual function. It is important to recognize that sexual dysfunction is not an isolated problem within the individual, but is strongly affected by the quality of the relationship with their sexual partner. Part of the medical evaluation would also include questions regarding the patients’ intrapersonal and interpersonal conflicts, their sexual history, life stressors and sexual preference. Etiologically relevant are questions about partner sexual dysfunction and adequate stimulation. Sometimes the devil is in the details. One way to get a thorough sexual history is by using printed forms. An AASECT certified sex therapist in your community would be pleased to collaborate with you in the development of these forms for your practice. (www.aasect.org) Primary care physicians can give their patients “permission” to discuss sexual concerns by including a Screening Checklist for Sexual Function on their intake forms. A simple form for example, was created by Dr. Sandra Leiblum, PhD.:

Please check all of the problems you are currently experiencing: o 1. Problems with little or no interest in sex o 2. Problems with decreased subjective arousal or feelings of sexual excitement o 3. Problems with decreased vaginal lubrication (dryness) o 4. Problems with persistent genital arousal o 5. Problems reaching orgasm o 6. Problems with pain during sex o 7. Other: _____________________ Which problem is most bothersome? (circle one) 1 2 3 4 5 6 7 Health care providers can order appropriate laboratory tests to evaluate sexual dysfunction. For erectile dysfunction it is important to rule out diabetes, thyroid disease, anemia and hyperlipidemia. It is also important to evaluate testosterone levels (total and free), FSH, LH and prolactin levels if the testosterone levels are low. Hormone testing is equally important when a woman presents with sexual dysfunction as a starting point in the treatment process. Sexual dysfunction can be extremely complex and requires the expertise of multiple providers from different disciplines: gynecologists, urologists, internists, family physicians endocrinologists, psychiatrists, sex therapists and physical therapists. It is helpful for a health care provider to develop referral relationships with providers they trust will be comfortable and competent in the treatment of a patients sexual concern. Two less understood complimentary fields of sexual treatment is Sex Therapy and Physical Therapy. A Certified Sex Therapist is licensed in psychology, medicine, social work, counseling, nursing or marriage and family therapy. Certified sex therapists hold an advanced clinical degree in psychotherapy training and follow a code of ethics. They are trained

to understand the complexity and co-morbidity of sexual dysfunction. Often, as a precursor to treatment, sex therapists refer to primary care physicians and others in the allied health field for a diagnostic evaluation for potential organic factors that may be influencing a patients’ sexual experience. Working collaboratively, sex therapists provide evaluations and recommendations for treatment that reflect biological, psychological and/or relationship factors. They also provide psychotherapy, sex therapy and sex education for couples and individuals. A specialty in the area of physical therapy is a licensed physical therapist specializing in the musculoskeletal management of sexual dysfunction. Treatment focus can be pelvic floor rehabilitation in men and women addressing muscle weakness, muscle pain and spasms. Therapeutic tools consist of biofeedback with internal vaginal or rectal sensors, vibrators, partner “work” and home management strategies. Regina would be best served in her community when her health care providers are working together in concert. When her physiology, psychology, interpersonal relationships and sociocultural influences are considered, she can rest assured she is getting the gold standard in treatment.  Rebecca H. Dnistran, MA is a NC Licensed Marriage and Family Therapist, a NC Licensed Professional Counselor and holds a Diplomate in Sex Therapy from AASECT. She is one of six founding members of The Center for Sexual Health, an organization of Sex Therapists, Medical Affiliates and Medical Consultants serving the Triangle and beyond in North Carolina. The Center’s mission: To work with individuals, couples and families for the maintenance and enhancement of sexual health and to provide a multidisciplinary biopsychosocial approach to the diagnosis and treatment of sexual difficulties. (www.centerforsexualhealth.com) MEDMONTHLY.COM |49

features

ANDROPAUSE

AND MALE SEXUALITY

By Michael A. Werner, MD, FACS

ndropause describes an emotional and physical change that many men experience as they age. Although the symptoms are generally related to aging, they are also associated with significant hormonal alterations. Andropause is a natural subtle decline in hormones that happens as men age. While medical professionals have known for a long time that the production of hormones by the testes slowly decreases as men age, interest has developed only recently in the clinical implications of andropause. Andropause is also referred to as male menopause, male climacteric andropause, male andropause, late onset hypogonadism, androgen decline in the aging male (ADAM) or viropause. The term andropause may be considered somewhat inappropriate because the process is not universal and occurs subtly over time. In women, menopause occurs universally and usually happens dramatically. Androgen decline or andropause is a fairly common condition and the incidence of andropause (or hypogonadism) increases with age. The incidence from ages 40-49 is estimated between 2%-5%. From ages 50-59, the incidence is estimated between 6% and 40%. From ages 60-69, the incidence is estimated between 20%-45%. The incidence from ages 70-79 is estimated between 34% and 70%. The incidence of hypogonadism in men older than 80 is estimated at 91%. 50 | JANUARY 2013

Symptoms of Andropause

Andropause is most commonly characterized by a subtle and gradual onset, and slow progression, of symptoms. • Diminished sexual desire and erectile quality. In particular, a decrease in nocturnal erections is a significant sign of decreased androgens. • Mood changes. This can also be associated with decreases in intellectual activity, fatigue, depression, anger and poor spatial orientation. • A decrease in lean body mass, along with decreases in muscle mass and strength. • A decrease in body hair. • A decrease in bone density resulting in osteoporosis. Osteoporosis can often lead to increased incidence of bone fractures and breaks. • An increase in fat surrounding the internal organs. Often these changes are attributed to the natural and unavoidable consequences of aging. However, not all men show andropause symptoms as they age and not all men show a significant decrease in androgens as they age. It is important to remember that not all of these symptoms need be present to identify andropause. They do not all appear to the same degree in all men, and some men may suffer from one or two – but not all – of these symptoms.

Causes of Andropause

There may be many factors that contribute to andropause. As men get older, the Leydic cells, which produce most of the testosterone “bursts” in the testes, do not secrete testosterone as frequently and each “burst,” on average, includes less testosterone. There is also a decrease in the hormones that prod the testes to make testosterone and there is an increase in the conversion (aromatization)

of testosterone to other hormones including estradiol and DHT.

The Effects of Testosterone on Andropause

Broadly defined, androgens are the overall grouping of male hormones. They are made in the testes and in the adrenal gland (a small gland located above the kidney that produces a significant number of hormones). The main functions of androgens are: • Initiation and maintenance of spermatogenesis. That is, they signal to a man’s body to produce sperm. • Male gender determination during pregnancy. • Sexual maturation at puberty, controlling sexual drive and potency. In men, androgens are known to affect muscle, bone, the central nervous system, prostate, bone marrow and sexual function. We know that testosterone causes “the androgenic effects” determining and shaping the male reproductive tract in an infant as well as the development of secondary sexual characteristics (body hair and male pattern baldness are examples). Androgens are also responsible for prenatal differentiation of the male fetus and for the development of the male reproductive tract. Androgens play an important role in stimulating and maintaining sexual function in men. Testosterone is necessary for normal libido, ejaculation and spontaneous erections.

ADAM Questionnaire:

Using a screening questionnaire can be helpful in diagnosing andropause. The most useful questionnaire is the ADAM (androgen decline in the aging male) Questionnaire. It is very simple and very effective at identifying those men who suffer from andropause. However, not all men who screen positively for these symptoms have andropause. The symptoms may be the

result of other causes so that a positive diagnosis can only be made with appropriate blood testing.

Androgen Decline in the Aging Male (ADAM) Please check YES or NO 1. Do you have a decrease in libido (sex drive)? q YES q NO 2. Do you lack energy? q YES q NO 3. Is your strength or endurance decreased? q YES q NO 4. Have you lost height? q YES q NO 5. Have you noticed decreased “enjoyment of life”? q YES q NO 6. Are you sad or grumpy? q YES q NO 7. Are your erections less strong? q YES q NO 8. Have you noticed a recent deterioration in your ability to play sports? q YES q NO 9. Do you fall asleep after dinner? q YES q NO 10. Has there been deterioration in your work performance? q YES q NO If you answered ‘yes’ to more than 3 questions, you may be experiencing the symptoms of andropause. Practices have extraordinary success in helping men achieve their goals when addressing issues of impotence and erectile dysfunction. Thirty percent of men suffer from premature ejaculation, a condition which usually has a very negative effect on his and his partner’s sexual satisfaction. Fortunately, this can almost always be managed successfully with a combination of behavioral and medical treatments. Assessment and treatment of andropause and reduced sex drive includes testosterone replacement therapy among the variety of solutions offered to patients.  http://www.wernermd.com/index.php MEDMONTHLY.COM |51

features

The Debate Around the “Medicalization” of Female Sexuality

If I hear one more time that women’s sexual dysfunction is a myth created by the media and that the search for medical solutions is merely a thinly veiled way for the pharmaceutical companies to fleece innocent and gullible women, I may shoot someone. By Bat Sheva Marcus, LMSW, MPH, PhD Medical Center for Female Sexuality 52| JANUARY 2013

The Numbers

Ask around: women have long been complaining to each other and their physicians about various sexual problems that present issues in their relationships and with their own quality of life: “I have pain.” “I don’t get turned on.” “I can’t have an orgasm.” Even if you do believe that the pharmaceutical companies are looking for ways to keep their shareholders happy, it is difficult to find fault given these statistics. Current studies indicate that 43% of women express dissatisfaction with their sex lives at some point in time. Hmmmm. Let’s say the “real” number is being inflated by 100% -- that would still leave us with one quarter of all women suffering from these conditions and their unhappy consequences. How real is this? For the skeptics, let’s say that number is still inflated and the real, discounted number is only 10% of all women who are experiencing female sexual dysfunction. Even that would 30 million women in US alone! Do the math: 21% would be 60 million women. And 43% would be 120 million. Are we painting a clear picture here? Whether it’s 30, 60 or 120 million women suffering from female sexual dysfunction, it’s only reasonable to accept that it’s a problem worth addressing.

Big Bad Pharma

Now let’s talk about the big bad pharmaceutical companies accountable to their shareholders. Profit and share-price are the motives for making a product which works and will sell to a large patient population driven. No question. When they look at the statistics they must be salivating! What a huge group of prospective users! An effective drug that solves low desire, for example, would be a boon! So what’s wrong with that? What if the motivation for studying a solution for millions of women is

‘‘

Even though we believe that our approach of integrating the psycho-sexual with the physiological is powerful, we accept that some women will decide on traditional talk therapy to address their needs. Just because there may be a physiological reason for a particular sexual condition, does not mean that there cannot be related psychological – or even psychiatric – dysfunction that needs to be addressed by a specialist.

profit? Personally, I don’t really care what their motives are as long as they are working on the problem. If Big Pharma is trying to produce a drug that may help low desire or arousal, good for them! This may also be good for some my patients, which is the point, isn’t it?

Medical Treatment and Psychotherapy

Strikingly, you most often hear complaints about the “medicalization” of female sexual dysfunction from psychotherapists. Many seem horrified at the possibility that physiology may be at the root of female sexual dysfunction, and claim that practitioners will push suffering women into spending their hard earned dollars on questionable medical treatment. In our practice, we have the opportunity each week to refer some of our patients – including some who have found medical treatment for their fsd - to local psychotherapists for longer term counseling connected with their experiences with sexual dysfunction. We recognize that the priority is getting patients the help they need in whatever way best suits their temperament, medical condition and wallet. Even though we believe that our approach of integrating the psycho-sexual with the physiological is powerful, we accept that some women will decide on traditional talk therapy to address their needs. Just because

there may be a physiological reason for a particular sexual condition, does not mean that there cannot be related psychological – or even psychiatric – dysfunction that needs to be addressed by a specialist. But let’s be fair - the reverse is also true. And finally, as part of the health care debate it’s hard to disagree with effective medical treatment that carries an annual cost of less than $2000, particularly when compared to upwards of $7000 per year for psychological counseling alone. So, factoring in the cost of different treatment options must be part of the equation for every patient.

“Quick Fix” vs. the “Long Haul”

To women who experience ongoing sexual difficulties, the choice between a quick fix and an interminable journey is unhelpful. Calling medical treatment for female sexual dysfunction a “quick fix” undermines the hard work patients do to face their condition head on. Patients will often overcome great embarrassment and insecurity to seek treatment. They may try unfamiliar or even uncomfortable procedures to address their problems. They may need to involve a disappointed or resistant partner in order to make progress. None of this describes a “quick fix” and the psychotherapeutic community’s knee-jerk assignment of that term demonstrates disrespect for women continued on page 54 MEDMONTHLY.COM |53

continued from page 53

who are sincerely struggling with an untenable situation. Two key questions remain at the fore when a patient considers treatment options: will it work and is it safe? After that, the next question is often: how long will it take (the adult version of, “Are we there yet?”)? Of course, the fact that medical treatment of FSD often resolves problems within a few months may alienate therapists who believe in a longer-term process. That, we believe, needs to be left up to the patient. At the root of this argument is another assumption: that intimacy and sex are the same. The sooner we recognize that this is not true in every case, the more open the psychotherapy community will be to considering other channels to help patients find complementary paths to solving the distress of FSD.

A “Quick Fix” for the Media.

As we watch the media respond to the news regarding Flibanserin, Boehringer Ingelheim’s drug to improve sexual desire in women currently in clinical trials, we see how desperate they are to find a pithy, newsworthy way to present an issue. That’s where “Flibanserin, Viagra for women” comes from. Such a synopsis ignores the different way the medications work (vascular for Viagra, hormonal/ neurotransmission for Flibanserin) and disregards the complexity of sexual dysfunction for women. The lack of depth in describing the problem and its possible resolution is astounding and only reflects poorly on responsible media coverage.

“The Consumer is Not an Idiot. She is Your Wife”

This quote is only one of many tenets of advertising and marketing proffered by David Ogilvy, considered the father of modern advertising. To suggest that women will be sheep and buy whatever cream or pill 54 | JANUARY 2013

is recommended, and keep using it even if it’s not working, is ludicrous and infantilizing. Women are smart consumers. When they have a problem they try a solution and they stop if it doesn’t work. I can list a slew of herbal “remedies” that have been on the market for sexual dysfunction. Some had significant marketing and PR dollars behind them, and nearly all of them are no longer being sold. I have the utmost confidence in women who are seeking solutions to obstacles that stand in the way of their goals. An intelligent, responsible person will evaluate treatment options with her own needs at the fore, and with an eye towards efficacy and safety and effort. She will not be convinced by phony claims, snake oil or an unsatisfying experience.

So, as you can see, this is not snake oil or fantasy, but a set of sound alternatives based on medical practice and fact. Virtually all conditions can be addressed in far less than one year with follow up assessment as needed. If you’ve ever met a young married woman who has been unable to consummate her marriage, a vibrant mom of teenagers who simply cannot find her libido, a post menopausal 55 year old who can no longer achieve orgasm, a young single woman who wrestles with her relationship because she cannot feel aroused, then you know how important it is to be prepared with all possible solutions. It is our job the help her have the sexual life she wants, regardless of what the critics say.  http://www.centerforfemalesexuality. com/sexual-dysfunction-specialist.html

MEDMONTHLY.COM |45

the arts

The Art@Hospitals Initiative - Pedro’s Wish By Ashley Austin Managing Editor

ou feel awful. You’re in the hospital. Aside from some grocery store flower arrangement, your room is sparse and dreary. The television remote is too far away to reach, so you stare at a

blank wall. Pedro Oliveira, born in Lisbon, Portugal, died six days after his diagnosis of leukemia. His dying wish was to create an environment in hospitals that was brighter through the medium of art. Though he lived only 31 years, his captivating and optimistic personality endures through the efforts of the Art at Hospitals initiative. This hospital project bloomed after his family and friends saw his spirits rise, even under these dire circumstances, once they brought in his artwork from home. Pedro believed others could also benefit from the color and energy of art. Pedro fell in love at university and married Nicoline. Their dream was to discover the world together, so they lived in many countries including Shanghai and Melbourne, absorbing the culture and art of the different environments. Nicoline and the Hospitals art initiative strive to keep Pedro’s spirit alive and create more positive

56| JANUARY 2013

surroundings for others who are sick and hurting. Dedicated workers for this initiative have ensured its continuing success. A second hospital in Buenos Aires was just inaugurated, with more than 200 pieces of donated art work and 28 murals. Art at Hospitals is proud to keep Pedro’s memory alive, along with over 500 other artists who are have committed to donate to further projects. Most Hospitals lack the finances to bring works of art into their rooms and halls. Art in Hospitals encourages artists from around the world to donate their art to hospitals in their area. The art need not be by professionals – it can be designed by beginners, schools and young people alike. Anyone who loves art is welcome to bring the warmth and color of their creativity to those who need inspiring the most. If you are an artist and would like to donate a work or works of art to Art@Hospitals, please get in touch with gisella@dumee.eu, dianaeloff@yahoo.com.ar, or schwirtzandrea@gmail.com  http://www.artathospital.com.ar/eng/index.php

Second project in Buenos Aires

MEDMONTHLY.COM |57

healthy living

Hot Onion Soup Ashley Acornley, MS, RD, LDN

Winter is the perfect time to experiment with homemade soups from scratch. With this particular recipe, enjoy the warm goodness of onions, leeks, garlic, and cheese melted together. This recipe is hearty, filling, but also lower in fat and sodium than many canned soups on the market. Enjoy this soup with a side salad, roasted vegetables, or small sandwich for a complete meal!

Nutritional Facts:

Calories: 195 Total Fat: 6g Total Carbohydrate: 27g Fiber: 2g Sugar: 6g Cholesterol: 10mg Sodium: 575mg Potassium: 275mg Phosphorus: 135mg Protein: 9g

Preparation: Makes: 8 servings Serving size: 1 cup Prep time: 10 mins Bake time: 25 mins

Ingredients:

1 ½ Tbsp. olive oil 1 large sweet white onion, halved, peeled, and sliced 1 large red onion, halved, peeled, and sliced 3 large leeks, washed and chopped 4 garlic cloves, minced 2 tsp. dried thyme leaves ¼ cup dry white wine ¼ tsp. ground black pepper 6 cups fat free, low sodium beef or vegetable broth 8 slices French bread ½ cup shredded Gruyere cheese 2 Tbsp. grated fresh Parmesan cheese

58 | JANUARY 2013

1. In a large saucepan, heat the oil over mediumhigh heat. Add the white and red onions, and sauté for 1 minute. Cover and reduce the heat to medium, and cook for 10-12 minutes, just until the onions begin to brown. Lower the heat if necessary to prevent burning. Add the leeks and continue to cook, covered, for 3 minutes. 2. Preheat the oven to 400 degrees. Line a baking sheet with foil or parchment paper. 3. Add the white wine and black pepper to the onions, and cook over medium heat until the liquid is just about evaporated. Add the broth and bring to a boil. Reduce the heat to simmer, and cook for 5-6 minutes longer. 4. Meanwhile, place the bread slices on the prepared baking sheet. Toast the slices on each side for 1-2 minutes, just until they are lightly browned. Sprinkle the slices with Gruyere and Parmesan cheeses, and place them under the broiled for 1 minute until the cheese melts. 5. Ladle the soup into individual bowls. And place a slice of toasted bread on top.

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 www2.state.id.us/dhw

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://bod.ky.gov

Arkansas P.O. Box 627 Helena, AR 72342 (870)572-2847

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

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

California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 (916)263-2382 www.medbd.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.dph.state.ct.us/ Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 doh.state.fl.us Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 www.sos.state.ga.us Hawaii P.O. Box 3469 Honolulu, HI 96801 (808)586-2704 optician@dcca.hawaii.gov

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South Carolina P.O. Box 11329 Columbia, SC 29211 (803)896-4665 www.llr.state.sc.us Tennessee Heritage Place Metro Center 227 French Landing, Ste. 300 Nashville, TN 37243 (615)253-6061 http://health.state.tn.us/boards/do/ Texas P.O. Box 149347 Austin, TX 78714 (512)834-6661 www.roatx.org 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 www.state.va.us/licenses Washington 300 SE Quince P.O. Box 47870 Olympia, WA 98504 (360)236-4947 http://www.doh.wa.gov/LicensesPermitsand Certificates/ProfessionsNewReneworUpdate/DispensingOptician.aspx

MEDMONTHLY.COM |59

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://bit.ly/uaqEO8 Arizona 4205 N. 7th Ave. Suite 300 Phoenix, AZ 85103 (602)242-1492 http://azdentalboard.us/ Arkansas 101 E. Capitol Ave., Suite 111 Little Rock, AR 72201 (501)682-2085 http://www.asbde.org/ California 2005 Evergreen Street, Suite 1550Â Sacramento, CA 95815 877-729-7789 http://www.dbc.ca.gov/ Colorado 1560 Broadway, Suite 1350 Denver, CO 80202 (303)894-7800 http://www.dora.state.co.us/dental/ Connecticut 410 Capitol Ave. Hartford, CT 06134 (860)509-8000 http://www.ct.gov/dph/site/default.asp Delaware Cannon Building, Suite 203 861 Solver Lake Blvd. Dover, DE 19904 (302)744-4500 http://1.usa.gov/t0mbWZ Florida 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399 (850)245-4474 http://bit.ly/w1m4MI 60 | JANUARY 2013

Georgia 237 Coliseum Drive Macon, GA 31217 (478)207-2440 http://sos.georgia.gov/plb/dentistry/ 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/ Illinois 320 W. Washington St. Springfield, IL 62786 (217)785-0820 http://bit.ly/svi6Od Indiana 402 W. Washington St., Room W072 Indianapolis, IN 46204 (317)232-2980 http://www.in.gov/pla/dental.htm Iowa 400 SW 8th St. Suite D Des Moines, IA 50309 (515)281-5157 http://www.state.ia.us/dentalboard/ Kansas 900 SW Jackson Room 564-S Topeka, KS 66612 (785)296-6400 http://www.accesskansas.org/kdb/ Kentucky 312 Whittington Parkway, Suite 101 Louisville, KY 40222 (502)429-7280 http://dentistry.ky.gov/ 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/provider/ licensing/occupational/dentist/about/ 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.dentist.state.ok.us/

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://bit.ly/zSHgpa 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 MEDMONTHLY.COM |61

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://bit.ly/zZ455T 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/site/default.asp 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://www.dchealth.dc.gov/doh 62 | JANUARY 2013

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/default.htm

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://bit.ly/obJm7J p

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://bit.ly/rFyCEW

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

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/

Oklahoma P.O. Box 18256 Oklahoma City, OK 73154 (405)962-1400 http://www.okmedicalboard.org/

Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220 http://1.usa.gov/wMdnxh

Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 (971)673-2700 http://www.oregon.gov/OMB/

Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400 http://1.usa.gov/xjfJXK

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/

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/

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://drl.wi.gov/board_detail. asp?boardid=35&locid=0 Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053 http://wyomedboard.state.wy.us/

MEDMONTHLY.COM |63

medical resource guide ACCOUNTING

Ajishra Technology Support

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

ADVERTISING

PO Box 15130 Scottsdale, AZ 85267 (602)370-0303 www.findurgentcare.com

MedMedia9

www.medmedia9.com

Ring Ring LLC

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

ANSWERING SERVICES Corridor Medical Answering Service

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

Docs on Hold

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

BILLING & COLLECTION Advanced Physician Billing, LLC

PO Box 730 Fishers, IN 46038 (866)459-4579 www.advancedphysicianbillingllc.com

64| JANUARY 2013

Applied Medical Services 4220 NC Hwy 55, Suite 130B Durham, NC 27713 (919)477-5152 www.ams-nc.com

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

VIP Billing

PO Box 1350 Forney, TX 75126 (214)499-3440 www.vipbilling.com

Axiom Business Solutions

Find Urgent Care

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

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

4704 E. Trindle Rd. Mechanicsburg, PA 17050 (866)517-0466 www.axiom-biz.com

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

CAREER CONSULTING Doctorâ&#x20AC;&#x2122;s Crossing 4107 Medical Parkway, Suite 104 Austin, Texas 78756 (512)517-8545 http://doctorscrossing.com/

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

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

CODING SPECIALISTS The Coding Institute LLC 2222 Sedwick Drive Durham, NC 27713 (800)508-2582 http://www.codinginstitute.com/

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

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

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

Practice Velocity 1673 Belvidere Road Belvidere, IL 61008 (888)357-4209 www.practicevelocity.com

COMPUTER, SOFTWARE American Medical Software

1180 Illinois 157 Edwardsville, IL 62025 (618) 692-1300 www.americanmedical.com

CDWG

300 N. Milwaukee Ave Vernon Hills, IL 60061 (866)782-4239 www.cdwg.com/

Instant Medical History

4840 Forest Drive #349 Columbia, SC 29206 (803)796-7980 www.medicalhistory.com

medical resource guide CONSULTING SERVICES, PRACTICE MANAGEMENT

DENTAL Biomet 3i

Manage My Practice

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

Medical Credentialing

(800) 4-THRIVE www.medicalcredentialing.org

Medical Practice Listings

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

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

Dental Management Club

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

myEMRchoice.com

24 Cherry Lane Doylestown, PA 18901 (888)348-1170 www.myemrchoice.com

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

Triangle Nutrition Therapy 6200 Falls of Neuse Road, Suite 200 Raleigh, NC 27609 (919)876-9779 http://trianglediet.com/

ELECTRONIC MED. RECORDS

Synapse Medical Management

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

Urgent Care America

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

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

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

www.pushpa.biz

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

Acentec, Inc 17815 Sky Park Circle , Suite J Irvine, CA 92614 (949)474-7774 www.acentec.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

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

Integritas, Inc. 2600 Garden Rd. #112 Monterey, CA 93940 (800)458-2486 www.integritas.com

FINANCIAL CONSULTANTS Revive Financial Rick Essman, D.C., Vice-President 3901-H Oleander Drive Wilmington, NC 28403 910-620-5910 Cell l 910-685-7438 Office 855-605-2319 (800 #) Office drrick@revivefundingsuite.com http://revivefundingsuite.com/

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

Sigmon & Daknis Williamsburg, VA Office 325 McLaws Circle, Suite 2 Williamsburg, VA 23185 (757)258-1063 http://www.sigmondaknis.com/

INSURANCE, MED. LIABILITY Aquesta Insurance Services, Inc.

Michael W. Robertson 3807 Peachtree Avenue, #103 Wilmington, NC 28403 Work: (910) 794-6103 Cell: (910) 777-8918 www.aquestainsurance.com

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

Medical Protective

5814 Reed Rd. Fort Wayne, In 46835 (800)463-3776 http://www.medpro.com/ medical-protective MEDMONTHLY.COM |65

medical resource guide INSURANCE, MED. LIABILITY

Nicholas Down http://bit.ly/yHwxb0

Martin Fried MGIS, Inc.

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

Professional Medical Insurance Services

16800 Greenspoint Park Drive Houston, TX 77060 (877)583-5510 www.promedins.com

Wood Insurance Group

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

LOCUM TENENS Physician Solutions

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

MEDICAL ARCHITECTS

www.martindfried.com

Barry Hanshaw 18 Bay Path Drive Boylston MA 01505 508 - 869 - 6038 JHans76271@aol.com www.barryhanshaw.com

Ako Jacintho

chuchinho58@gmail.com www.facebook.com/akojacintho www.akojacintho.com

Julie Jennings

(678)772-0889 juliejenn@silksynergy.com http://silksynergy.com/ http://www.coroflot.com/naddie09

MedImagery

Laura Maask 262-308-1300 Laura@medimagery.com

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

www.dicomsolutions.com

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

www.thetps.com

MEDICAL MARKETING MedMedia9

PO Box 98313 Raleigh, NC 27624 (919)747-9031 www.medmedia9.com WhiteCoat Designs Web, Print & Marketing Solutions for Doctors (919)714-9885 www.whitecoat-designs.com

medimagery.com

MEDICAL PRACTICE SALES

Marianne Mitchell (215)704-3188 http://www.mariannemitchell.com http://www.colordrop.blogspot.com

MEDICAL EQUIPMENT

Medical Practice Listings

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

MMA Medical Architects

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

ALLPRO Imaging

1295 Walt Whitman Road Melville, NY 11747 (888)862-4050 www.allproimaging.com

BizScore

Biosite, Inc

MEDICAL ART Brian Allen

www.artisanprinter.com

Deborah Brenner

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

Pia De Girolamo

66| JANUARY 2013

www.piadegirolamo.com

MEDICAL PRACTICE VALUATIONS

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

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

www.bizscorevaluation.com

Cryopen

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

MEDICAL PUBLISHING www.cryopen.com

Carolina Liquid Chemistries, Inc.

391 Technology Way Winston Salem, NC 27101 (336)722-8910 www.carolinachemistries.com

Greenbranch Publishing

info@greenbranch.com 800-933-3711 www.greenbranch.com

medical resource guide

MEDICAL RESEARCH

PRACTICE FINANCING Bank of America

Arup Laboratories

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

www.aruplab.com

Chimerix, Inc. 2505 Meridian Parkway, Suite 340 Durham, NC 27713 (919) 806-1074 www.chimerix.com

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

REAL ESTATE

www.crlcorp.com

55 Corporate Drive Bridgewater, NJ 08807 (800) 981-2491 www.sanofi.us

Scynexis, Inc.

3501 C Tricenter Blvd. Durham, NC 27713 (919) 933-4990 www.scynexis.com

Dermabond

Ethicon, Route 22 West Somerville, NJ 08876 (877)984-4266 www.dermabond.com

DJO

Headquarters & Property Management 1900 Cameron Street Raleigh, NC 27605 (919) 821-1350 Commercial Sales & Leasing (919) 821-7177 www.yorkproperties.com

STAFFING COMPANIES

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

SunTrust Mortgage, Inc.

Nicholas Lay, Senior Loan Officer 910.368.8080 Cell nick.lay@SunTrust.com NMLSR# 659099 www.suntrust.com

8319 Six Forks Rd, Suite 103 Raleigh, NC 27615 (919) 844-6601 Astaffinggroup.com

SUPPLIES, GENERAL BSN Medical

www.expertmed.com

Gebauer Company

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

Scarguard

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

Additional Staffing Group, Inc.

MORTGAGE PROFESSIONAL

www.djoglobal.com

ExpertMed

York Properties, Inc.

Sanofi US

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

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

Clinical Reference Laboratory 8433 Quivira Rd. Lenexa, KS 66215 (800)445-6917

CNF Medical

WEBSITE DESIGN MedMedia9

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

5825 Carnegie Boulevard Charlotte, NC 28209 (800)552-1157 www.bsnmedical.us

www.medmedia9.com

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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

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

ADVERTISE YOUR PRACTICE BUILDING IN MED MONTHLY 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 68| JANUARY 2012

classified listings

Classified To place a classified ad, call 919.747.9031

Physicians needed

North Carolina

North Carolina (cont.)

GP Needed Immediately On-Going 3 Days Per Week at Occupational Clinic General Practictioner needed on-going 3 days per week at occupational clinic in Greensboro, NC. Numerous available shifts for October. Averages 25 patients per day with no call and shift hours from 8:30 am to 5:30 pm. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

Immediate need for full time GP/FP for urgent cares in eastern NC Urgent care centers from Raleigh to the eastern coast of NC seek immediate primary care physician. Full time opportunity with possibility for permanent placement. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

3-5 days per week in Durham, NC Geriatric physician needed immediately 3-5 days per week, on-going at nursing home in Durham. Nursing home focuses on therapy and nursing after patients are released from the hospital. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com GP Needed Immediately On-Going 1-3 Days Per Week at Addictive Diease Clinics located in Charlotte, Hickory, Concord & Marion North Carolina General Practitioner with a knowledge or interest in addictive disease. Needed in October on-going 1-3 times per week. This clinic requires training so respond to post before October 1st. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Primary Care Physician in Northwest NC (multiple locations) Primary care physician needed immediately for ongoing coverage at one of the largest substance abuse treatment facilities in NC. Doctor will be responsible for new patient evaluations and supportive aftercare. Counseling and therapy are combined with physicianâ&#x20AC;&#x2122;s medical assessment and care for the treatment of adults, adolescents and families. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Pediatrician or Family Medicine Doctor in Fayetteville Comfortable with seeing children. Need is immediate - Full time ongoing for maternity leave. 8 am - 5 pm. Outpatient only. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

General Practitioner Needed in Greensboro Occupational health care clinic seeks general practitioner for disability physicals ongoing 1-3 days a week. Adults only. 8 am-5 pm. No call required. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Pediatrician or Family Physician Needed Immediately at clinic in Roanoke Rapids, NC Pediatric clinic in Roanoke Rapids, NC seeks Peds physician or FP comfortable with children for 2-3 months/ on-going/full-time. The chosen physician will need to be credentialed through the hospital, please email your CV, medical license and DEA so we can fill this position immediately. County Health Department in Fayetteville, NC seeks GP/IM/FP Full-Time, On-Going Shifts GP/IM/FP Needed Immediately at County Health Department in Fayetteville, NC. Approximately 20 patients per day with hours from 8 am -5 pm. Call or email for more information. 919-845-0054 physiciansolutions@gmail.com Occupational Clinic in Greensboro, NC seeks FP/GP for On-Going Shifts Locum tenens position (4-5 days a week) available for an occupational, urgent care and walk in clinic. The practice is located in Greensboro NC. Hours are 8 am-5 pm. Approximately 20 patients/day. Excellent staff. Outpatient only.

continued on page 70

MEDMONTHLY.COM |69

classified listings

Classified

continued from page 69

To place a classified ad, call 919.747.9031

Physicians needed

North Carolina (cont.)

Virginia

Diabetic Clinic 1 hour from Charlotte seeks FP/GP/IM for On-Going Shifts Primary care physician needed immediately for outpatient diabetic clinic one hour outside Charlotte, NC On-going. Hours are 8 am -5 pm with no call. Approximately 15-20 patients a day.

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

Addictive Disease Clinic in Charlotte, NC and surrounding cities seeks GP/FP/IM for on-going shifts An addictive disease clinic with locations with locations in Charlotte, NC and surrounding cities seeks a GP with an interest in addictive medicine for on-going shifts. This clinic has 15-25 open shifts every month and we are looking to bring on a new doctor for consistent coverage. The average daily patient load is between 20 and 25 with shifts from 8 am - 5 pm and 6 am - 2 pm. If you are interested in this position please send us your CV and feel free to contact us via email or phone with questions or to learn about other positions. Child Health Clinic in Statesville, NC seeks pediatrician or Family Physician comfortable with peds for on-going, full-time shifts. Physician will work M-F 8 am - 5 pm, ongoing. Qualified physician will know EMR or Allscripts software. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

South Carolina A family and urgent care in Little River, SC seeks an FP/EM physician for 1 to 2 days per week, on-going shifts. The practice is a one-physician facility and is looking for a physician to come in regularly. The practice is small and does not have a large patient load. The qualified physician will have experience in Family or Emergency medicine. If you have any availability and a SC medical license contact us today and we will do our best to work around your schedule. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

70| JANUARY 2013

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

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

continued on page 73

Practice for Sale in Raleigh, NC

PEDIATRICIAN

or family medicine doctor needed in

FAYETTEVILLE, 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

Comfortable seeing children. Needed immediately.

Call 919- 845-0054 or email: physiciansolutions@gmail.com www.physiciansolutions.com

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

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

66| DECEMBER 2012

Primary Care Practice For Sale Wilmington, NC Established primary care on the coast of North Carolina’s beautiful beaches. Fully staffed with MD’s and PA’s to treat both appointment and walk-in patients. Excellent exam room layout, equipment and visibility. Contact Medical Practice Listings for more information.

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

classified listings

Classified

continued from page 70

To place a classified ad, call 919.747.9031

Practice for sale

North Carolina

North Carolina (con't)

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

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

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

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

Washington Family Practice located in Bainbridge Island, WA has recently been listed. Solid patient following and cash flow makes this 17-year-old practice very attractive. Contact Medical Practice Listings for more details. email: medlistings@gmail.com or (919) 848-4202.  MEDMONTHLY.COM |73

Woman’s Practice in Raleigh, North Carolina.

We have a established woman’s practice in the Raleigh North Carolina area that is available for purchase. Grossing a consistent $800,000.00 per year, the retained earnings are impressive to say the least. This is a two provider practice that see patients Monday through Friday from 8 till 6. This free standing practice is very visible and located in the heart of medical community. There are 7 well appointed exam rooms, recently upgraded computer (EMR), the carpet and paint have always been maintained. The all brick building can be leased or purchased.

Contact Cara or Philip for details regarding this very successful practice. Medical Practice Listings; 919-848-4202

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

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

American Council on Exercise

ACE Certified: The Mark of Quality Look for the ACE symbol of excellence in fitness training and education. For more information, visit our website: www.ACEfitness.org

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A M E R I C A’ S A U T H O R I T Y O N F I T N E S S

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

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

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

To find out more information call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com

Internal Medicine Practice for Sale

Primary Care Practice for Sale Hickory, North Carolina

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

Established primary care practice in the beautiful foothills of North Carolina The owning physician is retiring, creating an excellent opportunity for a progressive buyer. There are two full-time physician assistants that see the majority of the patients which averages between 45 to 65 per day.

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

There is lots of room to grow this already solid practice that has a yearly gross of $1,500,00. You will be impressed with this modern and highly visible practice.

Listing Price: $430,000

Call for pricing and details.

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

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

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

Medical Practice Listings Selling and buying made easy

MedicalPracticeListings.com | medlisting@gmail.com | 919.848.4202 76| DECEMBER 2012

CALLING ALL WRITERS

Are you educated in the medical and health care field and looking to showcase your exceptional writing skills?

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

of the oldest Locums companies l Large 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

Med Monthly

919.747.9031 medmedia9@gmail.com medmonthly.com

Editorial Calendar: Feb. 2013 - ENT l March 2013 - Clinical Trials

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

Please direct all correspondence to driverphilip@gmail.com. Only serious, qualified inquirers.

NC MedSpa For Sale MedSpa Located in North Carolina We have recently listed a MedSpa in NC This established practice has staff MDs, PAs and nurses to assist patients. Some of the procedures performed include: Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, fractional laser resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing, and we are in the valuation process. Contact Medical Practice Listings today to discuss the practice details.

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

www.medicalpracticelistings.com MEDMONTHLY.COM |77

MODERN MED SPA AVAILABLE Located in beautiful coastal North Carolina

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

MedicalPracticeListings.com | medlisting@gmail.com | 919.848.4202

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.

PEDIATRICIAN

OR FAMILY MEDICINE DOCTOR NEEDED IN

ROANOKE RAPIDS, NC 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 e-mail medlistings@gmail.com www.medicalpracticelistings.com

Call 919- 845-0054 or email: physiciansolutions@gmail.com www.physiciansolutions.com

PRACTICE FOR SALE

OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina

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

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

Asking price: $385,000

List Price: $150,000 | Established: 2007 | Location: Colorado For more information contact Dr. Jack McInroy at 303-929-2598 or Shrink1324@gmail.com

To view more listings visit us online at medicalpracticelistings.com

Woman's Practice A vailable for Sale Available for purchase is a beautiful boutique womenâ&#x20AC;&#x2122;s Internal Medicine and Primary Care practice located in the Raleigh area of North Carolina. The physician owner has truly found a niche specializing in womenâ&#x20AC;&#x2122;s care. Enhanced with female-related outpatient procedures, the average patient per day is 40+. The owner of the practice is an Internal Medicine MD with a Nurse Practitioner working in the practice full time. Modern exam tables, instruments and medical furniture. Gross Yearly Income: $585,000 | List Price: $365,000

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

the top

Medical practices are going through seismic changes, and physicians are looking for ways to increase revenue or lower costs. There are many tactics that address the myriad ways to do both of those: by changing practice strategy; adding services; solving patient-flow and workflow problems that have been ignored; and focusing more on getting money that is owed to you.

OFFER YOUR PATIENTS ONE-STOP SHOPPING

For your patients’ convenience, do everything possible in-house: Draw blood, conduct urinalyses and stool guaiac tests, and so forth on your own. You should be able to bill for these items, and your patients won’t have to wait at an outside lab to get the services that they need.

GET NEW PATIENTS BY CREATING A NICHE

Consider doing wellness medicine, which widens the scope of potential patients to include everyone. Develop a subspecialty such as in dermatology, thyroid disorders, diabetes, or geriatrics. Get into occupational health — pre-employment physicals, drivers’ physicals, flight physicals, workers’ compensation for minor injuries, drug screening, etc — and advertise that you offer these services.

80 | JANUARY 2013

Medical Practice Management Tips for 2013

AVOID NO-SHOW GAPS IN THE SCHEDULE

Start with the basics: Have a no-show policy that charges patients either for the first or the second no-show appointment. It may be difficult to collect, but if patients wish to return to the practice, collect it via credit card when booking an appointment. Communicate the no-show policy to patients.

MAKE SURE THAT ALL PHYSICIANS ARE PULLING THEIR OWN WEIGHT

Though a daunting prospect, you must have a frank discussion with the physicians who are dodging a share of the duties, regardless of seniority. The senior doctor shouldn’t carry more weight than the other partners. All should be even stakeholders who are looking out for the common good of the practice.

PREPARE FOR IDC-10 TO AVOID HAVING BILLING LAGS AND MISTAKES WHEN YOU GO LIVE

Talk to vendors and confirm again that you are on the most up-to-date version of your office coding software and that your vendor will be ready. Confirm that the system can handle both code sets at once and can flip the switch overnight. Confirm that the vendor can move from diagnosis codes that were 3-5 digits in length to codes that will be 3-7 digits in length. Nonclinical coders in your office should take medical terminology and anatomy and physiology courses. This is the year to lay a solid clinical foundation.

THINK ABOUT A PROFESSIONAL SERVICES AGREEMENT IF YOU’RE CONSIDERING EMPLOYMENT

Professional services agreements (PSAs) have been around for many years but are now growing in popularity. Physicians may view a PSA as a way to get the advantages of employment without selling their practices, and hospitals see it as a mechanism for controlling doctors without employing them directly.

BE AWARE OF WHICH ASPECTS OF PREVENTION CARE ARE NOW REIMBURSED

The Patient Protection and Affordable Care Act has given physicians new tools to offer patients easier access to preventive care. Starting in January 2012, Medicare will eliminate its Part B deductible and copayments for a host of proven preventive services including bone mass measurement; some cancer screenings; diabetes and cholesterol tests; and flu, pneumonia, and hepatitis B vaccinations — among other services. Medicare now covers annual wellness visits.

BE MONEY SMART WHEN YOU MOVE TO AN EHR

Take a closer look at application service provider (ASP) technology. ASP technology means that the electronic health record (EHR) program and data are housed securely at a vendor’s or an institution’s location; you don’t need to have expensive servers and tech support in your office if you have high-speed Internet access. The downside to ASP technology is that when the Internet is down, so are you. Make sure that you have good, stable Internet service before considering this option.

GET PAYMENT EVEN IF YOUR PATIENT’S CHECK BOUNCES

Your practice’s financial policy needs to include your policy on bounced checks and what steps the practice will take to recover that payment. If there are bank charges, stipulate that the patient will be charged for those fees. If you’re in a state that allows you to collect a processing fee above the bank charges, that needs to be stipulated in the financial policy that a patient signs.

Read more at: http://www.millennium-mb.com/blog1/2011/12/01/the-years-best-medical-practice-management-tips/ MEDMONTHLY.COM | 81

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