Med Monthly July 2012 by MedMedia9

Med Monthly JULY 2012

DEALING WITH

PHYSICIAN BURNOUT

the

new intern al medicine issue

Learning to take care of yourself

EHR CONVERSION Best practices for replacing an EHR system

ALSO NO MORE PATIENT STATEMENTS: KEEPING YOUR CREDIT CARDS ON FILE p. 16

THE EVOLUTION OF INTERNAL MEDICINE p. 42

contents features 34 OVERBILLING HIGH-LEVEL E/M CODES OIG to send names of 1,700 docs who overbilled

38 PHYSICIAN STRESS AND BURNOUT Learning to take care of yourself 42 THE EVOLUTION OF INTERNAL MEDICINE A retrospective look at constant progression

Bartonella: A new frontier in chronic disease

research and technology 10 A NEW FRONTIER IN CHRONIC DISEASE 12 MEDTRONIC'S OUTCOMES OF SYMPLICITY SYSTEM Medtronic Symplicity™ System shows success

Physician stress and burnout

practice tips 16 A BETTER WORLD WITHOUT PATIENT STATEMENTS 18 PAS AND NPS IN PRIMARY CARE One part of the care delivery solution 20 EHR TECHNOLOGY Best practices for replacing an existing EHR system

legal 24 THE BENEFITS AND RISKS OF NEW SUBSPECIALTIES 26 CMS PROPOSES INCREASE MEDICAID PAYMENTS 28 INTERNISTS LOBBY CONGRESS FOR FIXED SGR

the kitchen 32 QUINOA FRUIT SALAD

the arts 48 CREATIVE COMPASSION

in every issue 4 editor’s letter 8 news briefs

56 resource guide 72 top 9 list

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editor’s letter Greetings Medical Professionals! Internal medicine has always stood at the edge of science, their research ever pushing the envelope all in the name of enhancing the ability to diagnose and treat the ill. Internists established some of the country’s most prestigious medical training institutions and designed the infrastructure of residency programs that is utilized even to this day. Our cover story, “The Evolution of Internal Medicine,” investigates the history of the specialty from its roots back in the 17th century through the present day. Interestingly, the article reveals how internal medicine has served as the foundation on which modern medicine was built and suggests how the specialty will maintain their leadership in the future. In addition to the highlights of this honorable specialty (both past and present), this issue is packed with vital tips on how to maximize your bottom line. Frank Rosella offers insight in identifying possible flaws with your current EHR system and also provides suggestions on how to select and implement a system that is perfect for your practice. Mary Pat Whaley addresses concerns regarding the elimination of paper statements and also illustrates the benefits of holding credit cards on file to guarantee timely payment from your patients. Finally, Alan Rosenstein tops off this issue with some invaluable advice to help physicians stay sharp by taking better care of themselves. His words of wisdom are practical and easy to incorporate in your daily routine so that you can take charge of your schedule and eliminate unnecessary stress. The Supreme Court’s recent favorable ruling on the constitutionality of the new healthcare law is a major turning point for our country. It’s no secret that there is a great deal of controversy surrounding the law and the next several months or even years are expected to be filled with heated debate, appeals and complicated policy changes. I want our readers to be assured that they can continue to turn to us for information that will help them evolve with healthcare during its tremendous transition. As your editor I promise that Med Monthly will remain the most objective and progressive magazine in healthcare, now and for years to come. Thank you for your continued support, I hope you enjoy our July issue!

Leigh Ann Simpson Managing Editor

4 | JULY 2012

Med Monthly July 2012 Publisher Philip Driver Managing Editor Leigh Ann Simpson Creative Director Bethany Houston Contributors Ashley Acornley, MS, RD, LDN Edward B. Breitschwerdt, DVM B. Robert Mozayeni, MD Suzanne Leder, BA, M. Phil, CPC, COBGC Frank J. Rosello Alan Rosenstein, MD, MBA Lisa P. Shock, MHS, PA-C Emily Walker Mary Pat Whaley, FACMPE

contributors Alan Rosenstein, MD, MBA is an internist and a medical director at Physician Wellness Services, which provides a comprehensive and confidential suite of services—The Physician EAP, Physician Intervention Services, and training and consulting—designed specifically for physicians and the organizations that employ them. He is a published author whose research and industry presentations has helped numerous healthcare organizations.

Ashley Acornley, RD, LDN holds a BS in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and recently completed her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog can be found at: ashleyfreshfromthefarm.wordpress.com

Mary Pat Whaley, FACMPE is board certified in health care management and a Fellow in the American College of Medical Practice Executives. She has worked in health care and health care management for 25 years. She can be contacted at marypatwhaley@gmail.com 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

Lisa P. Shock, MHS, PA-C is a PA who has practiced in primary care and geriatrics. She enjoys part-time clinical practice and is the President and CEO of Utilization Solutions in Healthcare – a specialty consultant company for physician practices and hospitals, offering services to help implement and improve the utilization of PAs and NPs in the health care system. Contact her with questions at lisa@pushpa.biz

Suzanne Leder, BA, M. Phil, CPC, COBGC is a certified AHIMA ICD-10 trainer and can answer your ICD-10 coding questions. Suzanne is also a Certified Obstetrics Gynecology Coder (COBGCTM). She has been the Ob-gyn Coding Specialty Alert editor for six years and counting. During her coding writing career, she has covered cardiology, gastroenterology, neurology, neurosurgery, orthopedics, otolaryngology, and physical medicine and rehab. MEDMONTHLY.COM |5

designer's thoughts Hello Medical Professionals! As an advocate for creative expression and the written word, I am incredibly excited to begin my journey as a part of the Med Monthly magazine team. As healthcare is a major issue in our nation’s affairs, I see, understand and project the need of conveying relevant, objective and innovative information to those who are its core. Being a part of a team that allows me creative freedom and analytical expertise greatly encourages me to use my artistic abilities to make a difference to all readers across the nation. With a B.S. in Communications: Advertising and Public Relations, and with the enthusiastic vitality that comes only from eager youth, I offer Med Monthly experience in a variety of communication, graphic design, advertising, marketing and social media endeavors. My strongest passion lies in creating and maintaining a brand image by using well-thought graphics, intriguing content, and social media to connect that image or idea with an audience. My experience ranges from leading product and design development projects to copywriting to graphic design, including print and website content and advertisements, email marketing, monthly newsletters, and corporate literature and proposals. An additional feather in my cap is the strong capability to take convoluted information and translate it into tangible results. I have a passion and a drive to excel in all of my work and my team’s accomplishments. My vision for this magazine is to provide our readers with innovative information while accompanying them with aesthetically pleasing, thought-provoking images. So often, medical journals’ content is lost in a mass of black and white text. I understand the need for innovative, objective content, and I have the desire for appealing, intriguing design. Doctors and administrators are constantly presented with data, configurations and text; presenting relevant articles with trending design is a refreshing break from their daily minutia. I am confident that my experience in design and content, my desire to extend hope in a struggling industry, and my love for the written word will be an excellent launch pad for Med Monthly magazine. I am eager to contribute to the magazine’s success, and I can truly imagine the exponential growth, assistance and understanding Med Monthly can bring to our readers.

Bethany Houston Creative Director

6 | JULY 2012

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news briefs California’s Stem Cell Agency’s New Strategic Plan for the Future

CMS Announces Private-Sector Commitments to Improve Primary Care In a strong show of support for more effective, more affordable, higher quality health care, 45 commercial, federal and state insurers in seven markets recently pledged to work with the Centers for Medicare & Medicaid Services (CMS) to give more Americans access to quality health care at lower cost. Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services. Simultaneously, participating commercial, state, and other federal insurance plans are also offering an enhanced payment to primary care practices that provide high-quality primary care. "We know that when we support primary care, we get healthier patients and lower costs," said Acting CMS Administrator Marilyn Tavenner, "This initiative shows that the public and private sectors can come together to meet the critical need for these services." In order to receive the new care management fee from CMS and insurers, primary care practices must agree to provide enhanced services for their patients, including offering longer and more flexible hours, using electronic health records; delivering preventive care; coordinating care with patients’ other health care providers; engaging patients and caregivers in managing their own care, and

8 | JULY 2012

providing individualized, enhanced care for patients living with multiple chronic diseases and higher needs. Approximately 75 primary care practices will be selected to participate in the Comprehensive Primary Care initiative in each designated market. Interested primary care practices in each of the markets should complete the application pre-screen tool online at the Innovation Center’s website. This is the first step in applying for the program. Practices will not be allowed to submit an application without a completed application prescreen tool. The Comprehensive Primary Care initiative is a four-year initiative administered by the Innovation Center. Applications will be accepted until July 20. For more information, please go to: http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html To access the application pre-screen tool, please go to: https://cmsgov.secure. force.com/cpci/cpciscreening

Creative partnerships to move promising stem cell therapies into clinical trials; a pioneering new kind of clinic to help deliver those therapies to patients; and a renewed commitment to delivering health and economic benefits to California - those are some of the key elements in the new strategic plan just published by California’s stem cell agency - the California Institute for Regenerative Medicine (CIRM) “This plan is the blueprint that will help guide us through the next phase of our work,” says Ellen Feigal, MD, Senior Vice President for Research and Development at the stem cell agency. “The science surrounding stem cell research is rapidly evolving and our strategic plan will help us respond to those changes and use our resources in the most effective way to achieve our goals.” The plan - which was developed in close consultation with CIRM board members, researchers, industry experts, patient advocates and other key stakeholders – is shaped by two key objectives; developing therapies that will deliver not just health but also economic benefits to the people of California; and the desire to make California’s investment sustainable. More information about the plan and the CIRM visit: http://www.cirm.ca.gov/

Avery Dennison Partners with Preventice to Develop Mobile Health Applications Avery Dennison Medical Solutions recently announced a partnership with Preventice, Inc., to produce patch-based wearable sensors for clinical monitoring of a patient's unique physiological characteristics. Courtesy of Wearable Technologies Preventice is a break-through developer of mobile health applications and patient monitoring systems that deliver cona new level of sophistication in monitoring technology. It also tinuous care, wherever an individual might be. Mobile health supports Preventice's laser-focus on providing physicians with applications, like those developed by Preventice, improve the new monitoring solutions to significantly improve the patient doctor-patient relationship by establishing a constant connecexperience and clinical outcomes." tion and exchange of information between care providers and Through this partnership, Avery Dennison Medical Solutheir patients. This connection encourages patients to tions will develop a new version of the Metria patchstay engaged in actively managing their health based wearable sensor and user interface for the while away from their healthcare providers Preventice Care Platform, which creates a realand feeds data to clinicians about a patime, continuous connection between patients tient's health status without impactN O O S G and healthcare providers through mobile, ing their daily lifestyle. COMIN Y L H cloud-based and sensor technology. The T "The potential to improve ON M D E M Metria solution, which incorporates senN I clinical care through the use of g in m o c p sor technology from Proteus Biomedical, on-body sensors and remote In the u e, Med u s is 2 will be sold as part of the Preventice Care 1 monitoring is endless," said Jon 0 2 August usiness, b s e Platform for remote monitoring applicaid v Otterstatter, co-founder, president ro ps ti Monthly p c ti e th s tions to hospitals and health care systems and CEO of Preventice. "We're ae r esign and fo d e c ti in the United States. confident that the addition of your prac to stage *Metria Wearable Sensor Technology products have . s s Avery Dennison Medical Solutions succe not been evaluated by regulatory agencies. to our ecosystem of partners who are focused on healthcare innovation creates

Virus Kills Cancer by Hitching a Ride on Blood Cells Researchers have found when a cancer-killing virus is injected in the bloodstream it hitches a ride on blood cells and evades attack from the immune system, allowing it to reach cancer tumors, and start destroying cancer cells. They suggest this means it may be possible to use promising "viral therapy"

during routine outpatient sessions, like chemotherapy, to treat a wide range of cancers. Certain viruses, like the reovirus, that causes colds and mild stomach upsets, prefer to attack cancer cells. They also stimulate the immune system to attack tumors. Using these "oncolytic" viruses to

kill cancer is a fairly new approach that is currently being tested. Trials are currently under way to test "viral therapy" as an approach to treat cancer in human patients. Med Monthly is investigating this research and looks forward to bringing you a detailed report in our upcoming issue. MEDMONTHLY.COM |9

research & technology

Bartonella: A New Frontier in Chronic Disease New molecular test leads to surprising new research implicating Bartonella in rheumatological illness By Edward B. Breitschwerdt DVM, CEO/CSO Galaxy Diagnostics & B. Robert Mozayeni, MD, CMO, Galaxy Diagnostics

ew research recently published in the journal of Emerging Infectious Disease supports an association between Bartonella infection and rheumatological symptoms. The researchers tested 296 immunocompetent patients for evidence of Bartonella infection. Bacteremia with one or more Bartonella species was found in (41 percent) of patients with a prior diagnosis of Lyme disease (47 percent), arthralgia/ arthritis (21 percent), chronic fatigue (20 percent) and fibromyalgia (6 percent). This study follows two decades of medical case series research implicating Bartonella infection in chronic diseases affecting the joints, neurologi-

10 | JULY 2012

cal and vascular systems. Bartonella are highly fastidious, immune-evasive, gram-negative bacteria which infect at very low levels of detection. As a result, conventional serological and polymerase chain reaction (PCR) testing technologies are of limited value for the confirmation of infection. These surprising new findings were made possible by a new testing technology developed by researchers at the North Carolina State University College of Veterinary Medicine (NCSU-CVM). The NCSU research team discovered a way to overcome past testing challenges through the development and use of a propriety enrichment media (Bar-

tonella alpha-proteobacteria growth medium or BAP-G-M). When paired with highly sensitive PCR testing, the BAPGM media increases the sensitivity of detection by 4 to 5 times over conventional methods. Popularly known as the key agents in cat scratch disease (CSD), trench fever, and Carrionâ&#x20AC;&#x2122;s disease, Bartonella were essentially rediscovered in the 1990s with the emergence of HIV and the clinical application of DNA testing technologies. There are now over 25 characterized species of Bartonella, 12 of which have been documented as pathogenic for humans. A wide range of animals serve as natural hosts for this zoonotic bacteria, most signifi-

cantly the cat and rodent populations, which may be transmitted by a number of different vectors including fleas, lice, ticks and biting flies. A 2004 Nature article describes Bartonella as one of the most important pathogens in emerging infectious disease along with Helicobacter pylori (H. pylori). Unlike H. pylori, however, Bartonella is not localized to the gastrointestinal (GI) tract, but can infect multiple systems in the body. Well-established as life-threatening in patients with compromised immune systems, the emerging research indicates that Bartonella are also a problem in patients with competent immune systems. Research on HIV patients, suggests a pattern of progressive presentations of bartonellosis from mild CSD symptoms to peliosis hepatitis and bacillary angiomatosis. Bartonella has also been documented as a cause of culture-negative endocarditis, osteomyelitis, meningitis, encephalitis, neuroentinitis and vasculitis. Mounting case evidence indicates that atypical presentations of cat scratch disease may not be nearly as uncommon as previously thought, especially in high-risk patient populations. Symptoms may range from recurring fever, headaches, insomnia, joint/muscle aches and pains to arthropathy, myalgia, neurocognitive and neuromotor dysfunction, seizures, vasculitis, and vaso-proliferative tumors or lesions, as well as the more common lymphadenopathy and splenomegaly. Risk factors associated with Bartonella infection include high levels of animal contact and vector exposure. In an earlier study using the Bartonella ePCR™ test, the NCSU research team found that 23.9 percent of 192 patients with occupational animal contact or extensive arthropod exposure were bacteremic with one or more Barton-

ella species when blood, serum and BAPGM enrichment culture PCR results were combined. Although this high prevalence of bacteremia is biased by testing at-risk, sick individuals, it clearly demonstrates that intravascular infection with Bartonella species is much more common in immunocompetent patients than was previously suspected. Importantly, Bartonella infection may also represent a safety concern in the blood supply in transplant medi-

‘‘

"Bartonella infection may also represent a safety concern in the blood supply in transplant medicine and chronic disease management." cine and chronic disease management. Of particular concern are medical conditions managed with therapeutic regimens that cause immune suppression, including rheumatologic diseases such as rheumatoid arthritis or lupus, or organ transplantation. Other conditions, such as cancer, may involve the use of medications that cause immune suppression, such as high-dose steroid components of lymphoma protocols. Blood banking practice must also

consider the potential for the transmission of Bartonella through transfusion of blood products. These safety issues indicate the need for better prevalence studies to determine the cost-benefit of screening for safety reasons, including the screening of blood products. Recommendations for medical practitioners: • Consider testing patients at high risk who present with general rheumatic or neurological symptoms for Bartonella infection. • Make clinical protocols involving immune suppression, including transplantation and cancer treatments, safer by testing high-risk patients for Bartonella infection. • Advise patients to exercise routine precautions to avoid animal bites and scratches when dealing with domestic or wild animals and to avoid exposure to arthropod and insect vectors. The emerging research on Bartonella is very compelling and the need for clinical research that directly addresses the role these bacteria play in human and animal health is clear. Because the genus Bartonella involves multiple animal reservoirs, animal and human disease, arthropod and insect vector transmission, and an environmental impact on human health, multidisciplinary research efforts following the One Health Initiative are needed to effectively address the far-reaching implications and the redefinition of “bartonellosis” as an emerging infectious disease of the 21st century. The Bartonella ePCR™ test is now commercially available at Galaxy Diagnostics. Galaxy Diagnostics holds an exclusive license to the BAPGM technology from North Carolina State University. For more information, see www.galaxydx.com More information on the One Health Initiative may be found at www.one healthcommission.org/  MEDMONTHLY.COM |11

research & technology

Medtronic Announces Six Month Outcomes of Symplicity System Trial of Medtronic Symplicity™ renal denervation system shows significant success at six months post-treatment By Wendy Dougherty

ix-month pooled outcomes from randomized and crossover patients following renal denervation presented at the 22nd annual Scientific Meeting of the European Society of Hypertension confirm previous Symplicity clinical trial findings. Medtronic, Inc., recently announced six-month pooled outcomes from randomized and crossover patients in the Symplicity HTN-2 clinical trial following renal denervation with the Symplicity™ renal denervation system showing significant, sustained blood pressure reduction in patients with treatment-resistant hypertension. The data presented at the European Society of Hypertension annual meeting showed patients (n=84) who received renal denervation treatment with Symplicity experienced a mean blood pressure reduction of -28/-10 mm Hg (p<0.001) at six-months following treatment compared with baseline. No evidence of renal impairment was observed and renal function measures remained unchanged. This pooled analysis included change in blood pressure at sixmonths for all patients random-

12 | JULY 2012

ized to receive renal denervation with Symplicity at baseline (n=49), as well as patients in the control group (n=35) who met entry criteria and crossed over to the treatment group following assessment of the initial six-month primary endpoint. “The Symplicity clinical program is the longest and largest clinical program of its kind evaluating renal denervation in resistant hypertension,” said Markus Schlaich, MD, Associate Professor, Head, Hypertension & Kidney Disease, Baker IDI Heart and Diabetes Institute in Melbourne, Australia. “This largest pooled analysis of controlled trial data at six-months adds to the growing body of clinical evidence about the safety, effectiveness and sustainability of blood pressure reductions achieved with renal denervation.” Renal denervation therapy is a minimally invasive, catheter-based procedure that modulates the output of nerves that lie within the renal artery wall and lead into and out of the kidneys. These nerves are part of the sympathetic nervous system, which affects the major organs that are responsible for regu-

lating blood pressure: the brain, the heart, the kidneys and the blood vessels. The Symplicity system’s catheter and proprietary generator and algorithms were carefully and specifically developed through years of clinical experience to enhance the safety and effectiveness of the renal denervation procedure. The Symplicity renal denervation system has been successfully used for nearly five years to treat more than 4,000 patients with treatment-resistant hypertension worldwide. “New treatment guidance issued by the European Society of Hypertension on the use of renal denervation to treat resistant hypertension supports the use of technology that has demonstrated enduring safety and effectiveness in clinical studies,” said Sean Salmon, Senior Vice President and President, Coronary & Renal Denervation, Medtronic. “We believe our Symplicity technology specifically designed for this procedure, coupled with encouraging results from the Symplicity clinical trials with three years of follow-up fall within these renal denervation treatment guidelines.”

Courtesy of Medronic

Six-Month Pooled Outcome Data from the Symplicity HTN-2 Study The Symplicity HTN-2 trial is an international, multi-center, prospective, randomized, controlled study of the safety and effectiveness of renal denervation in patients with treatment-resistant hypertension. One hundred-six (106) patients were enrolled from 24 investigational sites. At baseline, the randomized treatment and control patients had similar high blood pressures: 178/97 mm Hg and 178/98 mm Hg, respectively, despite both receiving an average daily regimen of five anti-hypertensive medications. Patients in the control arm of the study were offered renal denervation following assessment of the trial’s primary endpoint at six months following randomization. Pre-randomization, all patients in the study had an

office-based systolic blood pressure ≥160 mm Hg despite adherence to at least three antihypertensive medications given at optimal dosage. Mean change in systolic and diastolic blood pressure was -28/-10 mg Hg (n=84) from baseline (p<0.001) to six months posttreatment. Renal function measures were unchanged (eGFR: 82.1±20.2 vs. 80.5±18.9mL/min/1.73m2; p=NS). There was one right artery dissection in a crossover patient, which occurred while injecting contrast during angiography. No other serious procedure-related adverse events occurred.

About Treatment-Resistant Hypertension Treatment-resistant hypertension, defined as persistently high blood pressure despite three or more anti-hypertensive medications of different types including a diuretic, puts approximately 120

million people worldwide at risk of premature death from kidney disease and cardiovascular events such as stroke, heart attack and heart failure. Research suggests that nearly one third of treated hypertensive individuals are considered resistant to treatment. Additionally, these patients have a three-fold increase in risk of cardiovascular events compared to individuals with controlled high blood pressure.

About the Symplicity™ Renal Denervation System The Symplicity™ renal denervation system was launched commercially in April 2010 and is currently available in parts of Europe, Asia, Africa, Australia and the Americas. The Symplicity renal denervation system is not approved by the U.S. Food and Drug Administration

continued on page 14

MEDMONTHLY.COM |13

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(FDA) for commercial distribution in the United States. The Symplicity renal denervation system consists of a flexible catheter and proprietary generator. In an endovascular procedure, similar to an angioplasty, the physician inserts the small, flexible Symplicity™ catheter into the femoral artery in the upper thigh and threads it into the renal artery. Once the catheter tip is in place within the renal artery, the Symplicity™ generator is activated to deliver a controlled, low-power radio-frequency (RF) energy routine according to a proprietary algorithm, or pattern, aim-

ing to deactivate the surrounding renal nerves. This, in turn, reduces hyper-activation of the sympathetic nervous system, which is an established contributor to chronic hypertension. The procedure does not involve a permanent implant. The FDA granted Medtronic approval for the protocol for Symplicity HTN-3, the company’s U.S. clinical trial of the Symplicity renal denervation system for treatment resistant hypertension in August 2011. Symplicity HTN3 is a randomized controlled trial designed to evaluate the safety and effectiveness of renal denervation

with the Symplicity renal denervation system in patients with treatment-resistant hypertension. The study will include approximately 530 treatment-resistant hypertension patients across up to 90 U.S. medical centers. More information about HTN-3 can be found at www. symplifybptrial.com In collaboration with leading clinicians, researchers and scientists worldwide, Medtronic offers the broadest range of innovative medical technology for the interventional and surgical treatment of cardiovascular disease and cardiac arrhythmias. 

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practice tips

A Better World without Patient Statements Why moving into an electronic payment system benefits the practice and the patient. By Mary Pat Whaley, FACMPE

here are two things I’ve found over the years that medical offices have a hard time giving up. One is the appointment book. The other is patient statements. My first experience with creating patient statements was placing patient ledger cards on the copier. The copies were folded and slid into envelopes and mailed to patients. Despite a bad photocopy of handwriting of several different people squashed onto skinny lines, patients routinely understood what the bill said and paid the total. That was 25 years ago. Today the process of sending statements to patients is largely outsourced along with electronic claims, but it’s not very electronic. If we can get paid by insurance companies electronically, why not get paid by patients electronically? I suggest that the practice of sending patient statements is not only resource-intensive, but it is also a 20th century business practice unsuited for a 21st century business. Why do practices insist on clinging to an outdated method of billing? Here are the excuses I routinely hear for not eliminating statements: • “Patients must get statements, or they won’t know to pay us.” • “Healthcare payments are so complicated that patients need a statement to understand them.” • “It’s not legal not to send a statement.” • “We don’t know how much the

16 | JULY 2012

patient owes us until the insurance company pays.” • “We don’t get to see our patients face-to-face, so we have to send a statement.”

Let’s Address These Objections One at a Time “Patients must get statements, or they won’t know to pay us.” I disagree. Patients do not need statements to know to pay us. If they did, then we’d only have to send one statement and everyone would pay! We know that’s not true. “Healthcare payments are so complicated that patients need a statement to understand them.” It is our job to educate patients about their financial responsibility. We understand that insurance coverage is complex, but it’s not so complex that we can’t explain it to them. Our businesses, our very jobs, rely on our ability to explain to patients what they owe. It’s just that simple. “It’s illegal not to send a statement.” Nope. “We don’t know how much the patient owes us until the insurance company pays.” That may be true, but we have all the tools we need to make a

very educated estimate. There is no reason why we cannot estimate the patient’s portion and make a small adjustment (refund or additional charge) on the patient’s credit or debit card once the insurance company pays. “We don’t get to see our patients face-to-face, so we have to send a statement.” Most practices are dealing with this head-on by placing staff in areas, mostly hospitals, where staff can meet with patients and discuss financial responsibility. Setting up a statement-free practice is relatively easy.

Here are Some Tips: Use an online payment system that allows electronic payment plans. An electronic payment plan enables a practice to enter a payment plan once, and have the system draft the credit/debit card appropriately without staff management. It should also be able to send a receipt to the patient’s email, or to send a message to the patient to pick up the receipt through a secure portal. Load your contract allowables into your practice management system. If

your system doesn’t have that capability, create a cheat sheet of your top codes for each contracted payer, so your check-out staff can calculate what the patient owes. There are also systems that can put together your contract information and the patient information into an estimate of what the patient owes for you. Get online eligibility access that includes information about the patients’ benefits, deductibles, co-pays and co-insurance. This is available through your practice management system, your clearinghouse, or from a separate system that reads from your appointment schedule. Practices that offer procedures or surgery should employ a financial counselor to sit down with patients and talk through financial responsibility and set up payment plans. Coach staff on talking to patients about money. Teach them to become comfortable with collections.

Patient statements are a waste of time and resources. Think of what your life might be like without statements:

What’s the Bottom Line?

• 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 credit-card-on-file program, decide on a time frame to implement it. • Start communicating to patients that you are going to a creditcard-on-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!

People pay their bills via their credit/debit card routinely – this is not new or unusual for the majority of people. The ability to “set it and forget it” via electronic payment plans simplifies the payment system and speeds up cash flow. The ability to adjust a patient plan once insurance pays means no waiting to refund the patient or collect the remaining dollars. Your staff will still have to post the payments into the practice management system (although a few have integrated posting), but eliminating statements will save your practice money and time. 

• No monthly expense to generate or send statements via electronic service or printing and stuffing. • No need to sort them out of the mail, open them, post them, copy or scan them, and deposit them. • No returned checks. • When three or more statements don’t zero-balance the account, no need to prepare the accounts to be sent to thirdparty collections and write them off. • No need to dismiss the patient from the practice. • No need to post any collections payments and adjustment to the accounts. • No need to deal with the patient when they want to return to the practice and you have to manage the situation.

But what takes the place of statements? Credit Cards 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:

To find out more about electronic payment systems and other pracice management advice, visit www.managemypractice.com

MEDMONTHLY.COM |17

practice tips

PAs and NPs in Primary Care â&#x20AC;&#x201C; One Part of the Care Delivery Solution By Lisa P. Shock, MHS, PA-C

hysician assistants (PA) and nurse practitioners (NP) are skilled medical professionals who play an integral part in healthcare delivery. The healthcare system is facing a shortage of primary care clinicians. Current definitions of primary care include family medicine, internal medicine, pediatrics and obstetrics/gynecology. Currently, there is a shortage of primary care physicians

18| JULY 2012

and the American Academy of Family Physicians predicts that, if current trends continue, the shortage of primary care physicians will reach 40,000 within 10 years. This is critical when looking at health reform and examining the concept of increasing numbers of patients seeking access to medical care under a reformed system. Increasing utilization of PAs and NPs is part of the solution. Studies suggest that the

addition of a PA or NP to a medical practice may offer enhanced patient satisfaction, improved physician worklife balance, improved revenues and greater access to care for patients. As healthcare delivery is transformed, the implementation of the patient centered medical home (PCMH) as a vehicle for patient care is rapidly expanding. Primary care delivery in both internal medicine and family practice is shifting toward this system of population management of chronic disease. Recent studies from the American College of Physicians and the American College of Family Physicians state that PAs should be recognized as primary care providers in the PCMH model. Accrediting bodies such as (NCQA) and the Utilization Review Accreditation Commission (URAC) support the PCMH as a proven model for delivering high quality, cost-effective patient care and encourage the inclusion of physician assistants within the delivery model. Nationally, the American Academy of Physician Assistants (AAPA) supports the fundamental premise that standards used to define PCHM and care delivery models are not limited to physicians. Approximately 30,000 PAs practice in primary care of the nearly 80,000 PAs nationwide. Many PAs will practice in healthcare PCMHs; lead patient care teams and will participate in and be an integral component of quality performance reporting. Robin P. Newhouse, PhD, RN, NEA-BC, and her co-authors com-

pared advanced practice registered nurse (APRN) processes and outcomes to those of physician providers in a recent article in Nursing Economics. Sixty-nine studies published between 1990 and 2008 were analyzed and 28 outcome metrics were summarized and examined for nurses practicing in APRN roles. Newhouse and her co-authors describe patient outcomes for each of three groups: nurse practitioners, certified nurse-midwives and clinical nurse specialists. Outcomes for NPs examined metrics including: glucose control, lipid control, patient satisfaction, functional status and mortality. Study results indicated that APRNs provide safe, effective, quality care and play a significant role in promoting health and healthcare. Utilization of PAs and NPs in the PCMH model may exist in several ways. In some settings, PAs may be focused on acute care or on management of chronic conditions, while in other communities, PAs/NPs may maintain their own panels of patients alongside physicians, and in rural communities, PAs may practice alone with a physician located off site. Optimal utilization supports the patient to choose

a PA/NP as a primary care provider, ensuring and increasing access to care while the physician maintains oversight of the PA scope of practice. This

‘‘

able, demonstrated improvement in quality metrics and management of chronic disease populations.

"...The addition of a PA or NP to a medical practice may offer enhanced patient satisfaction, improved physician work-life balance, improved revenues and greater access to care for patients."

utilization model allows for continuity of care, fosters patient/provider relationships, and underscores chronic disease management efforts for challenging care conditions including diabetes and asthma. Ultimately, the role of the PA/NP within the PCMH will depend on the clinical setting, patient population, clinical competency and experience and the professional relationship between the PA/NP and the physician(s). Implementing a strategy to incorporate PAs and NPs into existing primary care practice models will offer measur-

About the author: Lisa P. Shock, MHS, PA-C, is a seasoned PA who has practiced in primary care and geriatrics since her days at the Duke PA program in the late 90s. She enjoys part time clinical primary care practice and is the President and CEO of Utilization Solutions in Healthcare – a specialty consultant company for physician practices and hospitals, offering a wide range of services to help implement and improve upon the utilization of PAs in the healthcare system. Contact her with questions at lisa@pushpa.biz 

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practicetips tips practice

EHR Conversion: Best Practices for Replacing an Existing EHR System Identifying flaws and evaluating EHR technology By Frank J. Rosello

he healthcare industry today is arguably experiencing the most change and challenges dealing with technology integration than any other industry. Health information technology is at the core of the global transition in healthcare as it's becoming more apparent that medical organizations will not be able to effectively coordinate care without having real-time access to patient data in order to measure every aspect of care delivery. Today, it's of critical importance for medical organizations to approach electronic health record (EHR) selection as a foundational aspect of their long-term business strategy in order to effectively navigate the future of healthcare with the emergence of accountable care, new payer models and payment reform. Only recently

20| JULY 2012

has there been tangible evidence that illustrates the challenges many ambulatory medical organizations are facing with adopting EHR technology. A recent KLAS report found that out of 400 providers surveyed, 35 percent are looking to replace their existing EHR system. Additionally, it was reported that more than 40 percent of groups with more than 100 physicians are also looking to change EHR systems. The health IT industry is calling this trend "rip and replace." Apparently there are needs, service requirements and functionality not being met by some of the existing EHR systems currently in use. Medical organizations that replace their existing EHR system state their reason for moving to a new solution was either due to a lack of needed functionality, lack of product

flexibility, issues with customer support, or system implementation and integration failures. The key to a successful EHR implementation, when replacing an existing platform, is to perform an evaluation by asking the right questions to understand if the problem is the system, the implementation, or both. Here are some questions to consider when performing this type of review: â&#x20AC;˘ Did the organization commit the right amount of resources to the initial EHR implementation/deployment? Areas to review should include: sponsorship, technology, financial, personnel, time and attention. â&#x20AC;˘ Did the organization clearly define the requirements of the EHR system to insure the system purchased had the features, functionality, and interoperability needed to support the operations and workflows of the organization now and in the future? â&#x20AC;˘ Did the organization purchase or enter into a partnership with a vendor to ensure optimal use of the technology? Accurately identifying the root cause or causes driving the dissatisfaction with the existing EHR system is paramount in order to move forward with the selection of the replacement system. Unfortunately in most cases, dissatisfaction with EHR systems is directly related to a poorly executed implementation plan. To help medical organizations and providers successfully "rip and replace" their legacy EHR system, consider the following six best practices: 1. Effective Project Planning - Take what was learned during the evaluation review and incorporate those findings to the new implementation plan. The plan should also include regular communication and updates to the staff and patients. Communication is very important during a transition of this magnitude and can be man-

aged through the creation of a health information management committee and change control board (CCB). 2. Expect Obstacles - Flexibility is of critical importance during this time of change. Even though a fair amount of experience and knowledge was gained during and post the implementation of the legacy EHR system, recognizing what the potential pitfalls are and developing a mitigation plan ahead of time will go a long way. 3. Map Out Workflows Before GoLive - Organizations should consider running a series of mock clinic tests before go-live. Furthermore, the physicians should be intimately involved with designing the templates and mapping out the workflows within the practice. By having physicians engaged to this extent will help to ensure full physician adoption.

22| MAY 2012

4. Existing Data Migration - It needs to be determined what data will be transferred from the legacy system and in what format. The objective is to capture as much discreet data as possible to ensure the continuity of patient's medical records and clinical reporting. 5. Training - Develop a comprehensive training plan that will address multiple learning styles: computerbased, scenario-based, shoulder to shoulder. The training plan should also incorporate competency evaluation and monitoring processes along with regular follow up with end-users. 6. Post Implementation Monitoring - Once the onsite support and training team concludes their work, successful organizations partner with an outside vendor to monitor the progress of all stakeholders including the physicians,

clinicians and non-clinical staff. By having an outside partner monitoring the operations post implementation will help to identify knowledge gaps and suggest workflow improvements that will ultimately lead to a successful EHR system implementation. An EHR system that is ineffective will ultimately lead to failure in the future. Medical organizations that do not have effective, efficient health information and data management practices today are at significant risk to become isolated and unsuccessful in the future. These best practices are crucial in making your healthcare organizationâ&#x20AC;&#x2122;s transition to a better suited EHR system successful and seamless. Article Source: http://EzineArticles. com/?expert=Frank_J_Rosello Article Source: http://EzineArticles. com/7108378 ď&#x201A;˘

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New England Journal of Medicine “Sounding Board” Discusses The Benefits and Risks of New Subspecialties in Internal Medicine

xisting criteria for determining subspecialties in internal medicine try to balance the needs of the public against a medical profession that has gained expertise within specific areas of practice, according to a new Sounding Board published in this week's New England Journal of Medicine. The American Board of Internal Medicine (ABIM) and its policies for establishing new areas of certification – or subspecialties – of internal medicine are detailed in the article. Co-Authored by Christine K. Cassel, MD, President and CEO of ABIM and David B. Reuben, MD, the current Chair of the ABIM Board of Directors, the article discusses the challenges ABIM faces from an internal medicine community that on the one hand worries about fragmentation of the field

24 | JULY 2012

and declining numbers of generalists and on the other wants information about specific expertise and knowledge made available to patients through certification. Currently, ABIM offers specialty certification in internal medicine and 19 subspecialties: Adolescent Medicine, Advanced Heart Failure & Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology, Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine and Transplant Hepatology. Over the last five years there were about 15 requests for new internal

medicine subspecialties, mostly from medical specialty societies, of these five were approved. The criteria for recognizing a subspecialty for a new certification pathway, most recently reexamined by ABIM in 2006, include: • The discipline must have a unique body of knowledge that cannot be fully incorporated into the “parent” discipline. • The discipline must have clinical applicability to be practiced in a form that is distinct from the “parent” discipline. • The discipline must contribute to the scholarly generation of new information and must advance research in the field. • There must be an important social need for the discipline and evidence that practice of the

discipline improves patient care. • The positive value of certification in the new discipline must outweigh any negative impact on the practice of general internal medicine or an existing subspecialty or on the basic education in the core competencies of internal medicine. ABIM has explored new types of recognition – including the focused practice designation, which serves to delineate not new areas of certification, but ways physicians within a specialty have focused their practice. ABIM launched a focused practice program in Hospital Medicine in 2010. More than 500 physicians have enrolled in the program. The article's authors, who note that subspecialty designation only has value when it is rigorous and meaningful to the public, conclude: “New specialties can benefit both patients and physicians. However, a proliferation of specialties without adequate justification may simply confuse the public without creating a social good.” About ABIM For more than 75 years, certification by the American Board of Internal Medicine (ABIM) has stood for the highest standard in internal medicine and its 19 subspecialties and has meant that internists have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care. ABIM is not a membership society, but a non-profit, independent evaluation organization. Our accountability is both to the profession of medicine and to the public. ABIM is a member of the American Board of Medical Specialties. For additional updates, follow ABIM on Facebook and Twitter. Copyright 2011 American Board of Internal Medicine. Used with permission. 

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legal

CMS Proposes Increased Medicaid Payments for Primary Care By Aaron Rabinowitz

he Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to implement a provision of the Affordable Care Act which provides increased payments for certain Medicaid primary care services. Under the proposed rule, primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, pediatric medicine, or related subspecialties would be reimbursed at the Medicare rates in effect for calendar years 2013 and 2014, in lieu of their usual state-established Medicaid rates. Primary care services must be delivered under the Medicaid physician services benefit to be eligible for the increased payments. Consequently, primary care services rendered by practitioners working under the supervision of a qualifying physician and billing under that physician’s Medicaid provider number – a nurse practitioner, for example – would be eligible for higher payment. CMS also clarified in the proposed rule that all of the requirements related to the increased payments apply to services reimbursed by Medicaid managed care plans. The proposed rule indicates that states would receive 100 percent federal financial participation to cover the increased payments for primary care services. In other words, the increased payments would be paid entirely by the federal government, with no matching payments required from the states. According to CMS, states would receive more than $11 billion to bolster their Medicaid primary care delivery systems. As Marilyn Tavenner, acting administrator for CMS, explained, the proposed rule "will help encourage primary care physicians to continue and expand their efforts to provide checkups, preventive screenings, and other care to Medicaid beneficiaries." Author Aaron Rabinowitz is a lawyer in the Health Law Group of the law firm Ober|Kaler. He can be reached at arabinowitz@ober. com This article is not to be construed as legal or financial advice and the review of this information does not create an attorney-client relationship. Reprinted with permission from Ober|Kaler (www.ober.com)

26| JULY 2012

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legal

Internists Lobby Congress for a Fixed SGR Doctorsâ&#x20AC;&#x2122; groups push to revamp the controversial formula before the â&#x20AC;&#x153;fixâ&#x20AC;? expires By Emily Walker

everal hundred internists and medical students were on Capitol Hill Thursday, meeting with their members of Congress to advocate for issues facing internal medicine. Chief among them, not surprisingly, is a fix for the sustainable growth rate (SGR), the Medicare formula that, year after year, calls for steep cuts in Medicare reimbursement rates for physicians. Congress always votes to push the cut down the road, and the current "fix" holds Medicare payment rates to doctors steady through the end of

28 | JULY 2012

2012. Before that fix expires, doctors' groups - including the American College of Physicians (ACP), which represents internists - as well as several lawmakers, have been pushing for bills to totally revamp the formula, which both Democrats and Republicans agree is flawed. Fred Ralston, MD, an internist in Fayetteville, Tenn., and former president of the ACP, said that he doesn't expect a permanent SGR fix to happen this year, but that doesn't mean physicians should stop pressing the issue. "We're certainly hearing it's likely

the can will be kicked ahead one year forward," Ralston said. "We're disappointed in this and we've been hearing this every year for more years than I can count." ACP member Pamela Hiebert, MD, an internist in Bozeman, Mont., agreed the SGR tops the list of pressing concerns for internists. "The main issue is to repeal or change the SGR," said Hiebert. "We are advocating that we improve the method for reimbursement for physicians. Especially primary care physicians; we need to make sure that they are paid fairly so they stay

in the business and they keep on taking care of patients." Hiebert met Thursday with her senator, Max Baucus, a Democrat from Montana. Baucus said that he's extremely open to hearing concerns of physicians and encouraged more doctors to engage with Congress.

‘‘

Health and Human Services], and just trying to do a better job for their patients." Ralston said the ACP also discussed the concept of health courts with lawmakers. He said the group will continue to lobby for medical malpractice caps, but realizes that a

" Especially primary care

physicians; we need to make sure that they are paid fairly so they stay in the business and they keep on taking care of patients." "We're all very busy and the more physicians can talk to us, the better idea we have of what's on their mind," he said. Baucus said much of what is on the mind of doctors are issues relating to reimbursement. "To be honest, I've been a little disappointed over the years that we haven't found a better formula to reimburse physicians." Baucus was one of the main architects and negotiators of the Affordable Care Act, the fate of which was being considered by the Supreme Court. Baucus said he doesn't think doctors have been waiting for the verdict before making changes to comply with the law. "Most of the healthcare providers I talk to say [that] irrespective of the court's decision, they're moving ahead," he said. "They're working with what's now in the law, with [the Centers for Medicare and Medicaid Services], with [the Department of

5-year pilot program testing out the concept of special courts for medical malpractice cases may be a more politically palatable option. In addition, Ralson said the ACP is pushing for "high value, cost-conscious care," by educating physicians and patients that more care doesn't always equal better care. "Many things, either from old information, or from unrealistic expectations of patients, are leading to care that is not necessary, [such as] routine EKGs or an MRI on day two of low-back pain for a low-risk patient," he said. "We know that the data suggest that 30 percent to 35 percent of what we spend on healthcare doesn't really add value." He said eliminating unnecessary spending is preferable to having cuts in medicine made "willy nilly." While that might sound to some like rationing care, Ralston calls it "rational care." Previously published by Med Page Today 

continued on page 32 MEDMONTHLY.COM |31

By the numbers... NPI and DEA numbers

What you need to know about the National Provider Identifier and the Drug Enforcement Administration numbers National Provider Identifier A National Provider Identifier (NPI) is a 10-digit identification number issued to health care providers in the United States. The number is issued by Centers for Medicare and Medicaid Services (CMS). The NPI began replacing the unique provider identification number (UPIN) in 2006 as the required identifier for Medicare services and other payers, including commercial health care insurers. The change to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the first numbers were issued in October of 2006. The NPI was proposed as an eight-position alphanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit in the last position to help detect keying errors. The NPI contains no embedded intelligence; that is it contains no information about the health care provider, such as the type or location. All individual HIPAA covered health care providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapist, athletic trainers, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes. More information regarding NPI numbers can be found at http://nppes.cms.hhs.gov

DEA Number The Drug Enforcement Administration (DEA) is a U.S. Department of Justice law enforcement agency tasked with enforcing the Controlled Substances Act of 1970. It shares concurrent jurisdiction with the Federal Bureau of Investigation (FBI) in narcotics enforcement matters. A DEA number is a series of numbers assigned to a health care provider allowing them to write prescriptions for controlled substances. Legally the DEA number is supposed to only be used for tracking controlled substances, however, the DEA number is often used by the industry as a general “prescriber” number that is a unique identifier for anyone who can prescribe medication. A valid DEA number consists of two letters, six numbers and a one check digit. More information regarding DEA numbers can be found at www.deanumber.com 

the kitchen

Earthen Fare

By Ashley Acornley MS, RD, LDN

Looking for a light, refreshing, yet nutritious salad to serve at summer barbeques? Give quinoa a try! Quinoa is considered an ancient whole grain that can be prepared just like rice or barley. Quinoa is a popular nutritional “superfood” due to its high protein content, so it is perfect for vegetarians, vegans and meat eaters alike to add to their diet. Unlike other grains, quinoa provides all nine essential amino acids, making this a complete protein. Quinoa is also naturally gluten free and cholesterol free. Each 1/3 cup of cooked quinoa contains about 160 calories, 2.5 grams of fat, 3 grams of fiber and 6 grams of protein. Prepare quinoa as you would prepare rice. Cover it with water or vegetable broth and boil until soft, about 15 minutes. Or, place 1 part quinoa to 2 parts water in your rice cooker.

Quinoa Fruit Salad Ingredients

Directions

¾ cup plain nonfat Greek yogurt 2 tablespoons lime juice 1-10 fresh mint leaves, minced 2 cups cooked quinoa 1 cup blueberries 1 cup grapes, halved ½ cup raspberries ½ cup strawberries, sliced into quarters 1 teaspoon agave syrup

1. Combine the yogurt, 1 tablespoon of lime juice and mint together. Pour over the cooked quinoa and mix well. Add salt and pepper to taste. 2. In another bowl, combine fruit, agave syrup and 1 tablespoon lime juice. 3. Refrigerate for 2 hours. Combine the bowls together and serve.

32| JULY 2012

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features

OIG to Send CMS Names of 1,700 Docs who Overbilled High-Level E/M Codes Frequency of reporting 99214 and 99215 increased 17 percent over 9-year period. By Suzanne Leder, BA, M.Phil., CPC, COBGC, certified ICD-10 trainer and Torrey Kim, MA, CPC, CGSC, editorin-chief of Part B Insider

f you examine your practice’s evaluation/management (E/M) trend line, does your frequency of reporting high-level E/M codes increase dramatically over the years? If so, you should determine the reasons why, before your Medicare administrative contractor (MAC) begins forcing you to make that determination. A recent Office of Inspector General (OIG) study found that physicians increased their billing of higher-level E/M codes across all categories (inpatient, outpatient, etc.) between 2001 and 2010. In fact, the OIG sent Center for Medicare and Medicaid Services (CMS) a list of 1,700 physicians who were identified as "consistently billing higherlevel E/M codes in 2010." The report results were summarized as follows

34| JULY 2012

‘‘

by the OIG in its report, "Coding Trends of Medicare Evaluation and Management Services," which was published on May 9. Outpatient: For outpatient services, the report noted that a shift was seen "in billing from the three lower-level E/M codes to the two higher-level codes. Combined, physicians increased their billing of the two highest-level E/M codes (99214 and 99215) by 17 percent" over the study period. Inpatient: When it came to hospital visits, the OIG noted that

"Among the physicians who consistently billed the two highest-level E/M codes were internal medicine, family practice, emergency medicine, nurse practitioners, obgyns and cardiologists."

ten were hematologists, cardiac and thoracic surgeons, surgical oncologists, pain management physicians, intensivists, hand surgeons, and allergists, among others.

High-Level Codes Don’t Necessarily Equal Fraud

billing the lowest code (99231) decreased 16 percent, whereas billing 99232 increased 6 percent and 99233 increased by nine percent. Emergency: The shift was even more pronounced among emergency department visits, the report stated. During the study period, physicians decreased how often they billed the four lowest codes (99281-99284), but increased billing the highest code (99285) by a startling 21 percent.

These Specialties did the Most Damage According to the OIG report, certain specialties seemed to report more high-level codes than others. Among the physicians who consistently billed the two highest-level E/M codes were internal medicine, family practice, emergency medicine, nurse practitioners, ob-gyns and cardiologists. Specialties who billed the two highest-level E/M codes the least of-

Many reasons exist that could cause a practice to legitimately begin coding more high-level E/M services than in the past. For instance, the practice may have begun seeing a more complex patient population who have more chronic problems that require intense management. Or the practice may have been audited and discovered the physicians were downcoding claims, so now the physicians are correctly coding based on the documentation, which warrants more 99214s and 99215s. If you fit into one of the legitimate billing categories such as these, you shouldn’t fret the new OIG study. If, however, you aren’t sure how your physicians arrive at their E/M codes, it’s time to offer a quick education session at your practice. The OIG recommends coding education as the number one priority following the results of this report, and also encouraged MACs to review physicians’ E/M billing patterns to avoid improper payments. "CMS should conduct additional reviews of physicians who consistently bill higher level E/M codes to ensure that their claims are appropriate," the OIG recommends. (To read the complete report, visit http://oig.hhs.gov/oei/reports/oei04-10-00180.pdf ) continued on page 36 MEDMONTHLY.COM |35

continued from page 35

Your Top 3 Hospital E/M Billing Questions Answered Can you navigate the intricacies of inpatient E/M services? Check these expert solutions. You may be able to select outpatient E/M codes (99201-99215) with your eyes closed, but inpatient E/M coding can be more tricky. With the OIG scrutinizing E/M billing like never before, you should consider these commonly asked questions to get the lowdown on how to report your hospital services.

Physician Presence may Dictate Code Question: Our physician saw a patient in the office, and then admitted her to the hospital later the same day. Can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay? Answer: The answer depends on whether the physician sees the patient on the same day in the hospital. Scenario 1: If the physician sees the patient in the hospital on the same day he saw her in the office, you’re looking at two face-to-face visits on the same date. Report only the appropriate initial hospital care code (99221-99223, initial hospital care, per day, for the evaluation and management of a patient…). According to current procedural terminology (CPT) coding guidelines, all initial hospital care services that begin in another place of location (such as the physician’s office) should be combined and coded using the appropriate level of initial hospital care. Since the 99221-99223 code will include the E/M provided in

Eight Hours may be the Magic Number for Same-Day Admit, Discharge

the office, you’ll report an initial hospital care code that includes the work done in both sites of service; this may lead to coding a higher level of initial hospital care than if you were considering the hospital services alone. Scenario 2: If, however, the physician does not see the patient in the hospital until the next day, bill each encounter separately. Choose the appropriate office visit code (99201-99205, office or other outpatient visit for the evaluation and management of a new patient …) or 99212-99215(office or other outpatient visit for the evaluation and management of an established patient …) for the office visit on day one. Then add an initial hospital care code from 99221-99223 for day two, when the physician sees the patient in the hospital for the first time. Remember that CPT uses initial hospital care codes to describe the first hospital inpatient encounter by the admitting physician. After that, you’ll report subsequent hospital care codes, 99231-99233 (subsequent hospital care, per day, for the evaluation and management of a patient…), until the date of discharge. When the physician discharges the patient, you’ll submit the appropriate hospital discharge day code, 99238 or 99239.

Answer: The answer to your question depends on several factors. First, you must determine whether the patient was admitted to inpatient status or to observation. That will help you at least review the appropriate code range. It appears that Question: Our general surgeon one of your physicians wants to bill admitted a patient to the hospital at 10:30 a.m., and later that day another an inpatient code (99223) whereas the other wants to bill a code from general surgeon from our group discharged the patient (at 3:30 p.m.). the observation range (99217). The admitting physician wants to bill Therefore, it looks like even the physicians didn’t clearly understand a 99223 and the discharge physician wants to bill a 99217. Which code(s) whether the patient was in the observation unit or inpatient. should each physician report?

36 | JULY 2012

If you bill from the wrong section, it will impact you from not only a correct coding standpoint, but also possibly from a compliance standpoint, since initial inpatient codes reimburse approximately 3.5 percent more than initial observation codes. If you find that the patient was in observation care, the second issue you must consider is the amount of time that the patient spent in the hospital (five hours). When coding this case, your eyes may go to the 99234-99236 (observation or inpatient hospital care, including ad-

Document Full Inpatient E/M Question: Our physician’s documentation did not meet the minimum requirements for an initial hospital visit (99221-99223). Therefore, can we bill a subsequent visit (99231-99233)? Answer: The answer depends on whether your physician was the admitting physician of record, or whether he simply provided a consultation during the patient’s hospital stay. Typically, the admitting physician cannot report a subsequent care code for his first visit with the patient. If your physician admitted the patient to the hospital and did not document enough for even the lowest-level initial hospital care code (99221), you should offer him pointers from an educational standpoint on how to appropriately code for this service. If he can’t bill anything for his initial visit, you’ve written off about $100 in potential reimbursement (which you could have collected if he’d documented enough for 99221). However, if another physician admitted the patient to the hospital and called your physician to provide a consult on the patient’s condition, you can report a subsequent hospital care code for your consultant’s services. Why: CMS changed the requirements for who can bill a subsequent hospital care code after Medicare stopped recognizing consult codes for payment in 2010. According to Transmittal 2282, dated August 26, 2011, In black and white: "Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241-99255) prior to Jan.1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay," the transmittal reads. It further notes, "Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay." Because the transmittal referenced above was written to explain how to code in the absence of consult codes, you should apply this rule to your physician’s consultation services and not to the rules guiding the admitting physician of record.

mission and discharge on the same date), but you should avoid this section. Why? Medicare requires the patient to be in observation care for a minimum of eight hours to justify reporting this code. In black and white: According to CMS Transmittal 1466, dated Feb. 22, 2008, "When a patient is admitted to observation status for less than eight hours on the same calendar date, the physician shall report a code from CPT code range 99218-99220." Therefore, if it’s an observation

patient, you should report a code from the 99218-99220 series. Important: No matter what code you select, you should only report one code to represent both physicians’ time with the patient, since they both work for your group and are the same specialty. In black and white: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician," CMS says in Section 30.6.5 of the Medicare Claims Processing Manual. "If more than

one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level."  MEDMONTHLY.COM |37

features

Physician Stress and Burnout: Learning to Take Care of Yourself By Alan Rosenstein, MD, MBA

n late 2011, Physician Wellness Services and Cejka Search released the results of the Physician Stress and Burnout Survey, reflecting a nationwide, multi-specialty response from over 2,000 physicians. Asking questions related to the prevalence, causes and effects of stress and burnout, the findings showed: • Almost 87 percent of all respondents identified themselves as moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, with 37.7 percent specifying severe stress and/or burnout. • Almost 63 percent of respondents said they were more stressed and/or burned out than three years ago, using a 5-point Likert scale, compared with just 37.1 percent who reported feeling the same level of stress or less over that period. The largest number of respondents (34.3 percent) identified themselves as “much more stressed” than they were three years ago. • When asked if their organizations did anything to help them deal more effectively with stress and burnout, only 15.7 percent said yes. The findings were a wake-up call for organizations and physicians, alike, about the importance of getting serious about addressing stress and burnout. Respondents, overall, noted many things that they felt would help them better deal with stress and burnout, which fell into these three major areas: 1. Greater flexibility and control over their working hours to mitigate burnout and stress. 2. More opportunities for and assistance with taking better care of them-

selves, and to understand and practice better self-care. 3. Support on multiple levels in dealing with stress and burnout in their lives.

Starting With Your Work and Practice Depending on your practice setting and other work-related circumstances, you may have varying degrees of control over your time and how you spend it—so, the goal of achieving greater flexibility and control over your working hours may need to be approached incrementally. In some areas, you’ll need support from your organization. In other cases, your biggest problem may be yourself, as you strive to balance providing good care and service with regaining control over your own work responsibilities and schedule. Here are some tactics that can help alleviate some of the stress and burnout associated with your work. The first step is to better understand what you actually want and need before you work to change things in your professional life: • Accept that time and age change a person, their personal goals, their pri-

orities and their bedside manner. Take time to examine what is important to you now—and how that might have changed from earlier in your career. Use this knowledge to frame the things that are important to you, as a physician and an individual, on a day to day basis so you can work to incorporate that in your work. • Perfectionism is a well-known trait in physicians, and especially surgeons. Striving for perfection is admirable but it can cause a great deal of stress. Is perfection necessary in everything you do? In what areas can you afford to be more flexible? • Related to this, how much of your stress is selfimposed vs. related to external factors? Understand who you need to ask for permission to change—yourself or your organization. Once you better understand your needs, as well as the factors in your environment that cause the most stress, start to look at specific tactics where you can free up or rearrange time for other priorities and needs. First, look at help that your organization can possibly provide: • Scheduling and time management—are there ways to utilize your time more efficiently? This might involve such things as setting aside

87% The amount of physicians and residents who consider themselves as moderately to severly stressed or burned out on an average day.

continued on page 40

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continued from page 39

specific blocks of time for the things you need to do, whether it’s surgeries, paperwork and charting, following up with patients, or other responsibilities. If you travel between locations, are there ways to optimize that time and minimize the time spent en route? • Are there non-critical or lowerpriority tasks that can be done by or shared with others? This may involve administrative help or moving work to ancillary staff, such as some of your paperwork, charting, and some patient-related appointments or communications. Ask yourself and your

administrators what is the best use of your time and where you can provide the most value. • How can you carve out specific break times that are respected and protected? As noted below, everyone needs time to refresh and reflect—and struggling to find and maintain that time can create more stress. • If issues with staff or colleagues are resulting in conflict or other work issues (e.g., operational or process issues, policies, resource allocation, etc.) that contribute to a stressful environment, how can they be resolved in an

effective and timely manner? Who in your organization is responsible for facilitating discussions and implementing solutions? Is there a way to provide input in a manner that is professional and receive feedback on results? These same principles apply even in smaller practices—or may be things you can address on your own. If collegial communications or cooperation are a problem, sometimes bringing in an outside facilitator or coach can help in identifying both issues and solutions.

Avenues to Obtaining Support • Get tips, support and suggestions from others in similar situations. By speaking openly with them, you can gain insight and perspective, as well as suggestions for coping. • Even if you aren’t having issues at home—but especially if you are—it can be valuable for you and your spouse or partner to sit down and have frank discussion and negotiation over household roles and responsibilities, which can be a big contributor to conflict. Similarly, discussions about parenting, childcare and eldercare issues, etc. can also be very helpful. • Where there is conflict, or potential for conflict, engage in crucial conversations—at home and at work—after thinking them through. • Consider the use of resources such as an employment assistance program (EAP), a physician coach, family and marital counseling, or individual counseling to promote mental and emotional health, and get help working on areas common to physicians such as: o Reflecting on your priorities and values at home and work o Self acceptance, trust and tolerance of others—and trying to be selective with controlling or perfectionist thinking o Giving people the benefit of the doubt, avoiding jumping to conclusions—and working on trust and identifying obstacles to it o Being more open to reasonable feedback—and seeing when you may be the problem o Acknowledging losses and giving yourself permission to grieve o Acknowledging and dealing with guilt feelings related to patient and care issues, relationships at work or home, or other parts of your life where you feel you have been deficient in some way. 40| JULY 2012

Taking Better Care of Yourself There are no mysteries surrounding self-care, which encompasses such things as: • Adequate, good quality sleep • Good, nutritious food • Exercise and physical fitness • Relaxation—physical and mental • Mental and emotional health • Intellectual stimulation and engagement.

‘‘

Similarly, take a look at the time you spend outside of work and go through some of the same evaluation process. Can you be more efficient with your time? Are there tasks or responsibilities that you can have someone else do or help with? What do you do now that really doesn’t provide value or enjoyment? You might be surprised at how you can re-allocate your time. But, don’t make this about creating another project on your to-do list that creates more stress. Remember that with self-care, you might have to start small and approach this incrementally, and that sometimes it’s okay to do nothing that appears to have redeeming value. Reading a novel or occasionally surfing the web can provide the kind of mental break you may need. More than anything, think of setting limits and boundaries on your time as a survival skill with long-term benefits. Specific things to consider that promote good self-care include: • Enroll in a yoga, Pilates or Mindfulness Meditation class, or other groups/activities that distract from or alleviate the stress of life for a time. • Take time to reflect on the positive parts of your life. Doing this prior to bedtime will assist with a good night’s sleep. • Read fiction, journal or meditate. Engaging in these activities before bedtime will also assist with sleep. • Identify more ways to integrate

""Don’t make this about creating another project on your to-do list that creates more stress... Sometimes it’s okay to do nothing that appears to have redeeming value.""

One of the biggest barriers for physicians to practice good self-care is time, between the demands of work and non-work responsibilities and relationships such as volunteer and community activities, family and friends, and the demands of daily living. So, how do you find the time? As previously noted, carving out time in the work day is a good first step. And, making that time matter more goes hand in hand. Some elements of self-care can be synergistic, such as the way exercise can also help “clear the cobwebs” and allow a mental break, as well. Or, sometimes activities that promote intellectual stimulation, such as reading an interesting professional paper, can be relaxing, too.

exercise into daily life—it’s the cheapest anti-depressant. • Go for a 10-minute walk outside the office—it can re-energize you and clear your mind. • Purchase exercise equipment for your home so it’s easier to use and access. • Get a “work out” or “running” or activity partner. • Improve nutrition practices: o Sit down to breakfast. o Take a lunch break. o Bring healthy snacks to work. o Have family dinners when ever possible.

Getting the Support You Need Nobody can do it all—and nobody has complete control over their lives. As noted earlier, physicians need support to address the things in their lives that contribute to stress and burnout. This is over and above some of the steps outlined above—this is about setting up a framework around your life that supports what you do and need to do to stay healthy. Make a commitment to yourself to take some time to develop an action plan for making your work and your life more manageable, and please consider using some of the suggestions offered in this article. You’ll have to make time for this activity, waiting until you have a free moment means never getting it done. You might want to start small, and review and build on your plan as time goes by. You’ll be surprised at how much control you really have to make important, meaningful changes to your stress level and overall satisfaction in life.  MEDMONTHLY.COM |41

features

The Evolution of In

temming its origins from the 17th century, internal medicine began when Thomas Sydenham’s concept of disease birthed the scientific discipline. After observing patients with telltale symptoms of what we now understand to be varying diseases, Sydenham first conceived the notion that these “humors” were more than an imbalance of general illness. After Sydenham created the framework for separation and allocation of diseases, Francois Boissier de Sauvages published the first methodical description of diseases, pronouncing the importance of disease

42 | JULY 2012

identification through symptom. Throughout the next several centuries, internists experimented with countless methods of actually treating these now classified diseases with little success. What now seem like primitive practices such as bloodletting and kitchen-table surgeries were the foundation of an internist’s clinical arsenal and the measure of their skill was based upon the reliability of their advice on the probable outcome instead of deductive, scientific reasoning. Even though their methods of healing and diagnosis would be considered today as backward and even crude, internists

were always at the forefront of scientific and medical discovery, applying their knowledge to treat their patients with the best of intentions. However, the turn of the 20th century brought a beacon of light to internal medicine – a physical cure to the diagnosis that was reached by deductive reason instead of hopeful speculation. Rooting in the Association of American Physicians (AAP), founded in 1885 by an elite group of physicians, internal medicine was formed under the pretense of clinical research and development, private practice, scientific experimentation and the desire to

nternal Medicine A retrospective investigation of how the fundamental ideals of medicine’s oldest and most time-honored specialty may restore the nation’s healthcare system. By Bethany Houston and Leigh Ann Simpson

build trustworthy relationships with patients. The first mention of the term “internal medicine” was coined by Dr. William Osler, president of the AAP in 1895 when he conducted the tenth anniversary meeting. "The time has come when able young men should be encouraged to devote themselves to internal medicine as a specialty. Content to labor and wait during the first 10 or 15 years of professional life, with pathology as the solid basis of development, such men will pass to the wards through the laboratories thoroughly equipped to

study the many problems of internal medicine… The opportunity for such a career is in every city with a hospital of 50 beds (Fordtran, MD, Armstrong, MD, Emmett, MD, Kitchens, Jr., MD & Merrick, MD, 2004).” Osler sparked the ideal of the “consultant-generalist” that, even through its evolution, remains a core belief among internists today. “The consult-generalist has been the naturalist of disease, concretely familiar with its protean manifestations and able to understand it in terms of physiological disturbance and, especially, pathology manifestations as

seen at autopsy. Such knowledge made for accurate diagnosis and prognosis, the good physician’s trademark skill. Osler’s clinical knowledge and skill at diagnosis had brought him into great demand as a consultant, as he could shed light on cases that left his colleagues confused. His sparkling personality and deep interest in the humanities rounded out the picture of the wise and humane consultantgeneralists physician, which he exemplified and which became the ideal of American internal medicine just as internal medicine began to split apart continued on page 44 MEDMONTHLY.COM |43

continued from page 43 into subspecialties.” (Huddle, MD, PhD, Centor, MD, Heudebert, MD, 2003).

The Great Divide During the early 20th century there was a separation within the specialty of internal medicine between the practicing internists and the academic leaders of the day. Modern medicine had been established by the 1920s and with it brought a shift in ideals towards the application of laboratory findings to advance their knowledge of clinical problems. It is during this time that the subspecialties of internal medicine begin to form while general internists, most still adhering to their faithful consultant-generalist values, were still the dominant force among practicing physicians. The American College of Physicians (ACP) was established in 1915 and helped internal medicine gain notoriety as it increasingly began to focus on science, clinical research and teaching. By the 1930s the new subspecialties of internal medicine were becoming more prevalent and started to form certified boards to solidify their specialty as legitimate. The ACP responded by forming the American Board of Internal Medicine (ABIM). “The purpose of this board was to establish more definite criteria for the title of specialist in internal medicine, so that the public would know whom to trust (Fordtran, MD, Armstrong, MD, Emmett, MD, Kitchens, Jr., MD & Merrick, MD, 2004).” The formation of the ABIM positioned internal 44 | JULY 2012

medicine as the authority among the subspecialties, setting the stage for the course of medicine for the next several decades. “Internal medicine might not have

"That family

practice rather than internal medicine assumed the mantle of primary given up by the traditional general practitioner was a reflection of the internists’ innate calling: clinical science and research."

kept its specialties had not the College ensured their retention in what was becoming internal medicine’s big tent by planning to issue subspecialty certificates when the American Board of Internal Medicine was set up in 1936. That plan ensured that postgraduate training in internal medicine would

take on the now familiar pattern of generalist internal medicine residency, followed by generalist practice or further training leading to subspecialization. (Huddle, MD, PhD, Centor, MD, Heudebert, MD, 2003).” Internal medicine flourished during the 1940s and 1950s, especially in its research and residency training. Most practicing internists during this era were able to share findings from their research in subspecialties with residents and still were able to provide clinical care to patients. The understanding of the complexities in the new subspecialties became highly regarded in training programs; however, the application of this knowledge became increasingly difficult in clinical practice. “Practicing internists might serve as consultants to general practitioners (GPs) on complex medical problems; but GPs were a shrinking proportion of the profession and as internists specialized, the GP became more likely to refer problematic patients to subspecialists than to general internists. Thus, the general internist was forced either to subspecialize or to do an increasing portion of primary care. By mid-century the consultant-generalist ideal was strong in academic training programs but weakened outside of them. (Huddle, MD, PhD, Centor, MD, Heudebert, MD, 2003).” As discoveries in subspecialties continued to captivate residents and academia, it also began to attract attention from the U.S. government. During the 1950s and 1960s there was a postwar boom of federal funding towards medical research causing departments of medicine nationwide to explode in size exponentially, especially in the specific

Core Values of General Internal Medicine Expertise in adult patient care subspecialties of internal medicine. This later caused clinical departments to organize residency programs by subspecialty, further encouraging the tendency of subspecialization. “As such, science was increasingly organized by subspecialty, and it was natural that clinical practice would follow suit. Thus, general internists became a shrinking proportion of internal medicine faculty, and their scope for clinical activity shrank as general medicine wards gave way to wards organized by specialty, led by cardiology and hematology-oncology. Consultant-generalism was in decline in departments of medicine by the early 1970s, and general internists were step-children in departments of medicine organized by subspecialty and led by specialists (Huddle, MD, PhD, Centor, MD, Heudebert, MD, 2003).” These developments are what lead to the origination of the family practitioner. That family practice rather than internal medicine assumed the mantle of primary given up by the traditional general practitioner was a reflection of the internists’ innate calling: clinical science and research. In the 1970s there was a tremendous push from the federal government to increase primary care training among internists, incentivizing residents with education grants. Thus primary care became more common among practicing general internists. Many internists enjoyed providing primary care as it allowed them to foster lasting relationships with their patients, treating them not only for their routine and preventative care but also their complex conditions. This contentment among intercontinued on page 46

Acquiring and sharing knowledge • • • • • • • • • • • • • • • • • • • •

Providing patient-centered, comprehensive, longitudinal care Treating complex and chronic illnesses Coordinating care in health systems Commitment to quality outcomes Commitment to preventive care Expertise in geriatric medicine Evidence-based practice of disease prevention and health promotion Using outstanding communication skills Establishing personal, ongoing doctor–patient relationships Cultural sensitivity and competency Breadth and depth of knowledge Practice of evidence (science)-based medicine Intellectual rigor Information management Education Commitment to lifelong learning Educating patients, other professionals, and trainees Adaptability New knowledge New diseases, treatments, technology, information technology, cultural diversity, and communications

Leadership • •

Understanding context Commitment to quality, quality improvement, and public good

Professionalism • • • • • • • •

Altruism Accountability Accessibility Commitment to excellence Duty and service Honor and integrity Respect for others Equity

(Larson, MD, MPH, Fihn, MD, MPH, Kirk, MD, Levin, MD, Loge, MD, Eileen Reynolds, MD, Sandy, MD, MBA, Schroeder, MD, Wender, MD, MPH, and Williams, MD, 2004)

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continued from page 45 nist, and the majority of primary care physicians, lasted until the late 1990s; however in recent years there has been an unfortunate increase in their dissatisfaction. “Practitioners remain committed to providing high-quality primary medical and hospital care and ongoing personal relationships with patients across a broad age group, especially

46 | JULY 2012

among the growing number of seniors, chronically ill adults, and people with multiple diseases. However, many practitioners struggle with low reimbursement, increasing administrative burdens, and demands for brief (5-minute) visits that frustrate doctors and patients. Declining application rates to U.S. medical schools show medicine is less attractive and, especially family medicine, are discouraged by the fields’ uncertain financial status – turning instead to ancillary specialties such as anesthesiology, pathology, radiology, and higher paying specialties like orthopedics, ophthalmology, cardiology, and gastroenterology. (Larson, MD, MPH, Fihn, MD, MPH, Kirk, MD, Levin, MD, Loge, MD, Eileen Reynolds, MD, Sandy, MD, MBA, Schroeder, MD, Wender, MD, MPH, and Williams, MD, 2004).” Many internists have taken action to elevate their dissatisfaction and ensure their financial stability. Concierge practices are becoming increasingly popular in the U.S. because the

model guarantees payment and enhances the patient-doctor relationship. Some internists have responded to the chaos in today’s healthcare system by learning new cash-based procedures that can be performed in an officebased setting to increase their revenue. All across the country physicians are investing in CME to obtain certificates in an array of procedures ranging from pain management treatments to Botox. Some general internists (and specialists) have even stopped taking new Medicare patients to eliminate the financial burden of decreasing reimbursement rates. These proactive measures have eased some of the financial strain on today’s practicing general internists, however their success is not enough to entice the next generation of residents to specialize in general internal medicine. At present, general internal medicine falls significantly behind among residency specialization choices compared to its subspecialties.

Hope for the Future Although the current statistics appear bleak, there is hope and a growing sense of optimism for the future of general internal medicine. Numerous studies are being conducted with the purpose of redesigning care delivery and reimbursement models in order to provide quality healthcare that is efficient and cost-effective, and affordable to patients. Many of these studies suggest that the traditional consultantgeneralist could once again become a role that is in high demand because of their knowledge of all specialties and understanding of complex and chronic

conditions. “General internal medicine is now an essential service, and may in time be the main vehicle of delivery of healthcare to an aging population, since resources are finite. One model for an equitable system of healthcare

“Instead of providing parallel, often uncoordinated services, all those involved in caring for a patient will seamlessly coordinate for optimal quality and efficiency."

delivery may be the integration of general internal medicine as the core matrix, around which the various subspecialties deliver quality care. This is now a reality in many hospitals, where all subspecialists serve for varying periods in general medical wards, some even achieving dual accreditation (Pinhero,

MBBS, MRCP, FAMS, 2009).” The future of general internal medicine will remain in primary and principle care of adults. However, due to their vital role in caring for the increasing number of elderly Americans, internal medicine will be dominated by the treatment of chronic disease; heart disease, diabetes, etc. Many of these progressive care delivery models place internists as leaders who advise groups of healthcare professionals, coordinating care based on patients’ specific treatment plans. These teams would consist of doctors, nurses, pharmacists, physical therapists and would be headed by general internists. The internists would consult with specialists and communicate directly with each member of the team to improve the coordination of care for individual patients, therefore improving patient outcomes and satisfaction. This movement to force a paradigm shift towards team-oriented care seems to be an increasingly popular solution. “Instead of providing parallel, often uncoordinated services, all those involved in caring for a patient will seamlessly coordinate for optimal quality and efficiency. As experts in chronic illness, general internists are well-suited to communicate effectively with specialists and to integrate their recommendations into an individual plan of care. (Larson, MD, MPH, Fihn, MD, MPH, Kirk, MD, Levin, MD, Loge, MD, Eileen Reynolds, MD, Sandy, MD, MBA, Schroeder, MD, Wender, MD, MPH, and Williams, MD, 2004).” These new healthcare delivery models suggest an interesting revival of the forgotten ideals of the consultantgeneralist that internal medicine, and

its subspecialties, were founded upon. “The pendulum has swung and it may now be essential to promote general internal medicine as the main vehicle of delivery of healthcare services to an ageing population, while still encouraging the development of the other subspecialties. (Pinhero, MBBS, MRCP, FAMS, 2009).” Going back to the original principles of early internists may be bring the U.S. healthcare system full-circle, delivering care that is rewarding to both patients and physicians.

Cited Works Fordtran, MD, J. S., Armstrong, MD, W. M., Emmett, MD, M., Kitchens, Jr., MD, L. W., & Merrick, MD, B. A. (2004). The history of internal medicine at baylor university medical center, part 1. Proc (Bayl Univ Med Cent)., 17(1), 9–22. Huddle, MD, PhD, T., Centor, MD, R., & Heudebert, MD, G. (2003). American internal medicine in the 21st century. J Gen Intern Med., 18(9), 764–767. Larson, MD, MPH, Fihn, MD, MPH, Kirk, MD, Levin, MD, Loge, MD, Eileen Reynolds, MD, Sandy, MD, MBA, Schroeder, MD, Wender, MD, MPH, and Williams, MD, (2004). The Future of General Internal Medicine. J Gen Intern Med., 19(1), 69-77. Pinhero, MBBS, MRCP, FAMS, (2009). Right-sitting of medical care: Role of the internist. Annals Academy of Medicine., 38(2), 163-5.  MEDMONTHLY.COM |47

the arts

Creative Compassion Healing children with colorful imagination By Leigh Ann Simpson

artin Fried, MD, is a gentle spirit who posses many talents both as an artist and as a physician. In addition to his impressive career as a pediatric gastroenterologist and board certified physician nutrition specialist, he has also been creating abstract art since 2005. And, according to his patients, his heart has as much depth and breadth as his intellect. For over the past 30 years Fried has made groundbreaking scientific discoveries in pediatric gastrointestinal infectious disease and has been an advocate for children and the advancement of his specialties. He founded and served as the director of the Division of Pediatric Gastroenterology and Nutrituion at the Jersey Shore Medical Center where he has been able to improve the lives of thousands of children with the same abstract thinking that he utilizes in his art. “When I first started at Jersey Shore Medical Center in November of 1992, and for the enduring 13 years, I was involved in caring for patients with Lyme disease and gastrointestinal symptoms,” Fried says. “Using the same creativity I use in art, 48 | JULY 2012

I became the first physician to confirm (with published research) that Lyme occurs in the Gastrointestinal.” Fried investigated this new area of knowledge and published five papers related to tick borne diseases including Lyme, Bartonella and Mycoplasma infections. Many of Fried’s patients claim that he has a rare sense of compassion for children and an extraordinary ability to connect with them on a personal level to correctly diagnose even the most complex illnesses. Most of his patients attribute his uncanny level of skill in diagnosis to his understanding of how important it is for a physician to be a good listener. Fried’s empathetic ear has allowed him to diagnose his patients’ complaints from the symptoms they describe with minimally invasive procedures. “As a result of being a good listener, I am often able to diagnose conditions such as Lyme disease which may have a negative lab testing in light of serious symptoms,” he says. “I also am able to begin treatment and not wait for a positive lab test because I listened and believed what the patient was telling me and didn’t need a test to confirm what they said.”

In the fast-passed world of medicine today many patients, especially children, are confused and often scared of their diagnosis, or lack of one. Fried understands the importance of relating personally with a child to help them overcome their illness. Hundreds of patients have provided personal testimony that Fried’s genuine presence and understanding played a large part in the success of their treatment. Fried credits much of his ability to truly connect with children to his long time mentor, Marcella Vitulli. Vitulli was the principal of an elementary school in Yonkers, New York where Fried volunteered long before he went into medical school. “From the moment I met her, I admired her ability to talk to children,” Fried recalls. “In my third year of medical school, I decided to become a pediatrician because of her role model. I felt helping children who have the rest of their life to benefit from my positive intervention was the best gift I could give to medicine.” Throughout his career, Fried has also published research papers on nutrition in Cystic Fibrosis, feeding handicapped children and the energy requirements of handicapped children. He continues to go above and beyond for the sake of pediatric health as an avid voice in the fight against childhood obesity. He frequently gives presentations at the local YMCA and other community events on the importance of healthy eating habits. “My devotion and dedication to my patients comes from an honest and sincere caring for them and their improved health,” Fried says. “I would do whatever it takes to see that they have healthier days.” Fried’s art is just another facet of his tremendous contribution to society. “My art is abstract and meant to be interpreted by the person looking at it in a favorable light. It is meant to enhance their life,” he says. “I believe there is a piece of artwork out there for everyone, it is up to the individual person.” Recently Fried has started to experiment with mixed media combining oil pastels, chalk pastels, and acrylic paintings in his creations. Many of Fried’s paintings can be found on display at his private practice in Ocean, New Jersey. In addition, Fried has displayed his art at the annual Jersey Shore Medical Center Photo and Art Exhibit for numerous years and several galleries in Asbury Park, N.J. have featured him as a new and emerging artist. To find out more about Dr. Martin Fried and his art please visit: www.martindfried.com 

Martin Fried has been using oil and chalk pastel, acrylic and water color to express his creative, genteel perspective for over 7 years.

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SOMETIMES, THE GAME THEY LOVE DOESN’T LOVE THEM BACK. More and more, young athletes are focusing on a single sport and training for that sport year-round — a practice that’s led to an increase in Overuse Injuries. Left untreated, overuse trauma to young shoulders, elbows, knees and wrists may require surgery and have lifelong consequences. For information on preventing and treating Overuse Injuries, visit these sites: orthoinfo.org

stopsportsinjuries.org

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://1.usa.gov/xMFQAK

Rhode Island 3 Capitol Hill, Rm 104 Providence, RI 02908 (401)222-7883 www.health.state.ri.us

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

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

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

Tennessee Heritage Place Metro Center 227 French Landing, Ste. 300 Nashville, TN 37243 (615)253-6061 www2.state.tn.us/health

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 www.dph.state.ct.us Connecticut 410 Capitol Ave., MS #12APP P.O. Box 340308 Hartford, CT 06134 (860)509-7603 ext. 4 http://www.dph.state.ct.us/

New Hampshire 129 Pleasant St. Concord, NH 03301 (603)271-5590 www.state.nh.us New Jersey P.O. Box 45011 Newark, NJ 07101 (973)504-6435 http://bit.ly/wLM20Y

Florida 4052 Bald Cypress Way, Bin C08 Tallahassee, FL 32399 (850)245-4474 doh.state.fl.us

New York 89 Washington Ave., 2nd Floor W. Albany, NY 12234 (518)402-5944 opunit3@mail.nysed.gov

Georgia 237 Coliseum Dr. Macon, GA 31217 (478)207-1671 www.sos.state.ga.us

North Carolina P.O. Box 25336 Raleigh, NC 27611 (919)733-9321 http://www.ncoptometry.org/

Hawaii P.O. Box 3469 Honolulu, HI 96801 (808)586-2704 optician@dcca.hawaii.gov

Ohio 77 S. High St. Columbus, OH 43266 (614)466-9707 http://optical.ohio.gov/

Texas P.O. Box 149347 Austin, TX 78714 (512)834-6661 www.roatx.org Vermont National Life Bldg N FL. 2 Montpelier, VT 05620 (802)828-2191 www.vtprofessionals.org 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 www.doh.wa.gov

MEDMONTHLY.COM |51

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 52 | JULY 2012

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 www.mass.gov Michigan P.O. Box 30664 Lansing, MI 48909 (517)241-2650 www.michigan.gov 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://mt.gov/ Nebraska 301 Centennial Mall South Lincoln, NE 68509 (402)471-3121 http://bit.ly/uBEqwK

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/

Utah 160 E. 300 South Salt Lake City, UT 84111 (801)530-6628 http://1.usa.gov/xMVXWm

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

Vermont National Life Building North FL2 Montpelier, VT 05620 (802)828-1505 http://bit.ly/zSHgpa

New Mexico Toney Anaya Building 2550 Cerrillos Rd. Santa Fe, NM 87505 (505)476-4680 http://bit.ly/vCnCP4

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

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/

Virginia Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4538 http://bit.ly/zDkIU2 Washington 310 Israel Rd. SE P.O. Box 47865 Olympia, WA 98504 (360)236-4700 http://1.usa.gov/tKBFHT 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://bit.ly/sEhr0Q Wyoming 1800 Carey Ave., 4th Floor Cheyenne, WY 82002 (307)777-6529 http://plboards.state.wy.us/dental/index.asp

MEDMONTHLY.COM |53

U.S. MEDICAL BOARDS Alabama P.O. Box 946 Montgomery, AL 36101 (334)242-4116 http://www.albme.org/

Florida 2585 Merchants Row Blvd. Tallahassee, FL 32399 (850)245-4444 http://www.doh.state.fl.us/

Alaska 550 West 7th Ave., Suite 1500 Anchorage, AK 99501 (907)269-8163 http://bit.ly/zZ455T

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

Arizona 9545 E. Doubletree Ranch Rd. Scottsdale, AZ 85258 (480)551-2700 http://www.azmd.gov

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

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

54 | JULY 2012

Idaho Idaho Board of Medicine P.O. Box 83720 Boise, Idaho 83720 (208)327-7000 http://bit.ly/orPmFU Illinois 320 West Washington St. Springfield, IL 62786 (217)785 -0820 http://www.idfpr.com/ 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

Louisiana LSBME P.O. Box 30250 New Orleans, LA 70190 (504)568-6820 http://www.lsbme.la.gov/ Maine 161 Capitol Street 137 State House Station Augusta, ME 04333 (207)287-3601 http://bit.ly/hnrzp Maryland 4201 Patterson Ave. Baltimore, MD 21215 (410)764-4777 http://www.mbp.state.md.us/ Massachusetts 200 Harvard Mill Sq., Suite 330 Wakefield, MA 01880 (781)876-8200 http://www.mass.gov Michigan Bureau of Health Professions P.O. Box 30670 Lansing, MI 48909 (517)335-0918 http://www.michigan.gov/lara 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/

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/

Nebraska Nebraska Department of Health and Human Services P.O. Box 95026 Lincoln, NE 68509 (402)471-3121 http://www.hhs.state.ne.us/

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

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/

Oklahoma P.O. Box 18256 Oklahoma City, OK 73154 (405)962-1400 http://www.okmedicalboard.org/ Oregon 1500 SW 1st Ave., Suite 620 Portland, OR 97201 (971)673-2700 http://www.oregon.gov/OMB/ Pennsylvania P.O. Box 2649 Harrisburg, PA 17105 (717)787-8503 http://bit.ly/havKVj 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/

Texas P.O. Box 2018 Austin, TX 78768 (512)305-7010 http://bit.ly/rFyCEW Utah P.O. Box 146741 Salt Lake City, UT 84114 (801)530-6628 http://www.dopl.utah.gov/ Vermont P.O. Box 70 Burlington, VT 05402 (802)657-4220 http://1.usa.gov/wMdnxh Virginia Virginia Dept. of Health Professions Perimeter Center 9960 Maryland Dr., Suite 300 Henrico, VA 23233 (804)367-4400 http://1.usa.gov/xjfJXK Washington Public Health Systems Development Washington State Department of Health 101 Israel Rd. SE, MS 47890 Tumwater, WA 98501 (360)236-4085 http://www.doh.wa.gov/PHIP/default.htm 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/section. asp?linkid=6&locid=0 Wyoming 320 W. 25th St., Suite 200 Cheyenne, WY 82002 (307)778-7053 http://wyomedboard.state.wy.us/

MEDMONTHLY.COM |55

medical resource guide

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

ADVERTISING

Ajishra Technology Support

Sweans Technologies

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

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

Applied Medical Services

VIP Billing

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

Axiom Business Solutions 1-800-Urgent-Care

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

Find Urgent Care

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

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 56| JULY 2012

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

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

MedMedia9

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

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

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

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

CAREER CONSULTING SEAK Non-Clinical Careers Conference Oct. 21-22, 2012 in Chicago, IL (508)457-1111 www.nonclinicalcareers.com

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

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

COMPUTER, SOFTWARE

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

American Medical Software

Mediserv

CDWG

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

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

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

Practice Velocity

Instant Medical History

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

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

medical resource guide

CONSULTING SERVICES, PRACTICE MANAGEMENT Manage My Practice

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

myEMRchoice.com

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

The Dental Box Company, Inc.

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

Dentistry’s Business Secrets

9016 Phoenix Parkway O’Fallon, MO 63368 (636)561-5445 www.dentistrysbusinesssecrets.com

Modern Dental Marketing Practices

504 N. Oak St. #6 Roanoke, TX 76262 (940)395-5115 www.moderndentalmarketing.com

Urgent Care America

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

ELECTRONIC MED. RECORDS ABELSoft

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

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

Utilization Solutions

Acentec, Inc

Medical Credentialing

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

www.pushpa.biz

(800) 4-THRIVE

www.medicalcredentially.org

Synapse Medical Management

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

DENTAL Biomet 3i

AdvanceMD

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

INSURANCE, MED. LIABILITY

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

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

5814 Reed Rd. Fort Wayne, In 46835 (800)463-3776

CollaborateMD

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

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

DocuTAP

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

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

Dental Management Club

Integritas, Inc.

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

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

Aquesta Insurance Services, Inc.

Medical Practice Listings

service@pushpa.biz (919) 289-9126

FINANCIAL CONSULTANTS

MGIS, Inc.

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

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

MEDMONTHLY.COM |57

medical resource guide

LOCUM TENENS

MEDICAL EQUIPMENT ALLPRO Imaging

Physician Solutions

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

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

Biosite, Inc

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

MEDICAL ART Brian Allen www.artisanprinter.com Deborah Brenner 877 Island Ave #315 San Diego, CA 92101 (619)818-4714 www.deborahbrenner.com Martin Fried www.martindfriend.com

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

Marianne Mitchell (215)704-3188 http://www.mariannemitchell.com http://www.colordrop.blogspot.com Nicholas Down http://bit.ly/yHwxb0 Barry Hanshaw 18 Bay Path Drive Boylston MA 01505 508 - 869 - 6038 JHans76271@aol.com www.barryhanshaw.com

58| JULY 2012

www.biosite.com

www.piadegirolamo.com

MEDICAL RESEARCH Arup Laboratories

www.cryopen.com

Carolina Liquid Chemistries, Inc.

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

www.marthapetty.com

Eduardo Lapetina 318 North Estes Drive Chapel Hill, NC 27514 (919)960-3400 eduardolapetina.com/index.shtml

PO Box 99488 Raleigh, NC 27624 (919)846-4747

Cryopen

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

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

BizScore

www.bizscorevaluation.com

Dicom Solutions

Martha Petty 316 Burlage Circle Chapel Hill, NC 27514 (919)933-4920

Pia De Girolamo

MEDICAL PRACTICE VALUATIONS

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 Clinical Reference Laboratory

www.dicomsolutions.com

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

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

Peters Medical Research www.thetps.com

MEDICAL MARKETING MedMedia9 PO Box 98313 Raleigh, NC 27624 (919)747-9031

www.crlcorp.com

507 N. Lindsay St., 2nd Floor High Point, NC 27262 www.Petersmedicalresearch.com Sanofi US 55 Corporate Drive Bridgewater, NJ 08807 (800) 981-2491 www.sanofi.us

www.medmedia9.com WhiteCoat Designs Web, Print & Marketing Solutions for Doctors (919)714-9885 www.whitecoat-designs.com

MEDICAL PRACTICE SALES

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

MORTGAGE PROFESSIONAL SunTrust Mortgage, Inc.

Medical Practice Listings

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

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

medical resource guide

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

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

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

SUPPLIES, GENERAL BSN Medical 5825 Carnegie Boulevard Charlotte, NC 28209 (800)552-1157 www.bsnmedical.us CNF Medical 1100 Patterson Avenue Winston Salem, NC 27101 (877)631-3077 7" www.cnfmedical.com

Dermabond Ethicon, Route 22 West Somerville, NJ 08876 (877)984-4266 www.dermabond.com DJO 1430 Decision St. Vista, CA 92081 (760)727-1280

www.djoglobal.com

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

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

STROKE TARGETS BY COLOR. Know where you stand. The odds are African Americans are twice as likely to suffer a stroke as white Americans. Beating the odds isn’t about winning, it’s about living. You have the power to end stroke. 1-888-4-STROKE / StrokeAssociation.org Photographed by Sean Kennedy Santos

MEDMONTHLY.COM |59

THINKING ABOUT SELLING YOUR PRACTICE?

Medical Practice Listings can help you sell your practice online! Now offering two types of listings to better serve all practice specialties and budgets. Standard Listing The Standard Listing offers you the opportunity to gain national exposure by posting your listing on our website which is viewed daily by our network of professionals. This option also includes a brief practice consultation to explain the benefits of marketing through the Medical Practice Listings website.

Professional Listing In addtion to the benefits in the standard listing our Professional Listing affords you access to services provided by our expert legal and marketing team and a Bizscore Practice Valuation. This valuation compares your practice with other practices in your area, provides projections and determines what your practice is worth.

Visit us today at www.medicalpracticelistings.com to learn more.

919.848.4202 | medicalpracticelistings.com

classified listings

Classified To place a classified ad, call 919.747.9031

Physicians needed

North Carolina

North Carolina (cont.)

Occupational Health Care Practice in Fayetteville North Carolina has two to five days of locums work per week. 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, and PH: (919) 8450054, email: physiciansolutions@gmail.com Occupation Health Care Practice located in Greensboro, NC has an immediate opening for a primary care physician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability insurance and an excellent CME, vacation and sick leave package. 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, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Family Practice physician opportunity in Raleigh, NC This is a locum’s position with three to four shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from one year of age to geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. 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, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Methadone Treatment Center located near Charlotte, NC has an opening for an experienced physician. You must be comfortable in the evaluation and treatment within the guidelines of a highly regulated environment. Practice operating hours are 6 a.m. till 3 p.m. Monday through Friday. 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, and PH: (919) 845-0054,email: physiciansolutions@gmail.com Immediate Full-Time Opportunity for Board Certified occupational health care MD in Greensboro, NC. Excellent working environment, wage and professional liability insurance provided. 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, and PH: (919) 845-0054, email: physiciansolutions@gmail.com

Cardiology Practice located in High Point, NC has an opening for a board certified cardiovascular physician. This established and beautiful facility offers the ideal setting for an enhanced lifestyle. There is no hospital call or invasive procedures. Look into joining this three physician facility and live the good life in one of North Carolina’s most beautiful cities. 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, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Board Certified Internal Medicine physician position is available in the Greensboro, NC area. This is an out-patient opportunity within a large established practice. The employment package contains salary plus incentives. Please send a copy of your current CV, NC medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. email: physiciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054. Family Practice physician is needed to cover several shifts per week in Rocky Mount, NC. This high profile practice treats pediatrics, women’s health and primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. 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, N.C. 27624, and PH: (919) 845-0054, email: physiciansolutions@gmail.com Locum Tenens opportunity for primary care MD in the Triad Area NC. This is a 40 hour per week on-going assignment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wages, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, NC medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to: Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. email: physiciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054. MEDMONTHLY.COM |61

Comprehensive Neuro-OphthalmicPractice Practice Ophthalmic and Neuro-Ophthalmic 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

Med Monthly Med Monthly is the premier health care magazine for medical professionals.

By placing an ad in Med Monthly youâ&#x20AC;&#x2122;ll reach: family medicine, internal medicine, physician assistants and more!

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919.747.9031

Also available online 24/7 Contact Cara or Philip 919-848-4202 for more information or visit MedicalPracticeListings.com

62| JULY 2012

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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 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.

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.

Medical Practice Listings Buying and selling made easy

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

Call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com MEDMONTHLY.COM |63

Exceptional North Carolina Primary Care Practice for Sale Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 1 hour from Raleigh, 15 minutes from Lumberton and about an hour from Wilmington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff. The gross revenue for 2010 is $856,000, and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building. Our Services: • Primary Health • Well Child Health Exams • Sport Physical • Adult Health Exams • Women’s Health Exams • Management of Contraception • DOT Health Exam • Treatment & Management of Medical Conditions • Counseling on Prevention of Preventable Diseases • Counseling on Mental Health • Minor surgical Procedures For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.

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. 211219A01

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

Pediatrics Practice Wanted Pediatrics practice wanted in NC Considering your options regarding your pediatric practice? We can help. Medical Practice Listings has a well qualified buyer for a pediatric practice anywhere in central North Carolina. Contact us today to discuss your options confidentially. Medical Practice Listings Call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com 64| JULY 2012

W H AT T O O K Y O U A L I F E T I M E TO LEARN CAN BE LOST IN MINUTES.

W I T H A S T R O K E , T I M E L O S T I S B R A I N L O S T. If you suddenly have or see any of these symptoms, call 9-1-1 immediately: Numbness or weakness of the face, arm or leg, especially on one side of the body • Confusion, trouble speaking or understanding • Difficulty seeing in one or both eyes • Trouble walking, dizziness, loss of balance or coordination • Severe headache with no known cause

Learn more at StrokeAssociation.org or 1-888-4-STROKE.

Classified 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 well-equipped 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 |65

EXCELLENT FAMILY PRACTICE FOR SALE North Carolina family practice located 30 miles from Lake Norman has everything going for it.

Medical Practice Listings For more information call (919) 848-4202. To view other practice listings visit medicalpracticelistings.com

Gross revenues in 2010 were 1.5 million, and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established. Excellent medical equipment, staff and hospital nearby, you will be hard-pressed to find a family practice achieving these numbers.

: d e t Wan Hospi

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We have a qualified buyer that is looking for an established hospice practice in the Dallas,Texas area. To review your hospice practice options confidentially, contact Medical Practice Listings at 919-848-4202 or e-mail us at medlistings@gmail.com.

Listing price is $625,000.

To view our national listings visit www.medicalpracticelistings.com

Practice at the beach Plastic Surgery practice for sale with lucrative ENT specialty Myrtle Beach, South Carolina Practice for sale with room for growth, located only three miles from the beach. Physicianâ&#x20AC;&#x2122;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 & trans-nasal esophagoscopy. Walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000. For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com

66| JULY 2012

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Classified

To place a classified ad, call 919.747.9031

Physicians needed

North Carolina (cont.)

Virginia

Internal Medicine Practice located in High Point, NC, has two full-time positions available. This wellestablished practice treats private pay as well as Medicare/Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your NC medical license to physiciansolutions@gmail.com - View this and other exceptional physician opportunities at www.physiciansolutions. com or call (919) 845-0054 to discuss your availability and options.

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

Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in NC and VA. Call today to discuss your options and see why Physician Solutions has been the premier physician staffing company on the eastern seaboard. Call (919) 845-0054 or review our corporate capabilities at www.physiciansolutions.com Pediatricians Needed Well established Pediatric office in Harnett County & Wake County, North Carolina seeks ongoing coverage for locum tenen opportunity. Pediatrician will see about 20 patients daily, hours are 9 a.m. - 5 p.m. No call or hospital duties. Please send a current CV to physiciansolutions@gmail.com or call (919) 845-0054 for details on this and other opportunities across the state. Physicians Needed Immediately We have several immediate needs for physician coverage for various facilities in North Carolina for addiction medicine. For immediate consideration please call or email us at physiciansolutions@gmail.com or call (919) 8450054. We can put you to work tomorrow! We have very competitive salaries, we pay for mileage, your accommodations if necessary. We look forward to hearing back from you.

68| JULY 2012

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 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.

MEDICAL PRACTICE LISTINGS Are you looking to sell or buy a practice?

View national practice listings by visiting our website or contact us for a confidential discussion regarding your practice options. We are always ready to assist you.

919.848.4202 medlistings@gmail.com | medicalpracticelistings.com We have in-house practice experts and an attorney ready to assist.

PRACTICE FOR SALE

NC MedSpa For Sale

OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina 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

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 To view more listings visit us online at medicalpracticelistings.com

www.medicalpracticelistings.com

Private Medical and Mental Health Care Practice for Sale Coastal North Carolina, minutes from Atlantic Beach

Established private internal medicine practice treating general as well as adolescent patients and licensed clinical psychologistâ&#x20AC;&#x2122;s combine for a high profile multi-disciplinary practice. The staff includes a medical doctor, physician assistant, three licensed clinical psychologists, and a complement of nurses and administrators. The internal medicine practice also uses locum physicians to treat primary care patients as needed. Excellent gross income with solid profits are enjoyed in this evergrowing practice located in a bustling community with handsome demographics. Two all brick condominiums house these practices which are offered for lease or purchase. This expanded services private health care facility has a solid following and all the tools necessary for enhanced services, income and expansion. For more details which include a BizScore Practice Valuation, financial statements, patient demographics and furniture and equipment details, contact one of our professionals.

Medical Practice Listings PH: (919) 848-4202 Email: medlistings@gmail.com www.medicalpracticelistings.com MEDMONTHLY.COM | 69

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

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 70| JULY 2012

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

MD STAFFING AGENCY FOR SALE Great opportunity for anyone who wants to purchase an established business.  One of the oldest Locums companies  Large client list  Dozens of MDs under contract  Executive office setting  Modern computers and equipment  Revenue over a million per year  Owner retiring  List price is over $2 million

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

Practice for Sale in Raleigh, NC Primary care practice specializing in women’s care Raleigh, North Carolina The owning physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however, that could double with a second provider. Exceptional cash flow and profit will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several well-appointed exam rooms and beautifully decorated throughout. New computers and medical management software add to this modern front desk environment. List price: $435,000

Primary Care Practice for Sale Hickory, North Carolina 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. 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. 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

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

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

MEDMONTHLY.COM |71

the top This month’s Top 9 List highlights some of healthcare’s most simple, revenue generating procedures that many general internists and other primary care providers are beginning to implement in their practices to ensure their financial success. Certifications for all of these procedures can be obtained at one or two day CME events and are proving to dramatically increase cash flow. Compiled by Leigh Ann Simpson

Cervical Epidurals and Cervical Facet Joint Injections This “in demand” procedure offer patients a non-surgical option for the management of (neck) cervical spine pain.

Platelet-rich plasma (PRP) Therapy The philosophy behind this new, high demand treatment is to merge cutting edge technology with the body's natural ability to heal itself. These platelets release healing proteins called growth factors that have been found not only to accelerate tissue recovery, muscular, skeletal and wound healing, but also have a cosmetic application.

Liposuction With the average fee collected ranging from $2,000 to $6,000, the relative simplicity of adding the procedure to a medical practice, and the exceptional results obtained with the newer techniques, it is no wonder physicians of all specialties are adding this procedure to their practice.

Fat Transfer/Grafting This new technology allows a physician to diminish or eliminate the appearance of wrinkles, creases, furrows, smile lines and other depressions of the face and body naturally at little or no cost of dermal filler. On average, physicians are charging $1,250 to $1,500 per treatment for this procedure and it offers your patients a more permanent, safe and natural looking result.

Botox There are over 90 different uses for Botox. Botox training is now available for treating TMJ, migraines and hyperhydrosis. These new uses and techniques will give you more revenue generating, in-house procedures to offer your patients.

Laser Liposuction The demand for this procedure is expected to increase by over 10 percent in the next two years. The advent and refinement of tumescent anesthesia and the improvement of medical protocols make this procedure practical, safe, and it can be performed in an office-based setting.

72| JULY 2012

Simple Revenue Generating Procedures

Joint/ Extremity Injections This procedure for common orthopedic conditions is simple to perform and learn, has a lower risk threshold and offers increased reimbursement as well. Your patients will also be pleased that you can treat them in your office rather than referring.

Microlipoinjection For a professional fee, most physicians charge $1,500 to $3,000 per surgical hour or a minimum of $500 for short procedures. The average time for the procedure is 30 to 45 minutes; therefore the average amount per injection is approximately $1,500.

Facial Aesthetics Medical grade chemical peels have become extremely popular due to their effective results against solar leutigos, age spots and other pigmentation disorders.

Have news youâ&#x20AC;&#x2122;d like to share about your medical goods or services company?

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