A W A R D - W I N N I N G
M A G A Z I N E
O F
T H E
M I C H I G A N
S T A T E
M E D I C A L
S O C I E T Y
www.msms.org
July / August 2015 • Volume 114 • No. 4
Perspectives in Independent Practice Five physicians discuss keeping the tradition of private practice alive and well in Michigan
(L-R) Martha Gray, MD, Nita Kulkarni, MD, Bobby Mukkamala, MD, Jeffrey Jacobs, MD and Megan Edison, MD
ALSO IN THIS ISSUE
• Remaining Independent: How Doctors in Private Practice Are Adapting in the Changing Environment
• Five Threats to Financial Independence • Critical Success Factors for a Successful EHR Implementation for Physicians Practices
Chief Executive Officer Julie L. Novak
Committee on Publications July / August 2015 • Volume 14 • No. 4
Cover Story
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Perspectives in Independent Practice FEATURES
16 Remaining Independent: How Doctors in Private Practice Are Adapting in the Changing Environment by Bill Fleming, Senior Vice President and Regional Operating Officer, The Doctors Company
Columns
4 Ask Our Lawyer By Daniel J. Schulte, JD “Peer Review Privilege Upheld in Michigan Supreme Court”
8 HIT Corner By Pradip Sengupta, HIT Implementation Partner, IPS Technology Services “Critical Factors for a Successful EHR Implementation for Physicians Practices”
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MDHHS Update From the Michigan Department of Health and Human Services “Getting Ready for the 2015-16 Flu Season”
LYNN S. GRAY, MD, MPH, Chair, Berrien Springs MICHAEL J. EHLERT, MD, Livonia THEODORE B. JONES, MD, Detroit BASSAM NASR, MD, MBA, Port Huron STEVEN E. NEWMAN, MD, Southfield
Managing Editor Kevin McFatridge Email: KMcFatridge@msms.org
Publication Office Michigan State Medical Society PO Box 950, East Lansing, MI 48826-0950 517-337-1351 www.msms.org All communications on articles, news, exchanges and classified advertising should be sent to the above address, attn: Kevin McFatridge.
Display Advertising CARL MISCHKA Email: cmischka@msms.org Phone: 888-666-1491
Design / Layout STACY LOVE, reZüberant! INC. Email: rezuberantdesign@gmail.com
Printing BRD Printing, Lansing, MI Email: lallen@brdprinting.com
Postmaster: Address Changes Michigan Medicine Hannah Dingwell PO Box 950, East Lansing, MI 48826-0950
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President’s Perspective By Rose Ramirez, MD “Ensuring Independent Practice is Here to Stay”
Departments
9 Obituaries 22
The Marketplace
23 MSMS Foundation Education Course Offerings 25
WealthCare Advisors
29
New MSMS Members
The mission of the Michigan State Medical Society is to promote a health care environment which supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine.
Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2015 it is published in January/February, March/April, May/June, July/August, September/October and November/December. Second class postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2015 Michigan State Medical Society
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A S K
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L AW Y E R
Peer Review Privilege Upheld in Michigan’s Supreme Court BY Daniel J. Schulte, JD, MSMS Legal Counsel Question:
I heard recently that the Michigan Supreme Court issued a significant decision upholding Michigan’s peer review privilege. Can you explain what the case was about and the significance of the decision? Answer: You are referring to the April 21, 2015 Michigan Supreme Court decision in Krusac v. Covenant Medical Center, Inc. The court s decision restores Michigan’s peer review privilege which prevents the discovery of information gathered and documents created in connection with a peer review activity in a medical malpractice cases or for other purposes. This case involved a patient who died as a result of injuries sustained when she rolled off an operating table following a cardiac catheterization procedure. The patient’s estate filed a medical malpractice case. The estate sought discovery of an incident report completed by a nurse present at the time of the incident. The nurse submitted by the report to her supervisor. The defendant opposed producing the incident report relying on two of Michigan’s peer review privilege statutes applicable to hospital peer review activities (MCL 333.20175(8) and MCL 333.21515). These statutes prohibit discovery of records, data and knowledge collected for or by individuals or committees assigned and carrying out a peer review function. All such records, data and knowledge are confidential and not subject to court subpoena (i.e. not subject to discovery in a medical malpractice and other civil cases, criminal cases or for most other purposes). The estate relied on the Court of Appeals decision in Harrison v. Munson Healthcare, Inc. That case also involved a plaintiff in a medical malpractice case seeking 4
to obtain discovery of an incident report. In that case the Court of the Appeals created an exception for and held that the peer review privilege statutes do not apply to “objective facts contained in an incident report.” Ultimately, the Court of Appeals in the Krusac case allowed the estate to discover the incident report. The Supreme Court recognized the relationship between the Krusac and Harrison cases and combined the two appeals. The combined Supreme Court case was significant. If allowed to stand, the Court of Appeal’s decisions in Krusac and Harrison would have created an exception to the peer review privilege statutes, unintended by Michigan’s legislature, for the “objective facts” contained in incident reports prepared by healthcare providers pursuant to a peer review activity.
In a 6-0 decision (Justice Bernstein took no part in the decision) the Supreme Court held that objective facts contained in an otherwise privileged incident report are not excepted from the peer review privilege.
in an otherwise privileged incident report are not excepted from the peer review privilege. Citing the statutes the Court pointed out that all “records, data and knowledge” collected by or for a peer review committee was protected from discovery by the privilege. The Supreme Court disagreed with the decision reach by the Court of Appeals, overruling Harrison and sending the Krusac case back to the trial court with the plaintiff not being able to discover the incident report. The Supreme Court was careful to explain that although an incident report prepared as part of a peer review activity is privileged and therefore not discoverable, a plaintiff’s opportunity to obtain these same facts through other forms of discovery (e.g. taking the depositions of the healthcare providers involved in an incident). Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors
In a 6-0 decision (Justice Bernstein took no part in the decision) the Supreme Court held that objective facts contained MICHIGAN MEDICINE
July / August 2015
Volume 114 • No. 4
MICHIGAN MEDICINE
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M I C H I G A N
S TAT E
M E D I C A L
‘‘Alone we can do so little, together so much.’’
I
t is with a feeling of some trepidation that I take on the role of the 89th President of the Alliance. Our Michigan State Medical
Society Alliance was organized in 1926, four years after the American Medical Association Alliance was founded, making it one of the nation’s oldest medical alliances.
My own involvement with the Alliance began when I attended an AMA meeting with my husband in Chicago. I happened to see an announcement that the AMA Alliance was having their luncheon at the Drake Hotel. I was rather curious about the Alliance’s activities and walked down to have lunch. Although at the time I was not a member of any Alliance, they invited me to join their luncheon – and afterwards introduced me to the Michigan delegation who very generously took me under their wings. The rest is history, so to speak. Much to my delight, here I am today. 6
It is a huge responsibility to follow in the footsteps of our Alliance leadership — Barb Grennan, Trudy Ritter, Jean Howard, and the late Suzi Pederson to name a few. In fact, I would like to salute all our past presidents, some of whom are here with us today. My challenge, indeed our challenge, is to build on their many accomplishments. Happily, the Alliance does not work alone. The dictionary defines “alliance” as a relationship forged between individuals or groups to achieve a positive outcome for all involved. Thus, the mission statement for our Alliance, in capsule form, is to work in partnership with the Michigan State Medical Society and the AMA Alliance, and to serve as a resource for the various county medical alliances. So, what in fact does the Alliance stand for?
S O C I E T Y
A L L I A N C E
A dvocate for quality health care. We support a team-based approach to health care that is physician-led and patient-focused.
L egislative awareness. We work to keep our legislators and their staffs informed and up-todate about major issues that affect physicians and their patients. Two good examples are: The ‘Graduate Medical Education’ bill and the very recently restructured SGR (Sustainable Growth Rate) legislation.
L ifelong friendship. This is quite clear. No explanations are required. Our presence here is a testament to that fact.
I mage-building for medicine. Doctor’s Day Awareness, commemorated on March 30th, was founded by an Alliance member over 30 years ago.
A ctive community participation. We engage our communities by involving them in our programs, most notably in two currently on-going high-profile projects: • Stop America’s Violence Everywhere, and • Doctors and Their Families Make a Difference A good example of community engagement! Last year, Genesee County took the initiative to focus on “Human Trafficking,” especially on the depth of the crisis which is all-too-quickly and alarmingly developing into a formidable problem across the state of Michigan. Importantly, our County Alliances also hold many immunization events; the first of many was hosted by the Muskegon team during our last Annual Meeting.
N ew health education. We build public awareness of critical medical issues by continually promoting healthy lifestyle behavior and children’s vaccination, and by fighting bullying and domestic violence.
C lose Support for the medical community. We support the families of our medical communities during times of illness or other problems by whatever means at our hand. We share information within the Alliance. The e-magazine, “Physician Family,” published by the AMA Alliance, is a great resource for the medical family.
E xcellent leadership training. We provide our members with opportunities for active involvement in committees, to accept Board positions, and to participate in meetings, such as the AMA Alliance Leadership Conference and Annual Meeting or the North Central States Alliance Leadership Conference.
MICHIGAN MEDICINE
July / August 2015
Moreover, both the MSMS and AMA Alliances publish online magazines that provide guidance as well as information on County and State Alliance events. The MSMA’s “Alliance in Action” and the AMAA’s “Alliance in Motion” are two valuable online resources. Check them out, if you haven’t already. Our Alliance has all the ingredients for greatness because of our members. Our members volunteer and work hard. They plan, develop and carryout action programs for their communities and medical families. They whole-heartedly support our Alliance activities, often driving one to three hours to attend Board meetings, while (by the way) taking care of their loved ones. The list goes on and on. As Henry Ford once said, “Coming together is a beginning; keeping together is progress; and working together is success.” All Alliance presidents set ambitious targets during their tenure. Indeed, their list of accomplishments is long. During the coming year, I would therefore like us to focus on one particularly grave issue: “Stop America’s Violence Everywhere” — better known as S.A.V.E. This is really a long-range effort. Later this year, on October 14, the AMA Alliance will celebrate the 20th anniversary of S.A.V.E. In connection with this event, I would like to challenge each County Alliance to develop its own S.A.V.E. program — or build on its existing program — so that we can collectively report on our activities to the National Alliance. Furthermore, I would like to propose that we strive to obtain official recognition, in effect getting a seal of approval on S.A.V.E. DAY, via proclamations from our local Mayors, City Councils, and even the Governor. Can you imagine the power of 16 official proclamations on our community projects! What do you say? Are you in? Lastly, I enthusiastically look forward to working with you during the next 12 months to carry on the mission of the MSMS Alliance. I am confident that the Alliance will continue to remain strong and will accomplish great things together with the assistance of its voluntary Board of Directors and, more importantly, YOU the Alliance members and their physician spouses. I leave you with my thanks for giving me the honor and the opportunity to serve you and a quote from Helen Keller: “Alone we can do so little, together we can do so much.”
Clara Sumeghy, President, Michigan State Medical Society Alliance
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H I T
CO R N E R
Critical Success Factors for a Successful EHR Implementation for Physicians Practices
OK,
now you are sold on upgrading your Healthcare IT and you have already selected the software based on business requirements and goals. What do you do now? How do you make sure that your EHR is successfully implemented and how do you know that you will achieve all potential benefits and ROI as expected?
Here are FIVE major factors that are often forgotten or not fully considered in an EHR implementation. It is quite common that the stakeholders of EHR implementation know about them but choose not to pay attention or ignore them to cut costs. However, if any of the following factors are neglected or not thought through to develop a project plan, an EHR implementation may not produce desired results‌ as a matter of fact, it may end up in a disaster.
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MICHIGAN MEDICINE
July / August 2015
The FIVE critical success factors are:
1. Workflow Definition In order to get the best out of an EHR installation a practice must have ALL its processes identified and documented with clarity. These process logical flow diagrams must also identify all data that transfer from one process to the other as well as from step to step within a process. The better the definition of workflow, easier will be the EHR implementation.
2. Work Standardization
OBITUARIES The members of the Michigan State Medical Society remember with respect their colleagues who have died. Ralph Abbott, MD
It is not uncommon to find different physicians within the same practice use a “slightly” different version of the same process. This may be due to physicians’ preferences or bias towards a particular type or test or medicine or procedure based on their years of experience. While it is expected to have variations within the same workflow, the goal should be to minimize it as much as possible to improve quality of services and reduce costs. Whatever the case may be (more variation or less), all process deviations must be well understood and documented for better and quicker implementation of EHR.
Genesee Died 4/17/15
( Frederick Cady, MD
3. Software Configuration One of the major factors to ensure successful implementation is to pay a tremendous emphasis on software configuration which is defined as the process of setting up the EHR package based on business requirements and business goals. For example, if a physicians practice has five locations and it wants to see billing summary information and patient medical history by location as well as by physician, it needs to be documented so that the EHR software can incorporate it during set up.
4. Project Plan and its Execution
Saginaw Died 4/23/15
( Sara Dora, DO Muskegon
EHR software implementation is not a one transaction type activity such as installation of a desktop software, or setting up of a PC, or a phone system. EHR implementation must be viewed as a project with multiple transactions among multiple parties. EHR implementation must have a plan with specific deliverables, tasks, and a time line. In order to increase the probability of success, project activities must be monitored by stakeholders on a regular basis to ensure proper execution.
5. Training
Died 5/1/15
( Jack Barry, MD Saginaw
One of the major activities that is also often ignored is appropriate amount of training given to ALL critical players. A practice may decide to cut the training plan short to save money. However, adequate training must be considered as a necessary evil and a mandatory task to get maximum return on investment. Without adequate training and support productivity of the organization will suffer due the change brought by a new tool such as EHR and it will be doomed for failure. The EHR project champion must plan properly and allocate training dollars to get project benefit for the practice. To conclude, the take away from this short article is to understand that an EHR implementation must be treated as a project and the probability of success will improve significantly provided the practice appoints a seasoned project manager. A good project manager will make sure that the project objectives are met and benefits for an EHR implementation are achieved through the development and execution of a detailed project plan.
Died 5/16/15
IN M E M O RY If you would like to recognize a colleague by making a gift or bequest to the MSMS Foundation in their memory, please contact: Rebecca Blake, Director
Contributed by Pradip Sengupta, HIT Implementation Partner from IPS Technology Services. For more about EHR implementation best practices, visit www.ipsts.com or call 248/528-9000. To know more about EHR implementation best practices, contact Dara Barrera at 517/336-5770 or djbarrera@msms.org; or, visit www.msms.org/hit. Volume 114 • No. 4
MICHIGAN MEDICINE
MSMS Foundation 120 W. Saginaw St. East Lansing, MI 48823 phone: 517-336-5729 email: rblake@msms.org 9
Perspectives in Independent
I
ndependent practice, though changing, is not dead. Data released by the American Medical Association in 2013 showed that even with an increase in hospital employment, more than half of physicians were self-employed in 2012, and 60 percent worked in practices owned by physicians. Private practice medicine remains strong despite an increase in hospital employment. Though the numbers are more optimistic than we may have thought, there are still many private practices that are closing up shop. Others are, with some resilience and creativity,
Recommendations
in it for the long haul.
In a 2012 report, The Physicians Foundation reviewed promising models for the maintenance of independent private medical practice and recommended the following: 1. A major outreach effort should be initiated to inform practicing physicians (and medical students and residents) that robust models of private practice exist that are viable, sustainable and professionally rewarding, even in today’s health care environment. 2. New models of private practice should be supported, tested and disseminated as they emerge. 3. Payers should be encouraged to increase their support for private practices, so that those practices are not absorbed by large hospital systems seeking to further increase their negotiating leverage. 4. A new national physician survey should be fielded as soon as possible, preferably in a way that will make it compatible with past surveys. 5. Focus group and survey research should be conducted to determine the public’s level of awareness and concern about what is happening to private medical practice. The Foundation observed that “while the traditional model of private practice may no longer be viable in today’s rapidly changing health care environment, the same pressures that are driving these practices out of business are also
This research makes room for cautious optimism that independent practices, with a bit of creativity and a lot of elbow grease, are not headed toward extinction. How are your colleagues making independent work? We’ll visit five physicians from across the state who are dedicated to keeping the tradition of private practice alive and well in Michigan.
giving rise to innovative new models and approaches that could well represent the leading edge of the next generation of private practice.” 10
July / August 2015
Practice How did you know independent practice was for you?
Martha Gray, MD What’s your background? I graduated in 1980 from the University of Michigan Medical School and am board certified in internal medicine and geriatrics. After my residency, I worked for two years at Henry Ford Hospital, but found I didn’t like staff model medicine. So in 1985, I started a small group practice, which was followed by a new practice called Partners in Internal Medicine in 1997. PIIM was founded when my original company grew too large.
What does your independent practice look like? Partners in Internal Medicine now has six full-time employed MDs, one part-time MD and one full-time nurse practitioner at two sites, Ann Arbor and Canton. We also contract with payors through the Accountable Healthcare Alliance and integrate with the University of Michigan and Trinity Health’s Saint Joseph Mercy Health System and St. Mary’s Health Care System. Our Ann Arbor office teaches outpatient University of Michigan residents. Personally, I work full-time patient care and full-time call, though no inpatient rounding since we use hospitalists. All PIIM administrative work is done after patient care hours and I act as COO for all macro operations of PIIM. We have 30 employees and do our own billing and have an EHR and Patient Care Medical Home. Volume 114 • No. 4
Independent practice is only for those physicians who understand business and are efficient and energetic and prioritize and lead, not follow. Many forces impact outpatient internists, but no one is a better patient advocate than the personal physician who understands the individual patient’s needs. I was lucky to work with a senior partner who apprenticed me in business from 1985 to 1997 while I was also learning to be a better clinician and communicator. All along I was involved in Michigan State Medical Society and American College of Physicians -two great leaders for internists.
What’s your secret to a successful independent practice? One of our secrets is hiring only nurses who use nurse phone triage for access demand. The cost is higher but MDs are freed up to talk to patients and spend less time on nonclinical care. Another secret is to focus on clinical care and make smart business decisions that serve patients. Many efforts from payors or government or hospitals interfere or have no added value to patient care, so doing a customized, flexible ‘work around’ of new policies or laws works well at PIIM. It’s also important to decide on leading edge technology for the purpose of patient care, not for some new trend or rule means patients will be served.
What do you find rewarding and challenging about independent practice? The most rewarding part of my day is helping patients move forward in life. Getting launched in a new computer system or a successful refund from pay for performance only reminds me about the shackles of internal medicine and why no one wants my job. Recruiting new outpatient internists is nearly impossible, which I find hard to believe since I enjoy my life in medicine and hope to continue for another 10 years. MICHIGAN MEDICINE
Bobby Mukkamala, MD What’s your background? I’m a graduate of the University of Michigan Inteflex program and board certified in otolaryngology. I completed my otolaryngology-head and neck surgery residency at Loyola University in Chicago, Ill. I returned to my hometown of Flint in 2000 post residency to go into solo private practice. I share offices with wife and solo OB-GYN practitioner, Nita Kulkarni, MD.
How did you know independent practice was for you? As a resident I thought I might go into academics, but I came to realize I enjoyed being the captain of my own ship. It’s the autonomy of private practice that did it for me. When I came back to my hometown, I knew I’d be busy and in demand as an ENT specialist. Being my own boss and making my own hours was especially appealing, as my wife and I had just had twin boys when we made the move back to Michigan. I love practicing in a small town. As an independent practitioner, it’s easier to control overhead costs when it’s me deciding on contracts, or maintenance or supplies. We’re very aware of costs, so we run much leaner than in non-independent situations. (continued on page 12) 11
What advice did you get along the way as you started your practice? I heard from other physicians who were making independent practice work. They told me to be involved and available, by participating in as many plans as I could. Affability was also on the list. Flint has quite a lot of people in private practice; it’s alive and well here. I was able to form my approach by those leading by example.
What advice do you give to others about going into independent practice?
The top 15 challenges facing physicians in 2015… Medical Economics, December 2014
1
If you find it critical to be your own boss and to maintain a high level of autonomy, you’ll be very satisfied in independent practice. If you don’t mind giving up some of that autonomy and the business side of medicine, then the employed model would be a better fit. Though independent practice isn’t for everyone, those interested shouldn’t be scared about doing so. You can participate in everything and have access to resources that are available to employed physicians, too.
Maintenance of certification
What do you find rewarding and challenging about independent practice?
Collecting co-pays and deductibles
It’s a challenge to keep abreast of the number of things we’re responsible for as solo practitioners. Instead of having a huge staff, we’re doing ICD-10 evaluations ourselves. Cost is also challenging, especially in the ramping up phase. It took us six months to become comfortable, but it could take up to five years. It’s definitely a financial risk.
ICD-10 implementation
2
HIPPA
3
Meaningful use 2
4
Getting paid
5 6 7
Administrative burdens
8
Rising operational costs
9
Pay for performance
10
I find it rewarding to be involved in as much detail with my practice as I want to be. I get to be hands on in all aspects. I am able to improve patient relationships and problems as they arise. Addressing a problem and finding an immediate solution is agility afforded by independent practice.
Independence vs. employment
What’s your secret to a successful independent practice?
Keeping pace with technology
Sharing costs without giving up autonomy. Don’t practice on an island and ignore the way the wind is blowing for medicine in general; be private, but do not ignore the changes. 12
Nita Kulkarni, MD What’s your background? I am an OB-GYN practicing in Flint, Michigan. I completed both my undergrad and medical school training at the University of Michigan and completed my residency at Rush Presbyterian St. Luke’s Hospital in Chicago, Illinois. Post residency, I joined a one-women, independent practitioner and it was her that convinced me I should go into solo practice myself. In 2000, I moved to Flint with my husband Bobby Mukkamala, MD to open our independent practices together.
How did you know independent practice was for you? My choice to go into independent practice hinged on the arrival of our twin boys in 2000 – that really changed the dynamic for me in terms of how I wanted to practice medicine. I realized we needed support from our familes for our new family and the compromises we would have had to make otherwise weren’t something I wanted to do. Pair that with the fact that I’m a hard worker who enjoys fully experiencing the fruits of my labor, and the choice was made.
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What advice did you get along the way as you started your practice?
12
My mentor was a private physician, and she truly gave me the courage to pursue independent practice. She encouraged me to let go of the fear, revealed the business side of medicine and helped me sort out the pros and cons associated. Through her I was also able to understand the importance of finding your niche in a community. In Flint, I’ve fallen into a group of two other solo practitioners who cover me over the weekend.
Payers dictating health care Patients dictating health care
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Staff retention
15
Avoiding liability
What advice do you give to others about going into independent practice?
What advice did you get along the way as you started your practice?
Make sure you have the capital. I don’t think now, with the looming changes in health care, that I’d be able to do what I did back then in making the choice to be in private practice. I’d see starting off with a group practice to really learn the ins and outs and to save money as being a good option for those interested in going solo at some point. You’re able to better leverage and pool your resources in a group.
I had many mentors along the way that I enjoyed working with and learning from – this is key. When you work closely with others, you depend on your colleagues a lot, so it’s important to develop strong bonds with them. I learned that finding people you enjoy to be an invaluable piece of advice.
What do you find rewarding and challenging about independent practice? Navigating human resources is very challenging. Hiring good, ethical, well-trained workers is harder than you’d think. It’s also a challenge to keep up with the changes in health care, as we know – there’s just so much out there to be read, kept on top of, learned, etc. It’s rewarding to me to be able to give my patients more humanistic care, as opposed to having to rush them in and out. I can call them, or take the weekends if I want – I enjoy the patient interaction. It’s an honor to be able to help people in such a happy time of their lives. Despite all the stress, nothing feels as good as celebrating a baby.
What’s your secret to a successful independent practice? A reliable office manager. Hard work. Managing volume.
How do you address the challenges in this transitional time in health care? We’re using the resources available to us from MSMS and I encourage my colleagues to do the same.
Megan Edison, MD What’s your background? I went to the University of Michigan for medical school and completed my pediatric residency at the Maine Medical Center in Portland, Maine. I’ve been practicing in the Grand Rapids area for eight years now. After my residency, I practiced in Maine for a while as part of a private office. I currently practice at Brookville Pediatric and Internal Medicine in Grand Rapids.
How did you know independent practice was for you? I grew up in Pentwater, Mich., which was a one-doctor town. That’s what I envisioned when I started getting interested in medicine. I liked the notion of working on my own and the fact that I’d be it - we’re trained to be leaders, so it made sense to me. When something is wrong, you don’t need to go through a committee, you fix the problem right then and there. I find it a lot more efficient way to practice. I also had a lot of exposure to community pediatrics and mentors who really enjoyed having their own office. Seeing people happy with the private practice system was inspiring.
“While it is indeed possible to survive and even thrive in private practice in the current environment, business as usual is not an option. Serious steps must be taken to adapt to the new realities, and implementing these steps may well take some physicians outside of their comfort zones.” — The Physicians Foundation, Survival of the Fittest: A review of promising models for the maintenance of independent private medical practice
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MICHIGAN MEDICINE
What advice do you give to others about going into independent practice? When I advise or mentor young physicians, I show them how autonomy works and feels and what it means to have the ability to make direct changes. I advise students to go into private practice, even when there are so many reasons people are moving away from the model. The roadblocks are enormous: massive amounts of regulation, so much to wade through, far above and beyond a typical small business. It can get overwhelming and I understand what students and young physicians face.
What do you find rewarding and challenging about independent practice? It’s the challenge of anyone running a business versus being an employee. The bonus is also the negative of being the person making decisions. A rewarding part of independent practice is the bonds you make with other physicians. We face the same issues together, and so it’s rewarding to discuss and determine how we can address those issues together. We’re able to strengthen our best practices through brain share, which is important because private practice can be very isolating.
What’s your secret to a successful independent practice? Understanding that your reputation really matters. People choosing you as a doctor is very much on you and the way you practice. You have to be wiling to guard and work for your reputation since you can’t fall back on anything else. Going the extra mile and fitting people into a schedule or making that personal call is important in private practice.
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What advice did you get along the way as you started your practice?
Jeffrey Jacobs, MD
I was told to really think it through. There is a business side of medicine that we don’t get taught in school and when we’re employed we don’t see the layers involved. Independent practice requires you to peel back all those layers.
What advice do you give to others about going into independent practice? What’s your background? I’m a graduate of Johns Hopkins University, NYU Medical Center and completed my residency at Bellevue Hospital Center at NYU. I’m currently a solo practitioner at Superior Pediatrics in Calumet and will celebrate my 6th anniversary there this July. My wife and I moved to Michigan from the Poconos in Pa. after looking to relocated somewhere a bit safer.
How did you know independent practice was for you? I’ve wanted to be a physician since I can remember – as a child I thought I might be a pediatrician or an orthopedist. Playing cops and robbers as kids, I always took on the role of EMT, responding first to help the situation. I oftentimes thought how great it would be to know your patients and their families very well - making house calls and do what needed to be done for them no matter what. I also thought that it would be awesome to be paid in chickens, pies or in services, if necessary. I never really thought that that was going to be a possibility. Being in private practice has allowed me to take care of my patients, no matter their ability to pay. I have been paid in eggs and other foodstuffs and have come home to find my lawn mowed or the snow shoveled. These forms of payment are generally frowned upon by hospitals. I made the switch to private practice after being an employed physician because I like to be in charge and like to know what’s going on, most especially when it comes to my patients.
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The same – think it out. Also, use the resources available to you.
What do you find rewarding and challenging about independent practice? The time commitment is serious. I’m wearing all the hats as the owner and physician – everything falls into my lap. I get to become a significant part of the families of my patients. We make house calls and see patients 24/7 when they need to be seen. I get to see more of the dynamics and health issues from the frontline, which leads to better care. My patients get me on the phone and I get to know them in and out. You just can’t get that as an employed physician.
Resources to help
W
e know physicians are concerned
that
stan-
dardization has limited
the ability to attend to the individual needs of patients. Many believe their ability to practice medicine and utilize their training and experience is being replaced by checklists and prior authorization burdens. Additionally, new models of care and reimbursement, as well as increased regulatory demands, are forcing physicians to consider new practice strategies. Physicians are being asked to comply with a number of regulatory or payer policies to monitor and report progress for population health management. While important, these reporting responsibilities are intensive and time consuming for practices. Coupled with the drive for
What’s your secret to a successful independent practice?
automation to EHRs and other issues
Taking things one step at a time. There are always new guidelines coming down or materials to order, new procedures – take them as they come. Have a good support staff. Don’t let things slide. Make use of those resources. Be convenient and remember who it is you’re there for.
billing, etc., many physicians believe it’s
How do you address the challenges in this transitional time in health care?
the control they enjoy in running their
We’re seeing that younger physicians tend to think that 5:00 is quitting time and that they’re tending to be more part time players who might want to work a little less. I’m seeing that medicine is now being approached as a job as opposed to a duty or calling. To that degree, I talk with young physicians are much as possible to try to get them to choose independent practice over employed. Independent practice is a very viable option. Sure, everything is a trade off, but let’s not discount independent practice.
like the complexity of ICD-10 coding/ easier to become employed by a larger system that can provide the infrastructure necessary to comply with these various responsibilities. Many physicians do not want to give up own practices. For instance, under an employment arrangement, physicians have less say about their work schedule, call coverage, record keeping requirements and other general business or administrative operations, as these are typically dictated by the physician’s employer. However, physicians who desire continued independence must also understand that some level of clinical integration will be required to survive in the future practice of medicine.
Helpful Hints from MSMS Ways to manage your concerns as an independent physician or if you are considering private practice: • Look for opportunities to collaborate • Look to MSMS for education opportunities and resources • Network with colleagues to see what is or isn’t working for them • Learn more about Physician Organizations and Independent Physician Associations and how they can assist in maintaining the independent practice that is desired while meeting the clinical integration and population health management expectations from payers, the government, purchasers and patients • Participate in organized medicine Physician Organizations There are options available to help physicians remain independent. Physician Organizations, especially in Michigan, will be critical to the way health care is delivered in the future. Physician Organizations, Physician Hospital Organizations and Independent Physician Associations can provide doctors with the ability to link their practices into a health care delivery network without the rigidity or potential loss of independence presented by an employVolume 114 • No. 4
ment arrangement. Affiliation with a PO can provide physicians with the administrative support offered by employment, such as assistance with HIT infrastructure and billing or reporting functions, without strict control over the physician’s behavior. In Michigan, affiliation with a PO is important, as it is required to participate in BCBSM’s Physician Group Incentive Program. Additionally, it can be helpful coordinating the requirements of multiple private insurance incentive programs and capturing the respective enhanced payments for quality outcomes.
MSMS is here to help! MSMS is prepared to help physicians navigate through the rocky waters of change ahead. We are committed to developing programs and resources that expand our ability to inform and assist physicians as the health care system continues to change. We invite our members to think of MSMS as an extra staff person for practices, helping them address reimbursement and coding issues and changes with payers, as well as remain up-to-date on pay-for-reporting and pay-for-performance initiatives - especially the CMS Physician Quality Reporting System and Physician Value-Based Payment Modifier, EHR/Meaningful Use program changes and implementation and legal and regulatory compliance requirements. Members can get real-time, practical updates from content experts via direct phone calls, presentations and education programs, written communications shared via listserves and Michigan Medicine. Much of this information is available at no extra charge and for those services in which there is a charge, it is often priced lower than that offered by other organizations or businesses. MSMS is continually working to develop partnerships with outside entities that that can offer services to members at a discount. MICHIGAN MEDICINE
Integrating services As we look to the future of independent practice, practicing in an integrated manner is critical. Public and private payment models will require physicians to become accustomed to a fee-for-value environment that emphasizes delivery efficiency and outcomes versus volume of services or procedures provided. As a result, integration and collaboration with other specialists and community service providers will be instrumental to managing defined populations of patients. Additionally, physicians will be incentivized to align with clearly defined networks of care in order to provide population-level care to patients within those networks that are evaluated on both cost and the quality. Under a new payment environment, physicians will need to emphasize system delivery efficiency – as opposed to service volume – and will rely more on other specialists or community partners accountability for their patients’ care. It will be difficult, if not impossible, to achieve the goals of this new environment without investments in advanced information systems that optimize quality and enhance communication for care coordination. The Physicians Foundation report sums it up best:
“For those who are willing to change and adapt to the new health care realities, it is possible not only to survive as an independent private practice physician but to thrive— and to achieve a high level of personal satisfaction in the bargain. But it will take real work to make it happen, and may require getting outside of one’s comfort zone, for example by becoming more directly involved in the business aspects of the practice.” 15
Remaining Independent: How Doctors in Private Practice are Adapting in the Changing Environment by BILL FLEMING, SENIOR VICE PRESIDENT AND REGIONAL OPERATING OFFICER, The Doctors Company
H
ealthcare is undergoing historic change – a transformation that is highlighted by the unprecedented trend toward
consolidation. At The Doctors Company, in the past decade, the percentage of member doctors in groups of one to five physicians has decreased from nearly 70 percent to slightly over 50 percent. Over the same period, the number of members in groups of 100 or more has doubled.
Robert Jackson, MD, MMM, a family medicine physician at Western Wayne Physicians in Allen Park, is one doctor who is determined to remain independent. “Inherently, I know my patients are better served by me being in private practice,” he says. Dr. Jackson and other independent physicians face many challenges, particularly increased financial and regulatory pressures. “As fee structures evolve, physicians need tools to understand how to thrive in the new financial models,” says Paul MacLellan, CEO of Medical Advantage Group, a leading healthcare consulting and management company headquartered in East Lansing and a wholly owned subsidiary of The Doctors Company. “When I first started my practice, I had an average of 2.5 fulltime employees per physician,” Dr. Jackson says. “Today, I have four employees for each physician in my practice. I now need staff to do referrals, I need staff to do quality initiatives, and I need staff to deal with computers. All the initiatives that I need to participate in take away from my margin, a margin that is already too low.” William Starbird, MD, FAAFP, a family medicine physician at North Branch Family Healthcare in North Branch, identifies emerging technologies as one of the bigger hurdles independent doctors face. “We must stay up to date on the changing technologies,” he says. “Down the road, these technologies will be a huge benefit. Unfortunately, right now, they are not. For example, electronic medical records are fragmented since they are not
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MICHIGAN MEDICINE
July / August 2015
“We must stay up to date on the changing technologies. Down the road, these technologies will be a huge benefit. Unfortunately, right now, they are not... It places a lot of burden on physicians to try to master the electronic format and practice medicine at the same time.” — William Starbird, MD, FAAFP
connected, and many can’t talk with each other. It places a lot of burden on physicians to try to master the electronic format and practice medicine at the same time. You have to make a conscious effort to do it.” Several years ago, Dr. Jackson adapted his practice to get more profit from his health plan relationships by taking on managed care risk and becoming one of the first Patient-Centered Medical Homes (PCMH). In the future, “we may have to form groups of primary care physicians so we can deliver more services, such as urgent care center, care manager, dietician, diabetes educator, health coaches and fitness instructors,” Dr. Jackson says. “These are services that I believe need to get delivered in the PCMH.” Even for independent physicians, Dr. Starbird says, the future of care will involve coordination and integration. “In the future, the model of healthcare will change dramatically. It will be more team-based, with the physicians being the ‘conductor’ of the healthcare orchestra to make sure the patient is managed correctly and making sure we are using all resources available, such as using evidence-based care. We must rely on nurse practitioners, mid-level practitioners, and home healthcare due to the changing population.” Medical Advantage Group specializes in assisting physicians to thrive in independent medicine, providing tools that help doctors improve performance, adopt healthcare technology, participate in managed care contracts, and achieve clinical integration.
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“We work to understand the contracts physicians are in and the changes needed in the practice to thrive in those contracts,” MacLellen says. “Between the commercial payers and CMS, the complexity is enormous. We sort through the endless rules and reports and help focus on the top few changes that will increase the physician’s revenue. Most often the changes are around office workflow and technology.” Recently, Medical Advantage Group developed a new solution to help physicians improve efficiency and patient care. “Our new centralized team of clinicians serves as an extension of our physicians for patients that need the most help,” MacLellen says. “Dieticians, social workers, pharmacists, registered nurses, nurse practitioners, and physician assistants work with our physicians and with their patients to manage those who most need help in efficiently using the system.” For his part, Dr. Jackson plans to spread the message about the key role independent doctors play in healthcare. “I will continue to talk to health plans and government officials in any way that I can to communicate the value of private practice and primary care.” Bill Fleming is senior vice president and regional operating officer of The Doctors Company. The Doctors Company is the exclusively endorsed medical liability carrier of the Michigan State Medical Society (MSMS). We share a joint mission of supporting doctors and advancing the practice of good medicine.
MICHIGAN MEDICINE
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M D H H S
U P D AT E
Getting Ready for the 2015-16 Flu Season
Y
ou know what they say: if you’ve seen one flu season, then you’ve seen one flu season. The 2014-15 flu season had many unique challenges. Before the flu season began, there were shipping delays of multiple flu vaccine presentations. We’ve become accustomed to flu vaccine hitting the market in July and August, but last season providers had to wait until September and October to start vaccination efforts. Michigan Department of Health and Human Services (MDHHS) Bureau of Laboratories (BOL) confirmed the first positive influenza specimens the week ending October 4, 2014 – one influenza A(H3N2), one influenza A(2009 pandemic H1N1), and one influenza B. There was no way to know what 2014-15 had in store for us. The 2014-15 flu season was the third consecutive flu season to begin early and peak at the end of December. Influenza A(H3N2) predominated throughout most of the flu season. Unfortunately, the main circulating H3N2 virus drifted from the vaccine strain, resulting in poor vaccine effectiveness. H3N2 typically has higher disease burden and severity in older and very young populations, which was evident last season. The flu-associated hospitalization rate among adults 65 years and older was more than 322 per 100,000 population, the highest rate ever recorded since the data began to be collected in 2005-06. As of May 23, there were 141 fluassociated pediatric deaths nationally, three of which were from Michigan. Influenza B viruses increased as the flu season wound down, and Michigan’s BOL identified B viruses of both Yamagata and Victoria lineages. One way to know when flu activity begins each season and which viruses are circulating is through the U.S. Outpatient In18
fluenza-like Illness Surveillance Network (ILINet). ILINet sentinels are providers who go above and beyond to assist public health with influenza surveillance. Sentinels’ primary responsibility is reporting the number of patient visits due to flu-like illness and total visits weekly. Michigan is always in need of more sentinel providers, especially in the North and Southwest regions (see map). In appreciation of their efforts, sentinels receive weekly feedback reports summarizing influenza data, can submit up to 11 specimens each year for free respiratory virus testing at BOL, and for those who report ILINet data at least half the weeks of the year – your staff will receive two free registrations to an MDHHS Fall Regional Immunization Conference! If you’re interested in becoming a flu sentinel provider, please contact Stefanie DeVita, RN, MPH, Influenza Epidemiologist, at DeVitaS1@michigan.gov. Two of the four flu vaccine strains changed for 2015-161. Flu vaccination recommendations for 2015-16 were voted on at the June 2015 Advisory Committee on Immunization Practices (ACIP) meeting and go into effect once the Centers for Disease Control and Prevention Director approves them and they are published in Morbidity and Mortality Weekly Report. The change in vaccine strains should provide a better match to circulating strains for the upcoming year. MDHHS’ 2015-16 flu handouts and materials will be posted on our website as they are updated (www.michigan.gov/ flu, click on Current Flu Season Vaccination Materials). Begin vaccinating your patients as soon as you receive flu vaccine in your offices and continue until the vaccine expires (typically June 30).
Also, save the date for MDHHS’ 4th annual flu webinar on August 26 from 12-1 PM. More information about the webinar will be sent out through the summer. Everyone aged 6 months and older should get flu vaccine in 201516, including special populations like adults with high risk conditions (diabetes, asthma, etc.), pregnant women, and persons in long-term care facilities (including staff). As you vaccinate your patients against flu, please make sure to assess them for all recommended vaccines – this includes adults! Pregnant women can and should get flu vaccine and Tdap while they are pregnant to protect themselves and their baby. We hope there will be better flu vaccine effectiveness in 2015-16, but the bottom line is that flu vaccine is the single best way to prevent getting the flu. Make sure you communicate this to your patients and keep them protected this flu season.
MICHIGAN MEDICINE
July / August 2015
Volume 114 • No. 4
MICHIGAN MEDICINE
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Patients trust you. You can trust Kerr Russell. A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business. ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS RELATIONS MATTERS MATTERS • • HEALTHCARE HEALTHCARE FRAUD FRAUD DEFENSE DEFENSE • • LICENSING LICENSING AND AND OTHER OTHER REGULATORY REGULATORY MATTERS MATTERS HOSPITAL
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W W W.KERR - RUSSE LL .COM
July / August 2015
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MICHIGAN MEDICINE
July / August 2015
Fall 2015 Education Course Offerings On-Demand Webinars
Practice Transformation
Physician Executive Development • Health Care Law for Physicians in ACO’s • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development and Monitoring Choosing Wisely Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction CDL-Medical Examiner Course Legalities and Practicalities of HIT • Cyber Security: Issues & Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media Summary of the Affordable Care Act HIPAA Security Rule End of Life Concerns & Considerations What’s New in Labor & Employment Law Preparing for the Medicare Physician Value-Based Payment Modifier Understanding and Preventing Identity Theft in Your Practice Stepping Up to Stage 2 Physician On-line Rating and Reviews: Do’s and Don’ts Patient Portals as a Tool for Patient Engagement
150th MSMS Scientific Meeting
Please visit www.msms.org/eo for complete listing.
Continental breakfast & lunch will be provided Dates: Wed-Sat, October 21-24, 2015 Morning, afternoon and evening clinical courses available. Location: The Somerset Inn, Troy Contact: Marianne Ben-Hamza (517) 336-7581 or mbenhamza@msms.org Intended for: Physicians and all other health care professionals
Symposium on Retirement Planning Dinner will be provided
Date: Wed, October 21, 2015 Location: Somerset Inn, Troy Contact: Caryl Markzon (517) 336-7575 or cmarkzon@msms.org Intended for: Retired physicians, physicians planning for retirement, spouses and office managers
If you have questions need more information, or to register for a webinar, conference or program please: • Visit www.msms.org/eo • Call MSMS Registrar at 517-336-7581
Recruiting is hard work. We can help. Medical Opportunities in Michigan connects Physicians, Physician Assistants & Nurse Practitioners with Michigan’s healthcare employers. Private practice memberships begin at $500.
Educational Conferences ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care Continental breakfast and lunch will be provided
Date: Wednesday, October 21, 2015 Location: Somerset Inn, Troy Contact: Caryl Markzon (517) 336-7575 or cmarkzon@msms.org Intended for: Physicians, executives, office administrators and all other health care professionals Volume 114 • No. 4
MOM is a service of the Michigan Health Council
800-479-1666 MICHIGAN MEDICINE
miMOM.org 23
refresh your practice.
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The professionals of Yeo & Yeo’s Health Care Services Group can help you get the maximum revenue for your services. • • • •
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MICHIGAN MEDICINE
July / August 2015
Five Threats to Financial Independence BY NICOLE GOPOIAN, JD, CFP®
F
inancial independence is an aspiration of many. The desire to pursue what is valued in life without financial constraint is liberating. While financial independence may be a heartfelt desire, many obstacles arise that may prevent this intention from becoming reality. We’ve identified five risks that threaten financial independence among physicians:
Failure to Maintain an Emergency Fund Life is messy. Emergencies happen. Opportunities can come out of nowhere. Wise financial planning requires planning for the unexpected. The best way to do this is by maintaining an appropriate emergency/ opportunity fund to account for unanticipated events. The general rule is to maintain three to six months of living expenses in a liquid cash account. For physicians, the recommended amount may be higher due to the highly specialized nature of their work. Failing to do so can create a situation that forces the use of credit card debt, loans from a 401(k) or home equity line, or other undesirable options out of desperation. Desperation decisions can quickly derail a thoughtful plan.
Outspending Your Income Many physicians make sacrifices to pursue their profession - lengthy periods of expensive schooling and low pay during residency. After training is complete, it’s common to experience an exponential increase in pay. This sharp increase in income can create an environment that breeds poor financial decisions, many times without even being fully aware of the implications. It is important to be conscious of spending patterns. Many people have no idea the amount that they’re spending and are shocked when then Volume 114 • No. 4
go through a budgeting exercise. Given that the span of peak earning years is condensed over a shorter period due to the length and cost of medical education, it’s critical to save the appropriate amount to achieve financial independence.
Supporting Adult Children It’s natural to want to help adult children if they fall upon hard times, or if they can’t quite launch after completing college or graduate school. This can be a dangerous pattern – for both parents and their adult children. Once financial support is given, it often creates a precedent that the support will continue, and then it becomes expected. Not only does this prevent adult children from achieving independence as self-supporting members of society, it also may derail a parent’s financial plan. As discussed above, physicians have fewer years to save. As a result, decisions affecting cash flow have a much greater impact. Make it clear to children that beyond a certain point; they will be entirely responsible for their own financial life.
Pouring Too Many Resources into Your Practice One of a physician’s greatest resources is their ability to earn income. The vehicle through which they do this is often their practice. It’s normal for them to want to MICHIGAN MEDICINE
pour all of their available cash flow into the vehicle that allows them to utilize their greatest asset. However, from a planning perspective this can be risky. It’s not prudent for anyone to have all or a majority of their net worth in one asset, especially one that is illiquid. It’s sensible to diversify assets to and create flexibility and reduce risk.
Chasing Returns and Investing for Thrills Investing is not intended to be an extreme sport. Day to day excitement should not be a goal of the portfolio. Instead, we focus on four qualities of a long term investment solution. First, investments should be coordinated with a financial plan. Looking at a plan in isolation or investments in isolation will lead to disappointment. They are intertwined and it’s important to look at the pieces together. Second, investments should be tailored to individual needs and reviewed regularly in conjunction with the financial plan. Third, investments should be durable in terms of being globally diversified, tactically managed, low cost and sensitive to taxes. Fourth, investments should be adaptive in response to changing market conditions, trends and legislative updates.
Nicole Gopoian, JD, CFP® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.
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T H E
M A R K E T P L A C E
Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fee should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted.
To place a classified or display ad call 888-666-1491 or email Carl at cmishka@msms.org. Fall issue of Michigan Medicine closes August 8th! Reserve your space today.
Pediatrician: Unique Opportunity in Ann Arbor Area Established Private Pediatric Practice is recruiting a full time general pediatrician to join our three provider practice near Ann Arbor. We are guided by this Mission Statement:
To provide the highest level of care in a warm welcoming environment, creating a community among our patients. When asked to describe what we do, our staff says, “Working together, we help create the best possible future for our patients” and “We provide individualized care with a high level of detail and time” and “We make it a fun experience for ourselves and the kids so this is a place that kids want to come back to” and “We work collaboratively; we demonstrate respect for each other, and we work as a team.” Our providers trained at Rainbow Babies and Children and the University of Michigan. The practice employs RNs for nursing support. We have used EMR for 10 years currently athenahealth, and the practice is PCMH designated.
To learn more, contact Scott Moore, MD at drmoore@mykidsdoc.org.
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LANSING: Office Space in Medical Building Two suites available: 1360 sq. ft. ready for clinical use with reception and exam rooms; 1600 sq. ft. Reception and Exam rooms. Beautiful Building, Great Location, Very Reasonable Rates. Busy urgent care on site for possible referrals. Contact Penny @ 517-281-0423 for more information.
Position now available: Nurse Practioner, Primary Care Excellent potential for growth and possible partnership. Part time to start. Livingston County. Fax resume or CV to 810-229-8685 Or email to bmc8680@gmail.com.
DON’T RENT – Own Your Own office Why pay rent to someone else—own your office! 1079 sq. ft. suite in Farmington Hills in med/dent bldg. EZ access to all Xways. 248-637-9700.
MICHIGAN MEDICINE
July / August 2015
Family Practices n Allen Park: Retired Orthopedic Surgeon offering turn key operation. Full PT Lab, receive patient files, lots of potential for a very low price asking $50,000. n East Pointe Primary Care: Near I94 and Kelly Road. 3 Exam rooms, 2 year old practice. Asking $60,000 includes equipment/goodwill and transition. Real estate available. n Farmington Hills: Long established Internal Medicine Practice, 10 Mile/Middlebelt area. Free standing building, 5 exam rooms, lab, x-ray. Very close to Botsford, St. Mary’s, and Providence Novi. Asking $175,000 for practice. n Garden City Internal Med Practice: Long established, majority of patients Medicare. Fully equipped, grossing in excess of $200,000 annually. Asking $70,000. n Mexican Town Detroit: 20 year old Primary Care Clinic. Staff is fluent in multiple languages. Seller financing available, priced to sell, work as you pay terms. Never in 25 years have I had the opportunity to offer more flexible terms. Price reduced to $589,000 for everything including real estate. n Lincoln Park: Walk-in clinic. Very visible, long established, seeing approximately 40 patients daily. Approx. gross income $800,000. Asking $250,000 for practice and $350,000 for real estate. n Podiatry Practices Detroit: 2 locations, very successful, grossing in excess of 600,000 annually. Fully equipped. Asking $300,000 for both locations. Real estate available. n Westside Detroit, Primary Care Practice: Established 2005, grossing in excess of $500,000 annually. Fully equipped. Asking $200,000 owner wants to retire.
Medical Buildings For Sale or Lease n Pontiac: Large professional medical building. Three story, suites 5005,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000. n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000 pos. cash flow excellent. Brick, single story asking $500,000 or lease for $1.00 square foot plus utilities.
For more details contact our practice specialist at Union Reality:
Joe Zrenchik, Broker 248-240-2141 (cell) joezrenchik@yahoo.com 248-919-0037 (office) Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.
Volume 114 • No. 4
MICHIGAN MEDICINE
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MICHIGAN MEDICINE
July / August 2015
Welcome to These New MSMS Members Chad Afman, MD Kent Shokhan Aghawais, MD
Kory Deason, MD
Jan Hunt, MD
Charles McCaslin, MD
Michael Salisbury, DO
Alphonse DeLucia, MD
James Johnson, DO
Dennis Means, MD
Mohamed Satti, MD
Hafeez Ahmed, MD
Steven DeRoos, MD
Leslie Jurecko, MD
Leon Mercer, MD
John Schuen, MD
Zain Alamarat, MD
Marilynn Dewald, MD
John Kemppainen, MD
Susan Millard, MD
M. Salim Siddiqui, MD
Mohd Baig, MD
Brij Dewan, MD
Shah-Naz Khan, MD
Dustin Miller, MD
Masood Siddiqui, DO
Alfred Baylor, MD
Leopold Fregoli, MD
Mark Kwartowitz, DO
Annu Mohan, MD
Lynn Smitherman, MD
Robert Budinsky, MD
Gregory Gadbois, MD
Patricia Lamb, MD
Gerald Morris, Jr., MD
Michael Solomon, MD
James Bullen, MD
Jodi Ganley, DO
Mia Layne, MD
Leon Oostendorp, MD
Olufemi Soyode, MD
Herminio Calderon, MD
Reda Girgis, MD
Whei Lim, MD
Edgardo Paguio, MD
Kiran Taylor, MD
Michael Cole, MD
Parin Gohel, MD
Jeffrey Lipsky, MD
Xinque Pan, MD
Karen Thompson, MD
Jason Coles, MD
John Gribar, MD
Lisa Lowery, MD
Joel Post, DO
Aijaz Turk, MD
Julie Conley, MD
Hind Hadid, MD
Andrew Luea, DO
Stephen Priest, MD
Burton VanderLaan, MD
Timothy Conroy, MD
Ismaeel Hashemi, MD
Kirti Majrekar, MD
Cory Rubin, MD, FAAD
Lydia Watson, MD
Sierra Cuthpert, DO
Robert Hoogstra, MD
Edward Mauch, MD
Nicole Ryke, MD
Anna Wright, MD
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P R E S I D E N T ’ S
P E R S P E C T I V E
Ensuring Independent Practice is Here to Stay by Rose ramirez, MD
Thank you to fellow Michigan State Medical Society members and my esteemed colleagues for the wonderful inauguration in May. It is such an honor to represent my colleagues in medicine as the voice of Michigan medicine as we celebrate our 150th anniversary. The MSMS staff worked hard to help make everything a success. I owe all of them a big thank you and especially to Tricia Keast, Rebecca Blake and David Fox. Our American Medical Association photographer, Ted Grudzinski attended our meeting and captured a lot of the fun moments, as well as the serious ones.
I
n this issue you’ve heard from some of your colleagues who have found (and worked hard for) success in independent practice. Even though the trend for physicians has been toward increasing hospital employment, private practice is predicted to continue. Many physicians, especially in ambulatory practices want the autonomy to practice in a way that fulfills their vision of caring for patients.
Personally, I have sustained a viable and successful private practice by thinking in an entrepreneurial way to provide services and an office environment that patients find desirable. I personally enjoy women’s health and cosmetic dermatology; so I have incorporated a cosmetic practice that provides laser hair removal, laser skin resurfacing, Botox and a number of other services and 30
products that patients are willing to pay cash for. I work with a team of providers and one of my physician assistants is excellent with sports medicine and joint injections. The team is encouraged to develop in areas of interest to provide a comprehensive set of services. At Jupiter Family Medicine, we have engaged with our physician organization, West Michigan Physicians Network and have attained a Patient Centered Medical Home designation for six years. This brings additional revenue for demonstrated high quality. I believe private practice has a place in the health care ecosystem as a place for rapid innovation and the ability to think creatively and act in a nimble manner to address patients needs and desires.
A 2014 Physicians Practice blog written by Gregory Mertz explains this well:
“Small practices will continue to be the backbone of medical care in rural settings and in those specialties that either provide care on a cash basis (plastic surgery, laser vision correction, etc.) or those that are underrepresented in a market (i.e. neurosurgery, general surgery). The demise of the small practice can be avoided through the development of either clinically integrated practice networks or the development of flexible merger models such as groups without walls.” One of the things I love about private practice – and I know I’m not alone here - is the ability to schedule a patient for as long a visit as I think they need instead of having a hospital administrator deciding how much time I should have with each patient. I enjoy a good doctor patient relationship and want to bring value to the patient. I am always looking for ways for patients to get their prescriptions at a less expensive place and really look forward to true transparency MICHIGAN MEDICINE
about out of pocket costs so I can help patients choose high quality specialty care at an affordable cost. (Okay, allow me a tangent here for a moment about something that I am passionate about that affects the affordability of health care for my patients. I am disgusted at the way Big Pharma prices their new drugs and am concerned about how hard it will be for patients to get the care they need as more out of pocket costs will be passed on to patients. The pharmaceutical industry spends more on lobbying than any other organization in the U.S. The cost of direct to consumer advertising is in the billions. These costs are passed on to US citizens in the form of higher drug costs and higher insurance premiums. Yet, what value do these activities bring except to increase the price of the drugs? The laws need to change so Medicare can take drug cost into account when approving a new drug for payment coverage.) I don’t think private practice will go away anytime soon and I appreciate the AMA and MSMS efforts on resources related to practice sustainability. If we want to help keep this option for our young doctors, we need to engage our medical students and residents to show them that many of us in private practice find great professional satisfaction in our ability to provide high quality care to our patients. As always, I welcome comments, suggestions and ideas from my colleagues, whether hospital employed or in private practice; it takes all of us to advocate for policies and legislation that help both our profession and our patients. Doctor Ramirez, a Kent County family physician, is president of the Michigan State Medical Society
July / August 2015
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