j a n u a r y 2 0 11
Podiatry Foot & Ankle Institute
Specializing Exclusively in the Comprehensive Medical and Surgical Treatment of Foot and Ankle Disorders
Also in this Issue
• Remembering Steve Kern • Doctors to be reimbursed through Medicare for end-of-life consultations with patients • Reuniting Rutgers University and Robert Wood Johnson Medical School-The Time to Act is Now • Major Tax Law Changes in 2010 Require Immediate Action
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Publisher’s Letter
Dear Readers,
Published by Montdor Medical Media, LLC
We are most sad to inform the New Jersey medical community of the passing of
Publisher and Managing Editor Iris Goldberg
Steven Kern, Esq. on January 10th. Steve was an ally and friend to many of our readers as well as a writer and special friend to New Jersey Physician magazine.
Photographer Ken Alswang, At Home Studios
His law firm, Kern Augustine, Conroy and Schoppmann focuses exclusively on defending and representing physicians and medical societies throughout the country. He is and will be dearly missed. Our cover story this month features the doctors of Podiatry Food & Ankle Institute, a practice that handles the most complex foot and ankle disorders. Antonella Cella, DPM and Edward Harris, DPM see patients needing some of the most sophisticated reconstructive surgical procedures as well as treating the more commonly seen problems of the lower extremities. Registration has opened for EHR Incentive Programs, in New Jersey this would apply to Medicare at this time while other states have also opened for Medicaid reimbursements. Information on how to register can be found inside.
Contributing Writers Iris Goldberg, Michael Goldberg, Lawrence Epstein, Richard McCormick, Steve Mizrach, CPA, John Fanburg, Esq., Carol Grelecki, Esq., Mark Manigan, Esq. New Jersey Physician is published monthly by Montdor Medical Media, LLC., PO Box 257 Livingston, New Jersey 07039 Tel: 973.994.0068 Fax: 973.994.2063
For Information on Advertising in New Jersey Physician, please contact Iris Goldberg at 973.994.0068 or at igoldberg@NJPhysician.org Send Press Releases and all other information related to this publication to
The state legislature has passed a philosophical exemption rule for mandatory immunizations. There are some limitations contained in this ruling that physicians treating patients under this rule should be aware of, such as not
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in an emergency. Should Rutgers University and Robert Wood Johnson Medical School be reunited? Richard McCormick, President of Rutgers says this should take place and the time for action is now. Please see if you agree with his reasoning. Finally, there have been some major tax changes that apply to your practice for
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With Warm Regards,
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Contents
COVER STORY
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PHOTO BY Ken Alswang, At Home Studios
Podiatry Foot & Ankle Institute Specializing Exclusively in the Comprehensive Medical and Surgical Treatment of Foot and Ankle Disorders
The surgeons at Podiatry Foot and Ankle Institute treat patients for a myriad of disorders that range in complexity from laser removal of toe nail fungus to intricate reconstructive surgical procedures. Dr. Cella and Dr. Harris are expertly trained to treat any illness or injury of the foot or ankle.
JANUARY
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Finance
Major Tax Law Changes in 2010 Require Immediate Action Congress finally passed the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010. The Act extends and modifies many of the provisions first enacted in the 2009 American Recovery and Relief Act.
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CONTENTS Hospital Rounds
Pediatric Cardiac Surgery Program Opens at Children’s Hospital of New Jersey Pediatric cardiac surgery is now available at Children’s Hospital of New Jersey (CHoNJ) at Newark Beth Israel Medical Center under a new partnership with NYU School of Medicine.
9 Rembering Steven Kern 10 STATLaw 11 Association News CMS Launches Physician Compare Website
12 Statehouse 14 Finance Major Tax Law Changes
16 Hospital Rounds Pediatric Cardiac Surger Program Opens at Children’s Hospital of New Jersey
18 Legal Issues Launch of Medicare & Medicaid Electronic Health Record Incentive Programs Our-of-Network Bill Undergoes Another Revision Prior to Leaving Committee
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Cover Story
Podiatry Foot & Ankle Institute
Specializing Exclusively in the Comprehensive Medical and Surgical Treatment of Foot and Ankle Disorders By Iris Goldberg
Edward Harris, DPM, FACFAS, FACFAO and Antonella Cella, DPM, MS, FACFAS of Podiatry Foot & Ankle Institute in Hackensack, maintain an all-inclusive podiatric practice, offering state-of the-art care for the entire gamut of foot and ankle problems that range in complexity from the latest laser removal of toe nail fungus to intricate reconstructive surgical procedures. With more than 20 years of combined experience, Drs. Harris and Cella perform an extensive list of foot and ankle procedures that include but are not limited to:
PHOTOs BY Ken Alswang, At Home Studios
In today’s current healthcare arena, where many physicians and surgeons choose to hone their skills in order to provide care within a narrowed, sub-specialized area of medicine, patients benefit from the significant expertise which results. Podiatrists have always been uniquely trained to deliver specialized treatment for a wide range of conditions affecting the foot and ankle. There is a misconception by some, however, regarding the extent of the podiatrist’s domain when serious foot or ankle disorders require expert attention.
• Comprehensive diabetic foot care • Treatment for common conditions such as bunions, hammertoes, bone spurs, heel pain, nail infections, warts and callus/corns with minor surgeries performed in office • Specialized bunion, hammertoe and forefoot reconstruction • Ankle arthroscopies for painful arthritic conditions and ankle instabilities • Repair of complex fractures • Ankle fusions/midfoot fusions • Advanced ankle and rear foot surgery • Tendon transfers for muscular imbalances and structural bone deviations, such as drop foot deformities • Treatment of sports injuries for pediatric and adult patients • Non-invasive neuromuscular stimulation for relief of pain caused by neuropathy, general leg, ankle and foot pain and diabetic ulcers • Vascular testing • Splints, casts, padding and orthotics Dr. Cella discusses some of the specialized procedures offered at Podiatry Foot & Ankle Institute that some might mistakenly believe are only performed exclusively by orthopedists. “Achilles tendon repairs, Charcot reconstruction, external fixators, ankle fractures, calcaneus fractures – all the rear foot problems,” she states. In fact, Dr. Cella is one of only a few hundred physicians in the country who are board-certified in rear foot/ankle and trauma surgery. One example of a rear foot surgical procedure is Charcot foot reconstruction.
p Edward Harris, DPM (left) and Antonella Cella, DPM (right) of the Podiatry Foot & Ankle Institute
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New Jersey Physician
Charcot foot is a softening of the bones of the foot that occurs in people with severe peripheral neuropathy, predominantly those
p Lateral radiograph of a midfoot/rearfoot reconstruction with beaming using large bore threaded screws as well as a subtalar implant for better support
with diabetes. The muscles lose the ability to support the foot, leading to a slackness of ligaments, dislocation of joints, damage to bone and cartilage and deformity. In the past, the only option for a patient with a severe deformity in the rear foot or ankle was amputation. Now with technologically advanced implants and external fixators that are strong enough to bear the entire weight of the body, the deformed foot can be saved. “When you do a reconstruction of a Charcot foot, you pretty much have to break the foot and put it back together,” explains Dr. Cella.
Besides reconstructive surgery, Podiatry Foot & Ankle Institute provides the diabetic patient with the entire spectrum of specialized foot care necessary for addressing the complications suffered by so many who are now afflicted as the diabetes epidemic continues to grow. “Treating the diabetic has now become a significant healthcare concern,” notes Dr. Harris.
dangerously long period of time to close before irreversible damage could occur.
Effective diabetic wound care is crucial for the prevention of amputations. Dr. Harris discusses the innovative modalities that he and Dr. Cella utilize in order to promote a more rapid healing process. “We use a variety of different products that help us close wounds,” Dr. Harris shares.
To maximize the success of a grafting procedure, the physicians at Podiatry Foot & Ankle Institute use a vacuum-assisted closure (VAC) device. The device consists of a vacuum pump, a canister with a connecting tube, an open pore foam and a semi-occlusive dressing. VAC therapy accelerates healing through negative pressure wound therapy (NPWT). By delivering negative pressure at the wound site through a patented dressing, this helps draw wound edges together, remove infectious materials and actively promote granulation at the cellular level.
There are two types of skin grafts that are used. Synthetic grafts are readily available and are a good choice for those whose morbidity prevents them from donating their own skin. For patients without contraindications, it is a relatively simple procedure to remove some skin from the leg and graft it to the wound. The grafts that are the patient’s own are less likely to be rejected. Either way, grafting allows a wound that would otherwise remain open for a
Besides caring for diabetic patients, Drs. Cella and Harris treat patients for the full spectrum of foot disorders. Sometimes, just the shape of a bone can result in a debilitating condition. One example of this is a painful Achilles tendon spur with a Haglund’s deformity. This occurs mostly from chronic pressure on the back of the heel from shoes. The calcaneus (heelbone) is the largest bone in the foot. However, it is shaped differently in different people.
p Dr. Harris examines a foot wound in a patient with diabetes JANUARY 2011
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The Achilles tendon attaches to the back of the calcaneus. Between the bone and the Achilles tendon rests a lubricated sac of tissue (bursa) that allows the tendon to slide easily against the bone during movement of the foot. The spur squeezes the soft tissues between the bone and the back of the shoe. Eventually, this irritates the soft tissue and causes inflammation. Over time, swelling and thickening of the tissues may develop which actually makes the pressure worse. A thick callus can grow and become inflamed while the individual is wearing shoes. The bursa on the back of the heel can become swollen and inflamed as well (bursitis). When the situation interferes with the quality of life, patients who are seen at Podiatry Foot & Ankle Institute will be evaluated to determine if they could benefit from a surgical procedure to reduce the prominence on the back of the heel by removing the exostosis. Dr. Cella shares the case of a woman with Haglund’s deformity that resulted in a partial tear of her Achilles tendon. She recently underwent a surgical procedure. “I detached the Achilles tendon at its insertion, cut the prominent bone, re-attached the tendon with an absorbable anchor and repaired all tears in the tendon,” Dr. Cella relates.
Some patients are seen at Podiatry Foot & Ankle Institute for an Achilles tendon rupture. This condition typically occurs in an unconditioned individual who sustains a rupture while participating in sports, or perhaps, merely from tripping. There is a vigorous contraction of the muscle and the tendon tears. The goal of treatment is to restore normal length and strength to the tendon. This is almost always accomplished by a surgical procedure to correct the tension between the muscle and tendon by accurately repairing the many tendon ends that separate as a result of the injury. Dr. Cella and Dr. Harris also perform surgeries on neglected Achilles tendon ruptures using muscle flaps and tendon grafts.
New Jersey Physician
Inside the joint, the bones are covered with articular cartilage, which is the material that allows the bones to move smoothly against one another within the joint. An ankle fusion actually removes the cartilage surfaces of the ankle joint and allows the tibia to grow together or fuse with the talus, thereby eliminating the pain.
Another procedure performed at Podiatry Foot & Ankle Institute is ankle arthrodesis (fusion). This surgery is performed when the ankle joint becomes worn out and painful, usually as a result of degenerative arthritis. Many people develop arthritis in the ankle years after suffering a fracture.
p O.R. picture after application of an external fixator for an ankle fusion
The ankle joint consists of three bones: the lower end of the tibia (shinbone), the fibula (small bone of the lower leg), and the talus (bone that fits into the socket formed by the
In order to perform the fusion, an incision is made in the skin to expose the joint. Then the surgeon uses a surgical saw to remove the
p Intraoperative picture of an Achille’s tendon rupture using a gastrocnemius fascial flap
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tibia and fibula). The talus sits on the top of the calcaneus (heelbone).
articular cartilage surfaces of the ankle joint. Once the articular cartilage is removed on both sides of the joint, the body will start to heal or fuse the two surfaces together, just as it does after a fracture. It is crucial for the angles of the cut surfaces to remain correct while the bones fuse. To hold the bones in place, Drs. Cella and Harris use large metal screws and metal plates. In some cases an external fixator is also used to hold the bones together while they heal. This apparatus has metal pins that are inserted through the skin and into the bone. The metal pins are connected to metal rods and bolts outside the skin that hold the bones in position while the ankle fuses. The external fixator is removed after the bones have healed, usually within 12 to 15 weeks.
Although some fractures of the ankle or foot may be repaired with casting, others will require a surgical procedure. Calcaneal (heel) fractures that require surgery can be serious and may lead to complications causing longstanding problems of the foot and ankle. While explaining this procedure, Dr. Cella reiterates the importance of choosing a surgeon who has been extensively trained in rear foot/ankle and trauma surgery.
At Podiatry Foot & Ankle Institute, external fixators are used in the management of foot and ankle pathology in conjunction with a variety of procedures. Some examples of these are Charcot reconstruction, ankle fractures, flatfoot reconstruction, as well as ankle fusions.
Surgery to repair an ankle fracture is performed at Podiatry Foot & Ankle Institute for those patients who have suffered a displaced ankle joint, involving either the bone on the inside of the ankle (medial malleolus), the bone on the outside of the ankle (lateral malleolus, which is also known as the fibula), or both. An incision is made on the outside and inside of the fibula and tibia. The soft tissue is dissected down to the fracture site. The fracture, itself, is cleaned and the bones are put back together in the exact way they were prior to the fracture. Once positioned, there are a variety of ways to stabilize the bones. The most common method is putting a screw across the fracture site for compression. This is followed by a metal plate with a series of screws to hold the fibula in its position. Lateral ankle ligament tear is another ankle injury commonly seen at Podiatry Foot & Ankle Institute. The ankle and foot are held together by ligaments and tendons. The ligaments on both sides of the ankle are tightly attached to the bones. On the outside (lateral) aspect of the ankle are 3 major ligaments that help to restrict the motion of the ankle joint. When there is an injury to the ligaments they can be stretched out or torn, leading to sprain of the ligaments which weakens them. In some cases, when the rotational forces are strong enough, the ankle can fracture as well. There can also be damage to the cartilage of the ankle joint leading to a defect of the cartilage (osteochondral defect). If left untreated, lateral ankle ligament tears can lead to lateral ankle instability, which causes chronic pain, loss of function and usually requires surgical correction.
While external fixation does not replace internal fixation, it does offer a number of specific advantages. Unlike internal fixation, which becomes a fixed, static construct once applied, external fixators can be adjusted in order to improve skeletal alignment or apply compressive or distractive forces across joint fusions. In addition, frames can be adjusted to correct severe deformities such as clubfoot, which would otherwise not be acutely correctable. Also, since external fixation constructs are designed to be extremely rigid and stable, it is possible for patients to have partial to full weightbearing while the device is in place.
Surgical treatment of calcaneus fractures usually involves making an incision over the outside of the foot and applying internal fixation consisting of a metal plate and screws into the broken heel bone. Dr. Cella explains that the goal of the surgery is to restore the normal alignment of the bone and return the cartilage surface as close to normal as possible. Post-operative patients must be monitored carefully. It is critical to control swelling and patients will be required to keep weight off of the foot for up to three months.
p A/P radiograph of an open reduction external fixation of an ankle fracture
p Complete inspection of tendon trauma is essential for a successful repair by removal and then reapproximation of a damaged tendon
p Lateral and oblique radiographs of a calcaneal fracture after open reduction with internal fixation
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In some cases, the stretched out ligaments can be tightened through arthroscopy. Small incisions at the front of the ankle allow for the introduction of a camera and with instrumentation, the ligaments are tightened. In most cases, however, the ankle joint will need to be opened over the area of the ligaments in order to visualize them. The ligaments can then be repaired by placing them back onto the bone in their anatomic position. Dr. Cella explains that in some cases, she will use absorbable bridge anchors to anchor the ligaments into the bone. This repair will tighten and strengthen the ligaments again. When the ligaments are too weakened to repair, cadaver tendon or a split tendon from the patient is used to create new ankle ligaments. This tendon is then routed through the bones of the ankle to reinforce it. One of the innovative treatments offered by Dr. Harris and Dr. Cella is a much improved
surgical correction for disorders of the toes, specifically hammertoes, claw toes and mallet toes, which result in deformity and significant pain. Many patients are seen at Podiatry Foot & Ankle Institute for treatment of these debilitating conditions. When toes are bent for long periods of time, their muscles shorten, leading to eventual deformity. Other causes include muscle nerve or joint damage resulting from osteoarthritis, rheumatoid arthritis, stroke and diabetes. Surgery to straighten the toe and allow for natural flexibility may involve cutting or realigning tendons, re-balancing muscle and/ or removing small portions of bone. Until recently, when bone was removed to correct and repair the rigid, bent toes associated with these disorders, a “k-wire” was then inserted to stabilize the toe for as long as six weeks. The wire protruded out from the opening in the toe. This process was often painful, uncomfortable and prone to infection.
The surgeons at Podiatry Foot & Ankle Institute now utilize the Smart Toe® Memory Implant, an innovative device that permits arthrodesis or fusion of the toe joint to be accomplished completely internally without the need for an external wire. Its “memory” capability helps compress the joint into its proper shape. Also, the one-piece design doesn’t interfere with nearby healthy joints and the Smart Toe® implant resists rotation problems common to traditional hammertoe, mallet toe and claw toe corrective surgeries. The risk of “pin tract” infection at the sight of the open wound that is common with “k-wire” stabilization is eliminated with the Smart Toe® procedure. “The process is now much easier and provides an optimum result that is long-lasting,” Dr. Harris emphasizes.
p Radiograph shows the Smart Toe™ implant that is totally internal and eliminates the complications associated with the traditional “k-wire” procedure.
Maintaining foot health is crucial for the quality of our lives. When illness or injury occurs, the impact can be devastating. At Podiatry Foot & Ankle Institute Dr. Harris and Dr. Cella have been specifically trained and are expertly qualified to care for and treat any disorder associated with the foot and ankle. For patients and referring physicians alike, it is imperative to know where to turn when disease or trauma to the foot or ankle interferes with normal its function. Those who choose Podiatry Foot & Ankle Institute can be assured of receiving the highest level of care and treatment that is available today. Podiatry Foot & Ankle Institute is located at Hackensack University Medical Plaza, 20 Prospect Avenue, Suite 803, Hackensack NJ 07601. To schedule an appointment with Dr. Harris or Dr. Cella, or for p Dr. Cella utilizes a curvilinear lateral incision for the repair of the lateral collateral ligaments with the use of a bioanchor modified Brostrum screw/thread bridge anchored into the fibula
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further information, please call 201- 488-FOOT (3668)
In Remembrance
Remembering Steven Kern By Michael Goldberg
Steven I. Kern, Esq., passed away on Monday, January 10th at Mt. Sinai Medical Center in Manhattan after a 7-week battle in the ICU following complications from a blocked artery. Steve was born in 1949 and raised with his brother Frank in Irvington and Union, NJ by his parents Bernard and Ruth. Shortly after losing his father to Hodgkin’s lymphoma, Steve was diagnosed with the same cancer and was treated with radiation when he was just twenty years old. He was a cancer survivor for more than forty years.
During this time, he made the most of life. Steven Kern attended Lehigh College and then continued on to The NYU School of Law. After graduating, he became a NJ Deputy Attorney General assigned to the State Board of Medical Examiners. He then went on to start his own law firm. Kern Augustine Conroy & Schoppmann, PC now has offices in NJ, NY, PA, and FL, and is nationally renowned for its expertise in defending and representing physicians, and for representing numerous medical societies throughout the country. Steve loved writing. He was an editorial consultant to Medical Economics Magazine and Modern Medicine.com, a frequent contributor to MedScape, MD News, and New
Jersey Physician, and a former member of the editorial board of New Jersey Lawyer. Steve is survived by his beloved wife Cheryl; his four loving children: Lindsay, Brian, Cynthia, and Alex; his brother Frank, his two grandchildren Maximus and Tyson; and his loving mother Ruth. A memorial service to honor the life of Steven Kern was held on Friday January 14th, 2011 at 3:00 pm at the Olde Mill Inn in Basking Ridge, NJ attended by family, friends and colleagues. Steve was a source of support and friendship to me during my reign as the former publisher of MD News magazine. He offered the same to Iris as she ventured forward during her first year as publisher of New Jersey Physician. Steve was a close personal friend as well, who is much missed.
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STATLaw Legal Issues
In Memoriam
It is with sadness that the partners of Kern Augustine Conroy & Schoppmann, P.C., share with you news of the passing of our fellow partner, friend and colleague, Steven I. Kern, Esquire. Steve was one of the firm’s founding members and a nationally recognized health law litigator. All of us at Kern Augustine Conroy & Schoppmann, P.C., were inspired by Steve’s dedication and excellence, and remain committed to providing our clients with only the highest levels of advocacy, service and representation.
Registration Opens for Electronic Health Records (EHR) Incentive Programs On January 3, 2011, CMS opened registration for the Medicare EHR Incentive Program and, in some states (not New Jersey as yet), the Medicaid EHR Incentive Program. The Medicare & Medicaid EHR Incentive Program Registration and Attestation System Web site is located at https://ehrincentives.cms. gov/hitech/login.action and Registration User Guides with step-by-step instructions are provided at http://tinyurl.com/24f6ef7. A Medicare guide comparing the EHR Incentive Program, the Physician Quality Reporting Incentive Program and the E-Prescribing Incentive Program is available at http:// www.cms.gov/MLNProducts/downloads/ EHRIncentivePayments-ICN903691.pdf.
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State Regulatory Activity
NJ State Board of Medical Examiners’ Athletic Training Advisory Committee has proposed significant rule changes to reflect statutory changes in practice, including allowing athletic trainers to work outside of the school or professional team setting. See: http://www.njconsumeraffairs.gov/proposal/ bmepro_010311.htm. - The NJ Dept of Banking & Insurance (DOBI) issued Bulletin 10-36, Assignment of Health Benefits Under Managed Care Plans, to try to clarify requirements of the law that takes effect January 16, 2011. See: http://www.state.nj.us/dobi/bulletins/blt10_36. pdf. - DOBI proposes rule amendments, http:// www.state.nj.us/dobi/proposed/prn10_304. pdf, under NJ’s Health Care Quality Act, to meet the Health Care Reform Act’s prohibition on requiring preauthorization in certain instances for emergency and/or urgent care services. - The NJ Dept of Health & Senior Services (DHSS) has re-proposed rules outlining the registration and application process for patients, caregivers, physicians, cultivators and dispensers to participate in NJ’s Medicinal Marijuana Program. The proposal is at http:// www.state.nj.us/health/med_marijuana.shtml. - DHSS proposes rules to require hospitals and skilled nursing facilities to establish a violence prevention program, and to minimize unassisted patient handling through requiring the use of patient handling equipment. The proposals are available at http://www.state. nj.us/health/legal/open.shtml.
Enforcement Activity CVS Pharmacies in New Jersey and New York have agreed to pay nearly $1 million to settle federal charges that CVS billed Medicare and TRICARE for prescriptions filled by a pharmacist who was excluded from participating in federal health care programs. An excluded person’s participation in services billed to federal healthcare programs results in false claims which, in this case, allowed for recovery of double damages for all such claims paid. Exactech, Inc., an orthopedic implant device manufacturer and distributor, has agreed to enter into a into a compliance and federal monitoring program and pay nearly $3 million to settle government claims that the company entered into consulting agreements with orthopedic surgeons as an inducement for the surgeons to utilize the company’s products, in violation of the federal Anti-Kickback Statute. Its northeast regional sales director entered a guilty plea related to the agreements and falsifying documents, which could result in imprisonment, monetary penalties, and restitution. Find more information on the above items at www.drlaw.com.
Association News
CMS Launches Physician Compare Website CMS recently launched the first phase of a searchable online physician directory for Medicare patients called Physician Compare. The site, currently includes information on contacts and addresses; gender, medical specialty, the professional’s education, residency or other training; and languages the professional speaks besides English. Eventually, Physician Compare will show whether physician practices have submitted data to SMS on the Physician Quality Reporting System (PQRS).
We have heard from several MGMA members that some of the posted information is incomplete and/or inaccurate information. We were concerned about this issue prior to implementation and made CMS aware of our concerns in our comment letter submitted to CMS on November 30th and in direct conversations with the agency. In our formal communication, we stated that “the information must be up to date, correct and easy to understand. In order to assure accuracy, MGMA recommends CMS establish
a process by which an individual physician, or physicians in a group practice can review and update their demographic information directly through the Web Site.” Additionally, we stated that “physicians and other providers involved in the treatment of a patient must have the opportunity for review and comment. Lawrence Epstein, Chair, NJMGMA Legislative and External Relations Committee
Let Brach Eichler’s Health Law Practice Group Help You Chart a Strategic Course For Your Health Care Business Health care providers have long come to rely on the attorneys of Brach Eichler to navigate the regulatory environment at both the state and federal levels. Now that health care reform is being implemented, Brach Eichler is ready to help you make sense of the significant changes, the statutory framework and the ramifications for health care providers in New Jersey. Health Law Practice Group Todd C. Brower Lani M. Dornfeld
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New Jersey Statehouse 9/11 health care bill, named for N.J. man, passes Congress Congress on Wednesday passed a $4.2 billion measure to provide health care and compensation for 9/11 responders and survivors. The legislation, slashed from the original $7.4 billion proposal, would aid emergency workers suffering health problems as a result of working at ground zero after the Sept. 11, 2001, terrorist attacks. The House gave its final approval of the bill, 206-60, after it cleared the Senate. A 57-42 Senate vote Dec. 9 was short of the 60 votes needed to break a GOP filibuster; Republicans had objected to the cost, among other concerns. Democratic Sens. Charles Schumer and Kirsten Gillibrand of New York successfully pushed a new version of the legislation, which would provide $4.2 billion over five years. The bill passed the Senate in a unanimous vote. The James Zadroga 9/11 Health and Compensation Act was named after Zadroga, a New York City police detective who died at 34 of respiratory problems in 2006; he’d been living at his parents’ Little Egg Harbor home. The bill would guarantee benefits for responders and recovery workers whose illnesses are linked to breathing toxic fumes during rescues and cleanup. Many workers wore only paper masks. “Thousands of New Jersey’s first responders and workers who answered the call to service in the wake of September 11th will now be guaranteed the benefits they deserve,” said Sen. Frank R. Lautenberg, D-N.J., a bill cosponsor. “It is shameful that we had to fight back Republican opposition to achieve this victory, but we are finally on track to fulfill the moral mandate we have to our war wounded.” The legislation calls for monitoring illnesses and examining their causes through a World Trade Center Health Program within the National Institute for Occupational Safety and Health. Costs would be controlled by limiting an existing program for first-responder medical monitoring to 15,000 new participants and allowing another 15,000 people to enroll in a program for residents and nonresponders. The legislation also would reopen the 9/11 Victims Compensation Fund, closed since 2003, for economic losses. In addition, the fund would be reopened to applications from people who did not apply because they were not sick at the time of the December 2003 filing deadline, according to Lautenberg’s office. Schumer credited emergency responders with the legislative victory. “We were sort of the players who moved the pieces on the chessboard,” Schumer said. “Without them, there wouldn’t have even been a game.” In a compromise with Sen. Tom Coburn, R-Okla., who objected to the bill’s cost, the measure was trimmed from $7.5 billion in the House and
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New Jersey Physician
$6.2 billion in the Senate. The legislation is among the final bills the 111th Congress considered.”Our Christmas miracle has arrived,” Gillibrand said. Zadroga’s father, Joseph Zadroga of Little Egg Harbor, was unavailable for comment Wednesday. The bill will head to President Barack Obama, who was expected to sign it.
Doctors to be reimbursed through Medicare for end-of-life consultations with patients. When the many planks of national health care reform were being debated last year, one part of the package that many critics latched onto was a clause pertaining to doctors consulting patients about endof-life counseling — essentially, patients having conversations with their doctors about living wills and appropriate or needed medical treatments and tests when the patient knows he or she may have a limited time left. On Jan. 1, new Medicare rules went into effect that allow the federal health insurance program to reimburse doctors for voluntary end-of-life counseling with patients. It’s perfectly reasonable that doctors should talk with patients who know that death is approaching about what kind of medical care they want and what they may not want, about what goes into crafting living wills and about health care proxies who can make medical decisions for a patient when that that patient can no longer make decisions. It should always be a patient’s decision whether to talk to a doctor about these important decisions. And, if patients choose to have these consultations with their doctors, their Medicare should cover it. For Medicare to purposefully not reimburse doctors for such important sessions with individual patients because of political conjecture and foolish propaganda about death panels and seniors with terminal conditions being urged to commit suicide would be wrong. This is a relatively minor but appropriate change in Medicare reimbursement rules that foremost benefits those who rely on Medicare coverage and those who need to be able to speak frankly with their doctors about some of the hardest decisions they’ll ever make in life. In whatever push materializes in Washington with the new Congress to repeal some or all of the reforms included in last year’s health care legislation, we hope the heated rhetoric and propaganda about this issue have been permanently put to bed and that this sensible change in Medicare reimbursement policy won’t be reversed.
Legislature Provides for Philosophical Exemption to Mandatory Immunizations
any other university in the state, and more than all of the state’s other public colleges and universities combined. But we must do better.
While provisions in the New Jersey Administrative Code grant students medical and religious exemptions from immunizations, currently no law permits philosophical exemptions. Accordingly, this bill would grant a philosophical exemption from a mandatory immunization to any person attending a public or private institution of higher education, public or private school, kindergarten, nursery school, preschool or child care facility in New Jersey. The bill provides that a student seeking a philosophical exemption shall submit a notarized, written statement to his school signed by the student, or if the student is a minor, by the student’s parent or legal guardian. The statement shall explain how a specific immunization conflicts with a personal, philosophical or moral belief held by the student or the student’s parent or legal guardian. The student’s school shall grant the exemption and keep the statement on file as part of the student’s immunization record. A student with a philosophical exemption shall not be permitted to attend school during a disease outbreak or threatened outbreak, as determined by the Commissioner of Health and Senior Services.
Add to those observations the untapped synergy between higher education and the state’s health care industry and the opportunities are clear. Reuniting Rutgers with Robert Wood Johnson Medical School would create an academic powerhouse that would significantly enhance the quality of New Jersey higher education and would benefit residents across the entire state.
This bill provides for philosophical exemptions from mandatory immunizations. Under current law, the State requires certain immunizations for students as a condition for attending public or private institutions of higher education, public or private schools, kindergartens, nursery schools,w preschools and child care facilities in New Jersey.
A philosophical exemption may also be suspended at any time by the commissioner in an emergency. Further, pursuant to N.J.S.A.26:4-6, a school official, taking into consideration the spread of a communicable disease, may prohibit the attendance of a student with a philosophical exemption and specify the amount of time the student must remain away from the school.
REUNITING RUTGERS UNIVERSITY AND ROBERT WOOD JOHNSON MEDICAL SCHOOL: THE TIME TO ACT IS NOW By By Richard L. McCormick, President – Rutgers, The State University of New Jersey
For far too long, medical research and education in New Jersey have fallen short of their potential for greatness. This is one of the most compelling conclusions in a comprehensive report on the future of higher education in New Jersey. This visionary report – released recently by Gov. Chris Christie and former Gov. Thomas H. Kean, who chaired the Governor’s Task Force on Higher Education – recommends an overhaul of medical research and education across New Jersey. Some of the ideas in the report – including proposals to consider merging medical training with other higher education institutions in Newark and South Jersey – are complex and deserve careful deliberation. But one major step toward excellence in medical education can, and should, be implemented immediately – reuniting Rutgers University with Robert Wood Johnson Medical School in New Brunswick and Piscataway. Why? Because virtually all of the best medical schools in the nation are affiliated with top research universities, attracting the highest levels of funding for research that benefits society and bolsters the local economy. Rutgers already brings more federal research funding to New Jersey than
As the Kean task force argues in its report, “For a state to be great, it must have a great state university. … For New Jersey’s students to receive the quality of higher education they deserve, and for all our citizens to have the economic future we want, Rutgers must become a great university. … Having a medical school would help Rutgers attract top-flight researchers, increase federal research grants, and create exciting interdisciplinary opportunities among Rutgers’ distinguished academic departments.”
Why now? Because Rutgers University and Robert Wood Johnson Medical School already have successfully collaborated for a half-century. Reuniting these world-class institutions can be easily achieved – providing an immediate boost to New Jersey’s national profile in teaching and research, and enabling the state’s leaders to focus their attention on solving higher education’s most chronic problems. Here’s a little background. The Rutgers Medical School was formed in 1961 and enrolled its first class in 1966. Four years later, the medical school was severed from Rutgers and absorbed into what is now the University of Medicine and Dentistry of New Jersey (UMDNJ). The medical school was renamed after Robert Wood Johnson in 1986. Since then, political pressure has squelched efforts to reorganize UMDNJ and reunify Rutgers with Robert Wood Johnson Medical School. “The need to reform medical education in New Jersey, and the institutions that serve it, is an important public policy and educational issue that has been discussed for years and left unresolved,” the task force report states. “Resolution of this serious matter for New Jersey is imperative.” Despite obstacles, Rutgers and the medical school already enjoy a highly productive relationship. Nine medical school buildings in Piscataway sit on 66 acres of Rutgers-owned property that we lease to UMDNJ. We jointly manage two of the region’s most successful research institutes: the Center for Advanced Biotechnology and Medicine and the Environmental and Occupational Health Sciences Institute. The medical school offers 12 joint programs with Rutgers, leading to advanced degrees in such fields as biomedical engineering, molecular genetics, health care management and neuroscience. Fully unifying the medical school’s resources in clinical studies and public health with Rutgers’ engineering and pharmaceutical programs would unleash an economic engine that would benefit many core state industries, including drug development and medical-device manufacturing. The overhaul of medical education in New Jersey should not overshadow the task force’s other significant proposals – including improved governance for higher education, greater assistance for students in need, and better funding for both the operating budgets and the capital facilities of the state’s public colleges and universities. But reuniting Rutgers University with Robert Wood Johnson Medical School is a critically important place to start. As the task force concludes: “The question is not whether to act, but when. The answer is now.” JANUARY 2011
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Finance
Major Tax Law Changes in 2010 Require Immediate Action
By Steven Mizrach, CPA, Dorfman Mizrach & Thaler, Certified Public Accountants and Advisors
After much speculation and anticipation, Congress finally passed the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010 (the Act). The president signed it into law on December 17th. The Act, in essence, extends the 2001/2003 Bush-era tax cuts for two years. The Act also provides a payroll tax holiday for 2011 and a change in the exemption amount and maximum tax rate for estate taxation. The Act extends and modifies many of the provisions first enacted in the 2009 American Recovery and Relief Act. Personal Income Tax Provisions
• Income tax rates. The Act extends the
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New Jersey Physician
10% individual income tax bracket as well as the 25%, 28%, 33%, and 35% individual income tax brackets for an additional two years, through 2012. • Capital gains rates. The Act allows the capital gains rates to remain at 0% for taxpayers below the 25% bracket and 15% for taxpayers in the 25% rate and above, through 2012. Without the legislation, the capital gains rates were scheduled to expire at the end of 2010, and revert to 10% and 20%, respectively. • Dividends taxed at capital gains rates. The current dividend rates of 0% for taxpayers below the 25% bracket and 15% for taxpayers in the 25% bracket and above are extended through 2012. Without the
legislation, these rates were set to expire at the end of 2010, taxing dividends at the ordinary income rates. • Employee payroll tax cut. For 2011 only, the Act reduces the Social Security tax rate on employees to 4.2% (from 6.2%) and reduces the self-employment tax rate to 10.4% (from 12.4%). Business Income Tax Provisions
• Employer-provided mass transit and parking benefits. The Act extends the increase (set at $230 in 2010) in the combined monthly exclusion for employer-provided transit and vanpool benefits through the end of 2011. • Exclusion for employer-provided educational assistance. An employee may
exclude from gross income up to $5,250 for income and employment tax purposes per year of employer-provided education assistance. Earlier legislation expanded this provision to include graduate as well as undergraduate education through the end of 2010. The Act extends this expansion of the exclusion for an additional two years, through 2012. The credit is subject to a phase-out for taxpayers with adjusted gross income in excess of $80,000 ($160,000 for married couples filing jointly). • Exclusion of 100 percent of gain on certain small business stock. The Act extends the 100% exclusion of the gain from the sale of qualifying small business stock acquired before 2012, and held for more than five years. In addition, the alternative minimum tax preference item attributable for the sale remains eliminated. Qualifying small business stock is stock from a C corporation whose gross assets do not exceed $50 million (including the proceeds received from the issuance of the stock) and that meets a specific active business requirement. The amount of gain eligible for the exclusion is limited to the greater of 10 times the taxpayer’s basis in the stock or $10 million of gain from stock in that corporation. • Bonus Depreciation. The Act extends the 50% bonus depreciation provision for qualified property acquired after December 31, 2007, and before January 1, 2013. In addition, it allows for 100% bonus depreciation for property acquired andw placed in service after September 8, 2010, and before January 1, 2012. Thus, taxpayers can claim a 100% depreciation deduction for property acquired and placed in service in the latter third of 2010, all of 2011 (and 2012, for certain property). Property placed in service during 2012 (2013 for certain property) would be eligible for 50% bonus depreciation. There are no investment or income limitations associated with the 100% or 50% bonus depreciation. As in the past,
qualified property includes leasehold improvements. • Small Business Expensing. Under prior legislation, for taxable years beginning in 2010 and 2011, small businesses may elect to expense up to $500,000 of capital investment, with the phase out beginning at $2,000,000. In view of the new 100% bonus depreciation rules, if property acquired and placed in service from September 9, 2010, through December 31, 2011, was in excess of the expensing limitations during that period, you should consider whether it would be advantageous to claim 100% bonus depreciation, rather than electing to expense the cost. • Expensing of Environmental Remedial Costs. The Act extends, from December 31, 2009, the election to deduct environmental remediation costs in lieu of capitalization through December 31, 2011. • Business Mileage Rate. The standard mileage reimbursement rate for 2011 will be 51 cents-per-mile, one cent increase from 2010. Estate and Gift Tax Provisions
• Increase in the Estate Tax Exemption. For decedents dying in 2011 and 2012, the Act greatly reduces the reach of the estate tax by granting estates a $5.0 million exemption for property subject to the tax. • Portability of the Estate Tax Exemption. If one spouse does not use all of his or her $5.0 million exemption, it may be used by the estate of the surviving spouse, effectively creating a $10.0 million exemption for married couples. • Reduced Tax Rate. Estates that exceed the $5.0/$10.0 million threshold will be subject to a new 35% tax rate, compared to the 45% rate that prevailed before 2010. • Alignment of Estate and Gift Tax Exemptions and Tax Rates. The gift tax exemption is increased to $5.0 million for gifts made in 2011 and 2012, and the tax rate on 2011 and
2012 gifts in excess of that amount is 35%. • Estates of Decedents Dying in 2010. The estates of those who died in 2010 faced considerable uncertainty prior to the passage of this legislation. A 2001 law repealed the estate tax for persons dying in 2010, but also imposed a carryover basis regime that required that heirs use the decedent’s tax basis for inherited property. Before 2010, that property had received a basis step-up at death. For some heirs, this 2010 requirement was a greater tax burden than would have been imposed by the estate tax. In addition, there was a risk that the estate tax would be retroactively reinstated for 2010, so many executors did not know what to do. Congress has now eliminated that uncertainty for 2010 estates. It has repealed carryover basis and reinstated the estate tax for 2010, but with the $5.0 million exemption and 35% tax rate that are also available in 2011 and 2012. The new law also provides that estates of persons dying in 2010 can elect out of the estate tax, provided that they accept the carryover basis regime. The estate tax return is normally due nine months after the date of death. In light of the special circumstances in 2010, the Act extends that filing date (as well as the payment date for the tax) for 2010 decedents to September 17, 2011. • Generation-Skipping Transfer (GST) Tax. The Act aligns the GST tax with the reformed estate and gift taxes. In 2011 and 2012, the GST exemption is increased to $5.0 million and the tax rate is 35%. In 2013, the GST tax, like the estate and gift taxes, will revert to a $1.0 million exemption and a 55% tax rate. The Act did not change prior law which allows for a 0% GST tax rate for GST transfer made during 2010. As you can see, the Act addresses many areas beyond merely extending prior tax provisions for an additional two years. Please feel free to contact us with any questions about how the Act affects your specific situation. JANUARY 2011
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Hospital Rounds
Pediatric Cardiac Surgery Program Opens at Children’s Hospital of New Jersey Pediatric cardiac surgery is now available at Children’s Hospital of New Jersey (CHoNJ) at Newark Beth Israel Medical Center under a new partnership with NYU School of Medicine. The on-site program directed by Sunil P. Malhotra, MD, operates in partnership the NYU School of Medicine and Ralph S.
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New Jersey Physician
Mosca, MD, Division Chief of Pediatric and Adult Congenital Cardiac Surgery at NYU Langone Medical Center. “The collaborative program ensures that infants and children have improved access to the most advanced care at CHoNJ with
immediate and smooth referral to NYU when necessary,” said Ronald J. Del Mauro, Chief Executive Officer of the Saint Barnabas Health Care System. Children’s Hospital of New Jersey at Newark Beth Israel Medical Center is an affiliate of the Saint Barnabas Health Care System. It is estimated that
between 500 and 600 children and adults in New Jersey with congenital heart disease require surgery each year. NYU Langone Medical Center’s Division of Pediatric and Adult Congenital Cardiac Surgery treats patients of all ages with inherited and acquired cardiac defects. Surgeons there have extensive experience with reconstructive procedures on pediatric patients with complex cardiovascular disorders. Both Dr. Malhotra and Dr. Mosca will operate at Newark Beth Israel Medical Center. Dr. Malhotra comes to CHoNJ from the University of Florida, Gainesville, where he served as Assistant Professor of Surgery and Pediatrics. He completed a cardiothoracic surgery residency at University of Colorado Health Science Center, Denver, and fellowship training in pediatric cardiac surgery at Stanford University, Palo Alto, CA. Dr. Malhotra has authored 18 peer-reviewed articles and presented at more than a dozen medical conferences across the country. He is a Diplomate of the American Board of Thoracic Surgery and the American Board of Surgery, as well as a member of the Council on Cardiovascular Surgery and Anesthesia, the American Heart Association and the Society of Thoracic Surgeons. The program provides the most sophisticated level of pediatric cardiac care in New Jersey while easing the emotional and financial strain on families who would otherwise have to travel out-of-state for this level of care. This new pediatric cardiac surgery partnership complements the comprehensive pediatric cardiology services already in place at Children’s Hospital of New Jersey including a 19-bed Pediatric Intensive Care Unit (PICU) – the largest in the state; digital pediatric cardiac catheterization laboratory; fetal echocardiography; and advanced electrophysiology treatments.
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For more information about pediatric cardiac services at Children’s Hospital of New Jersey at Newark Beth Israel Medical Center or to make and appointment, please call 973-926-3500. JANUARY 2011
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Legal Issues
Launch of Medicare & Medicaid Electronic Health Record Incentive Programs By John Fanburg and Carol Grelecki, Brach Eichler LLC
Limited states will begin registration on January 3, 2011 in the Medicare and Medicaid federal Electronic Health Records (EHR) Incentive Programs, with other states to follow in February, spring and summer of this year. Eligible providers in registering states may voluntarily sign up to receive financial incentives in exchange for implementing and using certified EHR technology in a meaningful way. While New Jersey is not slated to begin registration at this time, physicians and hospitals may begin to become familiar with what the incentive programs will entail, as other states, including New Jersey, will begin registering in the coming months. CMS has posted a link to its registration materials, which provides additional information at: https://www.cms.gov/EHRIncentivePrograms
The American Recovery and Reinvestment Act of 2009 provides a mechanism for funding health care reform through incentives for using electronic health records. In order
to improve health care delivery, the EHR Incentive Programs have been developed by directing federal resources to promote the use of such electronic records through a reward system. CMS reports that as much as $27 billion over ten years will be expended to support massive national adoption of EHR, of this New Jersey will receive $11.4 million. CMS indicates that eligible professionals can receive up to $44,000 over five years and hospitals may receive a $2 million dollar base payment under the Medicare EHR Incentive Program (with payment adjustment if meaningful use criteria are not met); and eligible professionals can receive up to $63,750 over six years and hospitals and critical access hospitals may receive a $2 million dollar base payment under the Medicaid EHR Incentive Program (with no payment adjustments to be made under the Medicaid program). Eligible professionals for these programs include non-hospital based physicians,
dentists, nurse-midwives, nurse practitioners, and physician assistants practicing in a federally qualified health center or rural health clinic and meeting certain volume thresholds. Applications must be submitted on behalf of each individual professional (rather than his or her medical practice), but payments may be reassigned. Eligible hospitals include acute care hospitals, critical access hospitals and children’s hospitals, subject to minimum volume thresholds. Medicare and Medicaid will each offer incentive programs. Providers and hospitals should evaluate the programs and decide which program would be more beneficial, as registration is only permitted for one program, not both. Once a provider or hospital is registered, the state will require the applicant to attest to the meaningful use of EHR. Using CMS “certified” software will help the user to meet the meaningful use criteria.
Out-of-Network Bill Undergoes Another Revision Prior to Leaving Committee By Mark Manigan and John Fanburg, Brach Eichler, LLC
In October, Gary Schaer, Chairman of the Assembly Financial Institutions and Insurance Committee, introduced legislation intended to further regulate the out-ofnetwork (OON) insurance market in New Jersey. In November, drastic changes were made to the bill that made it much more restrictive. Pushback by health care
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institutions and providers resulted in a failed vote to get the second version of the bill out of committee. After the failed vote, Chairman Schaer went back, for all intents and purposes, to his original bill, with some modifications. This bill was voted out of Committee on December 9, 2010. Key provisions of the released bill include:
• OON providers would be required to make 3 “good faith and timely efforts” to collect payment from patients and would be required to maintain related records for 7 years • Providers may waive a patient’s payment if the provider determines that the patient
Legal Issues has a “medical or financial” hardship so long as waivers are not granted “routinely or excessively” and he or she notifies the carrier in the event such a waiver is granted
for 1 year if a carrier or insurance entity determines that a provider engaged in a “pattern of violations” of the obligation to collect payments, as summarized above, for a period of at least 6 months
• At the time of scheduling, OON doctors and facilities would be required to inform patients whether the health care services they seek are in-network or OON and the provider must discuss with the patient: (i) his or her financial responsibility; (ii) any non-emergency services or elective procedures; and (iii) a cost estimate in the patient’s primary language; physicians in violation of this provision may be subject to licensure sanctions
• Carriers would be prohibited from terminating a provider from a managed care contract solely on the basis that the provider referred to an OON provider. The bill also restricts carriers from making unilateral changes to participating provider agreements more than once a calendar year and requires 30 days advance written notice of any such changes
• The proposed bill modifies the assignment of benefits law that requires a carrier to pay a provider directly (or pay the provider and patient jointly) to include self-funded health benefit plans. However, under the bill, OON providers may be excluded from the direct pay benefit
In order to become law, the bill must be approved by the entire Assembly, go through the Senate committee structure, a full vote of the Senate, and then be signed by the Governor. We will continue to closely monitor the progress of this bill. For More Information, please contact the authors at Brach Eichler, LLC, 973.228.5700
REGISTRATION OPEN! March 31 & April 1, 2011 Register Now for NJMGMA PMC 2011
“TUNE UP YOUR PRACTICE FOR HEALTHCARE REFORM“ Don’t miss this exciting two-day educational session at the Taj Mahal Hotel and Casino in Atlantic City, NJ. Featuring Naomi Judd, Grammy Award winning country singer, and former nurse, discussing how an unexpected life threatening diagnosis at the height of her career changed her outlook and focus on life. With an unwavering optimism and characteristic inner strength, Naomi stepped away from the spotlight to explore paths that have led to new successful endeavors. Outstanding program content, fantastic breakout sessions and a spectacular location…bigger and better than last year’s conference and the one you won’t want to miss! PMC 2011 will offer extensive educational breakouts that will touch on all aspects of your practice in today’s healthcare environment.
New Jersey Medical Group Management Association
More Details and Registration Available at www.pmc2011.org JANUARY 2011
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