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PHYSICIAN SPOTLIGHT PAGE 3
Alexander Garza, MD, MPH ON ROUNDS
theEstatePlanner BY STEVEN M. LAIDERMAN
Inheritors’ IRA Now Has Asset Protection Missouri recently joined list of states to protect retirement plans Missouri recently joined the list of states that protect the beneficiary of an IRA, 401(k) or other qualified plan. We’ll refer to it collectively as a retirement plan, as the law protects the owner or participant of the retirement plan ... 5
New Lines of Research
A New Gold Standard?
Wash U team performs first incisionless procedure for treating esophageal achalasia in St. Louis
‘‘
Endoscopic Myotomy) procedure on July 19, on a 54-yearAn incisionless procedure first perold female who awoke early the formed in St. Louis at Washington Uninext morning ready to go for a versity’s 7th Annual GI Live Conference run. in July may very well represent a new “We said, ‘no, you can’t do gold standard for treating esophageal that yet,’” recalled Murad, with — Michael Awad, MD, PhD, Director, achalasia. a laugh. Washington University Institute for “This is the closest we’ve gotten Immediately after completSurgical Education. to the Holy Grail dream of incisionless ing the procedure, Murad and surgery, where the patient goes to sleep, Awad could see how well the wakes up, feels no pain and has no side patient’s esophagus opened. effects or complications,” said surgeon Michael Awad, MD, PhD, “Other than minor bleeding and some CO2 which leaked into FACS, associate dean of medical student education, program director her abdomen, the case went great,” said Murad. “We’d practiced it of general surgery, and director of the Washington University Institute and really understood the game plan.” for Surgical Education. “We’re not totally there yet, but we’re very, When checking on the patient postoperatively that evening and very close.” the next morning, Awad was pleased to learn the patient had zero Awad and interventional gastroenterologist Faris Murad, MD, pain from the procedure. She only expressed slight discomfort from the assistant professor of medicine, and director of endoscopic ultrasound postoperative barium swallow study and the IV in her arm. at Washington University, performed the area’s first POEM (Per Oral (CONTINUED ON PAGE 6) By LyNNE JETER
The patient is our focus; a secondary aspect of this endeavor is the collaborative approach between surgery and GI.”
Marketing Clinical Practices
NCI Data Set Opens Access to Cancer-Related Genetic Variations How will this breast cancer drug react in patients that are HER2 positive? Will this new lung cancer therapy work in a patient with multiple genetic variations? Finding answers to those questions just got a bit easier with the rollout of a vast data set of cancer-specific genetic variations by scientists at the National Cancer Institute (NCI). ... 12
PHYSICIANS BUSINESS
CONFERENCE TOOLS FOR SUCCESS
By LyNNE JETER
A pair of faculty practice directors in St. Louis will share tips on how to market clinics to businesses and consumers at the inaugural Physicians Business Conference, slated for Oct. 26-27 at the Sheraton Westport Lakeside Chalet in St. Louis, and hosted by St. Louis Medical News. Jacqueline Stack, PhD, seJULY 2013
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nior director of marketing and communication for Washington University Physicians, and Sarah Gladson, MBA, director of marketing and communications for St. Louis University Medical School, will integrate their comprehensive healthcare marketing experience into their messages. “Even though our institutions (St. Louis University Medi(CONTINUED ON PAGE 4)
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PhysicianSpotlight
Alexander Garza, MD, MPH By LUCY SCHULTZE
As he returns to his hometown after four years of service in the Obama administration, Alexander Garza, MD, MPH, will be able to connect his alma mater with public-health practitioners at an international level. But he’s also interested in applying his experience to help local emergency responders provide the best care to the underserved population. “Being a former paramedic and medical director for emergency-medical services, I would really like to be engaged with that community in St. Louis,” said Garza, who joins the faculty of Saint Louis University this fall. Garza, a native of St. Louis, served as the Assistant Secretary for Health Affairs and Chief Medical Officer for the U.S. Department Homeland Security from 2009 until this past spring. The role included leading the DHS’s coordinated response to such events as the H1N1 pandemic, Haiti earthquake, Gulf Coast oil spill, Japan tsunami and Hurricane Sandy. Garza served as principal advisor on bioterrorism and health to U.S. Secretary of Homeland Security Janet Napolitano, and also advised the White House National Security Staff and Federal Emergency Management Authority. At SLU, he takes the title of associate dean for public health practice and associate professor of epidemiology. His focus will include developing relationships between the SLU College for Public Health and Social Justice and practitioners in government and industry engaged in public health and the local, national and international level. Garza, who received his master of public health degree from SLU, will also teach and mentor students in the areas of emergency management, public-health preparedness and epidemiology. “Getting a master of public health degree was quite honestly one of the most worthwhile educational endeavors of my entire career,” said Garza, who finished the degree in 2003. “It really opened my eyes about how to approach problems from a population standpoint. Medicine is very individualcentric, so learning how to take a broader perspective was very beneficial when it came to doing research and solving problems.” Growing up in Maryland Heights, Garza was always drawn to medicine – particularly the high-drama nature of emergency care. His mother worked as an emergency nurse in what is now Des Peres Hospital. Garza earned his paramedic certification while in college at the University of Missouri-Kansas City and worked as a paramedic before beginning studies at the University of Missouri-Columbia School stlouismedicalnews
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of Medicine. He completed a residency in emergency medicine with UM-Kansas City at Truman Medical Center, including a year as chief resident and clinical instructor. With an eye on an academic career, Garza then turned to public-health studies as a way to better grasp epidemiology and statistics. He commuted to SLU from Kansas City for weekend classes to complete his MPH degree. “The school has grown exponentially since I was there,” he said. “Combined with the School of Social Justice, it seems like the program has really taken off. “It was enticing to me to be part of a place that’s experiencing growth and on an upward slope.” Likewise, Garza said, his new position at SLU looked like a logical next step in his career. “As I was contemplating leaving the
administration, I was looking for a way to take all the experiences I have had and build a body of knowledge from them,” he said. “It made a lot of sense for me to join SLU, since they have a lot of programs which fit well within my skillset.” Garza has held previous academic appointments in emergency medicine at Georgetown University, the University of New Mexico and the University of Missouri. With the latter, he served as co-director and founder of an evidence-based medicine program within the emergency department at Truman Medical Center. Garza’s experience also includes working as an administrator for emergency medical services and serving in the U.S. Army Reserve Medical Corps. A lieutenant colonel, he has served as a battalion surgeon and civil affairs public health chief in Iraq and Africa. Garza joined the Department of Homeland Security in 2009, appointed by President Barack Obama and confirmed by the U.S. Senate. He oversaw the department’s medical and health-security matters, which included making sure DHS was prepared to respond to biological and chemical weapons and hazards. While such concerns were at the forefront in the wake of Sept. 11, 2011, tightened budgets have refined the department’s preparedness efforts.
“We’re still concerned about certain aspects of biodefense and chemical defense,” Garza said. “But more than acts of terror, you also have naturally occurring disasters like hurricanes and tornadoes that affect public health.” Emerging infectious-disease threats also occupied Garza’s attention during his time in the administration. “H7N9 in China and Middle East Respiratory Syndrome are two diseases the world is keeping a big eye on, because each of them could potentially become a pandemic,” he said. “Those are the sort of risks that threaten everybody and could cause a lot of issues in public health for the nation.” As he now shifts gears and prepares for new challenges, Garza is excited about returning to the St. Louis area — both for the job and for the off-hours opportunities. He’s looking forward to baseball games at Busch Stadium and to spending more time with family. Outside of work, Garza can often be found coaching his children’s baseball teams and taking them to swim-team practice and meets. The family also enjoys camping and other outdoor activities. He and his wife, Melissa, have three sons: Alex, 12, Sam, 10, and Daniel, 7. The move to St. Louis offers the chance to raise them in close proximity to their grandmother, uncles and cousins.
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Marketing Clinical Practices, cont. from page 1
Source: Hospice Perception Study 2010
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cal School and Washington University Medical School) are large, they comprise individual specialty practices, each with different referral patterns and volume requirements,” said Stack. “Sarah and I are both accustomed to doing marketing planning for small- to medium-(size) Dr. Jacqueline and very diverse groups. Stack Our session aims to help physician practices define their strengths and clarify their business objectives to communicate with other physicians, payers and the public.” “Marketing a Clinical Practice,” a one-hour seminar beginning at 4 p.m. on Saturday, will cover medical ethics, market research, patient outreach, professional networking, and cost-effective advertising. Representatives from an advertising agency and a market research company will join the discussion with Stack and Gladson. “There’s been a major shift in attitudes about marketing medical practices over the past 10 to 15 years,” said Stack. “More recent graduates accept and even expect marketing support from their practices, while many older physicians remember the very strict limitations and penalties for any public mention. Medicine has ethical and professional standards that set physicians’ marketing apart from other enterprises. Although some of the rules against advertising have been relaxed, it’s helpful for physicians to know how and where their individual and collective expertise can be promoted.” For example, how much should marketing cost a practice? “In most fields, the thumb rule is 4 percent of gross sales,” she said. “Yet most medical practices don’t budget anything for promotions – either advertising, the Internet or professional networking activities. Doctors are orientated to dose-response and are often surprised by the amount of advertising it takes to affect people’s behavior. The session hopes to clarify some of the tenets of marketing for these unique professionals.” The seminar discussion won’t dive deep in particular topics, said Gladson.
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“We’ll talk about marketing in general – brand, public relations, B2B versus consumer marketing, and the digital component, which includes web and social media,” she said. “We’ve come a long way since the time when it was good enough to hang out a shingle. There are so many ways to go about it now, depending on the market, budget, and specialty. So many factors go into marketing, and to whom it’s marketed. We’re looking forward to offering the best practices we’ve seen and we’re excited to be part of the program.” Gladson is also looking forward to hearing about best practices in other areas of healthcare from local industry leaders. “When you look at the agenda, a wealth of knowledge is being drawn from the community,” she said. “Look at Dr. John Ellena, (medical director) of BJC Medical Group, in addition to Dr. Tom Hale from Mercy (executive medical director for Telehealth Services), and Dr. Glenn Mitchell, who used to be at Mercy (as CMO) and is now in a consulting role (at Numerof & Associates). Lawyers are stepping forward to share their knowledge. So many people from throughout St. Louis are coming together to have a very rich discussion on healthcare.” Ellena, Hale, Mitchell and Edwin Trevathan, MD, MPh, dean of the Saint Louis University College for Public Health and Social Justice, will highlight “Implications of Population Health Management for Physicians and Hospitals,” for a seminar beginning at 10 a.m. on Saturday. Concerning legal seminars, Mark Gonnerman, founding member of Gonnerman, Reinert LLC, a healthcare defense law firm and also lead counsel for Missouri Professionals Mutual, will present “They Didn’t Mention this in Medical School: Dealing with Lawyers and Lawsuits.” This seminar, leading off the Saturday line-up at 8:30 a.m., will cover potential issues when interacting with lawyers before a lawsuit is filed, and also what to expect if you are sued or contacted by the Board of Registration for the Healing Arts. Topics include potential pitfalls when responding to records requests and subpoenas, or providing opinions or depositions. It will also include an update on tort reform in Missouri. Gonnerman will also present “An Ounce of Prevention is Worth a Pound of Cure: Tips for Minimizing,” a Saturday seminar starting at 2:30 p.m. Brown Smith Wallace is presenting two law-related seminars: “Operational and Legal Matters Regarding HIPAA Compliance,” beginning Saturday at 1 p.m. and moderated by Ron Present, healthcare industry group leader, and “Cultural and Legal Impact on Physician Consolidation,” beginning on Sunday at 2:30 p.m., and moderated by Ron Steinkamp, a principal with Brown Smith Wallace. Stack will also present “Medical Marketing in the Digital Age,” a Sunday seminar, beginning at 1 p.m. For more information on the 2012 St. Louis Physicians Business Conference, including descriptions of all seminars with presenters and participants, visit https://www.medicalnewsevents.com/ stlouismedicalnews
.com
theEstatePlanner BY STEVEN M. LAIDERMAN
Inheritors’ IRA Now Has Asset Protection Missouri recently joined list of states to protect retirement plans Missouri recently joined the list of states that protect the beneficiary of an IRA, 401(k) or other qualified plan. We’ll refer to it collectively as a retirement plan, as the law protects the owner or participant of the retirement plan. It’s well understood that a retirement plan is a great way to save for retirement, primarily because the assets in the retirement plan grow tax deferred. That is, until the money is removed from the plan at retirement, no income tax is due. These plans were designed to encourage savings for retirement. The incentive is for the plan owner or participant to drop to a lower income tax rate bracket at retirement than currently, and thus, pay less income tax. Generally, to avoid unlimited deferral, annual withdrawals must begin no later than April 1 of the year following the time after the retirement plan participant or owner reaches age 70 years, 6 months. One exception is a Roth IRA because that owner has already paid the income taxes on the plan assets. Another major benefit for Missouri healthcare professionals is that generally the retirement plan assets are protected from the claims of the physician’s creditors. This protection can vary from state to state. Because of medical malpractice lawsuit claims, and because professionals are a target in any litigation, asset protection is especially important to physicians. Because of the tax-deferred nature of these plans and the asset protection benefits, retirement plans are often a large portion of a physician’s net worth. Accordingly, choosing the right beneficiary has significant consequences to the physician’s estate plan. In most situations, naming a spouse as the primary beneficiary is the best option. A spouse can “roll over” the retirement plan into their own IRA. This allows the surviving spouse to continue the tax deferral and asset protection benefits. Sometimes this isn’t the best option, such as when the physician is concerned about the spouse’s ability to manage money, or in a subsequent marriage when the couple might not have the same ultimate beneficiaries. The physician may want to ensure that retirement plan benefits are paid to heirs. If the retirement plan names the spouse as beneficiary, the spouse can name all new beneficiaries, who may not be the same as the physician’s beneficiaries. Naming a trust as the beneficiary can solve his issue. But the cost is that the retirement plan may need to be distributed to the surviving spouse much quicker than may have been possible if the spouse was named. stlouismedicalnews
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If there’s no spouse, whether because the professional is divorced or the retirement plan owner is the sole surviving spouse, the question will be who to name next as beneficiary. Often, it includes the physician’s children or grandchildren. When retirement plan benefits are inherited by a beneficiary, the plan is commonly referred to as an “inherited IRA.” With an inherited IRA, the retirement plan owner is often concerned with what the children or grandchildren will do with the retirement plan assets if they’re named as beneficiaries. Again, naming a trust is a solution to that dilemma. If the trust is properly drafted to accept the inherited IRA, the beneficiary can withdraw the inherited IRA over their life expectancy, just as if named individually as beneficiary. When paid to a trust, there’s the added benefit of controlling how the money is invested and withdrawn from the inherited IRA. That is, the retirement plan owner can avoid the beneficiary drawing out all of the money from the inherited IRA all at once, and control where the balance, if any, goes when the beneficiary dies. Some physicians are convinced there’s no need to protect the beneficiary from withdrawing too much too soon, or that the beneficiary will make foolish investment choices. Another major reason for naming a trust as beneficiary has been asset protection for the beneficiary. While the retirement plan owner or surviving spouse has the asset protection benefits afforded retirement plans, this isn’t always true for inherited IRAs. However, Missouri has recently joined the list of states that protect inherited IRAs from the claims of the beneficiary’s creditors. Thus, it’s no longer necessary to name a trust as a beneficiary of a retirement plan to afford the beneficiary the asset protection benefits afforded to the retirement plan owner. However, we still recommend naming a trust for all of the other reasons we use trusts, such as the ability to control investment decisions, how much is withdrawn, and to control the ultimate beneficiary. While asset protection for an inherited IRA in Missouri is no longer an issue, planning for receipt of an IRA by a beneficiary is still alive and well. Steven M. Laiderman, principal of The Laiderman Law Firm PC, an estate planning, probate, and business law firm based in St. Louis, has extensive experience in estate planning. His business practice focus extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions. He also represents clients in the negotiation of real estate leases, sales and acquisitions. A frequent speaker, he serves as adjunct professor at the Washington University School of Law, teaching estate planning and family wealth management classes. He may be reached at Steve@ LaidermanLaw.com.
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A New Gold Standard? continued from page 1 “We wrote her (a script for) IV pain medication,” he said. “She didn’t use it once. We’d also written (a script) for Tylenol, but she didn’t take even one Tylenol. That’s almost unheard of after a procedure like this.” Within a couple of days, the patient returned to her daily routine. “She’s noticed a huge difference,” said Murad. “We’re thrilled with her outcome so far.”
The Long Preparation
Murad and Awad began preparing for the introduction of the incisionless procedure to St. Louis for two years, when they first heard about POEM being introduced in the United States. Worldwide since 2010, some 1,400 POEM procedures have been performed. Nationally, there have been only 200 POEM cases, mostly at two locations. The largest POEM center in Portland, Ore., accounts for roughly half of them. Awad trained with Lee Swanstrom, MD, FACS, of The Oregon Clinic in Portland, who was the first doctor to perform natuDr. Faris ral orifice surgery in the Murad United States. The second largest center is Chicago; roughly 35 POEM procedures have been performed at NorthShore Hospital, and perhaps 25 cases at Northwestern Memorial Hospital. “One of the first times POEM came up in the U.S. was two years ago at a Society of American Gastrointestinal and Endoscopic Surgery (SAGES) conference in San Diego,” said Murad. “I was presenting at the conference and had heard discussion about POEM, but it was the first time I’d seen video and learned more about it. A consensus meeting discussing the best approach to POEM with preliminary data and other details was very enlightening. POEM has been slow to take hold in the U.S. because so much goes into it, and the procedure takes highly skilled people.” In St. Louis, a collaborative approach
Current Gold Standard for Treating Esophageal Achalasia The Heller myotomy is most commonly used to treat achalasia, a dysfunction of the lower esophageal sphincter (LES), which fails to relax properly, making passage to the stomach difficult for food and liquids. Initially performed by Ernest Heller in 1913, the procedure, now performed laparoscopically, involves cutting the LES muscles. The myotomy only cuts through the exterior esophagus muscle layers that are squeezing the muscle, leaving the inner mucosal layer intact.
was taken with minimally invasive surgery and interventional endoscopy. This collaboration paired surgical experts in performing laparoscopic Heller myotomy, with interventional endoscopy and an esophagologist. Awad and Murad co-directed the start of the POEM program at Washington University. “In medicine, there’s been a huge push in the past five to 10 years toward minimally invasive surgeries so patients have better recovery times,” said Murad. “About seven years ago, the concept of NOTES (Natural Orifice Transluminal Endoscopic Surgery) laid the foundation for this procedure coming into play. If you look at what we do from a gastroenterology point of view, we’re limited by our equipment. Once the concept of NOTES came about, there’s been a huge push for more equipment for our scopes and procedures. That’s revolutionized the thinking.” Because the POEM procedure pairs specialists in surgery and GI, Murad and Awad began concentrated efforts to expedite bringing the POEM procedure to St. Louis. “POEM is a convergence of disciplines, with both specialties focusing on the GI tract,” said Awad. “Traditionally, the approach to those disorders has come from different angles. GI approached it through use of medications and limited therapeutic maneuvers (injection of Botox and balloon dilation). On my end, we usually approach disease of GI tract with keyhole surgery. We’ve been trying for years on a national level to make our procedures less invasive, and a huge jump was made 20 years ago
with the advent of laparoscopic and minimally invasive surgery. It was a huge advance toward less pain, faster recovery, and fewer complications for patients.” To better prepare, Murad attended multiple national conferences that focused on POEM, in addition to taking various hands-on training courses. Awad attended the second annual POEM conference in Orlando earlier this year, while also reconnecting with his Portland mentor. Murad and Awad held five labs to practice the technique, and established procedures and criteria for the program. “We were ready early this year, but it was a matter of getting our first case, a good candidate that hadn’t been manipulated with dilations, injections, or previous esophagus surgery,” said Murad. Once the patient was selected, the two specialists had a trial run with the operating room team the night before the first POEM procedure. Washington University’s approach to POEM is unique, emphasized Awad. “Dr. Murad and I were both hands-on during the procedure, doing it in concert, with each of us doing an equal amount of the procedure,” he said. “The patient is our focus; a secondary aspect of this endeavor is the collaborative approach between surgery and GI.”
Lagniappe
During the preparation phase, Awad and Murad connected with Haruhiro Inoue, MD, a professor at Showa Univer-
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sity Northern Yokohama Hospital and Digestive Disease Center in Japan, who has performed 423 POEM procedures. The timing worked well for Inoue (pronounced “in-you-way”) to keynote the July 19 St. Louis Live Endoscopy Conference and also proctor the first POEM case at Washington University. “It’s too early for us to know long-term outcomes, but right now they’re matching laparoscopic outcomes,” said Murad. “As our understanding of the procedure improves, it might lead to better long-term outcomes.” Referrals primarily come from gastroenterologists, typically after primary care physicians have referred patients for the swallowing disorder. “We don’t understand the ultimate etiology of esophageal achalasia,” said Murad. “It may be virally mediated, triggered by something in the environment. I wouldn’t say it’s an autoimmune phenomenon. Changes occur to the esophageal muscles and over a period of time, it becomes even more difficult for food and even liquids to pass since the muscles don’t work the way they’re intended. The goal of the POEM procedure is to release the muscle at the end of the esophagus so that food and liquids pass to the stomach rather than getting stuck in the esophagus.” “Is the POEM procedure the new gold standard? That’s the hope,” said Murad. “We don’t have quite enough evidence yet to say that, but it’s emerging, and very promising. However, this particular procedure requires a great deal of technical expertise and a lot of specialized training. It won’t be done in all corners yet.”
POEM Procedure for Esophageal Achalasia Symptoms: Weight loss, chest pain/ heartburn, regurgitation. Preoperative examination: Esophageal manometry, barium swallow study, blood test, and x-ray exam of chest and abdomen. POEM surgical steps: 1. With the patient in the operating room under general anesthesia, an endoscopy of the upper gastro-intestinal tract is performed to determine the length of the required incision of the muscle layer. 2. After the injection of a saline solution is made under the mucosa, a “mucosal incision is created which allows the endoscope to enter the submucosal space”. 3. A submucosal dissection is then performed down the esophagus to the top of the stomach. After creating the tunnel in the submucosa, the inner muscle layer is cut along its length. 4. The mucosal entry is closed by clips that will eventually fall off. Possible postoperative symptoms: Fever up to 101 degrees, chest pain due to the muscle layer incision performed, and throat discomfort. Day after surgery: A barium swallow study to confirm that the mucosal incision is tight and not leaking. SOURCE: Showa University Northern Yokohama Hospital.
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PHYSICIANS BUSINESS CONFERENCE TOOLS FOR SUCCESS
SEMINAR PROGRAM & REGISTRATION OCTOBER 26 & 27, 2013 | SHERATON WESTPORT LAKESIDE CHALET PRESENTED BY ST. LOUIS MEDICAL NEWS
BUILD YOUR OWN EDUCATIONAL EXPERIENCE Physicians and healthcare business managers may choose from a lineup of seminars detailed on the next page of this program to develop the tools they need to provide financial solutions to many post-health reform challenges. More than 20 seminars in 11 business categories will cover myriad subjects on the business side of healthcare. Local experts in each field will present the conference seminars specifically designed for St. Louis healthcare professionals.
REGISTRATION BEGINS NOW Because seating is limited for each seminar, we strongly encourage healthcare professionals to register early to ensure a seat in their choice of seminars. Complete registration information and seminar costs follow the list of individual seminars and their content, beginning on the next page. Seminars are listed chronologically by day. Select your seminars by number and follow the step by step registration procedure whether you are registering by phone or web site.
SEMINAR DETAILS INSIDE Seminar content details, along with bios of the individuals and organizations involved in the presentation, are listed on the adjacent page of this program guide. Because seminars will be presented on a category of business information instead of an individual company and its services, healthcare professionals will gain insightful knowledge about each subject to then make informed choices about the company best-suited to provide services and solutions for them. This style of presentation will create a truly educational experience for each seminar.
Attendees may register online at www.saintlouismedicalnews or via phone at 615-844-9307. stlouismedicalnews
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PHYSICIANS BUSINESS CONFERENCE
SEMINAR CONTENT AND DETAIL Saturday
Panelists - Thomas H. Hale, MD, PhD Thomas Hale, MD, is executive medical director for Mercy’s Telehealth Services, a position he assumed in June 2009. John Ellena, MD Dr. Ellena is Medical Director, BJC Medical Group.
SEMINAR 1 SATURDAY 8:30 A.M. – 10:00 A.M. 1.5 HOURS PERSONAL FINANCIAL MANAGEMENT FOR PHYSICIANS This workshop focuses on a physician’s personal finance practices. Topics of discussion include creating a retirement plan, choosing a financial planner, the personal benefits of medical real estate investments, managing debt, and the importance of disability income insurance. Speaker: Jeremiah Dellas, a wealth management advisor at Fifth Third Bank, responsible for the development and ongoing coordination of investment management, insurance planning, wealth planning, and private banking services for high net worth clients.
SEMINAR 9 SATURDAY 8:30 A.M. – 10:00 A.M 1.5 HOURS THEY DIDN’T MENTION THIS IN MEDICAL SCHOOL DEALING WITH LAWYERS AND LAWSUITS From records requests to lawsuits, dealing with lawyers and malpractice lawsuits can be an unavoidable part of the practice of medicine. This seminar will discuss potential issues when interacting with lawyers before a lawsuit is filed, as well as what to expect if you are sued or contacted by the Board of Registration for the Healing Arts. Topics include potential pitfalls when responding to records requests and subpoenas or providing opinions or depositions, what to expect if you are named in a lawsuit or contacted by the Board of Healing Arts, and an update on tort reform in Missouri. Speaker: Mark A. Gonnerman, Founding member of Gonnerman Reinert LLC Gonnerman Reinert LLC defends doctors and other healthcare providers from initial claims through trial. Gonnerman Reinert LLC serves as lead counsel for Missouri Phrofessionals Mutual.
SEMINAR 7 SATURDAY 10:00 A.M. – 11:00 A.M. 1 HOUR ASSET PROTECTION PLANNING The United States is an increasingly litigious society. Many individuals are interested in methods available to avoid the loss of family wealth to creditors, bankruptcy and divorce. There are several popular estate and gift tax planning tools for protecting your assets. This session provides attendees with an overview of some of the methods for protecting family wealth. Speaker: Steven M. Laiderman, Principal of The Laiderman Law Firm PC Laiderman Law Firm is an estate planning, probate and business law firm based in St. Louis. His business practice focus also extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions.
SEMINAR 10 SATURDAY 10:00 A.M. – 11:30 A.M. 1.5 HOURS IMPLICATIONS OF POPULATION HEALTH MANAGEMENT FOR PHYSICIANS AND HOSPITALS In light of healthcare reform legislation, spiraling healthcare cost increases, and the looming retirement of the Baby Boomer generation, there is an increasing focus on managing population health. But what that means – and what it means for physicians and hospitals – is less clear. This session defines what is required to manage population health, the key milestones on the way there, and what doctors need to know. Speaker: Glenn Mitchell, MD, MPH Dr. Mitchell is a Senior Consultant at Numerof & Associates, Inc. He was formerly Chief Medical Officer at Mercy Health System. NAI is a strategic management consulting, bringing a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs, and enhance customer value.
SEMINAR 17 SATURDAY 11:00 A.M. – NOON 1 HOUR SURVIVING THE CHAOS WHILE MAINTAINING YOUR INDEPENDENCE AND INCREASING YOUR INCOME This session will review major drivers of practice revenue, profitability and growth. We will review opportunities to maximize revenue and profitability on current operations and talk about exploring opportunities to expand business through new ancillary offerings and through leveraging existing resources (staff, equipment, and space). We will also review the changing Medicare and private insurance payment environment including those that tie payments to quality and cost effectiveness. We will explore how independent physicians can participate in Accountable Care Organizations (ACO) and the key elements for success. Speaker: Mike Linder, Owner and CEO/President of St. Louis based KSL Billing + Management KSL is a revenue cycle management company serving nearly 300 physicians across Missouri, Illinois, and Kansas.
SEMINAR 20 SATURDAY 11:00 A.M. – NOON 1 HOUR NAVIGATING YOUR REVENUE STREAM – BEST PRACTICES FOR MAXIMIZING CASH FLOW Effective revenue cycle management (RCM) will increase your net collections and assure prompt payments. Your revenue cycle is driven by medical procedure codes, detailed documentation, data capture, complex reimbursement guidelines and denial management…and your personal efforts can affect these outcomes. This fast-paced, practical workshop offers RCM strategies that physicians and managers can execute immediately to maximize reimbursements, sustain cash flow, improve liquidity and increase profitability. Learn proven methods for converting your medical procedures to cash. Speakers: Alan F. Dombrowski, vice-president of Hawthorn Physician Services Corporation, a nationally-recognized healthcare revenue cycle management company headquartered in St. Louis. Alan is a certified billing and management executive with more than 25 years in healthcare business management. Craig A. Williams is director of sales for Hawthorn. He began his 30-year healthcare career with Blue Cross and Blue Shield of Indiana where he served as manager of Medicare claims processing and as professional provider representative for the Medicaid program of Indiana. Stan Hosler joined Hawthorn in 2012 as a sales and marketing associate, responsible for new business development in the southeastern states. He has more than 15 years’ experience at Contel Corporation and Coca-Cola Company.
SEMINAR 4 SATURDAY 1:00 P.M. – 2:30 P.M. 1.5 HOURS OPERATIONAL AND LEGAL MATTERS REGARDING HIPAA COMPLIANCE This panel discussion will explore HIPAA compliance and cover data protection and transfer issues; business associates compliance determination; security breach and reporting; employee hiring, training and monitoring; employee handbook, policies and procedures; corrective action options for violations; and employee best practices. Moderator: Ron Present, Health Care Industry Group Leader, Brown Smith Wallace Panelists: Gerry Richardson, Partner, Evans and Dixon Tony Munns, Member, Brown Smith Wallace
SATURDAY SEMINAR GRID 8:00
8:30
9:00
9:30
10:00
10:30
SEMINAR 1
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
EXHIBIT HALL OPEN 4 HOURS
SEMINAR 20
SEMINAR 4 SEMINAR 7 SEMINAR 9
SEMINAR 17 SEMINAR 10
8
SEPTEMBER 2013 2013 > JULY
SEMINAR 2
LUNCH 1 HOUR
SEMINAR 12
SEMINAR 6
SEMINAR 8 SEMINAR 22
SEMINAR 14
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TOOLS FOR SUCCESS
The 2013 St. Louis Physicians Business Conference seminars will be presented in segments of an hour to one-and-a-half hours. Regardless of length, all seminars are priced the same. Lengthier seminars will typically headline multiple speakers.
SEMINAR 12
SEMINAR 6
SATURDAY 1:00 P.M. – 2:00 P.M. 1 HOUR CONSUMER-DRIVEN HEALTHCARE – WHAT YOU NEED TO KNOW Trends point to an increasingly consumer-driven model for healthcare. As consumers bear more of the cost burden of their own healthcare, they will demand more information about cost, quality and outcomes than they have historically. This session will walk through what this shift will mean for providers and how they should prepare. Speaker: Kim E. White, MBA Kim E. White is a Consultant at Numerof & Associates, Inc. NAI is a strategy consulting firm focused on organizations in dynamic, rapidly changing industries. Working globally across the healthcare industry, NAI brings a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs and risk, and enhance customer value.
SATURDAY 3:30 P.M. – 5:00 P.M. 1.5 HOUR MARKETING A CLINICAL PRACTICE This seminar will cover strategies for the small to medium sized practice and include discussions on medical ethics, market research, patient outreach, professional networking and costeffective advertising. In addition to the primary speakers, representatives from an advertising agency and a market research company will join the discussion. Speakers: Jacqueline Stack, PhD, Senior Director Marketing and Communication, Faculty Practice, Washington University Physicians Sarah Gladson, Director of Marketing and Communications SLUCare, The Physicians of Saint Louis University
SEMINAR 14 SATURDAY 4:00 P.M. – 5:00 P.M. 1 HOUR THE PHYSICIAN PRACTICE AS EMPLOYER Subjects that will be covered in the seminar will include interviewing techniques; recruitment agreements; non-competes; retention of employees and benefit packages; negotiations; and establishing compensation packages. Speakers: Elizabeth Ortmann Vincenzo, Esq., Senior Director of Compliance at Express Scripts Diane Robben, Esq., Partner, Sandberg, Phoenix & von Gontard, P.C.
SEMINAR 2 SATURDAY 2:30 P.M. – 3:30 P.M. 1 HOUR BUSINESS FINANCIAL MANAGEMENT FOR PHYSICIANS This workshop focuses on the business financial aspect of managing a practice. Key topics include qualifying for a business loan, understanding the P&L, Revenue Cycle Management, Accounts Receivable and Reimbursement Concerns, and Managing Debt and Growth. Speaker: Mersed Halilovic Halilovic is a business banking officer at Fifth Third Bank, focusing on the healthcare industry. He provides customized solutions around credit and capital for small to medium size businesses.
SEMINAR 8 SATURDAY 2:30 P.M. – 4:00 P.M. 1.5 HOURS AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE – TIPS FOR MINIMIZING YOUR RISK OF A MALPRACTICE CLAIM Although some malpractice lawsuits are unavoidable, oftentimes small changes in your practice can prevent a patient from turning into a plaintiff. This seminar will discuss issues that commonly lead to medical malpractice lawsuits, and provide tips on how to minimize your risk. Topics include communicating with patients, charting and EMR issues, obtaining informed consent, and dealing with the disgruntled or non-compliant patient. Speaker: Mark A. Gonnerman, Founding member of Gonnerman Reinert LLC Gonnerman Reinert LLC defends doctors and other healthcare providers from initial claims through trial. Gonnerman Reinert LLC serves as lead counsel for Missouri Professionals Mutual.
SEMINAR 22 SATURDAY, 2:00 P.M. – 3:30 P.M. 1.5 HOURS FOUR RISKS TO YOUR WEALTH Asset Protection is key to the preservation of a physician’s wealth. Physician’s invest years in their education and practice and dedicate themselves to achieving success in their profession. However, the failure to plan for unforeseen events can result in the loss of professional reputation and wealth. There are four primary ways that wealth may be lost: mismanagement, lawsuits, taxes and divorce. With proper planning it may be possible to minimize the risk of loss of wealth in these four areas. In today’s litigious society, one accident or mistake could lead to claims against your practice and wealth. Speaker: Rodney S. Ferguson, ChFc, CLU Rod is principal and founder of Ferguson Financial Group, LLC, a financial planning firm. Ferguson Financial Group is a District Agency for the New York Life Insurance Company. Rod specialties include working with small business owners and professionals in the area of estate, business succession, retirement and risk management planning.
Sunday SEMINAR 16 SUNDAY 10:00 A.M. – 11:00 A.M. 1 HOUR USING SOCIAL MEDIA TO ENHANCE PATIENT EXPERIENCE AND INCREASE REVENUE Attendees will leave this seminar understanding how a social media strategy can directly impact revenue, initiate community dialogue, provide important patient information, and result in revenue-enhancing referrals. Case studies will be presented to illustrate healthcare industry social media success and generate discussion. Attendees will get a better understanding about the future of social media in medicine as well as the competitive power of social media to compete for patients. Discover best management practices for your social media involvement and how to reach your current and prospective patient base effectively. Speakers: JoAnna Dettmann and Kaysha Kalkofen Co-founders of St. Louis based digital marketing firm tSunela bring a great deal of internet marketing and social media experience to this discussion about why social media strategies must be a part of every healthcare provider’s marketing and communications plan. Dettmann and Kalkofen have many healthcare clients and speak nationally on social media subjects.
SEMINAR 13 SUNDAY 10:30 A.M. – NOON 1.5 HOURS PRACTICAL ASPECTS OF THE LIFE CYCLE OF A MEDICAL PRACTICE A panel of physician practice advisors will comment on effectively managing a practice from start up to maintenance. This will include topics such as hiring the right experts, legal structure, taxes, credentialing, space and equipment, financing, hospital and other affiliations, billing/ coding, compliance, revenue cycle analysis, auditing to increase profits, malpractice insurance, and reimbursement. Speakers: Tony Soukenik, Partner, Sandberg, Phoenix & von Gontard, PC Bhavik Patel, Partner, Sandberg, Phoenix & von Gontard, PC Eric Humes, CEO, Omniscient HC and Keystone IT Chastity Werner, Health Care Consultant, Anders
SUNDAY SEMINAR GRID 8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
LUNCH SEMINAR 11
1:30
2:30
3:00
SEMINAR 15
3:30
4:00
4:30
5:00
5:30
SEMINAR 21 SEMINAR 3
1 HOUR
SEMINAR 5
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EXHIBIT HALL OPEN 3 HOURS
SEMINAR 13 SEMINAR 16
1:00
SEMINAR 18
SEMINAR 19
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PHYSICIANS BUSINESS CONFERENCE
SEMINAR CONTENT AND DETAIL SEMINAR 11
SEMINAR 18
SUNDAY 11:00 A.M. - NOON 1 HOUR REDUCING COSTS ACROSS SERVICE LINES Cost reduction is a perennial topic for healthcare providers. But the methods used historically have not typically focused on the leading factor in cost generation: clinical decision making. This session will walk through a systematic approach to reducing costs that addresses this sensitive area, the key considerations you’ll need to take into account, and steps you can take to build consensus within your practice or organization. Speaker: Jill E. Sackman, DVM, PhD, Senior Consultant at Numerof & Associates, Inc. NAI is a strategy consulting firm focused on organizations in dynamic, rapidly changing industries. Working globally across the healthcare industry, NAI brings a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs and risk, and enhance customer value.
SUNDAY 2:30 P.M. – 3:30 P.M. 1 HOUR 2013 HEALTHCARE REAL ESTATE STRATEGIES This informative seminar will investigate how real estate occupancy costs can be a source for improving your practice bottom line. Topics covered will include: The current medical office market conditions; The impact the market has on real estate occupancy costs; Various occupancy choices based on career stage and market conditions; The pros and cons of leasing vs. purchasing vs. development; and real estate exit strategies. Speaker: Ann Dulle Ann Dulle is a senior associate and member of the National Healthcare Services Group of CBRE Inc., a Global Fortune 500, publicly traded company. Her architectural career, which included planning services for medical office practices, spanned 13 years, and then transitioned to commercial real estate property management in 2001 with Equity Office Properties and Duke Realty.
SEMINAR 15
SEMINAR 21
SUNDAY 1:00 P.M. – 2:30 P.M. 1.5 HOURS IS THERE A DOCTOR IN THE HOUSE? Exclusive home mortgage financing programs with low down payment options for Physicians will be featured. One of the area’s top realtor teams will discuss the dos and don’ts of buying and selling luxury homes. Also, representatives from Wells Fargo Advisors and Wells Fargo Business Real Estate will be on hand to discuss how to finance and protect your practice. Speakers: Michael Burge, Sales Manager, Wells Fargo Home Mortgage Michael Burge is a Professional Mortgage Banker with nearly 30 years of industry experience. He was the Founder and First President of the Missouri Association of Mortgage Professionals and was recruited by Wells Fargo specifically for his expertise in serving healthcare professionals. Donna Heinrich, VP, Wells Fargo Business Real Estate Finance Donna Heinrich has been in the banking industry for 30 years. Donna has been at Wells Fargo for 16 years with the last 7 years at Wells Fargo Business Real Estate Finance. Charles Grbcich, VP and Investment Officer, Wells Fargo Advisors Charles G. (Chuck) Grbcich is dedicated to providing exceptional service to his clients. Since entering the brokerage business, he has specialized with rollover retirees, mid-level corporate executives, and families committed to achieving their financial goals. Mr Grbcich also works with corporations assisting with their 401k plans, pensions, and other financial needs.
SUNDAY, 3:30 P.M. – 5:00 P.M. 1.5 HOURS FOUR RISKS TO YOUR WEALTH Asset Protection is key to the preservation of a physician’s wealth. Physician’s invest years in their education and practice and dedicate themselves to achieving success in their profession. However, the failure to plan for unforeseen events can result in the loss of professional reputation and wealth. There are four primary ways that wealth may be lost: mismanagement, lawsuits, taxes and divorce. With proper planning it may be possible to minimize the risk of loss of wealth in these four areas. In today’s litigious society, one accident or mistake could lead to claims against your practice and wealth. Speaker: Rodney S. Ferguson, ChFc, CLU Rod is principal and founder of Ferguson Financial Group, LLC, a financial planning firm. Ferguson Financial Group is a District Agency for the New York Life Insurance Company. Rod specialties include working with small business owners and professionals in the area of estate, business succession, retirement and risk management planning.
SEMINAR 5 SUNDAY 1:00 P.M. – 2:00 P.M. 1 HOUR MEDICAL MARKETING IN THE DIGITAL AGE This seminar will explore the development of websites and social media for the small to medium sized practice. Medical marketing experts will discuss developing a practice web site “somewhere between a brochure and the Library of Congress.” A social media discussion will discuss the pros and cons of getting out there and the perfect fit. Speaker: Jacqueline Stack, PhD, Senior Director of Marketing and Communication, Faculty Practice, Washington University Physicians
SEMINAR 3
SEMINAR 19 SUNDAY, 4:00 PM. - 5:00 P.M. 1 HOUR BUSINESS TECHNOLOGY FOR PHYSICIANS Have you begun using a computer to record patient information? Are you starting to see the benefits of this new medium? Are you aware of the risks? This seminar walks you through where we have been, where we are today and where technology is leading us in the future. This presentation will recap HITECH and the recent changes to the HIPAA laws and what this means for your practice’s technology architecture. We will also explore the future modalities of data collection, aggregation and analytics. Data and the ease of accessibility through mobile platforms are a driving force behind the success of tomorrow’s healthcare. Speaker: Eric W. Humes As CEO of Keystone IT, Eric Humes has established his company as a thought leader in healthcare IT. As a technology firm, Keystone focuses on the quality and efficiency of patient care as its number one priority. Keystone IT provides strategic consulting, support and cloud services to physician practices and hospital systems throughout the Midwest.
SUNDAY 2:30 P.M. – 4:00 P.M. 1.5 HOURS CULTURAL AND LEGAL IMPACT ON PHYSICIAN CONSOLIDATION This topical panel discussion will discuss cultural changes of FFS to PFP; loss of independence; physician group conflict – new/tenured and primary/specialists; corporate environment changes; practice transitions legal issues; physician employee transitions; and benefit transitions. Moderator: Ron Steinkamp, Principal, Brown Smith Wallace Panelists: Brian Rogers, Partner, Evans and Dixon Ron Present, Health Care Industry Group Leader, Brown Smith Wallace
CONFERENCE COMMITTEE MEMBERS
St. Louis Medical News would like to thank the committee members below for their dedicated support constructing the conference seminars. Dawn Van Houten, FIFTH THIRD BANK
Ron Present, BROWN SMITH WALLACE
Larry Henry, ST. LOUIS MEDICAL NEWS
Ray Harter, MPM INSURANCE
Elizabeth Vincenzo, EXPRESS SCRIPTS
Jon Rehg, SANDBERG PHOENIX
Jackie Stack, WASHINGTON UNIVERSITY IN ST. LOUIS
Lauren Bowman, EVANS & DIXON
Diane Robben, SANDBERG PHOENIX
Marshall Burstein, NEW YORK LIFE
Eric Humes, KEYSTONE IT CONSULTING
Michael Burge, WELLS FARGO HOME MORTGAGE
Michael Abrams, NUMEROF & ASSOCIATES
Sarah Gladson, ST. LOUIS UNIVERSITY
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SEPTEMBER JULY 2013 2013
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TOOLS FOR SUCCESS
REGISTRATION FOR CONFERENCE AND SEMINARS Follow the simple registration steps below to create your personal educational experience at Physicians Business Conference. Registration for seminars will automatically create a conference badge for you that will admit you to the PBC Exhibit Hall.
EXHIBIT HALL
HOW TO REGISTER 1
SELECT SEMINARS Review the seminar information, choose your seminars by day and
2
REGISTER ONLINE Go to the St. Louis Medical News web site at
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time and make note of each seminar number chosen. Because several seminars will be given concurrently, be careful not to pick seminars presented at the same time.
www.saintlouismedicalnews.com. Access the conference registration form where indicated on the site. Fill out the registration form completely, listing each seminar by number. We will use this information to confirm your registration by email. The complete conference program, seminar information and registration form is on the web site. You can pay for all seminars selected by credit card on this secure site.
REGISTER BY PHONE Call (615) 844-9307 to register by phone. An authorized Medical News representative will walk you through the registration process, review your seminar choices by seminar number, get your contact information and credit card information.
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CONFIRMATION During the registration process, you will be asked several questions – name, address, phone number and email address – to confirm registration and seminar selection. You will receive confirmation of selected seminars and procedures for entrance to those seminars. St. Louis Medical News will hold this personal information in strict confidence. It will not be disclosed to any other organization.
An exhibit hall at the 2013 St. Louis Physicians Business Conference will highlight companies and organizations that provide services and products to healthcare professionals, providing attendees the opportunity to gain additional detailed information focused on the business side of healthcare. Entrance to the exhibit hall is free; attendees must have a badge to gain access. Badges are available at conference registration to qualified healthcare professionals. Seminar attendees automatically receive a conference badge.
SEMINAR PRICES Seminars begin at $25 each, with a price reduction based on volume of seminars. The discounted seminar cost rewards participants for purchasing multiple seminars by giving them additional FREE seminars. The following table demonstrates the seminar discount structure.
Seminars Purchased
Cost
Free Seminar(S)
Total # Seminar(S)
Cost Per Seminar(S)
1
$25
0
1
$25
2
$50
0
2
$25
3
$72
1 FREE
4
$18
4
$96
2 FREE
6
$16
5
$112
3 FREE
8
$14
6
$120
4 FREE
10
$12
Each additional seminar purchased (more than 10) $8 EACH
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SEPTEMBER JULY2013 2013
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New Lines of Research
NCI Data Set Opens Access to Cancer-Related Genetic Variations By CINDy SANDERS
How will this breast cancer drug react in patients that are HER2 positive? Will this new lung cancer therapy work in a patient with multiple genetic variations? Finding answers to those questions just got a bit easier with the rollout of a vast data set of cancer-specific genetic variations by scientists at the National Cancer Institute (NCI). Yves Pommier, MD, PhD, chief of the Laboratory of Molecular Pharmacology at the NCI, was one of three lead researchers on Dr. Yves the study, published July Pommier 15 in Cancer Research, that pinpointed more than six billion connections between cell lines with mutations in specific genes and the drugs that target those genetic defects. Paul Meltzer, MD, PhD, chief of the Genetics Branch at the Center for Cancer Research and James Doroshow, MD, director of the Division of Cancer Treatment and Diagnosis, were the other principal investigators. Pommier explained the new database builds upon the NCI-60 cancer cell line collection, which is comprised of nine different tissues of origin – breast, ovary,
prostate, colon, lung, kidney, brain, leukemia and melanoma. In their Cancer Research article, the authors note the NIC-60 panel is the most frequently studied human tumor cell line in cancer research and has generated the most extensive cancer pharmacology database worldwide. “Most of the cell lines are from cancer tissues that are hard to treat and are usually resistant to therapy,” he said. “The genomic database is unmatched and enables researchers to mine all the gene expression in relationship to a drug.” Pommier continued, “Each drug has a different profile in the cell line because they act on different targets.” In this most recent study, the investigators sequenced the whole exome of the full NCI-60 cell lines to define novel cancer variants and deviant patterns of gene expression in tumor cells. “The whole genome for the cell line has never been done before,” he said. “Many, many genes had never been sequenced.” The researchers cataloged the genetic coding variations, developing a list of possible cancer-specific gene aberrations. The group then used the Super Learner algorithm to predict the sensitivity of cells with variants to more than 200 anti-cancer drugs … those approved by the FDA and
those still under investigation. By studying the correlation between the gene variants – such as TP53, BRAF, ERBBs, and ATAD5 – and anti-cancer agents including vemurafenib, nutlin and bleomycin, the researchers were able to predict outcomes, showing one of the many ways the data could be used to validate and generate novel hypotheses for future investigation. Access to the data is freely available through multiple sources including the CellMiner and Ingenuity websites. By opening up the scalable data on the whole genome sequencing and drug connectivity, Pommier and his colleagues hope to help other researchers connect cancerspecific gene variants with drug response to move the science forward. “It’s an evolving system,” he said, adding that profiles on drugs in clinical trials will be added to the database as information becomes available to keep the data set current. In explaining how the system works, Pommier said a researcher interested in a specific agent could plug that drug into the database. “You’ll get the profile activity of the drug, and then you can ask if there is any match to any specific gene mutations,” he said. From there, Pommier continued, the researcher could query, “Are these cells more resistant or receptive to
the drug?” Getting those answers rapidly should help researchers move major lines of oncology drug development toward personalized medicine to achieve optimal outcomes in a safer, more efficient and effective manner. With the added knowledge provided by the data bank, Pommier said researchers might separate patients into groups based on their genetic profile and therefore be able to use specific drugs in a more rational manner. “Between a targeted drug and a clinical application, you need a verification in the middle,” he stated. That’s just what this new database offers.
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AUGUST 2013
Asset Protection Planning for Missouri Residents, Part 2 By JIM BLASE
The first portion of this article was published in the August issue of St. Louis Medical News, and focused on presenting an overview of the wide variety of asset protection techniques currently available to Missouri residents. This second installment of the article will focus on additional and important selected aspects of asset protection planning for Missouri and non-Missouri residents.
MAP Trust and QST for Nonresidents
Can the MAP Trust and QST be utilized by nonresidents of the state of Missouri? The short answer to this question is “theoretically, yes.” Missouri law provides that the law of the jurisdiction designated in the terms of the trust instrument applies unless the designation of that jurisdiction’s law is contrary to a strong public policy of the jurisdiction having the most significant relationship to the matter at issue. The problem is that insulation from liability as against a particular state’s creditors could easily be considered contrary to a strong public policy of that state, i.e., if the injury or other damage occurred in the other state. The ability of a nonresident to utilize either or both of Missouri’s asset protection statutes would be greatly enhanced if the nonresident were willing to change the administration of the trust to Missouri, e.g., by designating a Missouri individual or corporation as trustee. Obviously most individuals will not be excited about taking this relatively extreme step, however.
The “Best” Asset Protection Strategy
What is the best asset protection strategy depends upon the facts of each particular situation. Obviously the QST can only be used by married couples. The MAP Trust, on the other hand, is the best creditor protection technique currently available to Missouri single residents. Titling assets in tenancy by the entirety form combined with a TOD or POD designation effective at the death of the surviving spouse will normally be all that most Missouri married couples will require, provided that their automobiles are titled in the name of the principal driver only, TOD to the other spouse or other individual or entity. If the couple owns a significant amount of life insurance, they may wish to couple this basic asset protection technique with a “bypass-type” spendthrift trust at the first spouse’s death which will own the life insurance proceeds for the benefit of the surviving spouse. (This technique is sometimes referred to by the author as a “hybrid joint trust.”) Missouri married couples with somewhat larger estates may choose to utilize the two-share form of QST, in order to insulate approximately one-half of their assets from liability for the surviving spouse. Residents with taxable estates (i.e., net worths in excess of $5.25 million) will typically need to stlouismedicalnews
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utilize the two-share form of QST, in order to guarantee that they will be able to utilize each spouse’s $5.25 million exemption, since the availability of the spousal portability benefit at the surviving spouse’s death is not automatic.
Limitation on Asset Protection Strategies
Remember that no Missouri asset protection strategy will avoid existing or reasonably foreseeable creditor situations. This would include not only the transfer of assets to a MAP Trust, but also the transfer of individually-owned assets into tenancy by the entirety form. Also, for federal bankruptcy purposes there is a potential five-year waiting period before transfers to a MAP Trust will become effective as against creditor claims in bankruptcy. There is likewise no guarantee that the Missouri asset protection laws will be effective if a claim is brought in another state.
Treatment of Existing Trust Arrangements
Obviously a large percentage of clients already executed and funded their separate or joint revocable trusts prior to the enactment of the MAP Trust provisions in 2004 and/or the QST provisions in 2011. The question thus becomes how to deal with these existing arrangements. There are several primary factors which will affect this decision. Two of the most important factors affecting the analysis for married couples with
existing revocable trusts are (i) the size of the federal estate tax exemption, which has now grown to $5.25 million, or 3,000% of what it was in 1981, and (ii) the availability of the new spousal portability election. Whereas in the past most married couples were essentially required to establish and fund two separate trusts, in order to achieve two federal estate tax exemptions, today most married couples no longer need to establish two trusts in order to avoid federal estate taxes and, even if they do, they normally do not need to fund the separate revocable trusts in full. The single most important asset protection question for married couples with existing and funded joint revocable trusts (whether in one-share or two-share form) is whether they will be able to establish to a court of law or jury that the trusts not only meet all of the requirements of a QST under the Missouri statute, but also whether every asset which was used to fund the trust was owned by the couple as tenants by the entirety at the time it was transferred to the trust. If the couple is not in a position to prove the source of all of the trust’s assets, they will need to consider returning the trust assets to joint names, and either establish and fund a new trust which qualifies as a QST, or add TOD and POD designations to their existing joint trust. The most important asset protection question for married couples with existing separate trust agreements is whether and to what extent separate funded revocable trusts are still necessary, in light of the new $5.25 million estate tax exemption and new
spousal portability election. If the couple needs to fully fund two separate trusts to ensure two federal estate tax exemptions (i.e., because the effectiveness of the spousal portability election is not automatic), they should consider terminating their existing separate trusts and establishing and funding a new two-share QST. When the couple terminates the existing separate revocable trusts, they should make sure that the assets which they transfer to the new two-share QST have been owned by them in joint names for more than just one day, i.e., in order to ward off a creditor attack that there was never any true intent to establish a tenancy by the entirety. A two-share QST does not require that all assets transferred to the same be owned in joint names at the time of the transfer to the QST; however, it is important that separately-owned assets which are transferred to the two-share QST not be commingled with the previously jointly owned assets, e.g., by establishing a third and/or fourth share, to hold these separate assets. And, of course, these additional separate shares will not be insulated against future creditor attack. If the couple’s combined estate is only marginally over the $5.25 million level, they may wish to consider the limited strategy of transferring a large portion of the trust assets out of the trust and into their asset-protected joint names, and then add a TOD or POD designation to the survivor’s revocable trust. The only disadvantage to this (CONTINUED ON PAGE 14)
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Asset Protection, continued from page 13 limited strategy is that it will not protect the jointly owned assets after the first spouse’s death, as would be the case with the twoshare QST technique. If the couple’s estate is substantially below the $5.25 million level, they should consider terminating their existing separate revocable trusts and either establish and fund a two-share QST (i.e., for the surviving spouse’s added protection) or establish a one-share QST. If a one-share QST is utilized, the recommended plan is to keep all or most assets in joint names, and then add TOD or POD designations to the trust to be effective at the surviving spouse’s death. The reason for not physically funding a single-share QST is that this would require the need to trace the funding of the trust in the event of a lawsuit.
Not to be Overlooked
The favorable asset protection laws in Missouri should not be viewed as a substitute for other forms of insurance protection, including umbrella insurance and malpractice insurance. Joint claims against a married couple may still occur, and the result of malpractice and other claims may be a garnishment against the individual’s future income, etc. Business and real estate owners should continue to consider utilizing a corporation, limited liability company or other entity in order to insulate the owner from personal liability for suits involving the business or real estate. Married couples should pay particular attention to the effect asset protection planning may have on their marital property rights in assets which are retitled from separate names into joint (or “tenancy by entirety”) form, either as a final step towards
creating greater asset protection, or as a preliminary step where ultimately the new jointly-owned assets will be transferred to a QST. While Missouri law provides that transfers to a QST will not affect the marital rights of the spouses in the transferred property, transferring assets into joint names (again, either as an ultimate step or as a preliminary step towards funding a QST) may have this effect, if a postnuptial agreement clarifying the couples’ marital rights in the retitled assets is not also entered into. Regular spendthrift trust planning (available in most states) is also still an option, including normal bypass trust planning for a surviving spouse and spendthrift trusts for children and other descendants after the clients’ death. Lifetime spendthrift trusts for the spouse and other third parties which are designed primarily for estate tax minimization purposes, including the socalled “spousal limited access trust” and irrevocable trusts for children, should still be recommended in appropriate cases.
Conclusion and Additional Reading Material
Existing Missouri law includes a unique combination of provisions whereby clients desiring to minimize the chance of a successful lawsuit recovery against their existing assets can readily do so. Utilizing a roadmap similar to that included in Parts 1 and 2 of this article, the advisor’s job is to make the clients aware of the approach or approaches which work best in their particular situation. James G. Blase, CPA, JD, LLM, is a Principal with Blase & Associates, LLC Attorneys at Law in St. Louis. He can be reached at www.blaselaw.com
GrandRounds Mercy Clinic Announces New Physicians and New Locations
Mercy Clinic, the multi-specialty physician group affiliated with Mercy Hospital recently added new doctors and established a new oncology practice. Adonis Bernardo, MD, an occupational medicine physician, joined Mercy Clinic Corporate Health located at 11700 Studt Ave., Creve Coeur. Dr. Bernardo earned his medical degree from the University of Santo Thomas in Manila, Philippines. He completed his residency Dr. Adonis Bernardo in internal medicine at Saint Louis University Health Sciences Center where he also completed a fellowship in preventative/occupational medicine. Demetrious (Jim) Politis, DO, family medicine physician, joined Mercy Clinic West County Family Practice, located at 14377 Woodlake Drive, Ste. 300, in Chesterfield. Dr. Politis earned his medical degree from Kirksville Col- Dr. Demetrious Politis lege of Osteopathic Medicine in Kirksville, Mo. He also completed an internship at the Normandy Osteopathic Medical Center in St. Louis, Mo. Kavitha Kosuri, DO, medical oncologist with Mercy since 2010, established a new practice Mercy Clinic Medical Oncology, located in the David C. Pratt Cancer Center Dr. Kavitha at 607 S. New Ballas Rd., Kosuri Ste. 3125, Creve Coeur.
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GrandRounds SLU Researchers to Test Treatment for Children with Hepatitis B
Clinical Trial at SLU to Assess Gene Therapy in Patients with Poor Heart Function
Saint Louis University researchers are studying a combination of two medications to treat children who have early stage hepatitis B, a liver disease caused by one of the most common infections worldwide. The Hepatitis B Research Network (HBRN), which includes seven pediatric medical centers across the country, will initially test this treatment in a small group of children. For this study, researchers will use one drug that works on the immune system, activating it to recognize and fight the virus, followed by another drug to kill the virus. Investigators are evaluating whether the combination of two drugs is effective since this phase of infection previously had no treatment, said Jeff Teckman, M.D., professor of pediatrics at Saint Louis University and principal investigator of the pediatric study. In the immune tolerant phase of hepatitis B, which is commonly found in children and young adults, a large amount of virus is present in the body but the immune system doesn’t recognize it. Since the system does not fight the virus, it is difficult to treat the infection. In this trial, the course of the treatment will include testing the effectiveness of the first drug for the first eight weeks, followed by the combination of drugs for further 40 weeks. Teckman said that this trial is a test to see if it’s possible to offer an early treatment and avoid damage later in life. Saint Louis University is the only medical center in the region that is part of this trial, and is also running a similar trial for adults. To participate in the pediatric trial, children should be between ages 3-18 and must be diagnosed with immune tolerant chronic hepatitis B. For more information or to participate in the trial, contact Jacki Cerkosko, clinical research coordinator at 314 977 5239.
Saint Louis University has enrolled its first patients in a new clinical trial that will further assess the efficacy of gene therapy in patients with advanced heart failure. The new study, “CUPID 2b”, follows the initial exploratory study, “CUPID” that enrolled 40 patients nationally and tested whether MYDICAR – a genetically-targeted regulatory protein replacement therapy – could repair heart muscle that was damaged by a prior heart attack or cardiomyopathy, a heart muscle disease. The new trial will enroll a total of 200 patients in 52 sites worldwide. “This trial is the next important step in advancing gene therapy as a treatment for advanced heart failure according to Paul Hauptman, M.D., professor of internal medicine at Saint Louis University School of Medicine and principal investigator of the study. They are assessing whether the early impressive improvements seen in CUPID can be replicated in a much larger number of patients. The therapy involves infusing a type of regulatory protein – SERCA-2a – down the coronary arteries that may help the heart cells better utilize calcium, which is similar to an engine getting better gas mileage. This outpatient procedure is performed in a cardiac catheterization lab and aims to increase the level of SERCA-2a, which is reduced in
the individual heart muscle cells in patients with heart failure and can thereby change the way those cells function A patient will undergo a heart catheterization procedure to have the therapy delivered, which will not be any different from a catheterization procedure that they have received before. SLU is the only medical center in the region and one of only 33 in the nation that is participating in the study. To participate in the trial, please contact the Cardiology Research Office at Saint Louis University at 314-577-8876.
Career Development Program in OB/GYN Moves to Washington University A research career development program in obstetrics and gynecology is moving to Washington University School of Medicine in St. Louis from the University of CaliforniaSan Francisco. The Reproductive Dr. Kelle Moley Scientist Development Program (RSDP) will support the salaries and training of 15 MD or MD/PhD fellows who want to become physician scientists in obstetrics and gynecology. Physician scientists usually pursue faculty positions that allow them to treat patients as well as conduct lab research. The program, which will support three scholars every year for five years, is funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at
the National Institutes of Health (NIH). Robert Jaffe, MD, former director of the RSDP, retired. As a result, grant applications were sought for new leadership. The goal of this program is to develop a group of physician scientists who will conduct basic science research to address important problems in the field says Kelle Moley, MD, the James P. Crane Professor of Obstetrics and Gynecology and new recipient of the grant. The RSDP is the premier national training program for physician scientists and is a testament to the strength of the school and to the leadership of Kelle Moley according to George Macones, MD, the Mitchell and Elaine Yanow Professor and head of the Department of Obstetrics and Gynecology at the School of Medicine. More than 85 reproductive scientists, including Moley (1992-98), have participated in the RSDP since it began in 1988. Four now are chairs of obstetrics and gynecology departments, and nine are division directors or vice chairs within their departments. Sixty-four of these physician scientists have remained in academic medicine. Applicants from any major medical center within North America may compete for these awards. Inquiries can be directed to Amanda Heflin, MBA, the program administrator of this multicenter grant, at heflina@wustl.edu or 314-747-3598.
YOU ARE SPECIAL. Your case is unique and you don’t want to be a number, you want to get the best treatment possible by people who will remember your name. You like things done a certain way, and for someone to understand what makes you special.
WE ARE SPECIALISTS. The people of Saint Louis University Hospital are specially trained to treat your unique case. We are caregivers at every level. We are exclusively SLUCare, the physicians of Saint Louis University, and we are steeped in the Jesuit tradition of teaching and research while continuing to be focused on the future with breakthrough services and technology.
Concussion Seminar Coming September 23 A free seminar on “Knowing the Dangers of Concussions” will be presented at the Chesterfield, MO, YMCA at 6:00 pm, September 23. The seminar will be presented by Dr. Matthew Bayes, Blue Tail Medical Group; Betty Sisco, PA; John D. Wright, PhD, ABPP Staff Neuropsychologist; and Steve Easterday, St. Louis Physical Therapy. This informative seminar will discuss this timely subject as athletes from the region begin preparation for the 2013 football season. For further information, call 314724-0291 or email amalyn@stlpt.com.
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Bruce Bacon, MD Professor of Gastroenterology and Hepatology
Gabriella Espinoza, MD Assistant Professor, Department of Ophthalmology Residency Program Director, Saint Louis University Eye Institute
Michael Lim, MD Associate Professor of Medicine Co-director, Center for Comprehensive Cardiovascular Care at Saint Louis University Hospital (C4)
sluspecialist.com 314-577-8000
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