PSG
Rumblings SPRING 2021
PENNSYLVANIA SOCIETY OF GASTROENTEROLOGY / NEWSLETTER
President’s Message / Ravi K. Ghanta, MD, PSG President
www.pasg.org
Dear Colleagues, It has certainly been a whirlwind ending to the year 2020 between the election and the COVID-19 pandemic. Many of us are grateful to have a fresh start in 2021 and to move past some of the chaos. Spring is also in the air and it is nice coming off winter to the refreshing changes of the new season. As vaccinations are becoming widely distributed, we are hopeful to be inching closer and closer to a more normal way of life. However, we still have a lot of work ahead of us. @RAVIGHANTA5
COVID-19 has been and continues to be an enormous stressor that will have a long-lasting effect on many of our colleagues. So many have had devastating impacts to their medical practices, financial livelihoods, and more importantly, their physical and mental health. The past year will be a time that most of us will never forget. Our Annual Conference which was scheduled for September 2021 was cancelled due to uncertainty related to the pandemic. This was a very difficult decision to make but was made in
the best interest of our members. However, we have now experienced the possibility of virtual conferences as an option. Our goal is to have our Annual Conference in the Fall of 2021 and it is tentatively scheduled in September 2021. We were truly hopeful we would be able to hold an in person Annual Meeting, but we decided to play it safe with a virtual meeting. I am grateful for the digital platforms that are now available to us and that have been successfully implemented by other organizations. I do miss the time when we met in person at the Annual Conference. It was a wonderful opportunity to meet colleagues and have our families attend as well. One of our goals for the meeting has been to make it a family friendly event which we will eventually return to once safe to do so. As we learn new information and discover new ways to treat and prevent COVID-19, we need to continue to work together to support each other and our patients. continued on page 2
PSG/SOCIAL: @PAGastroSoc
INSIDE: 2 President’s Message
7 L egal Corner
11 Events and CME
3 Berks Health Initiative
8 One Physician’s Calling
12 Finance Update
4 FIT Update
10 Practice Management
15 PSG Updates
President’s Message
continued from page 1
I want to stress that PSG is here for you, and is an organization run for your colleagues and by your colleagues. If you feel there is a topic that would be of broad interest for our members, please let us know. We would also love to hear any updates in your career, new accomplishments, awards, etc. to highlight in the newsletter. We at PSG want to be part of your work family and want to be a valuable resource to you. If you are a member of the PSG, I thank you for your support. If you are affiliated with the field of GI or
hepatology, I ask you to consider joining this wonderful organization which will have its 40th Anniversary this year. One of our goals is to have every GI fellow in the state of Pennsylvania join as a member of the organization because 1) trainees are the future of the specialty and 2) this allows collaboration amongst training programs throughout the state. Membership fees are complementary for fellows and even residents who have an interest in our specialty and the application process takes only minutes to complete. The PSG has also been supporting its engagement with non-clinical
members such as administrators, office managers to improve practice efficiency. Non-clinical members are encouraged to join with only a nominal fee. As the PSG, we are your state GI organization, and can only be as strong as the commitment of our members. We want to remain active and continue to grow but need your support and engagement. I hope you enjoy this issue of Rumblings and look forward to hearing from you. Please stay safe!
Ravi Ghanta, MD President Pennsylvania Society of Gastroenterology
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Berks Health Initiative—Eight Years Getting Gutsy Aparna Mele, MD gutsyandmini Every year, Guts and Glory Digestive and Wellness Expo is held here in Berks County in late September. The Expo was created and hosted by nonprofit My Gut Instinct and is sponsored by Penn State Health St Joseph. Guts and Glory is a free, large scale, non-profit community-wide celebration of health for all ages and showcases a farmer’s market, educational booths, community outreach, fresh locally sourced food made by local chefs, fitness zones, yoga, massage meditation, and wellness experts, to name a few features. This free admission, interactive, annual event for all ages is designed to educate the health curious, elevate the understanding of the health conscious, and raise community awareness of the importance of digestive health and overall wellness through the free exchange of information and resources. The Guts and Glory event aims to provide people with health knowledge and empower them to take action to live healthier lives and become beautiful from the inside, out, because “We aim to provide people with health knowledge and empower them to take action to live healthier lives and become beautiful from the inside, out, because we believe beauty starts on the inside,” said founder Aparna Mele, MD. “We also want to show the community that eating and living healthy is not only easy to do, but it can also be fun and delicious too!” Aparna Mele, MD, a board-certified gastroenterologist with Digestive Disease Associates since 2007 is the founder and president of My Gut Instinct, and the organizer of this event. She came to the field of
medicine with extensive experience in international relief work overseas and is actively involved in local philanthropic work directed towards patient education and promotion of societal health. She created her nonprofit to celebrate a united community spirit of health, wellness, positivity, and empowerment and to encourage community members to find inspiration to take an active role in their own well-being all year long. The mission at My Gut Instinct, a non-profit organization, is to collaboratively inspire and empower the Greater Reading community to embrace health and eat and live better for longevity. The organization aims to increase awareness of preventable diseases that impact community health. The organization focuses on preventing these avoidable diseases through motivating the community to make healthy choices, promoting cancer screenings, and raising awareness for various health concerns. Guts and Glory Digestive and Wellness Expo is the result of her endeavors and has been running for the past seven years, welcoming hundreds of visitors each year! It is a far-reaching, educationally inspiring, community giving, and feel-good event held annually, now celebrating their 8th year. The event has enjoyed extensive media coverage and public accolades for their health movement in the community. Their clever mascot, a 6’1’ mannequin named GUTSY GIRL or her “minime”, tabletop version named MINI GUTSY, can be found throughout town, spreading the word about Guts and Glory every fall. To stay engaged with the community, the My Gut Instinct team also runs a
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monthly blog year-round, featuring wellness articles to continue the conversation about getting and staying healthy in body, mind, and soul. Numerous community sponsors and volunteers make the event possible, and the organization welcomes health-minded businesses committed to community health to join and participate. Highlighting the work of this forward-thinking gastroenterologist in Berks County at PA Society of Gastroenterology can bring attention to her important work and draw more visitors to help this amazing event grow! This year’s 8th annual event will be held at Willow Glen Park, home of Shocktoberfest on the last Saturday of Sept 2021. For more information about My Gut Instinct, their free wellness blog, and the Guts and Glory event, visit www.mygutinstinct. org. Stay up to date with volunteer, sponsor and vendor opportunities as well as enjoy healthy recipes and inspirational motivation on Facebook and Instagram.
FIT Update: Coffee and GI Health Travis Magdaleno, MD Gastroenterology Fellow, PGY-5
B EEP BEEP BEEP! It is 5 am. You roll over and silence the alarm clock.
It is Wednesday morning, and you are nearing the home stretch of your Tuesday night call. Some call nights are quite manageable, however last night was not the case with two urgent endoscopies - food impaction at 7 pm followed by a severe upper GI bleed at 1am – not to mention multiple patient calls about colonoscopy preps. Somehow you find the strength to get out of bed, wash up, get dressed, and head to the kitchen to get ready for your full day of office patients. In the kitchen, you fill the water in your drip coffee machine, measure the ground coffee, and brew a fresh cup of medium roast Peets coffee for your travel mug. As you drive to the office and savor every sip of your coffee, you wonder… why is coffee so magical?
Coffee has certainly evolved since it was first traded in the 16-17th century. We now have a multitude of ways to enjoy this magnificent substance and the ability to obtain high quality coffee beans from around the world. As gastroenterologists and hepatologists, we often receive questions from our patients regarding the benefits and risks of certain foods/supplements. Personally, my patients have inquired about the impact of caffeine on their health – inspiring me to further research this interesting topic. Below we will review some of the effects that coffee and caffeine have on gastrointestinal health.
Reflux
Coffee has long been associated with reflux disease. In our Fellows clinic, we have several informational handouts for patients suffering from GERD. Lifestyle changes, such as avoiding triggers like coffee and tea, are a large component of the treatment of reflux disease. However, whether coffee is linked with reflux remains rather controversial in the literature. A 2013 article published in Food Science Technology and Research reviewed 15 articles published from around the word assessing the link/effect of coffee and GERD (1) - only five articles found described a positive correlation between the two. Researchers studied the effects of caffeinated vs decaffeinated coffee on esophageal pH, gastric acid secretion, and LES pressures. Interestingly, bean qualities were also studied with respect to GERD symptoms. Unfortunately, the evidence within each category yielded conflicting results. The conclusion of this
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review article reports that although patients may complain of abdominal pain or burning sensation after drinking coffee, the relationship between GERD and coffee remains inconclusive. Further studies were recommended. A prospective cross-sectional study published in 2019 in Taiwan investigated this clinical question further (2). Prior to undergoing a screening endoscopy, 1,837 patients were interviewed about their symptoms of reflux and their daily consumption of coffee and tea. Baseline demographic data was collected and EGDs were performed to evaluate for objective findings of reflux (i.e. erosive esophagitis). The prevalence of symptomatic reflux in this population was 25.4%, however of these individuals, 71.2% did not have erosive changes on endoscopy. On EGD, 23.3% were found to have findings consistent with erosive esophagitis, and of these patients, 78.4% were symptomatic. However, multivariant analysis showed no association between coffee or tea consumption and either symptomatic reflux or erosive esophagitis. Although, there was a positive association with reflux symptoms and findings of erosive esophagitis in individuals who had a hiatal hernia and those with features of metabolic syndrome. A negative (protective) association was found in females and those with H.pylori infections. Personally, when discussing lifestyle changes with patients, I recommend the use of a food diary to identify trigger foods. At the office visit, we discuss common culprit foods that trigger symptoms and I provide them with educational materials.
Liver
Interestingly, newer data has shown that coffee is beneficial for patients who suffer from chronic liver disease or advanced fibrosis/cirrhosis. Early studies from Japan and Europe in 2005 discovered coffee consumption is associated with lower liver enzyme (GGT and ALT) levels when compared to matched controls that did not consume coffee. This was also confirmed in the US using information from NHANES database in 2014 (3). Regarding liver fibrosis and coffee, in 2009, the HALT-C study was published which only included patients with F3 (bridging fibrosis) or F4 (cirrhosis) disease (4). This study showed that at baseline, increased coffee consumption was associated with milder liver disease. Furthermore, over the 4-year study period, patients who consumed > 3 cups of coffee per day had a lower risk of experiencing adverse outcomes with regards to their liver disease, particularly decompensation or the development of liver cancer (11.1 vs 6.3 per 100-patient years – almost a 50% decrease). This observation was not seen with other sources of caffeine, such as tea (4). Does the coffee preparation matter? Interestingly, it may. For unclear reasons, the apparent benefits were only observed in patients who consumed drip filtered coffee, not with espresso or boiled (Turkish) coffee. It has been proposed that drip coffee reduces concentrations of cafestol and kahweol – chemicals that have been shown to increase LDL levels. Additionally, espresso and Turkish coffee are often consumed with refined sugar, which may offset the health benefits. In fact, those
individuals who consumed espresso coffee were noted to have lower HDL levels, higher triglycerides, and increased prevalence of metabolic syndrome. Another difference between the preparations is the amount of caffeine consumed. Despite high concentrations of caffeine in espresso, the overall volume consumed is small, therefore the amount of caffeine consumed is typically larger in drip coffee drinkers (4). In our center, I have discussed coffee and liver health with our transplant hepatologists and inquired about their personal approach to this topic. Although it does not appear to be a heavy focal point during their patient encounters, when it does arise, they advocate for continued use of coffee. At this time, it is difficult to recommend a specific amount/dose or method of coffee intake, however they do suggest avoiding the extra sugar-laden caffeinated beverages, which may do more harm than good.
Colon Health
Diarrhea is one of the most common complaints that we come across as gastroenterologists. Part of my assessment for this concern includes a thorough medical and surgical history, review of the patient’s medication list, supplement use, and dietary intake – including the use of artificial sweeteners and coffee habits. Coffee is well regarded as a promotility agent, however the mechanism behind this phenomenon is unclear. In the late 1990s, a European study performed colonic manometry in 12 healthy volunteers (5). Over a 10-hour period, subjects ingested black Colombian coffee, water,
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decaffeinated coffee, and a 1000kCal meal. The investigators measured the effects of each stimulant on colonic motor responses. They found an 8oz cup of caffeinated coffee generated similar colonic motor activity to that of a 1000kCal meal (23% greater than decaf coffee, and 60% stronger than water)! Colorectal Cancer (CRC) is another very important and popular realm of colon health, which has recently been revitalized with the unfortunate death of actor Chadwick Boseman last year. Although coffee intake is not a topic I usually discuss during office visits for CRC screening, I did come across some interesting data to suggest maybe I should. In 2016, a population-based case control study in Northern Israel was published in Cancer Epidemiology and Biomarkers Prevention evaluating the association of coffee intake and risk of colorectal cancer (CRC) (6). They evaluated approximately 10,000 patients diagnosed with CRC and separated them into 2 groups: those who consumed coffee and controls. In addition to demographic data, coffee consumption data collected included: daily intake (cups/day) and coffee type (filtered, instant, espresso, boiled black, or decaffeinated). They discovered that overall, coffee consumption was associated with a 26% risk reduction of developing CRC (OR 0.74; 95% 0.64 – 0.86, P<0.001). This relationship was also observed in patients who consumed decaffeinated coffee. Furthermore, this inverse relationship was found to be dose dependent. When compared to <1 serving/day, consuming 1-2 servings was associated with a 22% reduction, 2-2.5 servings equated to continued on page 6
FIT Update: Coffee and GI Health continued from page 5
a 41% reduction, and >2.5 servings to a 54% reduction. All odds ratios were statistically significant. The authors concluded that coffee consumption appears to be associated with reduction of CRC in a dose-dependent fashion. One year later in 2017, a prospective study was published in Gastroenterology evaluating the relationship between coffee intake and mortality rate after a diagnosis of CRC had been made (7). Patients with a diagnosis of CRC were asked about their coffee intake prior to their diagnosis (baseline) and after diagnosis. Subjects were followed for a median of 7.8 years. Compared with nondrinkers (controls), patients who consumed greater than 4 cups/ day had a 52% lower risk of CRCrelated death, and 30% reduced risk of death from any cause. Additionally, the authors examined coffee intake before and after the diagnosis of CRC. Compared to patients who consistently consumed low volumes of coffee, patients who continued to consume >2cups/day after their CRC diagnosis had a significantly lower risk of CRC-related death and death from any cause.
Conclusion
As gastroenterologists, coffee is a topic which has infiltrated our work environment in many different aspects. It is not only a substance that many of us rely on to get us through the post-call night workday, but also a topic that our patients may wish to discuss. It appears to have many benefits, especially in the realm of hepatology and colorectal cancer. As of now, there is not enough data to suggest how/if we should incorporate these apparent benefits into our guidelines. Depending on the clinical situation, my personal approach, when prompted, is to promote the regular use of coffee unless the patient is suffering from adverse events (i.e. reflux, diarrhea, palpitations, etc.). Lastly, on a personal note, I have grown to truly enjoy my coffee, especially over the past 20 months of being a GI fellow. Not only for the bold taste and energy boost after a brutal call night, but also (and more importantly) for designated morning “coffee time” my wife and I share on the weekends, which makes all those long nights worth it.
References
1. Z hang Y, Chen SH. Effect of Coffee on Gastroesophageal Reflux Disease. Food Sci. Technol. Res.. 2013;19(1), 1 – 6. 2. W ei TY, Hsueh PH, Wen SH, Chen CL, Wang CC. The role of tea and coffee in the development of gastroesophageal reflux disease. Ci Ji Yi Xue Za Zhi. 2019;31(3):169-176. 3. X iao Q, Sinha R, Graubard BI, Freedman ND. Inverse associations of total and decaffeinated coffee with liver enzyme levels in National Health and Nutrition Examination Survey 1999-2010. Hepatology. 2014;60(6):2091-2098. 4. F eld JJ, Lavoie ÉG, Fausther M and Dranoff JA. I drink for my liver, Doc: emerging evidence that coffee prevents cirrhosis [version 2; peer review: 3 approved]. F1000Research 2015, 4:95 5. R ao SS, Welcher K, Zimmerman B, Stumbo P. Is coffee a colonic stimulant?. Eur J Gastroenterol Hepatol. 1998;10(2):113-118. 6. S chmit SL, Rennert HS, Rennert G, Gruber SB. Coffee Consumption and the Risk of Colorectal Cancer. Cancer Epidemiol Biomarkers Prev. 2016;25(4):634-639. 7. H u Y, Ding M, Yuan C, et al. Association Between Coffee Intake After Diagnosis of Colorectal Cancer and Reduced Mortality. Gastroenterology. 2018;154(4):916-926.e9.
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Legal Corner
Private Equity, Gastroenterology Consolidation, and the Corporate Practice of Medicine Doctrine
Richard E. Moses, DO, JD
@therealgidoc The healthcare environment is changing. Practice consolidation is extremely active, especially in the Gastroenterology field, largely being driven by private equity partners. Gastroenterology is particularly interesting to investors because of lucrative services such as endoscopy, ambulatory facilities, and numerous ancillary services. The American Medical Association propagated the initial version of the Corporate Practice of Medicine (“CPOM”) doctrine under the auspices of protecting the public. CPOM generally prohibits non-licensed persons, including individuals and business entities, from employing physicians to practice medicine on their behalf. The intent of the doctrine was to ensure that only licensed medical professionals delivered medical care and that lay persons and entities not influence treatment decisions. The idea was
to protect patients from potential abuses because commercialized medicine could divide a physician’s loyalty between profits and the delivery of quality care. Private equity and other nonphysician investment deals create a managed services organization (“MSO”) that in turn buys out the Gastroenterologists from the practice being acquired. In exchange for a cash payout, the physicians give up managerial control of nonclinical decisions through a managed services agreement with the MSO. All nonclinical services to the practice are then managed by the MSO, which is a partnership between the private equity group and the practice. Physicians need to be sure that the structure of the entity formed complies with the state’s CPOM doctrine. States with CPOM laws allow professional service entities to practice medicine if owned by physicians licensed in that state. Pennsylvania’s CPOM doctrine is codified under the Medical Practice Act of 1985 (63 P.S. §§ 422.1, et seq.). Exceptions to the CPOM doctrine in Pennsylvania include practicing medicine through a professional corporation, limited liability partnership, or restricted professional company. Only licensed physicians may be shareholders of or partners or members in professional corporations, limited liability partnerships, or restricted professional companies that have been formed to provide medical services. The statute requires all beneficial owners of these entities be licensed persons. Health Maintenance Organizations, licensed hospitals, and health care
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facilities may also employ physicians and provide health services in Pennsylvania. As a consequence of the CPOM doctrine, nonphysician investors desiring to offer physician services, either alone or with other services, set up two entities. These are a captive, or friendly, professional corporation (PC) and the MSO that contractually furnishes all nonphysician services to the PC. The MSO is paid a fee for providing these services to the GI practice. Fees need to be paid at fair market value for the services provided. MSO services may not interfere with the professional’s clinical judgement, and the MSO may not control the medical aspects of the medical practice. Health care providers must be extremely careful in complying with the CPOM doctrine. Violating these laws could result in a physician’s loss of license and repayment of all revenue for billed services to patients, insurance companies, and the government, in addition to fines, penalties, and potential criminal charges. In light of the structural complexity of these business deal, it is mandatory to ensure that the corporate or business arrangements comply with the complex requirements of the CPOM doctrine. Physicians must consult with a health care attorney to get advice and recommendations prior to getting involved with private equity or other business ventures.
One Physician’s Extraordinary Calling James W. Srour, MD 10,000 people and most of these are located near the cities, leaving a large percentage of the population with virtually no medical care.
@Srour
Enter Dr. Beattie. At the age of 15 years-old, Amanda Beattie went on her first medical mission trip. What she experienced on that trip set the stage for the rest of her life. Her mission was to be a doctor for the express purpose of helping the underserved people somewhere in the world. During medical school, a rotation in Ghana further cemented her decision. For her, there was no turning back. While she was in her general surgery residency, she began to consider sites for her practice. Unlike most of us, she was not looking for a wellequipped hospital in a nice city with good schools and a comfortable climate. She already knew what she wanted- a place where most would not go voluntarily, a place with little or no medical care was available.
On the west coast of Africa lies the nation of Mauritania, a desert country covering an area about 8.5 times as large as Pennsylvania. Bordered by Mali, Senegal, Western Sahara and the Atlantic Ocean, it is a difficult environment with a population of about 4 million mostly Arab and French speaking people. With such a small population in this vast land, medical resources including doctors and healthcare workers are spread very thinly. There are approximately 2 physicians per
After arriving in Mauritania, Dr. Beattie spent a year learning
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French and then Arabic. At that point, she was able to converse with the medical board to explain what she was trying to do and convince them to grant her privileges to work in their country. And convinced they were! In the meantime, she found a village called Chinguetti, 300 miles from the coastal capital of Nouakchott. There she found a small hospital building with virtually no equipment and no physicians. Perfect! The dream job she had been looking for. With no other medical facilities within a vast perimeter, Dr. Beattie found herself taking care of all manner of medical problems, including primary care. For any but the simplest of lab tests, she needed to have patients travel 2 hours each way by bus. If she needed x rays or more technical studies, patients had to travel 7 hours. Knowing that she would need to upgrade the hospital services, Dr. Beattie contacted charitable donors and was successful in setting up her own diagnostic and x-ray facility. She trained herself to use the equipment,
2021 (post vaccination) and we would like to collect and deliver equipment including scopes, light sources, biopsy forceps, snares cleaning equipment and supplies. Are you going to be upgrading your equipment in the foreseeable future? Or possibly closing a practice due to retirement? We would appreciate your consideration for this need. The value of the donated equipment is tax deductible through Dr. Beattie’s 501c organization. Monetary donations are also gratefully accepted.
and then taught local people to take over these duties. Soon she was able to obtain equipment for the operating room and begin performing basic elective surgeries. Recently, a donor purchased a CT scanner which is scheduled for installation. Two more physicians are now working at the facility. The Hospital De La Fraternida has now become a self-sustaining community hospital with patients coming from all over the country to benefit from the excellent medical and surgical care. In 2017, the president of Mauritania knighted Amanda Beattie, MD for her outstanding work on behalf of the country. He then requested that she take over as director of the Community Hospital at Oudane, a town forty miles from Chinguetti. Her MBA helped with this! She and her colleagues now run a training program for young physicians. Their goal is to attract more help for the villages. When does she sleep?
Imagine how this could help the people of this almost forgotten land. You can help Dr. Beattie change the world! Dr. Beattie tells me that the most common complaints she encounters are, not surprisingly, GI including heartburn, abdominal pain, diarrhea and the like. Unfortunately, colon and gastric cancers are also common, and are usually diagnosed by a palpable mass, meaning generally at late stage. There is, of course, no screening and resources for endoscopic evaluation essentially unavailable. Here is where we can help. Dr. Beattie wants to build an endoscopy center at her hospital. I know it can be done as I was able to bring one to a small hospital in South India about 25 years ago, using donated equipment and the services of visiting gastroenterologists. There is a group of physicians planning a trip to Mauritania in the fall of
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Perhaps in the future you may consider volunteering for a shortterm mission trip? Think about it! If you would like to donate equipment, please contact me. James W. Srour, MD Jushla2@gmail.com For monetary donations: Health Outreach to the Middle East (H.O.M.E.). Attn: Mauritania Project 3403 Cartwright Road Missouri City, TX 77459
Practice Management Update Introducing: New PSG Membership Opportunity for GI Practice Managers R. Fraser Stokes, MD. PSG Practice Management Task Force Chair. August 2020
“ You don’t get paid for the hour. You get paid for the value you bring to the hour.” — Jim Rohn, American entrepreneur, @FraserStokes author, and motivational speaker
The PSG is excited to announce a
new membership category for GI practice managers. This membership would be open to those that are involved in business management functions for practices, academic departments, clinics, and ambulatory surgery centers that provide care for digestive diseases. The PSG board’s goal is to provide value to our members by helping business managers run their practices more efficiently. The PSG would hope to become a place for these professionals to learn ways to better do their job, to meet and develop relationships with their peers, to share strategies and ideas with others, and to easily ask and have answered GI business questions.
The plan is first to have dedicated programming for practice managers at our annual meeting, both for networking and for education. Secondly, we hope to arrange for quarterly Zoom meetings for the practice manager members to discuss issues of interest. Lastly, we intend to have occasional articles written in Rumblings by GI managers covering topics that they feel are most important for their peers. The bylaws are undergoing change to incorporate the specifics of this membership that will be available to all managers that work on a team with a PSG physician member. The membership fee will be set at $50, and the membership application will be easily submitted via the PSG web site. I am happy to report that Gary Macioce of SWGI Specialists in Uniontown, PA, and Stephen Gildea of Blair Gastroenterology Associates in Altoona, PA have agreed to be co-chairs of this newly formed group of practice managers. Mr.’s Macioce and Gildea will also serve on the larger PSG practice management task force where they can share managers’ ideas from Zoom and on-site meetings with PSG physician leaders.
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Potential discussion items include billing and coding; infection control, physician and staff recruiting, leadership strategies, prior authorization, infusion services, group purchasing organizations, EMR systems, ancillary services (e.g. pathology, anesthesia), advanced practice providers, pandemic preparedness, clinical research opportunities, and relevant lecture topics at the annual meetings. On behalf of the board of the PSG, I encourage you to discuss this valuable new opportunity with the managers at your GI workplace.
CME (GI) /EVENTS/2021 Thomas Jefferson Liver Disease Symposium April 10, 2021
Digestive Disease Week May 21-23, 2021 https://ddw.org/register/ registration/
jeffersonCPD@jefferson.edu
PSG Virtual Scientific Meeting September 11, 2021 https://www.pasg.org/ annual-meeting.html
ACG 2021
COVID-19 Update
Las Vegas, NV October 22-27, 2021
Looking for up to date information and resources for COVID-19? Please check out the PAMED COVID-19 Resource Center.
https://acgmeetings.gi.org/
https://www.pamedsoc.org/education-cme/public-health/covid/ corona-virus
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$/Finance Update David B. Mandell, JD, MBA
Shielding Your Wealth from Liability: Asset Protection Tools Are Not Equal
medical patient, bad habits might mean smoking, drinking too much or a poor diet. From an asset protection standpoint, bad habits might include owning property in a physician’s own name, owning it jointly with a spouse, or operating any medical practice with business assets exposed.
@OJMGroup
A s an attorney and consultant to
more than 1,500 physicians, I have advised many gastroenterologists regarding tools and strategies to shield assets from unforeseen future liability. In this article, I hope to dispel some incorrect assumptions and provide one of the most important fundamentals of asset protection: protective tactics and tools are not equal. In fact, each can offer varying levels or degrees of protection.
Asset Protection: A Matter of Degree
The most common misconception that physicians have regarding asset protection is to think that an asset is either “protected” or “not protected.” An asset protection professional approaches a physician with unprotected assets much in the way that a doctor treats a patient. Like physicians, asset protection professionals will first try to get a client to avoid bad habits. For a
Beyond bad habits, we try to structure a physician’s assets so they have the best protection that is reasonably possible under the circumstances, which can range from how much the doctor wants to spend and how much the asset is worth to the client’s marital status, state of residence and interest in estate planning. Guiding this process is the knowledge that each asset protection tool, like any medicine, has certain efficacy and costs/benefits. For the past 20 years, I have used an asset protection rating system ranging from –5 (totally vulnerable) to +5 (highest level of protection). The goal of asset protect planning is not to move all assets to a +5 position—this simply is not possible, even in the states that have the most protective laws. On the other hand, too many physicians, including gastroenterologists, have too many of their personal or practice assets in negative positions with little or no shield. At a minimum, nearly all physicians would do well to move the bulk of their personal and practice assets to positive positions.
Highest Level of Protection: Exempt Assets State and federally exempt assets are the best +5 protection tools that can be leveraged by physicians. In addition to enjoying the highest +5
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level of protection, they involve no legal fees, state fees, accounting fees or gifting programs. In other words, you can own the exempt asset outright in your name, have access to any values and still have it 100% protected from a typical lawsuit against you. Each state law has assets that are exempt from creditor claims, thereby achieving a +5 status. Many states provide exemptions for qualified retirement plans and IRAs, cash within life insurance policies, annuities, and primary homes. Consult an asset protection expert to learn the exemptions in your state; and, if protection is important to you, be sure to maximize these +5 tools.
Joint Ownership Forms: Top Protection for Some Assets Against Some Creditors in Some States
In about 20 states, tenancy by the entirety (“TBE”) is a form of joint ownership available to married couples that may provide the top level of protection for claims against only one spouse. In some states, this protection applies only to real estate owned by TBE; in other states, both real property and personal property, like investment accounts, can be shielded through TBE. However, inherent in TBE are several risks, including the fact that TBE never provides any protection against joint risks (such as lawsuits that arise from jointly owned real estate) and all protections are lost in the event of a divorce. For this reason, even in states where TBE can be protective, we often recommend that it be combined with legal tools such as those described below.
Bridging the Gap: Legal Tools
Legal tools, such as limited liability companies (LLCs), family limited partnerships (FLPs), and a variety of trusts, are often used to bridge the gap between negative protection positions and +5 exempt assets (or TBE in limited circumstances, per above). FLPs and LLCs can provide good asset protection against future lawsuits, allow for maintenance of control by the client, and can provide income and estate tax benefits in certain situations. Specifically, these tools will generally keep a creditor outside the structure through charging order protections, which typically allow a physician to create enough of a hurdle against creditors to negotiate favorable settlements. For these reasons, we often call FLPs and LLCs the building blocks of a basic asset protection plan. There are also many types of trusts that provide significant protection for clients. These can range from life insurance trusts or charitable remainder trusts to grantor retained annuity trusts and more. In recent years, many states have passed statutes allowing domestic asset protection trusts (DAPTs) which can be an ideal trust protection tool for many physicians. Each trust type has its pros and cons, costs, and benefits. Obviously, for all these legal tools, asset protection benefits are reliant upon accurate drafting of documents, proper maintenance, respect for formalities and suitable
ownership arrangements. If all these are in place, the physician can enjoy solid asset protection for a relatively low cost.
Conclusion
Asset protection planning, like any sophisticated multidisciplinary effort, is one with relative pros and cons for each tactic or strategy. A physician should be guided by an advisor who utilizes all available tools to provide the highest levels of protection with reasonable costs. SPECIAL OFFERS: The author has recently completed Wealth Planning for the Modern Physician. To receive free print copies or e-book downloads of this book or Wealth Management Made Simple, text PSGNEWS to 844-418-1212, or visit www. ojmbookstore.com and enter promotional code PSGNEWS at checkout. David Mandell, JD, MBA, is an attorney and author of more than a dozen books for doctors, including Wealth Planning for the Modern Physician. He is a partner in the wealth management firm OJM Group (www.ojmgroup.com) and can be reached at 877-656-4362 or mandell@ojmgroup.com.
Disclosure:
OJM Group, LLC. (“OJM”) is an SEC registered investment adviser with its principal place of business in the State of Ohio. SEC registration does not constitute an endorsement of OJM by the SEC nor does it indicate that OJM has attained a particular level of skill or ability. OJM and its representatives are in
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compliance with the current notice filing and registration requirements imposed upon registered investment advisers by those states in which OJM maintains clients. OJM may only transact business in those states in which it is registered or qualifies for an exemption or exclusion from registration requirements. For information pertaining to the registration status of OJM, please contact OJM or refer to the Investment Adviser Public Disclosure web site www.adviserinfo.sec.gov. For additional information about OJM, including fees and services, send for our disclosure brochure as set forth on Form ADV using the contact information herein. Please read the disclosure statement carefully before you invest or send money. This article contains general information that is not suitable for everyone. Information obtained from third party sources are believed to be reliable but not guaranteed. OJM makes no representation regarding the accuracy or completeness of information provided herein. All opinions and views constitute our judgments as of the date of writing and are subject to change at any time without notice. The information contained herein should not be construed as personalized legal or tax advice. There is no guarantee that the views and opinions expressed in this article will be appropriate for your particular circumstances. Tax law changes frequently, accordingly information presented herein is subject to change without notice. You should seek professional tax and legal advice before implementing any strategy discussed herein.
2021 PSG ANNUAL SCIENTIFIC MEETING SEPTEMBER 11
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PSG Updates/Milestones Austin Chiang, MD was featured in the New York Times for his approach on debunking misconceptions and not people in order to promote facts, not fiction. You can read the full article here: https://www.nytimes. com/2020/12/14/technology/to-quash-vaccine-misinformation-this-doctor-opts-forfacts-over-fighting-fiction.html
Neilanjan Nandi, MD is the Host of Reach MD’s podcast GI Insights featuring cutting edge talks with leading faculty. Recent topics include insights w/Brian Lacy, MD on the latest 2020 ACG IBS guidelines, the role of diet in Ulcerative colitis w/Maria Abreu, MD and applying Virtual Reality as a Digital Therapeutic with Brennan Spiegel, MD. Catch these GI Insights and more. Link: www.reachmd.com/GIInsights
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Dr. Keerthi Kesavarapu “This year blessed us with a little baby girl. Our little bundle brought us joy amid the pandemic.” —Keerthi Kesavarapu, DO
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