Today's Practice: Changing the Business of Medicine

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COLORADO EDITION CONTRIBUTORS

Becky Rudolf

PUBLISHER Charles Tramont ctramont@todayspractice.com

Healthcare Management Partners, LLC brudolph@hmpperforms.com

Randall C. Schauer Fox Rothschild LLP rschauer@foxrothschild.com

BUSINESS MANAGER Kathy Schauer kschauer@todayspractice.com

Doreen Jaress MySuccess Inc. djaress@mysuccess.com

Bob Smith

EDITORIAL ASSISTANT Nancy Smoot nsmoot@todayspractice.com

MARKETING EDITOR Nathan Purcell npurcell@todayspractice.com

MySuccess Inc. bsmith@mysuccess.com

Alan Brandfon Priority Payment Systems Atlantic abrandfon@ppsatlantic.com

Richard Wagner, JD qliqSoft richard@qliqsoft.com

Allan W. German Solaris Imaging agerman@solarisimaging.com

PRACTICE MANAGEMENT EDITOR Candy Caverley ccaverley@todayspractice.com

Christopher Hynes, JD, CFP Hynes Financial chris@hynesfinancial.com

Brendan J. King, Esquire

LEGAL EDITOR Neil Thomson Esq. nthomson@todayspractice.com

TECHNOLOGY EDITOR Bob Smith bsmith@todayspractice.com

Estate Preservation Law Offices bking@estatepreservationlaw.com

Philip C. Gallant, CLTC The Optimus Group, LLC phil@theoptimusgroupllc.com

Alan Finston Whatcom Physical Therapy alanf@whatcompt.com

Ron Meritt On Advertising rmeritt@on-advertising.com

FINANCE EDITOR Chris Hynes, JD, CFP chynes@todayspractice.com

Keith Clark Abode Systems kclark@abodesystems.com

R. Scott Liff Liff Laboratories

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PRACTICE MANAGEMENT IN SYNC Managing the business & cultural aspects of a practice merger

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THE LATEST BLISTERING PHRASE IN HIRING

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STRESS

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THE PERFECT COMPLIMENT

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Addressing the elephant in the corridors, the exam rooms, and in the mirror.

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Upgrade your human resource function to better support your strategic mission, while more effectively administering the basics.

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FINANCE ESCAPE FROM THE TAX TRAP

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Can you become a Financial McGyver?

DEFINING YOUR INVESTMENT PHILOSOPHY

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SPECIAL FEATURE: PRACTICE CULTURE DEVELOPMENT SERIES

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ARTICLE DIRECTORY

LEGAL 15

BUILD A STRONGER FOUNDATION

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ESTATE PLANNING FOR RETIREMENT ACCOUNTS

Upgrade your human resource function to better support your strategic mission, while more effectively administering the basics.

Understand and benefit from today’s landscape.

MARKETING 59

YOUR REPUTATION

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LOCAL SEARCH ENGINE OPTIMIZATION

Protecting & using it to your advantage.

The importance to your practice.

TECHNOLOGY 31 5 ESSENTIAL CONSIDERATIONS IN CHOOSING A SECURE TEXT MESSAGING SERVICE

36 IS YOUR PRACTICE READY FOR EMV? 39 KEY BENEFITS OF MEDICAL RECORD SCANNING

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SPECIAL FEATURE: Practice Culture Development Series

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special feature: practice culture development series

In Sync. managing the business & cultural aspects of a practice merger featuring becky rudolph, MS healthcare management partners, l.l.c.

EDITOR’S NOTE: Becky Rudolph is the founding partner of Healthcare Management Partners, LLC in Denver. In this article she will touch upon the business and cultural aspects of a practice merger. With a background in psychology she has been focused on the business and people aspects of health care for the past 30 years.

The emphasis on physician practice management, operational efficiency, organizational development and mergers has evolved over the last 15 years. Becky is called upon for the nuts and bolts of how to blend everything into one functional business model after the attorneys and CPAs are finished. She turns several business cultures and systems into one seamless entity; dealing with everything from finance to business process to cultural aspects.

INTERVIEWER: Among physicians, there’s a growing perception that there’s a benefit to larger practices. From the non-physician side, what are the actual benefits you have seen with practice mergers?

BECKY RUDOLPH: Having been involved with practice mergers predominantly for the past 15 years, I would say the economies of scale are there, but the knowledge of how to get to those economies is a mystery to most organizations. Many of the mergers I’ve been involved with have started with exorbitant overhead, and by working through streamlining business and management systems, they’ve been able to cut their overhead from 70% to 80% down to 50% to 55%. This of course takes time and expense may actually rise for a brief period while new systems emerge.

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In Sync...

INTERVIEWER: The legal and financial issues have been worked out; now it is time to call you to help us with the nuts and bolts. What do we do next?

BECKY RUDOLPH: When I consult on a merger, the initial step is an organizational analysis of each entity to determine the operational strengths and weaknesses. Each practice is going to have its own culture and management style. I think it’s important to look at any potentially conflicting management and practice styles because dealing with hot topics early on can lead to relatively easy negotiation of the issues. When conflict happens, people are on edge; they have formed an opinion and there is much more to deal with as everyone thinks they’re right. Potential partners will be willing to manage things more openly and positively if we can talk about each of the practices’ styles—what is relevant, what is not, and what the group agrees to adopt as the business culture. Make no mistake—when change happens, chaos will follow, and mergers create massive change for the inside of each business. Fear and doubt rule and the staff member thoughts are: “Am I going to have a job?” or “We don’t do it that way” or “Our office is better than yours.” The physicians are caught in the middle, trying to navigate these issues and practice medicine at the same time. If you do not address the issues with management and staff, fear and doubt can and will undermine the most positive intent.

“Each practice is going to have its own culture and management style.”

The model I use in dealing with change I like to call the Change-Chaos Model; it is characterized by the acknowledge that change creates chaos, and chaos has to be managed by systems, protocols, and uniform implementation. Conflict has to be addressed, decisions made and implemented; then with solid directives from the stakeholders and the business will settle down to a

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Becky Rudolph, MS

(continued)

day-to-day process that will run smoothly. This kind of transition takes 18 to 24 months. There’s no easy way out—it takes a lot of hard work and communication. But the new culture blending all parties emerges in to one new entity where the mentality of all goes from “I” to “we.”

INTERVIEWER: So is it good to start with a hybrid model of the care centers and eventually ends up with the fully integrated? Or stay with the care center? Or does it depend on the situation?

BECKY RUDOLPH: I think it’s all about nuance. There are certain things within the operational structure that immediately need to be part of a complete merger. Business systems—billing, financial systems, management styles, and front-office operation— need attention and consistency from the beginning. Other processes can wait until the group is more comfortable in moving forward together. Because staff is the biggest culture killer behind the scenes in any practice, the most important factors are giving thought and attention to consistency of knowledge and training. When working with physicians, it is important to get them to realize that they all practice in the same fashion about 85% of the time.

They all have an excellent standard of care, and thus subscribe to similar standards of practice. About 15% of what they do in clinic is physician preference, so staff must be trained consistently to accommodate these physician preferences. When staff can be trained to cover a multitude of situations instead of being able to work for only 1 or 2 physicians, coverage becomes much more consistent and patients can be accommodated.

That’s one of the efficiencies you gain, as it keeps physicians in production day to day. So I agree with a blended model to start with full integration as the ultimate goal.

It is best to look at processes from the beginning of the merger and streamline sensibly. It is so important that decisions about the business make sense to all partners.

INTERVIEWER: Are there factors that can predict whether a merger’s likely to be successful?

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In Sync...

Becky Rudolph, MS

(continued)

BECKY RUDOLPH: If the physicians do not like each other, you’ve got challenges to overcome that need close attention and mediation to find positive resolution to the conflict. If there is a huge disparity in production and it is not addressed up front, it will tank the merger as feelings will arise concerning fairness. If there is one controlling group and you don’t set up an executive committee model that represents the needs of the entire partnership, it’s going to scuttle the merger. These are the business/social/cultural issues that are the hardest to get your hands around unless you spend time with each physician. As the Consultant on a merger I find out each physicians preferences and what they think works so the issues can be mediated. It is a sure formula for conflict if thoughts and feelings are not dealt with from behind the scenes.

INTERVIEWER: What about practices’ inequities and inequalities with productivity? Does that play into whether a merger’s successful or not? How do you deal with that?

BECKY RUDOLPH: The shaky ground regarding this issue is the willingness for people to have an open and honest conversation about inequities or perceived inequities. I find Physicians as a group are usually very conflict-avoidant. They want in no way to hurt anyone’s feelings, especially someone as valued as a partner. So they’ll tend to talk about inequities through the back door and not address them in the open air so people can come up with creative solutions about how to deal with them. Once they are to the point where a trusting conversation can ensue, they can come up with some pretty creative solutions.

INTERVIEWER: Is there a management style you would recommend?

BECKY RUDOLPH: The management style I find most effective is one that is highly collaborative and focuses on communication at all levels. In many cases, management is pretty unprepared for dealing with the scope of the

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merger. So people become very territorial and the management staff can split the physicians and ramp the chaos, even at the partnership level. The conversations have to be highly collaborative from the beginning, and I think that a high-level Consultant is the key to bringing something like this together. A consultant is a neutral party to help unify the physicians and managers until things calm back down and people feel they’re on solid ground. The Consultant can help all parties select best practices for running the business that are a blend of the former organizational preferences. When the new processes make sense to people at every level of the organization and a new identity has emerged, it is very possible that current management can rise to the occasion and run the new business model.

I think it’s really significant to address culture, deal with change, bring the partners together into a unified voice, and ensure management knows the direction in which they are headed. If these items are dealt with early, the potential for conflict lessens and all parties can focus on the change and chaos management necessary to make the new organization work. about the author:

Becky Rudolph, MS Founding Partner, Consultant Healthcare Management Partners Denver, Colorado

Thirty-years of accomplished health care management, effective, result-oriented leadership with a rare acumen for organizational and business development. Over the coarse of her career Becky has built and sold two businesses; over the past fifteen years Becky has focused on physician practice management where she has demonstrated proven excellence in working with medical professionals to attain thier goals. Her expertise includes: practice merger and acquisitions; innoovation and change management techniques; medical practice turnaround; billing and coding services; practice start-ups; physician recruitment; succession strategies, planning and implementation; ancillary business lines for physician practice and surgery center build out. Extensive experience in executive management and leadership in all phases of operations, expense control, budgeting, risk management, human resources, business development, marketing, strategic planning and organizational development.

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special feature: practice culture development series

building a stronger

Foundation upgrade your human resource function to better support your strategic mission, while more effectively administering the basics. featuring randall c. schauer fox rothschild llp

One of the challenges facing many medical practices is how to effectively and uniformly administer the human resources (“HR”) function across a number of offices, oftentimes with a diversity of cultures and historic practices. This article is not going to focus on HR issues unique to a medical workplace, but rather the HR issues unique to multi-location operations and the unique HR opportunities and challenges those pose. As the administrative work historically associated with a large part of the HR function are capable of being performed by computers or entry-level individuals, and the legal mandates in the workplace become greater and more complex, many organizations are wrestling with how to both gear up the strategic and compliance capabilities, while pushing other administrative items down to the appropriate level, or even outsourcing. As employment law advisor to many medical practices, I have seen many examples of what does and does not work in this industry.

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Building a Stronger... (continued) There are several benefits to effectively implementing what is sometimes referred to as “shared HR services.” It allows a “total solution” and “total approach” to problems by centralizing the HR function, rather than having it administered in whatever number of offices may be involved in your Practice. On the conceptual level, this approach allows the hiring of a high-level HR professional who has the capacity, and also the work and educational capability, to provide strategic advice at the highest levels of the organization in the administration of the HR function, broadly including recruiting, training, compliance, benefits, and productivity. This person can interface with legal counsel and the Board of Directors of the organization in the strategic function, helping the business to successfully execute strategy. Another component of the centralized office are administrative experts who can improve organizational efficiency by making sure that the HR function and other work processes, including benefits administration and tracking legal compliance item such as use of FMLA leave by employees across the organization, are consistent with the needs of the specific organization and its employees.

A third skill set that is required in the multi-office environment are the individuals that interface with the office managers and staff to assure consistent enforcement and administration of HR initiatives and policies among all offices. This position would be responsible for providing or initiating training; being available for daily consultation as workplace issues present themselves to the office managers; and periodic visitation to offices for feedback and understanding. These individuals would be critical to implementing best practices in the HR world, and assuring that staff morale does not diminish through feelings of alienation or distance. With the benefits above, there should be improved career development for all staff development and training, while obtaining efficiencies in the professional provision of HR services.

Critical to the success of a centralized HR function is that the office managers understand the critical need for uniform administration of consistent policies across the

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Randall C. Schauer organization, by referring HR issues to the appropriate HR professional, rather than handling it themselves (and freeing the Office Manager for other tasks). In any organization, it is lack of consistency that most often turns workplace decisions into claims that will need to be addressed either in settlement or in litigation, as there is disparate treatment of individuals by managers who may not have known what others were doing and have treated individuals in different classifications differently, even if there is no difference in the demographics of the individuals involved. Hopefully the organization can obtain better management information by consistently gathering information across an organization, rather than the practice management only hearing about HR issues after they have become a problem.

“Critical to the success of a centralized HR function is that the office managers understand the critical need for uniform administration of consistent policies across the organization” On the other side of the coin, issues that need to be addressed which can undercut a centralized HR function in a multi-office environment is the loss of face-to-face contact; employee involvement with the HR management staff; a lack of ownership of Human Resource problems at the office level; and possible IT problems with an extended network.

Management should also be aware that a smooth transformation to provision of centralized HR services is critical in assuring that the efficiencies and enhanced benefits of a centralized model are not lost. In that regard, management needs to define and achieve business goal as early as possible. The centralized HR group must be extremely diligent initially so as to be taken seriously be other management, particularly office managers. It is important that office managers understand what the

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Building a Stronger... (continued) process will look like. Initially also, there should be a high visibility of the central HR staff in the offices to help with buy-in and confidence around the new model.

In summary, management needs to consider strategic issues as to why an enhanced, upgraded central HR function is useful; consider how it will affect the business strategy, understand the relationship between the HR professionals, office managers and line managers, and how it will provide both day-to-day administrative support while providing the strategic input at the corporate level. Management will need to be very attentive to managing the change process from the current system, oftentimes one of a laissez-faire management with office managers being relatively empowered versus centralized management. Operational issues will need to be considered with regard to location and access. Finally, there needs to be understanding of what changes and goals are reasonably expected from the process to avoid failure of implementation.

And while this model may not work for all, it is one that can provide significant improvement in recruitment, compliance, risk avoidance, and efficient provision of benefits and other employee programs. With a commensurate improvement to the bottom line.

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Randall C. Schauer about the author:

Randy C. Schauer Partner, Fox Rothschild LLP Randy's practice focuses on all aspects of labor relations and employment law. He handles the full spectrum of the employment relationship from pre-hire procedures to post-termination closure, including unemployment compensation and statutory compliance issues such as Title VII, ADA, FLSA, FMLA and OSHA compliance. Randy negotiates, drafts, and enforces contracts protecting client's rights in all aspects of the employment relationship, including employment and separation, confidentiality and non-competition, intellectual property protection, and independent contractor arrangements.

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special feature: practice culture development series

the latest blistering

phrase by bob smith MySuccess Staffing Solutions

There is a phrase that is bouncing around in both the Technology and Medical fields; “Hire Slow – Fire Fast”.

Nice intention – but it misses the mark completely. If you are competing for the best talent you can get, then you can’t waste time. In some markets there are 4 jobs for every candidate.

If you are the only company in your space that is growing and the market around you is staying still and no competitors are looming, then take your time. (Of course I am being sarcastic). No business facing the potential of growth is alone in its quest.

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We suggest that you “Hire Effectively and Fire Efficiently” and this phrase is not even close.

On this basis, you want to have a very clear understanding of the direction and strategy of your business, be aware of how the position you are filling will affect that strategy and understand the results that you want the person in that role to generate. Also, you want to understand what Skills, Knowledge, Experience, Attitudes and Beliefs that the ideal candidate brings so that you can more easily recognize a winning combination.

Be prepared to act in your hiring process, but utilize all your resources (an interviewing team, key associates, Executives from other areas, Mentors or Advisors), they can help you get additional perspective on the upside and concerns that go with every candidate.

“We suggest that you ‘Hire Effectively and Fire Efficiently’... and this phrase isn’t even close. “

As for Fire Efficiently, it’s important to make the release of someone be a necessary next step – not your first step (unless it is for “cause”). Informal (versus formal) Performance Improvement plans let someone know that they are not meeting needs and expectations. It also lets them know that a significant change has to happen quickly.

Very often, people will take themselves out of the game, because they don’t want to be someplace where they can’t really fit.

The process you use to determine if someone is a fit after they are hired, is as important as the hiring process. It tells everyone in the affected area, what the standards for performance are and how the company’s culture is represented in the process. It tells people what you really stand for as a company and what you can be counted on, relative to fair treatment.

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Bob Smith

(continued)

Have a well-formed and clear hiring process and efficient shared model for performance evaluation and accountability. It can save the company a fortune and people a lot of grief.

One additional point that can really make a difference occurs during the hiring process. You can let people know that you are not just filling a role, but you are building culture that has to be a great fit all the way around. You might specify a time frame to review “the fit” (1 or 3 or 6 months) and then spell out what happens if there doesn’t seem to be a fit. For example, “It is our custom to make sure that we as a company are a good fit for everyone that works here and we want to be a fit for each person working. We check-in to make sure things still make sense for us to be together. If either of us decides that a change out of the company is best, then we provide 1 day severance for every 2 months someone is employed. (or whatever your compliance and labor laws allow). If a separation is the next step, we will do it with respect and appreciation. That is what you can count on from us and that is what we want to be able to count on from you.”

As you can see, it is a very mature approach to working relationships, managing performance and value. Of course, make sure your legal resources concur that you are in compliance with how your State Labor Laws impact your workplace. about the author:

Bob Smith Founder/Senior Partner MySuccess Staffing Solutions Las Vegas, NV As Founder of Mysuccess, Inc., Bob has applied studies from program work at MIT Systems Thinking Lab, along with Organization and Growth Strategy and beyond with MAP (mental Aptitude Patterning) Relationship and Communication tools. Bob now works with key individuals and teams within companies that want to boost performance through Relationship, and has provided corporate and executive strategy for industry leaders such as Marriot Corporation, Sears, Northwest Airlines, Children’s Hospital, Pulte Homes, Staples Inc., GAP Inc. and numerous startups and fast growth companies.

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What BVIPA Members are saying: “...when BVIPA helps me analyze the contractual offers, I am in a much better position to accept or place a counter offers due the assistance of a IJHIMZ RVBMJmFE UFBN I would not want to go alone in this market.�

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“Boulder Valley IPA has been great to work with all these years. Whenever we need help getting our claims paid with a contracted insurance, BVIPA is more then willing to contact the insurance company on our behalf to help resolve the issues.“ - BVIPA Member

“Any questions we have had regarding our contracts, reimbursement or just general questions have been answered by BVIPA very professionally and promptly-often the same day. “ - BVIPA Member

Boulder Valley IPA is run by individuals with old school values: honesty, integrity and hard work for the dollars earned. They are a 1st class organization.

- BVIPA Affiliate Member

Boulder Valley IPA’s purpose is to coordinate the delivery of high-quality, affordable health care services through a physician-directed, market responsive, and accountable system. This system is designed to provide physicians the tools to enhance the viability of, and satisfaction in, independent medical practice.

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Stress. addressing the elephant in the corridors, the exam rooms, and in the mirror.

featuring cynthia ackrill, md president of wellspark

As physicians we are no strangers to stress- learning to perform under pressure is part of the package. But in “perfecting” this skill, could we be losing sight of the real impact of stress in our lives and in the lives of our patients? The changes in healthcare are about to make our patients mental well-being more critical to our revenue.

And if we don’t make our own mental well-being more of a priority we cannot reverse the alarming numbers (40%!) of physicians who would choose to leave practice if they could!

Early in my career I was always fascinated by the fact that patients with essentially the same clinical picture could be experiencing their diseases in such a wide range of ways—from profound misery to cheerful acceptance to even apparent vitality of spirit in the face of death. What made one person focus on the suffering and another on hope, possibility or gratitude? Clearly, those who were not handling the stress of life well were less resilient in the face of medical challenges. (I was also bemused by the arbitrary separation of physical and mental health—as if putting the diagnoses in separate books and under separate insurance codes teased apart the intricacies of human experience?!)

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Stress...

Cynthia Ackrill, MD

(continued)

Equally apparent were the varied reactions of fellow clinicians under the strain of ridiculous hours and whopping mental and physical demands. The very mechanism of the stress reaction reduces blood supply to the frontal lobe, that part of the brain responsible for self-awareness. (Thus explaining the “What was I thinking” phenomenon!)

The job of our brains is to filter out the billions of bits of information it receives moment to moment searching for anything that might be a threat to us. That identification process (mostly amygdala based) is dependent on our perception—our genetics, stories, experiences, and current psycho-physiological state.

To make matters worse, many high achievers train themselves to further ignore the signals and alarms of the stress reaction. Sadly this leads to higher risk for costly mistakes, career or personal dissatisfaction, burnout, relationship and health problems. We have all witnessed the burnout of far too many excellent, caring doctors.

When coaching physicians, I often find we need to work on down-regulating the stress, before we can effectively address leadership or career strategies.

I spent 10 years studying brain mapping (qEEG), various forms of biofeedback, and the mechanics of behavior. I had the opportunity to see first-hand how simply changing thoughts minute to minute radically alters our physiology and our brain activity. I found that patients with high perceived stress scores had a much harder time learning new patterns of behavior, or fighting the depression or health decline of extended cortisol overload.

Stress—our reaction to the perception that our homeostasis or safety has been threatened, or that we do not have the skills or energy to meet the challenge—has been estimated to be somehow involved with 70-90% of all doctors visits! Yet we barely have time to review labs and adjust meds, much less ask questions that might open a can of worms about dealing with the complicating factors of real life. We were not taught to empower our patients to handle stress—we weren’t taught healthy ways to handle it ourselves!

To be effective in addressing the role of stress we need a better model to develop the language to help our patients and ourselves. (Our brains love models!) The term “stress” is so overused and misunderstood that many myths have taken root.

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Once the alarm is sounded the mostly sympathetic reaction involves some 1400 chemical reactions—a very energy intensive process! This is a one-sized-fits-all reaction designed to protect early man from chasing wildebeests. But there has been no software upgrade to help us deal with constant onslaught of annoying emails, EMR challenges, technology breakdowns, or interrupted sleep. The chronic ringing of the alarm bell depletes the energy balance of every physiological and psychological system.

We know this—the research is overwhelming and our experience lives it—but we need to find ways to clearly and succinctly discuss this with our patients and proactively step up our own stress management.

TODAY ’ S P R A C T I C E : C H A N G I N G T H E B U S I NES S OF M EDI C I NE

July /August 2014

Stress...

Cynthia Ackrill, MD

(continued)

In this model there are 3 entry points to change the balance:

Proactively reducing the exposure to internal and external stressors (seeing this as proactive choosing how to spend our precious time and energy.)

Reframing our perspective to sound the alarm less often—acceptance, mindfulness, attitude work.

Raising our resilience by increasing the habits that support our fitnessphysically, mentally, emotionally, and spiritually.

about the author:

Cynthia Ackrill, MD Human Performance Consultant President of WellSpark

Dr. Ackrill is a Human Performance Consultant, Coach, and Speaker President of WellSpark.

I find this way of looking at stress empowers patients and professionals to see they have choices that will increase their energy, their confidence, and their personal accountability to take an active role in their health, performance, and overall well-being. By choosing to balance the energy we spend with thoughts, behaviors, and practices that renew our energy, we can make the subtle shifts that take the bite out of stress.

What small change can you make today that will find you more energy, more ease? How can you help your patients take a more active role in their stress management and well-being?

J u l y /A u g u s t 2 0 1 4

Stress—our reaction to the perception that our homeostasis or safety has been threatened, or that we do not have the skills or energy to meet the challenge—has been estimated to be somehow involved with 70-90% of all doctors visits!

Dr. Ackrill works with professional leaders and teams to expand performance capacities and resilience. With the latest science and research, she provides innovative ways to optimize energy, creativity, focus, and access to brilliance for enhanced, sustainable performance. Her work includes the systematic management of stress, addressing specific lifestyle/health risk challenges, facilitating behavior change, and creating collaborative cultures to support excellence. She coaches individual leaders, their teams, consults on wellness programming, organizational effectiveness, and cultural shifts, and speaks at off-sites and conferences.

Cynthia L. Ackrill, MD brings a unique and thorough background to the subject of health as a business strategy and the power of mission and values based leadership. She combines her knowledge as a primary care physician with her extensive experience in neuro-psycho-physiologic approaches to behavior, performance, and health, and her training in coaching. She is a graduate of Duke University and the University of Maryland School of Medicine, a Fellow of the American Institute of Stress, a charter member of HeartMath, and a former board member of the International Society of Neurofeedback and Research. A certified Wellcoach® and Well People coach, and certified Professional/Executive coach, Dr. Ackrill has also completed training in positive psychology, intrinsic motivation, and peak performance coaching. She enjoys the “diagnosis” of systemic issues and facilitating groups toward mutuality of purpose and is a certified Team Advantage leader.

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P RA CT I CE MA NA GE ME NT

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July /August 2014

the perfect complement The right partner means the right patient outcome.

by alan finston p.t., ocs During the course of patient care, the recognition of the need for referral for outpatient physical therapy frequently arises. The nature of this referral could be for a condition as common as chronic low back pain, or more involved like post surgical rehabilitation or a chronic disease process. Whatever the condition or illness, it is important to remember that there are a number of options for outpatient physical therapy services and that qualifications and credentials are an important factor in determining what may be the best clinic partner for your patient’s care.

The American Physical Therapy Association (APTA) has an advanced certification program with specialization areas for a number of advanced areas of study/focus. An APTA certified specialist must have a minimum of 2,000 hours of experience in their clinical practice area and demonstrate advanced knowledge with coursework and testing. APTA certified specialists may be in one of 8 clinical practice specializations: Orthopedics, Geriatric, Cardiopulmonary, Neurological, Pediatric, Sports, Women’s Health, and Clinical Electrophysiology. In addition, the APTA website has a link to allow a search in your patient’s geographic area to help find the closest APTA certified specialist in the specific area of medical focus for the prospective patient.

Other criteria for partnering with a given physical therapy office may be of a more practical nature and include issues such as “Can the clinic get my patients seen in a timely manner?”

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P RA CT I CE MA NA GE ME NT

The Perfect Compliment...

Alan Finston, P.T., OSC

(continued)

If a clinic is so busy that it can’t schedule a new patient for three to four weeks out, it presents difficulty for a patient obtaining the necessary care in a timely manner.

Physicians should consider the timeliness with which the prospective physical therapy partner clinic is able to see their patients.

The following are questions which on the surface seem obvious, but have a huge impact on the quality of care that occurs in a given physical therapy care cycle.

Additionally, the referring Physician should consider the experience they have had with the physical therapy clinic’s services in the past. Are the patients satisfied with their care? Have the patients had a lot of different therapists or have they been seen by a consistent provider?

• Do they have convenient hours?

Sometimes this is important, however it is situational.

What is the “word of mouth” about the office? Is it a clinic which takes time with their patients and spends the effort to tailor the therapy to the patient’s individual conditions or injury, or is it more of a “cookie cutter” approach, where patients experience a more generic protocol of techniques and exercises for a given condition? Would a physician feel comfortable sending a family member to that office? If no, then partnering with that clinic may not be an advisable proposition.

A typical referral cycle can be anywhere from 4-8 weeks , and up to 2-3 visits/week. Anything longer than that without a progress note/update may be indicative that care is occurring without adequate updates and reassessments.

• Is the physical therapy clinic’s communication timely with the physician’s office?

• Is the clinic conveniently located near the patient’s home or work?

• Is the support staff available for assisting with scheduling, as well going the extra mile to ensure that the patients are seen in a consistent manner and with the appropriate therapist?

• Is the billing office efficient and effective at answering patient’s questions and dealing with insurance billing issues?

Finally, it is important to remember that the care the patient receives in the physical therapist’s office is a reflection of the physician who made the referral. You want your patients to feel like they have received appropriate care with a physical therapist that is capable, talented, skilled, possibly with advanced specialist certification from the APTA, and most importantly professional. This reflects well in the patient’s outcome to physical therapy, as well as on the physician who made the referral. A professional partner relationship with a quality clinic can prove to be a win-win-win for patient, physician, and the partner clinic providing the valuable and necessary service. about the author:

• Does the office send timely evaluation reports, progress notes, and discharge summaries?

Alan Finston - P.T.,OCS Ritm Certified Scenar Therapist Founder, ScenarPT Blaine, Washington

• Is there a good impression that care is occurring in an appropriate manner?

• Is the clinic requesting multiple referrals for continued care without appropriate progress notes or rechecks with the physician’s office?

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Alan is the founder of Whatcom Physical Therapy, a multi-location Physical Therapy Clinic based in the state of Washington. Alan received an MPT from the University of Puget Sound in 1993 and a BA from Whitman College in 1987, and is Board Certified Orthopedic Specialist (OSC) American Physical Therapy Association, 6/01, Level II Orthopedic Certification in North American Institute of Manual Therapy.

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T E CHNOL OGY

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ESSENTIAL CONSIDERATIONS IN CHOOSING A SECURE TEXT MESSAGING SERVICE by richard wagner, jd compliance evangelist, qliqsoft

It’s well beyond crunch time. Following the Sept 23rd HIPAA Omnibus deadline, as the CIO of healthcare provider facility you’ve come to discover that a number of your physician and nurse providers have been communicating with one another over standard text message, exchanging information in a HIPAA noncompliant manner. The time has come for these events turn into reportable breaches, so you decide to implement a secure text messaging application. What are the most important features you must take into consideration in choosing a vendor?

TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NES S OF M EDI C I NE

July /August 2014

“Using a cloud-based, decrypt-store-re-encrypt service leaves your stored PHI at the mercy of your vendor’s security controls.“

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T E CHNOL OGY

5 Essential Considerations... (continued)

1. Peer-to-Peer Encryption

Any secure text messaging service is better than nothing, but not all services are created equal. A P2P encryption infrastructure ensures that PHI is only being sent directly from user to user, cutting out the middle man vendor server. Using a cloud-based, decrypt-store-re-encrypt service leaves your stored PHI at the mercy of your vendor’s security controls.

2. Data Archiving

Just because you use a P2P encryption product doesn’t mean that you can’t store your own data. The best secure text messaging services give their users complete control over their data, allowing them to store messages in their own data center or cloud. This sort of data can provide all sorts of benefits to a CIO, from provider benchmarking information to even medical malpractice defense evidence.

RICHARD WAGNER, JD

ly-stored PHI. However, if the secure texting application can provide access logs to the secured application, an analyst can easily show that PHI in question was kept safe. This can be all the difference in a multi-million dollar privacy lawsuit.

5. Intuitive Usability

Finally, a secure text messaging service will only be effective if your users decide to adopt it as a replacement to SMS. Therefore, usability is paramount. A simple interface goes a long way in achieving this, as do intuitive features such as group messaging and file attachment. A usable service not only keeps your providers happy, but it also helps getting your users to buy in and stop texting PHI.

3. Read Confirmation and Time Stamps

These features add two essential benefits: usability and compliance protection. Read receipts ensure that urgent information was communicated to the recipient, allowing the sender to take other actions if necessary. Moreover, in the event of a lost phone or other security incident, the ability to prove that the PHI-containing message was never read by a potential malicious third party is an essential component to a breach analysis.

4. Access Logs

Speaking of breach analyses, the new breach standard outlined in the HIPAA Omnibus Regulations requires the analyst to prove that PHI was not accessed by a third party. Proving a negative can be almost impossible, especially in the context of a lost phone with local-

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about the author:

RICHARD WAGNER, JD Compliance Evangelist qliqSoft With a background in healthcare data security and privacy, Richard provides qliqSOFT and its customers guidance on IT regulatory compliance issues. Prior to his time at qliqSOFT, Richard served as the compliance and security officer for a number of health IT and provider organizations. Richard has also consulted industry groups on regulatory issues, assisting the ILHIE on their efforts to create a statewide health information exchange and guiding the ABA eHealth Security subgroup in interpreting the recent HIPAA/HITECH Omnibus regulations. Richard has a law degree with a concentration in health law studies from the Saint Louis University School of Law.

TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NES S OF M EDI C I NE

July /August 2014

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T E CHNOL OGY

is your practice ready for

EMV?

By Alan Brandfon

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TO D AY ’ S P R A C T I C E : C H A N G I N G T H E B U S I N E S S O F M E D I C I N E

July/August 2014

In Your Practice Ready...

(continued)

The evolution of EMV technology is something that will impact every business that accepts payment cards. EMV (which stands for the original founders Europay, MasterCard and Visa) is a global card security standard that has been widely adopted outside the United States to combat counterfeit cards and fraud. The United States is in the process of migrating from traditional magnetic stripe technology to chip technology following EMV standards.

EMVCo, which is owned by American Express, JCB, MasterCard and Visa manages and maintains the EMV specifications.

Since April of 2013, acquirers and processors have been required to support acceptance of EMV chip transactions.

In October of 2015, any practice that does not process 75 percent of its transactions through an EMV-enabled terminal must assume the liability for fraud.

How does EMV work?

At a very high level, there are two basic types of EMV certified transactions: “Contact” and “Contactless.” A “Contact” EMV transaction is a chip card that must be inserted into the terminal. A “Contactless” EMV transaction (using a card or Smartphone) can be tapped on the POS terminal or a peripheral device. With card present transactions, either a signature or a PIN is required. Most US processors have opted for “chip and signature” cards; “chip and PIN” is more prevalent in Europe.

The EMV Migration Forum reports that an estimated 17 to 20 million chip-enabled cards had been issued in the US by the end of 2013. The group expects another 100 million or more chip-enabled cards to be issued in 2014.

How Will EMV Impact Your Practice?

Practices that have not adopted contact chip technology

by October of 2015 will be liable for losses linked to card fraud, if EMV chip technology could have prevented the fraud. Hospitals, physicians’ offices and all other health-

July/August 2014

Alan Brandfon care providers that accept credit or debit cards for payment are strongly urged to upgrade their equipment at some point before the liability shift.

How Can You Get Ready for EMV? Now is the time to begin to adopt EMV protocol, ahead of the October 2015 deadline. EMV compatible terminals are now available and can be implemented in your place of business. Start planning to replace your current terminal, whether hardware or virtual, computer-based systems.

Regions that have transitioned to EMV already have seen drastic reductions in fraud losses. As the amount of fraud continues to rise in the U.S., an investment in payment technology is inevitable to provide a more secure environment for your patients to pay for appointments, medications and other services.

In October of 2015, any practice that does not process 75 percent of its transactions through an EMV-enabled terminal must assume the liability for fraud. about the author:

Alan Brandfon Managing Partner Priority Payment Systems Atlantic

Alan Brandfon is the Managing Partner of Priority Payment Systems Atlantic and holds an M.B.A. in Accounting. Alan obtained his C.P.A. in 1992 and has worked in the financial industry for over 22 years. Mr. Brandfon's major focuses include increasing cash flow, collecting receivables, decreasing bad-debt expense, lowering credit card expenses and offering a myriad of payment solutions to all businesses.

Mr. Brandfon presently sits on the Advisory Board of Governors at the Boca Raton Resort and Club, a Blackstone company.

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T E CHNOL OGY

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TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NES S OF M EDI C I NE

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Key benefits of medical record scanning by allan w. german Solaris Imaging Pro.

There are many benefits associated with the digitization of paper medical records.

Whether or not your organization is using or considering a term purchase of an EMR (Electronic Medical Record) System, DMS (Document Management System) or just looking to clear up some valuable space currently being over-run with boxes of old documents, the digitization of your paper records is a critical step in realizing new financial and operational benefits.

The introduction of the Health Insurance Portability and Accountability Act (HIPAA) has made it far more critical to identify more viable solutions to address paper medical records and security issues.

Managing paper medical records required a certain standardized set of practices in place for protecting medical privacy, and when and how this information could be shared.

As a result there were key security concerns associated with paper medical records that needed to be addressed.

J u l y /A u g u s t 2 0 1 4

Paper records are often hard to track and locate. There is a greater chance that a document in the patients chart can be misplaced or even worst end up in a different patients chart.

Typically paper medical records are stored on shelves or an off-site storage facility. These type of environments are vulnerable to a number of security and preservation issues. This especially applies to areas of the country that are affected by tornados, hurricanes and severe flooding.

Faxing and copying paper medical records can potentially end up in a trash can or accidentally be transmitted to the wrong recipient or location. This creates a further security concern and the prospects become greater for identity theft.

There were many other security issues which included misfiled or misplaced medical records.

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T E CHNOL OGY

Key Benefits...

Alan W. German

(continued)

In addition, medical offices can greatly improve on regulatory compliance, reduce labor costs, increase productivity around shared documents across all aspects of the organization (patient records, human resources, accounting etc.). Add to this list a reduction in the cost of storage and the retrieval of documents, paper, paper clips, staples, folders, labels, printing, mailing, faxing and special delivery.

I am often reminded of a story that was shared with me by a practice administrator for a large group of physicians. As she was trying to locate a patient chart, she announced to her staff that that the first person who could locate the chart would be treated to lunch that day.

Which begs the question, “Is a medical office the right place to be conducting a Treasure Hunt?”. about the author:

“Is a medical office the right place to be conducting a Treasure Hunt?”

Currently, if you only have paper files, chances are that you do not have a disaster recovery capability in place. A catastrophic event could virtually cripple the practice.

Most physicians operate their practices as cost centers and not profit centers. Office space is becoming more important as physicians struggle with overhead, and one way to shrink costs is by removing filing cabinets and shelves which allowing for maximized space and increased patient volume.

J u l y /A u g u s t 2 0 1 4

Alan W. German Senior VP of Sales and Marketing Solaris Imaging Pro. Boca Raton, Florida

Allan W. German is currently the Senior VP of Sales and Marketing for Solaris LLC a Florida based custom document imaging and management software company. Allan has over thirty five years of experience in the document imaging and software industry, including six years in healthcare principally in sales and management positions. Previously he was a National Account Executive with Ricoh and Toshiba Business Solutions, an HP Accredited Sales Professional and was VP of Sales for The Digital Library Systems Group a wholly owned subsidiary of Image Access Inc. where he was responsible for creating a brand name for digitization software that was specifically designed for University and College Libraries.

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L E GA L

Estate Planning

for retirement accounts understand and benefit from today’s landscape Brendan J. King, Esquire estate preservation law offices

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TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NES S OF M EDI C I NE

July /August 2014

F

or many of us, “qualified retirement accounts” such as IRAs and 401Ks make up the bulk of our retirement savings. These accounts, which are funded with pre-tax earnings and grow income tax-free, are great vehicles for saving and investing, but pose a unique challenge in the estate planning process.

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L E GA L

Estate Planning... (continued) Because qualified retirement accounts are funded with pre-tax dollars, distributions that are later taken from the accounts are fully income taxable to the recipient – both to you during your life as the original account owner/contributor, and to your beneficiaries after your death.

In a typical retirement scenario, qualified retirement accounts are used to supplement retirement income and are spent slowly over a period of years. When the original account holder reaches age 70 ½, he/she must begin taking “required minimum distributions” (RMDs) from the account – and as the money comes out, the income taxes get paid. Most owners avoid taking more than the RMD to minimize the income tax obligation in any one year and maximize the tax-free growth of the account.

Upon the owner’s death, the account passes automatically to the beneficiaries named by the owner when he/she set up the account. If a spouse is named he/she may elect a “spousal rollover” and continue deferring distributions until 70 ½. All other non-spousal beneficiaries have two options: 1) take a lump-sum distribution and pay all the

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Brendan J. King, Esquire income taxes at once, or 2) establish an “inherited IRA”, which allows the new owner to begin taking RMDs calculated on the basis of his/her actuarial life expectancy. The latter is clearly a better option for income tax planning (taxes paid in any one year will be minimal because withdrawals are stretched over a long period of time) and retirement savings (the account balance continues to grow tax-free).

Now for the estate planning challenge: statistically, inherited money is spent at a substantially faster rate than earned/saved money. This means that after the account holder dies, children and other beneficiaries are more likely than not to withdraw the account in one lump sum, pay all the income taxes at once, and spend the money. For the average beneficiary, the damage consists of a huge tax hit and a loss of potential future earnings – not an ideal result, but not the end of the world.

But what about beneficiaries who are financially vulnerable because they are young, disabled/receiving benefits, struggling with an addiction, facing bankruptcy or on

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Estate Planning... (continued)

Brendan J. King, Esquire

the verge of a divorce? The safest option in these cases is to designate a trust for such person’s benefit rather than name the person directly as beneficiary. However, IRS regulations only permit a “designated beneficiary” to stretch the withdrawals over a beneficiary’s life expectancy, and most trusts used in estate planning do not meet this requirement. Bottom line: the trust would have to withdraw the account funds over a shortened period of time – as few as five years – resulting in higher income taxes and loss of tax-free growth.

This poses a tough choice for qualified retirement account owners: Do you name your beneficiaries directly so they will have the option of using their life expectancy to stretch the distributions, but risk them losing the account to impulsive spending or third parties (creditors, divorcing spouses, etc.)? Or do you protect the inheritance inside a trust for the benefit of your beneficiaries, but knowing they will end up paying higher income taxes and losing the long term tax-free growth?

The good news is that there is now a third option: name a special “Retirement Trust” that acts as a “designated beneficiary”, allowing the life expectancy of the individual beneficiaries inside the trust to be utilized to stretch the distributions to the trust over the life expectancy of the individual(s) (thereby minimizing taxes/achieving long term tax-free growth), while at the same time protecting the account and the distributions from financial threats the beneficiary may face.

If you have a qualified/pre-tax retirement account, take the time to think about your intended beneficiaries and whether they may be financially vulnerable based on age, marital status, health/disability, financial acumen, personal or professional activities that may expose them to lawsuits, prior bankruptcies or judgments, or any other reason. If so, you should consider establishing a Retirement Trust as part of your estate plan. Even if you have done Roth conversions on your IRAs, there are still RMD components and post-conversion taxable growth with which to contend.

J u l y /A u g u s t 2 0 1 4

about the author:

Brendan J. King, Esquire Partner Estate Preservation Law Offices Worcester, Massachusetts

Brendan J. King is a founding partner at Estate Preservation Law Offices. Brendan has earned a reputation for his expertise integrating asset protection and wealth preservation with estate planning. He has extensive experience in the complexities of estate planning and probate matters, and in managing the administration of trusts and estates. Additionally, his Master of Laws in Taxation uniquely positions him to understand and respond to tax consequences fundamental to estate planning. Brendan’s industry knowledge is broad, encompassing estate planning, asset protection, tax planning, business and succession planning, trust and estate administration, elder and disability law and financial aid planning. Prior to establishing the firm, he was a partner at the Worcester law firm of Fusaro, Altomare & Ermilio where he established and chaired its Estate, Trust and Tax Department.

Brendan has long been involved in community outreach. He is a former board member of Forward in Health and travelled with that organization on a medical mission to Haiti. He has served the Worcester Art Museum as a trustee, corporator, and president of its Members Council. He served on the Worcester State Foundation as vice-chair of the Planned Giving Committee, and on the Becker College Board of Trustees. He is a lifetime member of the National Eagle Scouts Association and serves on the Board of Directors for the National Education for Assistance Dog Services (NEADS).

Brendan is a presenter at numerous community and professional seminars on a variety of topics. He was a co-host on Money Matters Radio for several years and has been a guest on local radio and cable TV shows.

Brendan has been recognized three times as a Massachusetts Rising Star by Super Lawyers, a Thomson Reuters Service. He is a past recipient of Worcester Business Journal’s Forty under 40 award.

“Do you name your beneficiaries directly so they will have the option of using their life expectancy to stretch the distributions, but risk them losing the account to impulsive spending or third parties (creditors, divorcing spouses, etc.)?”

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F I NA NCE

Escape tax trap from the

Can you become a Financial McGyver?

by christopher hynes, jd, cfp advisor to the advisors

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®

TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NES S OF M EDI C I NE

July /August 2014

In Wyle E. Coyote fashion, at the bottom of the dreaded Fiscal Cliff at the end of 2012, sat a large (albeit metaphorical) trampoline that propelled many of our clients into higher income tax brackets at a frightening speed. While federal estate and gift taxes remained largely unchanged, income taxes increased dramatically. As such, when many of our physician clients completed their 2013 income tax returns, their feathers became more than a bit ruffled by the resulting increase in Uncle Sam’s portion of their income last year.

Clearly, the reappearance of the 39.6% tax bracket and the 2% payroll tax along with tax rate newcomers—20% (capital gains), 3.8% (ACA tax) and .9% (Medicare increase) will combine with a 3% itemized deduction phase-out (Pease provision) to ensure that we’re all paying our “fair share.”

When bad news like this hits, you could just say “Uncle” (and then in this case, “Sam”) and begin Dreaming of a Lean Christmas or engaging in the fruitless pursuit of playing the political blame game.

Instead, as tax and financial planners, we endeavor to offer practical solutions to our clients that will not only enable them to keep more of what they earn now but also help them Escape from the Tax Trap that many of them have been unknowingly building for years. By way of example, below is a paraphrased excerpt from a discussion we recently had with Tom, a 59 year old gastroenterologist who was recently referred to us by his investment manager (with whom we’ve been working for several years). Some facts: Tom owns 50% owner of his incorporated practice along with one other partner.

They have 5 other employees (3 admin. and 2 nurses). His adjusted gross income is approximately $650,000 and he contributes the maximum to his SEP IRA annually. He has a substantial net worth including $500,000 in his SEP and $1.5 million in various after-tax investment accounts. Tom is very involved with 2 non-profits as a board member, volunteer and donor.

HYNES: Good morning Tom, how have you been?

TOM: Well, I just met with my CPA last week and I’m more than a little freaked out. He told me about all of the tax increases and that new itemized deduction phaseout along with Alternative Minimum Tax that I always seem to fall into and how it’s going to affect me. Let me tell you, it’s all a bit unsettling.

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P RA CT I CE MA NA GE ME NT

Escape from... (continued) HYNES: What did he suggest you do?

TOM: Well, at first he suggested that I max out my SEP. But, after running some numbers, we figured out that I had already done that for the year. Then, he discussed the possibility of ‘hiring’ my wife and then taking her earnings and contributing the maximum we could to a SEP for her.

What do you think of that strategy?

HYNES: Well, I think that could be a good anesthetic to relieve your immediate financial pain. But I’d rather discuss options to heal that pain at its source.

TOM: Ok. Now you’re talking my language, I think. What do you mean, specifically?

HYNES: Contributions to pre-tax retirement plans such as SEPs, 401(k)s, 403(b)s etc. delay the imposition of taxes rather than avoiding them altogether. So, by providing a short-term fix you create some long-term issues.

TOM: I see. But, I’ll be in a lower tax bracket when I retire so I’ll make out on the deal, right?

HYNES: Not necessarily. That seems to be an accepted ‘truth’ in financial planning but let’s look at that chestnut critically. You’re familiar with the $17 trillion deficit and the $125 trillion unfunded liabilities of the U.S. government?

TOM: Yes, we were in New York City a couple of weeks back and when I looked at the debt clock I almost threw up my corn beef sandwich from the Carnegie Deli. It’s simultaneously alarming and depressing.

HYNES: Well, there are only 2 ways the government can deal with this debt: Spend Less or Tax More. Which do you think they’re inclined to do?

TOM: Ok, I get your point.

HYNES: Also, let’s look at tax rates in the context of histo-

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Christopher Hynes, JD, CFP® ry…since the Temporary Income Tax was levied in 1913, the average tax rate has been much higher than it is currently.

TOM: So, I could actually distribute the money from my SEP at a higher tax rate than I was able to deduct when I contributed it. Ugh. Great! But it’s too late now, the money is already trapped in there. I’ll just begin taking it out when the government forces me to—at age 71, right?—and roll the dice. Let’s talk about what I can do to lower my current income tax bill without trapping me in the same predicament.

HYNES: We do have strategies to lower your current income tax—beyond your SEP IRA—that we’ll discuss at our next meeting. For now, let’s talk about converting that SEP to a Roth IRA so you won’t be taxed on that money again.

TOM: Hang on…I’ve already looked at a Roth conversion and I’m not interested in paying all those taxes up front.

That would be a huge hit.

HYNES: I understand. Many of our clients feel the same way.

That’s why we suggest a review of several advanced concepts that could enable you to offset a big chunk of those taxes when you convert your traditional IRA to a Roth.

TOM: Sounds either illegal or too good to be true…which is it?

HYNES: Well, neither, of course. One idea is to take about $1 million of your brokerage account balance and donate it to a Charitable Lead Trust (CLT). The CLT would be set up for a 10 year period only. During that time, your Donor-Advised Fund (DAF) would accept annual “lead” gifts from the CLT at 5% of the initial CLT balance—in this case, approximately $50,000. At the end of the 10-year term, the CLT balance would be returned to you tax-free.

You could continue to donate to your 2 favorite charities; your DAF would just act as an intermediary of sorts. This would enable you to maintain control over your lead gifts and even let them accumulate over time.

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Escape from... (continued)

Christopher Hynes, JD, CFP®

TOM: OK, I’m tracking. So, I imagine there’s a tax deduction for the charitable contribution, right?

HYNES: Yes. And because interest rates are low, that deduction is sizable.

TOM: Even though I get the money back?... Well, provided that my investment returns do better than the payout I make each year, I’ll get it back—and maybe more, right?

HYNES: Correct. The tax calculation is based on a rate that is currently much lower than your 5% CLT distribution rate. So, even though you could have a balance left at the end of the CLT term, there is still a present-value tax deduction that approximates 50% of the amount you contribute to the CLT. That rate changes around the 20th of each month but you can use the lowest rate from the preceding 2 months if the rate ticks up as it has been recently…

about the author:

Christopher Hynes, JD, CFP® Attorney and Certified Financial Planner Advisor to the Advisors Worcester, Massachusetts As one of approximately 1,800 attorneys who are also Certified Financial Planners ™, Chris Hynes’ education, training and experience furnish him with a unique perspective on complex financial structures, issues and products. Since his admission to the Massachusetts Bar almost 20 years ago, Chris has provided estate planning, insurance planning, financial and tax counsel to hundreds of individuals, businesses and non-profit entities. While serving as Senior Partner and Director of Advanced Planning for an independent, 10-advisor Massachusetts-based wealth management team, Chris quickly earned a reputation among his peers as a financial innovator in the insurance and fixed product arena.

So, in short, you would be able to offset all of your income tax liability from the IRA conversion. As an aside, this would have to occur over a 2-year period because the deduction could be no more than 30% of your total Adjusted Gross Income in any one year. Then, as long as you could achieve better than a 5% annual after-tax return in the CLT (to offset your Lead payments), you would receive all of your money back at the end of the 10-year term and, in the meantime, your Roth will have been growing tax-free for the next 10 years.

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: 50 50

a creative resource

MNAY / J UNBEE R/D 2 0E1CE 3 MB E R O VEM

WWW. WWW. T TO OD D AY AY S SP PR RA AC CT T II C C E.COM E .COM

2012

logo campaign brochure website display outdoor tradeshow signage publication stuff *

optimists make the best

graphic designers. just let us handle it.

www.divisioniv.com * stuff is a non-specific term, not to be confused with “things”. elaboration is provided on a situational basis.

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WWW.TODAYSP WWW.TODAYSP R RA AC C TI TI C CE E .C .C OM OM

F I NA NCE

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July /August 2014

defining your

investment philosophy by philip c. gallant, cltc the optimus group, llc

When asked to describe what their investment philosophy is, many investors will respond with an answer tied to their level of risk. Oh, I’m a gambler some might say. Or another may say, I don’t like a lot of risk, but I know I need to invest in the market. There are any numbers of answers that may come along those lines.

The reality is however that an investment philosophy has more to do with the way you believe investing should be done, keeping a long time horizon in mind.

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F I NA NCE

Investment Philosophy... (continued) Short-term vs Long Term An investor with a short term time horizon may be more likely to attempt to achieve returns based upon tactical asset allocation and playing hunches about market movement. Additionally, someone with a shorter time horizon would likely be more interested in strategies to short the market and pick stocks based on sectors they feel will likely be impacted by economic trends. While in the short term an investor or their broker can experience gains in a portfolio based upon this strategy, it is unlikely that a long-term investment plan using this strategy will succeed unless there are countless hours dedicated to research, analysis, tactical allocation strategies and quite frankly, a little luck. But this type of investing can actually be exciting and fun for the right type of individual, if they feel comfortable with the associated risks and costs that come with it.

For the long-term investor however, especially one who is counting on some reasonable predictor of the likely performance of a portfolio, investing like a short term investor for long-term results can be cause for many sleepless nights and a good deal of anxiety. Watching your lifetime retirement savings swing back and forth on a daily basis is not a fun way to relax and enjoy retirement. Many advisors who are dealing with long-term portfolios are likely to recommend some form of indexing strategy which tends to lower expenses since index investing reduces trading costs and offers broader diversification.

Do Markets Fail?

When determining an investment philosophy, perhaps the real question to ask is whether or not you believe that markets fail, or are they efficient? In other words, an investment philosophy really boils down to whether you believe you or your broker can or need be smarter than the market and can “beat” a certain index or benchmark with more savvy investment decisions, or whether you believe that the market gets you returns and you or your

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Philip C. Gallant, CLTC

broker have little or nothing to do with the outcome. In fact, if it were possible for sophisticated investors and professional money managers to do exactly what I am describing, there would only be the need for one mutual fund, one money manager, and one Investment Company. But there is empirical evidence that this seems impossible since most of the large investment banking firms offer dozens upon dozens of mutual funds from which to select.

“...if it were possible for sophisticated investors and professional money managers to do exactly what I am describing, there would only be the need for one mutual fund, one money manager, and one Investment Company.”

This style of investing relies upon the fact that in a zero sum game, an investor can come out ahead, if they are right more than 50% of the time in picking which way a stock, or a fund or the market will move and playing that hunch correctly. Belief in this investment philosophy causes an investor to stock pick, market time, and track record invest. Stock picking, track record investing and market timing are the keys to investing for millions who reply upon research and data to pick winners and losers.

But is this a long-term strategy?

Are markets efficient?

The efficient market theory says that for the long-term investor, the goal is to achieve market returns. The only way to do that is to index all open markets and all asset classes and to let the market provide the returns. With the efficient market style of investing, the most critical issue is the determination of an investors risk tolerance, and that can be measured by knowing how much risk an investor is willing to assume for an expected rate of return. Concurrent with this philosophy is the fact that fixed income in the portfolio exists not to supplement returns, but rather to mitigate risk and the shorter and less volatile the fixed income portion of the portfolio is

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Investment Philosophy... (continued) the better. Asset allocation starts in this style with the division of the portfolio into equities and fixed income with an eye towards the historical returns of asset classes rather than the track record of specific mutual fund managers or stock brokers.

The more aggressive an investor is, the larger the portion of the portfolio invested in equities. The more conservative the investor, the less portion of the portfolio invested in equities. But here’s the difference. The actual holdings in both portfolios are exactly the same. And why shouldn’t they be if the investor is simply seeking market returns and is not relying upon a fund manager to do anything more than rebalancing to the asset allocation appropriate for the accepted risk tolerance. In this scenario, there is a reliable and known method for making sure that both sides of the investment highway the expected low as well as the expected high- now becomes predictable 95% of the time. It’s called standard deviation. The standard deviation of a portfolio will outline what is to be expected on both the upside and the downside 95% of the time. You may know it as the bell curve.

Once the standard deviation of an investment portfolio is known, and assuming the portfolio is designed to be rebalanced regularly within the scope of the deviation as opposed to trading to beat a benchmark, the only thing left to do is to test the tolerance of that portfolio against inflation adjusted income needs to see if it will withstand the desired income withdrawals required. If that can be done, an efficiently designed investment portfolio is more likely to deliver great results over the long term.

The Problem In our microwave, 24 hour news, phone app, internet based society it becomes very tempting to forget the discipline required to stick with a properly diversified and balanced investment portfolio. The media and opinion makers as well as the advertising wizards are extremely adept at convincing us to look for quick fixes, get rich

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Philip C. Gallant, CLTC

quick schemes and do it ourselves solutions to our investing needs. Often, a portfolio that is designed to work over the long-term by living within the investor’s acceptable risk parameters does not provide the adrenaline rush of exciting trading stories or hot stock winners. Yet, the academic modeling that has gone into the development of Modern Portfolio Theory and disciplined long-term investing suggests that the larger and more important factor should outweigh the desire for a great gain on a hunch. It may not be sexy, but in the end once you understand what you are doing with your portfolio and why, you might feel a little more confident that you can take some play money and try your hand at the other strategies just for fun. For wealth building and retirement income, perhaps it is better to leave that to the global market and a well constructed portfolio that provides you with market returns within your acceptable level of risk as measured by the standard deviation in your portfolio. about the author:

Philip C. Gallant, CLTC Managing Partner The Optimus Group, LLC

After having served as an agent and sales manager for two major life insurance companies, Mr. Gallant became the National Sales and Marketing Director for Long- Term Care Insurance at John Hancock Life Insurance Company, located in Boston, Massachusetts. During his tenure at John Hancock, Mr. Gallant worked extensively to train thousands of John Hancock representatives about the growing problem of long- term care financing in the United States. His expertise and success lead to rapid advancement at John Hancock where he eventually was appointed Brand Manager for Long-Term Care Insurance, responsible for oversight and coordination of product development, marketing, branding and sales.

Mr. Gallant is a member of The National Ethics Bureau, The Million Dollar Round Table – Court of The Table, the National Association of Insurance and Financial Advisors, The Capital District Association Of Insurance and Financial Advisors, The American Association for Long-Term Care Insurance and holds his professional certification in Long-Term Care (CLTC) from the Corporation For Long- Term Care.

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www.hynesfinancial.com 71 elm street

worcester, ma 01609

FEE-BASED RETIREMENT INCOME PLANNING

direct: 508.751.5350

fax: 508.751.5351

ESTATE AND LONG-TERM CARE PLANNING

EDUCATIO

In with the new.

As one of approximately 1,800 attorneys who are also Certified Financial Planners速, Chris Hynes' education, training and experience furnish him with a unique perspective on complex financial structures, issues and products. Since his admission to the Massachusetts Bar in 1995, Chris has provided estate planning, insurance planning, financial and tax counsel to hundreds of individuals, businesses and non-profit entities. call to discuss your options today. 508.751.5350

ON PLANNING

SMALL AND MID-SIZED BUSINESS PLANNING

401K AND 403B PLAN MANAGEMENT

M A RK E T I NG

your

reputation protecting

& using it to your advantage

by ron meritt Reputation Management is the attempt to influence and shape how your practice is perceived by all interested parties, including your patients, their families, the general public, your employees, potential patients and vendors.

The past few years have seen a sea change in the ways that a company’s reputation is shaped and how quickly it can change. The onset of social media has had a major impact on how people view, and you maintain, the reputation of your practice. It wasn’t that long ago that when a patient had an experience (whether good or bad) with a medical practice, he or she would share it with friends and family. If the experience was an especially bad one (like something which prompts a malpractice suit) a person might contact a lawyer or even a reporter –which would then lead to the general public finding out, as well.

Of course, these days a person can post a review of your practice online, and it becomes part of your practice’s reputation – for the entire world to see – within mere seconds.

Even if a comment is a total lie, it’s out there, like it or not.

If it’s a negative review and you are made aware of it, your practice has two options. You can choose to ignore it (which is probably not a good idea) or your can take a proactive stance to try to combat the negative comments.

If you choose the second approach, you can choose a desig-

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nated individual (either an in-house person or an outside entity) who is known as a “Reputation Manager” to regularly monitor social media on your behalf and act to refute any negative comments. This person can post positive pieces in sufficient numbers to make the negative commentary display less prominently in search results or on social media sites. He/she could also join online conversations. For example, the Reputation Manager can respond to negative posts about your practice with comments that they have had only good experiences to report.

Your practice can and should take positive advantage of social media. The first step in reputation management is to monitor references to your practice and its individual doctors. To do this, have your designated Reputation Manager sift through social media on a regular and consistent basis, looking for any references to your practice. This can be done most effectively through social media monitoring, using tools such as Google Analytics and similar processes.

They will help give you a “snapshot” of current public opinion of your practice. Armed with this information, you can address any problematic issues which have been revealed. Reputation Management campaigns can also be conducted to increase the visibility of positive opinions or to decrease the visibility of any negative comments.

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Your Reputation... (continued) There are several things which can happen which could damage the reputation of your practice. They can include (but are certainly not limited to) the following items:

Ron Meritt • Remind your entire staff about the importance of treating each patient the way he/she would like to be treated.

• You are sued for malpractice by a patient.

• An employee, such as a member of your front office staff, does something which upsets a patient or a patient’s family member.

• A patient passes away and your practice is blamed for the death (whether or not it’s a legitimate charge, it can still do irreparable damage to your practice).

One effective way to cultivate a good reputation for your practice is to become known for associations with activities/causes/initiatives which will produce positive “buzz.”

A few examples: • Submit an op/ed piece to your local paper or a website on a health-related topic.

• You receive a professional sanction.

• Submit pieces to print or online medical journals and make sure to publicize the fact that you wrote them.

• An employee or patient files a sexual harassment or other type of lawsuit.

• Sponsor a “fun run” with proceeds going toward a good cause, such as breast cancer awareness.

• A doctor or other employee gets in trouble with the law, such as being charged with a DUI.

• Donate money to a worthwhile local non-profit, such as a food bank or a women’s shelter.

Always remember, the actions of each member of your staff reflect – either in a positive or negative way – on your practice.

No matter what you choose to do, make sure you let the public know what you’re up to. You can do this by developing and distributing news releases touting what you’ve already done, along with upcoming events.

There are numerous ways your practice can utilize Reputation Management in a proactive manner, helping to engender a positive reputation. Here are just a few suggestions (again, this is by no means a complete listing): • Educate the entire staff of your practice about how to deal with patients in a manner which will enhance your reputation.

• Along those lines, remind every member of your staff of the old adage that “The customer is always right” – of course, in this case, the customer is your patient.

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You should also embrace social media: • If your practice doesn’t have one yet, build a website.

• Set up a Facebook page for your practice, and encourage your patients to “friend” and follow you.

• Use Twitter to communicate with your patients and the public at large, providing them with useful information.

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Your Reputation... (continued)

Ron Meritt

• You should be on LinkedIn – it’s a great way to stay connected and network with other physicians and members of the medical community.

Of course, these days a person can post a review of your practice online, and it becomes part of your practice’s reputation – for the entire world to see – within mere seconds.

The bottom line is a pretty simple one: The only truly effective way to create a positive reputation for your practice, one which will endure, is through appropriate behavior. A positive reputation isn’t given automatically – it’s earned, one interaction at a time. about the author:

Ron Meritt President On Advertising Phoenix, Arizona

Ron Meritt’s background and experience includes television broadcast production, on-air talent, advertising sales, business marketing and strategic public relations. Ron spent a total of 24 years on television before retiring from broadcasting, and opened On Advertising in 1994.

His keen insight into the workings of journalism and protecting reputations through strategic crisis communications strategies has combined to protect clients throughout the United States from media attacks. On Advertising customizes marketing programs and brand management for all industries, however with a particular focus on healthcare.

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M A RK E T I NG

local search engine optimization

&

the importance to your practice.

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by keith clark

July /August 2014

Local Search...

Keith Clark

(continued)

Every business wants to appear at or near the top search results for the major search engines like Google, Bing and Yahoo! The overwhelming majority of click-throughs result from pages that land in the top ten or, at least, on the first page of search results. The higher the search engine listing of your website, the higher the click through rate.

However, that’s only a part of the search game. Recognize that “dominance” plays an important role to the consumers influence. So consider the other “Search” real estate: maps, organic, sponsored, mobile, and the all-important Local Listings.

The objective of local Search Engine Optimization (SEO) is to help your website achieve the highest placement possible in search engine results pages. As the internet continues to grow in both size and importance, it can become even more difficult to get noticed.

What is Local Search?

Local search is simply a search that is intended to find something within a specific geographic area. For example, a user may search for "pediatricians in Las Vegas". Any local-centric business that draws clients from within a specific service area must be concerned about creating an effective local search optimization campaign. Typically, local online searches result in the completion of a transaction offline, and more and more local searches are being conducted with mobile devices such as smartphones.

Searching Locally In today’s digital world, people use search engines to look for services and products within their local reach such as restaurants, doctors, lawyers, and lawn care services. As a result, the major search engines now deliver more localized search results into their organic listings.

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A recent survey from Pew Research found that over 79% of U.S. consumers conduct local searches on the internet before making a buying decision offline. As a result, it's become increasingly important that businesses understand what local search is and how it works.

Small and mid-sized businesses need to recognize and take advantage of the fact that people are using search engines to find them locally. After all, if you’re running a practice in Las Vegas, do you really care if people in Miami view your website?

Fresh, relevant, quality, professionally-written and optimized content is also what attracts the attention of the search engines – translating into higher revenues for your practice.

How does one improve their local search engine optimization process? Just like standard SEO, creating relevant and compelling content is crucial. Well-written copy for your user and proper local keyword research goes a long way in giving your business a competitive advantage in the SEO battle. Successful local SEO can demand more creativity.

The fact that local search results are being listed before organic web results gives your practice a golden opportunity. To take advantage, you now need to pay more attention to local business listings as an essential part of your search engine marketing (while still optimizing for the traditional web listings).

The Importance of Content Today your practice must be strategically engaged on available digital media outlets. Your customer base is more diverse than ever and they like to get their information from a variety of marketing channels and platforms including websites, blogs, and social media. This makes fresh, unique and relevant content critical. Although this can make your job more difficult, it can also create unprecedented marketing opportunities.

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Local Search...

Content is what draws in visitors and it’s what keeps them engaged. Fresh, relevant, quality, professionally-written and optimized content is also what attracts the attention of the search engines – translating into higher revenues for your practice.

Social Media One of the best ways to create a content marketing campaign is with an effective social media program. You make it easy for customers to find your business and to talk about it online. Social media sites will help boost your local search results, your long-term brand awareness and increase sales.

How? Social media lets you communicate directly with your customers, create engaging discussion topics, take your marketing viral, boost your online brand awareness, and helps propel your business to the top of organic local search results. Some engagement examples include using monitoring tools to listen for conversations around important topics that you can service or be an information resource. Establish a keyword list and be notified anytime someone in the geographical area posts a question or related comments.

Here are some examples that will help you achieve those goals: START A BLOG. To truly understand the importance and effectiveness of content marketing, start a blog. Write information that your customers want to read instead of dictating to them. Let your visitors leave comments and reviews.

BUILD A FOLLOWING ON FACEBOOK. Half of Facebook users follow a specific brand and more than half of them eventually purchase that brand. “Likes” on Facebook spread brand awareness virally, delivering information to everyone befriended by your followers.

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Keith Clark

(continued)

OPEN A TWITTER ACCOUNT. Twitter is a great way to keep in touch with your current customers. Increasingly, Twitter users follow a specific brand and most will eventually purchase that brand. Twitter posts should be used to engage your clients by providing them with helpful information about your products and services. Offering special deals to your Twitter followers is a great way to grab their attention.

SEO Practices for Organic Local Search Even without a social media campaign there are many SEO practices that can greatly improve your local search rankings. Here are some basic, simple and effective practices that will help you achieve higher organic search results and improve your click through rate.

CONTENT IS KING. Carefully crafted quality content establishes you as an authority in your field. Create useful, information rich sites, microposts and posts that clearly add value to the visitor’s experience. The more useful the visitor finds the information, the more likely he/she will pass it on to their friends, followers and connections.

CUSTOMER REVIEWS. Encourage customer reviews.

Consumers love online reviews because they can see what others think about you and your product or service before they make a purchase or decide to use your services. In addition, reviews on social media sites improve your organic search engine rankings and will drive free web traffic.

KEYWORDS. Give serious thought to the keyword selection. Put yourself in the searcher’s mindset. What keywords would he/she use to find you? You’ll find that long tail keywords – specific key phrases that are four or more words long – are often the most effective keywords. Potential clients tend to search long tail

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Local Search...

Keith Clark

(continued)

keywords when they’re close to scheduling an appointment.

WEBSITE DOMAIN (URL) NAME. Don’t underestimate how important a good domain name is. Having your most important keyword in your domain name will give you tremendous advantage over your competitors. (ex. On name: SantaFePediatrics.com) PAGE TITLES. Your website page titles (especially your home page) need to be targeted to the primary terms that you're trying to rank for. For example, if you're a pediatrician, your home page title should target your pediatrician services in your locality.

MANAGE YOUR LOCAL BUSINESS LISTINGS. Nearly every major search engine and Internet Yellow Pages (IYP) offers a free method that allows your practice to claim and manage your local business listing data. This includes the Big Three: Google, Yahoo, and Bing. Take advantage of this tool by working with professionals on claiming, optimizing and managing your local business listings on the local search engines and major IYP’s, related sites such as local medical directories or review sites. Add all relevant categories that describe your practice offerings that can be easily found when users search for you.

SITE PROMOTION. Many businesses think that their job is complete as soon as the website is launched. You website needs to be promoted just like any other product or service. Plan it into your business budget accordingly. Discuss this with a digital marketing agency or industry related consultant to find out what marketing mix will work to maximize your exposure and give you the proper return on investment. Each tactic has different weighing factors but ultimately it’s about marketing.

to start your monthly reporting as to whats working in marketing or advertsing and even tracking offline promotions like coupons or event signups.

Todays consumers find local businesses in many channels. Getting timely local search marketing consistently and dilllingently has many benefits to meet your organization’s goals.

Some top factors if you had sort chronologically: - Physical Address in City of Search - Proper Category Associations - Proximity of Address to Centroid - Domain Authority of Website - Quantity of Structured Citations (IYPs, Data Aggregators) - City, State in Places Landing Page Title - Quantity of Native Google Places Reviews (w/text) about the author:

Keith Clark Abode Systems

Keith Clark, a digital marketing strategist with over 25 years experience related to small businesses and large brand enterprises. As the original founder of Abode Systems, a firm that prides itself on providing innovative resources to maximize exposure at all levels sustainably and within budget.

TRAFFIC AND NEXT STEPS. Most local directory sites have some kind of traffic measurement dashboard providing stats like asked for directions, views of your business, number of reviews,etc. These are good places

J u l y /A u g u s t 2 0 1 4

TODAY’S PRA C T I C E: C HA NGI NG T HE BUS I NES S OF M EDI C I NE

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WHEN:

9.13.2014

7:00AM - 12:00PM WHERE: JOIN US AT THE FOUR-DIAMOND, AWARD-WINNING OMNI INTERLOCKEN HOTEL. 500 Interlocken Blvd Denver, Colorado 80021 Phone: (303) 438-6600

REGISTER ONLINE:

BUSINESS

PRACTICE MANAGEMENT EFFICIENCIES IN A TIME OF EXTREME COMPLIANCE MANDATES Registration Opens

7:00 AM

Breakfast and Exhibition

7:30 AM

Introductions

8:30 AM

Becky Rudolph MS Psychology Heathcare Management Partners, Denver, CO

OR RSVP BY CALLING OR BY EMAIL

MEDICINE

CME SYMPOSIUM

www.MMPSEVENTS.com

702.557.5023

OF

Liability Aspects of Electronic Documentation

8:45 AM

Michael S. Victoroff, MD COPIC, Risk Management Consultant

kschauer@meridianmps.com

The Importance of Policy and Procedures

9:30 AM

Randall Schauer, Esq. Partner, Fox Rothschild LLP

Break

10:15 AM

10:30 AM

Practice Management in a Time of Compliance Mandates Alan Kimura, MD, MPH Partner, Colorado Retina Associates

KEYNOTE SPEAKER PRESENTED BY:

11:15 AM

ICD-10 Transition Marvelle Anderson Marvel J Hammer RN BS CPC CCS-P ACS-PM CPCO MJH Consulting based in Denver, Colorado

CME Accreditation and Designation This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Nevada State Medical Association (NSMA) through the joint providership of Sunrise Health System and Meridian MPS. The Sunrise Health System is accredited by the NSMA to provide continuing medical education for physicians.

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The Sunrise Health System designates this live activity for a maximum of 3.0 AMA PRA Category 1 CreditsTM. Physicians

their participation.

TODAY ’ S P R A C T I C E : C H should A N G I Nonly G Tclaim H E Bthe U Scredit I NEScommensurate S OF M EDI Cwith I NEthe extent Julyof/August 2014

exclusive to our attendees:

meridian mps golf rate

BUSINESS

OF

MEDICINE

CME SYMPOSIUM

ATTENDEE EXCLUSIVE FOR PHYSICIANS WHO WOULD LIKE TO DO FOURSOMES:

$88

FEE PLUS CLUB RENTAL OF $48

The Golf Club at the Omni Interlocken Hotel takes golfing in the Denver area to a whole new level.

Get ready for exciting golf in a breathtaking setting at our 27-hole championship golf course.

The course consists of three individual regulation 9-hole courses - Eldorado, Vista and Sunshine.

Designed by Graham & Panks International, (a partnership between David Graham, 1981 U.S. Open Champion and PGA Senior Tour player and Gary Panks), the Omni Interlocken Golf Course was ranked third in the "Best Resort Courses of Colorado" survey.

For some of the best world-class golf in Denver, come to the Golf Club at the Omni Interlocken Hotel.

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CME SYMPOSIUM SERIES

CALL FOR RESERVATIONS: (303) 438-6600 OMNI INTERLOCKEN RESORT 500 INTERLOCKEN BLVD, BROOMFIELD, CO 80021 J u l y /A u g u s t 2 0 1 4 TODAY’S PRA C T I C E: C HA NGI NG T HE BUS I NES S OF M EDI C I NE 69